Every finding on record at Nicholasville Nursing and Rehabilitation

Based on observation, interview, record review, review of the facility's signage, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions to protect the residents for 4 of 27 sampled residents, Resident (R) 21, R34, R39, and R41. Observation on 08/19/2025 revealed staff donned (put on) N-95 masks over surgical masks prior to entering rooms designated as Covid positive rooms.Observation on 08/19/2025 revealed rooms designated as Covid positive rooms were without proper signage for droplet precautions. Observation on 08/20/2025 revealed staff exited a room designated as a Covid positive room without removing an N-95 mask and wearing the same mask to another department. The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, no date given, revealed the facility had infection prevention and control programs designed to provide a safe, sanitary, and comfortable environment. Additional review revealed the program helped to prevent the development and transmission of communicable diseases and infections with procedures for all staff to be responsible for following all policies and procedures related to the program including to use personal protective equipment (PPE) according to facility policy. Further review revealed staff would be educated on the facility's infection and prevention program related to their job functions. Review of the facility's policy titled, Covid-19 Prevention and Management, dated 03/05/2025, revealed the facility was to follow updated recommendations set forth by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) regarding prevention and management of the Covid-19 virus. Further review revealed the policy was to ensure proper treatment and prevention of the transmission of Covid-19 to other residents and care team members. The policy stated care team members would be required to wear eye protection, N-95 or surgical mask over N-95, gown, and gloves prior to entry and remove prior to exiting the quarantine or isolation room. Continued review revealed surgical masks could not be used under an N-95 mask. Review of the facility's door signage Special Droplet/Contact Precautions, undated, revealed everyone must wear proper PPE including a facemask at all times which included an N-95 upon entering the room. 1. Review of Resident (R) 21's Face Sheet revealed the facility admitted the resident on 08/01/2025 with diagnoses to include low blood pressure, dementia, and hypothyroidism. Further review revealed his assigned room was designated as Covid positive. Review of R21's SAR-COV-2 [severe acute respiratory syndrome coronavirus 2] (Covid-19) Resident Testing Data revealed a test performed on 08/13/2025 had positive results. Observation of the Business Office Manager (BOM) on 08/19/2025 at 10:50 AM revealed the BOM entered R21's room, a room designated as Covid positive with a surgical mask under an N-95 mask. During an interview with BOM on 08/19/2025 at 3:00 PM, she stated she had been working at the facility for about nine months. When asked if the facility had provided any training for putting on and disposing of PPE for Covid positive rooms, she stated yes and no. When asked what that meant she stated when she had entered the Covid positive room with the mask under the N-95, she did not know any better. She stated the Director of Nursing Services (DNS) had given her one-on-one training yesterday, and she now knows not to wear any mask under an N-95. She stated if one wore a surgical mask under the N-95, it interfered with its seal, possibly exposing her, which could lead to spreading Covid.2. Review of R34's Face Sheet revealed the facility admitted the resident on 06/30/2025 with diagnoses to include high blood pressure, heart failure, and cellulitis in right lower limb. Further review revealed R34's assigned room was designated as Covid positive. Review of R34's SAR-COV-2 (Covid-19) Resident Testing Data revealed a test performed on 08/16/2025 had positive results. Review of R34's Physician's Orders revealed a verbal order was given on 08/16/2025 for droplet precautions to include mask, gown, gloves and eye protection, required every shift. Review of R34's Care Plan revealed a focus of at risk for respiratory distress related to confirmed Covid-19, initiated on 08/19/2025. Further review revealed resident would be free from symptoms of respiratory distress with interventions to include droplet precautions.Review of R39's Face Sheet revealed the facility admitted the resident on 07/14/2025 with diagnoses to include multiple fractures, high blood pressure, and chronic kidney disease. Further review revealed R39's assigned room was designated as Covid positive. Review of R39's SAR-COV-2 (Covid-19) Resident Testing Data revealed a test performed on 08/13/2025 had positive results.Review of R39's Physician's Orders revealed a telephone order was given on 08/14/2025 for droplet precautions to include mask, gown, gloves, and eye protection required every shift for isolation for ten (10) days.Review of R39's Comprehensive Care Plan (CCP), dated 08/18/2025, revealed R39's focus placed her at risk for respiratory distress related to confirmed Covid-19. Further review of the CCP revealed the goal was for the resident to be free from or have reduced symptoms of respiratory distress with interventions placed on 08/18/2025 to include droplet precautions. Review of R41's Face Sheet revealed the facility admitted the resident on 12/10/2021 with diagnoses to include diabetes, high blood pressure, and acute ischemic heart disease (reduced blood flow to the heart muscle). Further review revealed R41's assigned room was designated as Covid positive.Review of R41's SAR-COV-2 (Covid-19) Resident Testing Data revealed a test performed on 08/18/2025 had positive results.Review of R41's Physician's Orders revealed a verbal order was given on 08/18/2025 for droplet precautions to include mask, gown, gloves and eye protection every shift until 08/28/2025 with an end date given as 08/28/2025. Review of R41's CCP, dated 08/18/2025, identified the resident at risk for respiratory distress related to contact with confirmed Covid-19. R41's goal was to be free from or have reduced symptoms of respiratory distress with interventions to include droplet precautions. Observation on 08/19/2025 at 12:10 PM revealed no signage for droplet precautions on the door of the room where R39 and R41 resided. Further observation at 12:20 PM revealed there was no signage for droplet precautions on the door of the room where R34 resided. Both rooms were designated as Covid positive rooms. 3. Observation on 08/19/2025 at 1:00 PM revealed State Registered Nurse Aide (SRNA) 4 donned (put on) PPE to deliver lunch trays to the room where R39 and R41 resided. SRNA4 placed an N95 mask over a surgical mask. When exiting the room, she removed the PPE inside the room then placed the used N95 into the door caddy where clean PPE was stored outside of the room. During an interview with SRNA4 on 08/19/2025 at 1:07 PM, she stated she had never received any education about how to place the N95 mask. She also stated they were disposable, and she should have placed it into the trash can to prevent cross contamination.During an interview with SRNA6 on 08/20/2025 at 3:35 PM, he stated he would not wear a mask under an N-95. He added if a mask was worn under an N-95, it could cause cross contamination, and that was how he was trained.During an interview with SRNA5 on 08/21/2025 at 11:10 AM, she stated the facility had provided training on infection control which included DNSning an N-95. She stated she was trained not to place any type of mask under an N-95 because it could increase chances of becoming infected and spreading germs. During an interview with SRNA9 on 08/21/2025 at 1:29 PM, she stated she was trained not to double mask when using an N-95 because it interfered with proper sealing, increasing chances of cross contamination and spreading germs. In an interview with SRNA16 on 08/22/2025 at 9:06 AM, she stated she did wear a surgical mask under her N-95 for extra protection, and no one had told her otherwise. During a brief interview with the Director of Nursing Services (DNS) on 08/19/2025 at 11:25 AM, she stated the staff was not trained to wear a surgical mask under an N-95, adding it interfered with the seal of the N-95, which could possibly spread Covid throughout the facility.4. Observation on 08/20/2025 at 3:10 PM revealed therapy staff exited the room where R34 resided, a Covid positive designated room, still wearing an N-95 mask. Continued observation revealed therapy staff walked to the end of A Hall, through B Hall, and then to the therapy department with the same N-95 mask on and disposed of the mask in the garbage can in the therapy department. Further observation revealed the N-95 mask in the therapy garbage can. During an interview with therapy staff at 3:15 PM on 08/20/2025 after observation, she stated she was an Occupational Therapist (OT) and had worked at facility for nine months. When asked if she had received infection control training since working at the facility, especially pertaining to Covid positive rooms and proper donning and doffing (removing) PPE, she stated she was sure she had but could not remember. When ask if the N95 mask she wore in R34's room was the same that she disposed in the therapy garbage, she stated it was the same mask. She stated the concern was if proper donning and doffing was not practiced upon entering and exiting a Covid positive room, the infection could be spread throughout the facility. During an additional interview with the DNS on 08/22/2025 at 3:05 PM, she stated she had been at the facility one month. She stated prior to her coming to the facility, she could not say what the infection prevention and control procedure was. However, she stated she had now provided infection control in-services over two to three days to make sure she covered all shifts and all staff. She stated, after the first resident tested positive for Covid, each staff person received a packet of information. She stated she reviewed the kinds of precautions, what PPE to wear, and observed return demonstrations of DNSning and doffing PPE. The DNS stated her expectation was for staff to follow the education and posted signage on resident room doors to protect all residents and staff. She stated, if staff did not follow infection control precautions, infections could spread to the residents, staff, and the community.During an interview with the Executive Director who was also the Infection Preventionist (IP) on 08/22/2025 at 8:32 AM, she stated she had been at the facility as the Executive Director since February 2025 and had served as IP since August 2025. She stated her expectations of staff members, as both the IP and ED, were they should know and follow the policy for infection control and proper DNSning/doffing of personal protective equipment (PPE) to prevent spreading germs. She stated staff was trained upon hire in infection control and then yearly and as needed. She stated each time there was a resident placed in isolation, the facility performed additional training as needed. She stated staff was trained on all the different types of isolation and should know the procedure and refer to the door signage. She stated further, if a resident was on contact isolation, staff should be putting on PPE each and every time they entered the room. She stated all PPE would be taken off prior to exiting the room. She stated proper signage should be on each isolation room door to explain what PPE was needed and when to remove it to prevent spreading the virus of Covid positive rooms. She stated, if proper signage was not on the room door, staff would not have guidance to follow, and there would be a risk of spreading germs. The Executive Director also stated staff was trained not to double mask and should not be doing that.

Based on observation, review of medication package inserts, and review of the facility's policy, the facility failed to ensure the provision of appropriate environmental controls to preserve the integrity of medications in 1 of 2 sampled medication refrigerators. Observation on the B Unit on 08/20/2025 revealed no medication refrigerator temperature log was initially observed, and when provided by the facility, temperatures had only been documented from 08/16/2025 to 08/20/2025. In addition, observation on the A Unit revealed an opened but unlabeled medication in one of the medication carts and an opened but unlabeled medication and an expired medication in the medication refrigerator.The findings include: Review of the facility's policy titled, Medication Storage, dated 01/02/2024, revealed the facility would ensure all medications housed on the premises would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Further review revealed refrigerated products were maintained within 36 to 46 degrees Fahrenheit (F) with charts kept on each refrigerator and temperature levels recorded daily by the charge nurse or other designee. Continued review revealed medication rooms were routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.Review of Aplisol (brand name for tuberculin pure protein derivative used as a skin test to diagnoses tuberculosis) package insert, dated 08/28/2024, revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation, which might affect potency.Review of Azelastine (eye drops to treat allergy symptoms) package insert revealed storage instructions that included the bottle should be discarded after opened for 28 days.Observation of A Unit medication room refrigerator on 08/20/2025 on 2:45 PM revealed the refrigerator's temperature log was not readily visible, then was found crumpled in the floor by the refrigerator. Further observation revealed Aplisol 5 unit/0.1 milliliter (ml) package opened, with no opened date recorded, and one bisacodyl suppository (used to treat constipation) for Resident 20, with an expiration date of 7/31/2025.Observation of A Unit medication cart for even rooms on 08/20/2025 at 3:05 PM revealed Azelastine 0.05% Ophthalmic solution, with no opened date marked.Observation of B Unit medication room refrigerator on 08/20/2025 at 3:13 PM revealed the temperature was 40 degrees (F) but with the August 2025 temperature log not readily apparent. When located, the log revealed the only dates with the temperature recorded were from 08/16/2025 to 08/20/2025. Further review revealed Aplisol 5 unit/0.1 ml opened but with no opened date marked. Continued observation revealed the following inventory of the refrigerator: eight bisacodyl suppositories, 10 milligrams (mg); one acidophilus chew and two acidophilus capsules; two Prevnar 20 vaccines; one Comirnaty Covid vaccine; 21 Novalog Flex pens; four Lantus Solostar pens; seven Lyumjev kwikpen; one Toujeo Solostar pen; three Fiasp flextouch pen; one liraglutide GLP-1 injection; humulin 70/30 insulin vial; and daptomycin 800 mg/100 ml normal saline NS.During interview with Licensed Practical Nurse (LPN) 4 on 08/20/2025 at 2:55 PM, she stated it was important to have a log to ensure temperatures were in the safe range. She also stated it was important to discard medications when they expired because they might not be effective.During interview with LPN 7 on 08/22/2025 at 2:15 PM, she stated the reason for maintaining refrigerated medications in the right temperature range and disposing of medications that were expired was that those medications might have decayed or not be effective.During interview with Registered Nurse (RN) 3 on 08/22/2025 at 2:20 PM, she stated the reason for maintaining the medication room refrigerator in the specific temperature range was to maintain stability of the medicines and disposing of medications that were expired was to avoid giving medication to residents that might not be effective anymore.During interview with the Director of Nursing Services (DNS) on 08/20/2025 at 3:00 PM, she stated she was sure the medication log was there yesterday but was unable to locate it and a new log was started. She stated temperatures were important for medication stability and when medications expired, the efficacy might be affected.During additional interview with the DNS on 08/22/2025 at 2:00 PM, she stated she had contacted the pharmacist consultant who had advised that the medications stored in the refrigerator without a log must be discarded. During additional interview with the DNS on 08/22/2025 at 3:13 PM, she stated the expectation was the policies in place were to be followed. She stated that was important because medications were not effective if not stored properly. She stated she had spoken to the Assistant Director of Nursing (ADON), and they would be working on medication storage together, with both of them providing monitoring.During interview with the Executive Director on 08/22/2025 at 3:37 PM, she stated the medication rooms were checked by in-house staff. She stated the nurses were responsible for audits of medication rooms and carts. She stated that was a night nurse task, with the expectation that it was to be carried out nightly. She also stated that was important so there were no expired medications, and those medications in the refrigerator were at the right temperature. She stated that was important so medications would be effective.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to maintain correct recordkeeping of all controlled drugs, which ensured an accurate inventory of medications by accounting for controlled medicines the facility received, dispensed, and administered. A review of narcotic count sheets revealed staff failed to sign inventory sheets for controlled narcotics and sign narcotic count sheets at the change of shift, for four of four medication carts. The findings include: Review of the facility's policy titled, Storage of Controlled Substances, revised date 08/2020, revealed, At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. Observation on 09/08/2024 at 10:30 AM, revealed the facility had two medications carts per hall (four medication carts/narcotic books total). Review of Hall A even medication cart narcotic book on 09/09/2024 at 3:00 PM, revealed seven out of 36 shift changes were missing two signatures from licensed personnel, between the dates of 08/16/2024 to 09/07/2024. Review of Hall A odd medication cart narcotic book on 09/09/2024 at 3:30 PM, revealed 19 out of 78 shift changes were missing two signatures from licensed personnel between the dates of 07/12/2024 to 09/07/2024. Review of Hall B front medication cart narcotic book on 09/09/2024 at 4:00 PM, revealed 41 out of 144 shift changes were missing two signatures from licensed personnel between the dates of 05/04/2024 to 09/01/2024. Review of Hall B back medication cart narcotic book on 09/09/2024 at 4:30 PM, revealed 40 out of 138 shift changes were missing two signatures from licensed personnel between the dates of 05/04/2024 to 09/06/2024. During an interview with State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) 10 on 09/10/2024 at 9:30 AM, she stated she could count narcotics with another staff member. She stated if there were any narcotics to waste, she informed the nurse. She stated she could waste narcotic medications with a nurse. She stated any discontinued narcotics were wasted by the Director of Nursing (DON). She stated medications were signed in by the nurse when they arrived from the pharmacy. During an interview with SRNA/KMA1 on 09/10/2024 at 9:45 AM, she stated wastes were done by two people and then placed in the waste bin on the side of the medication cart. She stated nurses checked in new medications that arrived from the pharmacy. She stated the nurse would collect all discontinued medications. She stated she was not sure what the process was for returning or crediting controlled medications. She stated if a resident was discharged and still had controlled medications in the cart, then she gave them to the nurse. During an interview with Registered Nurse (RN) 1 on 09/10/2024 at 10:00 AM, she stated narcotic waste was done by two staff members, and the count was done by the off-going and on-coming nurse. RN1 stated the DON wasted all narcotics once they were discontinued. During an interview with the DON on 09/10/2024 at 10:15 AM, she stated narcotics were wasted by two people and then given to her. She stated she scanned the medication to the pharmacy so the resident would get credit. She stated the controlled medication was disposed of in the drug disposal destroyer that was kept in the DON's office. During an additional interview with the DON on 09/12/2024 at 9:45 AM, she stated her expectation of staff counting narcotics and narcotic cards was that each shift counted and signed/dated the narcotic book per facility policy. During an interview with the Administrator on 09/12/2024 at 10:00 AM, she stated her expectation was that narcotic counts were to be done timely and correctly for resident safety.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards for four of four medication carts. Undated opened medications were found in all medication carts. The findings include: Record review of the facility's policy titles, Administration Procedures for All Medications, effective date 09/2018, revised date 08/2020, revealed the facility staff was to check the expiration date on the package/container before administering any medication. The policy stated when opening a multi-dose container, place the date on the container. Observation on 09/08/2024 at 10:30 AM, revealed the facility had one medication room per hall (two total) and two medications carts per hall (four total). 1. a. Observation on 09/08/2024 at 11:00 AM, revealed one of the four medication carts, the B Hall front cart, contained an opened, undated vial of purified protein derivative, PPD (used in a tuberculin skin test to help diagnose tuberculosis). Further observation revealed the cart contained the following medications that were opened and not dated; Linzess (for irritable bowel syndrome), Fiasp insulin (to lower blood sugar), Geri-Tussin (thinned mucus), Chloraseptic throat lozenges, MiraLAX (a laxative), Milk of Magnesia (a laxative), guaifenesin (thinned mucus), Flonase nasal spray, Ventolin inhaler (a bronchodilator), Incruse inhaler (treated chronic obstructive pulmonary disease (COPD)), polyvinyl eye drops, neo/poly/dex eye drops, sulfa sodium eye drops, and Carboxymethylcellulose sodium eye drops. b. Observation on 09/08/2024 at 11:15 AM, revealed a Unisom (used to induce sleep) bottle was found in the B Hall front medication cart that was not labeled or dated. In an interview at the time with Registered Nurse (RN) 2, she stated a resident had ordered it from the store and delivered to the facility, and staff confiscated the bottle and placed it in the medication cart. She stated the medication was not being dispensed to any residents. 2. Observation on 09/08/2024 at 12:00 PM, revealed the B Hall back medication cart contained the following medications that were opened and not dated: Chloraseptic throat lozenges, calcium antacid, and guaifenesin. 3. Observation on 09/08/2024 at 3:00 PM, revealed the A Hall even medication cart contained the following medications that were opened and not dated: Milk of Magnesia, Spiriva inhaler (used to treat COPD), Symbicort inhaler (used to treat COPD), Flonase nasal spray, and an ipratropium albuterol nebulizer (used to treat COPD). 4. Observation on 09/08/2024 at 3:30 PM, revealed the A Hall odd medication cart contained the following medications that were opened and not dated: MiraLAX, Milk of Magnesia, ipratropium albuterol nebulizer, Enulose (treated constipation), and albuterol inhaler (a bronchodilator). During an interview with the Director of Nursing (DON) on 09/12/2024 at 9:45 AM, she stated her expectation of medication storage was for staff to store and date medication properly and for staff to check the shelf life and discard medications when needed. The DON stated, We don't want to give expired medications to residents; they may not be effective. During an interview with the Administrator on 09/12/2024 at 10:00 AM, she stated her expectation for staff was to follow the medication storage guidelines for resident safety.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 64 residents in the facility, Resident (R) 24, R55, R60, R63, and R267. The findings include: Review of the facility's policy titled, Enhanced Barrier Protection, dated March 20, 2024, revealed it was the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug resistant organisms (MDROs). The policy stated residents with a wound or an indwelling medical device needed to have EBPs for the duration of their stay at the facility or until the wound had healed or the device was removed. The policy stated the requirement of EBPs should be used during high contact resident care activities such as bathing, dressing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, during care or use of devices such as central lines, urinary catheters, feeding tubes, tracheostomy, or ventilator tubes, and during wound care. Review of the policy titled, Administration Procedures for All Medications, dated 08/2020, revealed medications were to be administered in a safe and effective manner. Review of the facility's signage Enhanced Barrier Precautions revealed instructions to include everyone must clean hands, including before entering and when leaving the room, and providers and staff must also wear gloves and a gown for high contact resident care activities including wound care for any skin opening requiring a dressing. 1. a. Review of R55's Orders, dated 09/05/2024, revealed an order for the resident to be on EBP. Observation on 09/08/2024 at 10:15 AM revealed R55's room did not have EBP signage on it, nor did it have personal protective equipment (PPE) hanging on the door for staff to use during care. Observation on 09/08/2024 at 11:16 AM revealed staff hanging signage for EBP on R55's and R267's room doors. It was also observed that staff was hanging PPE holders on those doors. Observation of R55 on 09/10/2024 at 10:10 AM revealed R55 was being placed into his wheelchair. His indwelling catheter bag did not have a dignity cover, and the resident's catheter tubing and catheter bag were both touching the floor in the resident's room and then in the hallway. In an interview with State Registered Nurse Aide (SRNA) 2 and SRNA4, an orientee, on 09/10/2024 at 10:37 AM, she stated the bag and tubing should be at a level below the resident's bladder, but the tubing and bag should not touch the floor. In an interview with Licensed Practical Nurse (LPN)1 on 09/10/2024 at 11:03 AM, she stated, during rounds on her residents, she made sure the catheter was patent, and it was not touching the floor. b. Review of 267's Orders, dated 09/08/2024, revealed she had an order to be on EBP. Observation on 09/08/2024 at 10:33 AM revealed R267's room did not have EBP signage on it and did not have PPE hanging on the door. c. Review of R63's Orders, dated 08/14/2024, revealed an order to be on EBP. Observation on 09/08/2024 at 1:14 PM of staff passing out lunch trays revealed that SRNA7 and SRNA9 entered the room of R63, room [ROOM NUMBER], and pulled up R63 in her bed after delivering her meal tray. room [ROOM NUMBER] had a sign for EBP on the door. Neither SRNA7 nor SRNA8 donned (put on) the appropriate PPE needed for resident care. SRNA7 left room [ROOM NUMBER], without performing hand hygiene, and delivered another tray to room [ROOM NUMBER]. d. Review of R60's Order Listing Report, dated 09/01/2024 through 09/30/2024 with an order revision date of 07/10/2024, revealed an order summary for R60 to include EBP when engaging in high contact resident care. Observation on 09/11/2024 at 8:50 AM revealed the Wound Care Physician, after performing wound evaluation in room [ROOM NUMBER] on R60's lower left extremity, exited the room still wearing gloves and a gown. Further observation revealed the physician removed the gloves and gown in the hallway and stepped back into room [ROOM NUMBER] to dispose of the gown and gloves. Hand Hygiene was not observed after the physician removed the gown and gloves. Continued observation revealed room [ROOM NUMBER] was designated as requiring EBP. In an interview with SRNA3 on 09/09/2024 at 8:51 AM, she stated the EBP signage meant that she put on PPE when doing resident care but not when passing meal trays. When asked if pulling a resident up in bed was considered resident care, she stated, Yes. SRNA3 stated when passing meal trays staff should hand sanitize or wash their hands after each tray was delivered. In an interview with SRNA8 on 09/10/2024 at 7:13 PM, she stated the catheter bag should not be placed on or touching the floor. She stated for residents with EBP signage posted on their doors, staff was to put on a gown and gloves prior to entering the resident's room to provide care. She stated she always did this even when passing lunch trays. She also stated she used hand sanitizer or washed her hands after exiting a resident's room after passing meal trays or providing care. In an interview with SRNA9 on 09/10/2024 at 7:26 PM, she stated, when asked about EBP signage and what EBP required her to do, she did not immediately know what the State Survey Agency (SSA) Surveyor was referring to. Then she stated it meant that staff wore a gown, gloves, and a mask when providing resident care. SRNA9 stated staff did not need to put on PPE when delivering a tray to a resident's room but did need to put on PPE when performing resident care such as changing a resident or giving them a bath. In an interview with the Minimum Data Set (MDS) Nurse on 09/12/2024 at 4:30 PM, she stated everyone including physicians should be donning and doffing (taking off) proper PPE for isolation rooms, and all should be trained. She stated performing proper isolation procedures prevented germs from being carried into another resident's room. In an interview with the Director of Nursing (DON), with the Assistant Director of Nursing (ADON) in attendance, on 09/12/2024 at 8:25 AM, when asked about staff being observed placing EBP signage on R55's and R267's doors and putting up a PPE storage hanger on their doors, the DON stated that what was observed was that staff member changing the door hanger to one that allowed the door to shut completely. She also stated staff did not put up the EBP signage on 09/08/2024 at 11:16 AM because both R55's door and R267's door had that signage on it already. When asked what her expectations were for staff when they saw the EBP signage on the door, she stated staff should put on PPE when going into a resident's room to perform a high contact activity and remove PPE prior to exiting the room. She stated hand hygiene should always be performed after that procedure. She stated delivering a tray was not considered high contact activity but pulling a resident up in bed was. The DON stated she was also currently the facility's interim Infection Preventionist. She stated staff have had numerous in-service trainings on EBP. 49050 2. Observation on 09/11/2024 at 8:27 AM during medication administration revealed Registered Nurse (RN) 2 dropped three different medications for R24 on the top of the medication cart. She then picked up the medications with two plastic medication cups and placed the medication in the other cup with the accompanying medications. In an interview with RN2 on 09/11/2024 at 8:31 AM, she asked, Was this the proper way to handle medication touching the cart? She stated she had disinfected the entire cart before beginning medication administration. In an interview with the Director of Nursing (DON) on 09/11/2024 at 2:46 PM, she stated it was her expectation that nurses and Kentucky Medication Aides (KMA) would dispense medication safely and appropriately. In an interview with the Administrator on 09/12/2024 at 5:39 PM, she stated it was her expectation that nurses would dispense medication accurately and appropriately. In an interview with the facility's Medical Director on 09/12/2024 at 10:20 AM, he stated it was his expectation that staff should follow the facility's infection prevention policies because that was why they were in place.

Based on observation, interview, record review, and review of facility's documents and assessment, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by the resident assessment for 3 of 64 residents in the facility, Resident (R) 5, R6, and R117. The findings include: Review of the document Facility Assessment Tool for Nicholasville Nursing and Rehabilit 08/2023 through 07/2024, dated 07/01/2024 revealed, Licensed nurses providing direct care: 5-6 per day (3-4 day shift, 2 night shift). Nurses aides: 8-10 per day (5-6 day shift, 3-4 night shift). Review of the document PBJ [Payroll Based Journal] Staffing Data Report CASPER Report 1705D, FY Quarter 3 2024 (April 1- June 30), dated 09/05/2024 revealed, One Star Staffing Rating, (the lowest rating). Review of the document Nicholasville Nursing and Rehabilitation-Monday September 09, 2024 - Census 64 revealed for nurse aide total assigned for 7:00 PM to 7:00 AM there were two aides working and one aide was on day two of orientation. Three additional aides were added by hand. Review of the document Call Light Audit, dated from 06/29/2024 through 09/02/2024, provided by the Director of Nursing and performed by the facility's Scheduler, revealed call light answering times ranged from 10 minutes to 69 minutes. Observation of nurse aides on 09/09/2024 at 10:21 AM, revealed two State Registered Nurse Aides (SRNA) and one nurse on each hall. In an interview with R5 on 09/08/2024 at 4:23 PM, she stated there was only two aides and one nurse on each unit. She stated it took a while for staff to answer the call lights between 9:00 AM to 5:00 PM. In an interview with R6 on 09/09/2024 at 10:14 AM, she stated there were staffing shortages at night. She stated it took her a long time to get help turning in the bed. R6 stated, They do not have enough staff here. Some are good, but they have trouble keeping help. In an interview with R117 on 09/11/2024 at 1:33 PM, she stated it took a long time for staff to answer the call lights. R117 also stated she would look at the time on her phone, and it would take up to four hours for staff to come and change her. In an interview with the Minimum Data Set (MDS) Nurse, a Registered Nurse (RN), on 09/10/2024 at 4:08 PM, she stated she was having trouble getting her work caught up. She stated she worked on the weekends trying to get resident assessments done according to the time requirements. She stated she came from another facility when this facility changed ownership. She also stated she was new to this role, and it was taking her time to adjust. She stated she had to cover on the floor and take call periodically. In an interview with RN1 on 09/10/2024 at 2:49 PM, she stated she was the only nurse on the floor. She stated she also had a Kentucky Medication Aide (KMA) to help with medication. She stated she was at the desk working on four different tasks at once. She also stated she had an admission this morning that she had not been able to get to because she was busy with other work, and she was the only nurse on the unit. In an interview with SRNA2 on 09/10/2024 at 10:17 AM, she stated today SRNA5 was pulled to the B Hall to help, which left two aides and one orientee on the A Hall. Observation of the MDS Nurse on 09/11/2024 at 2:37 PM, revealed she was sitting at the nurses' station on A hall with her computer on a tray table doing work. In an interview with the MDS nurse on 09/11/2024 at 2:38 PM, she stated she came and worked at the nurses' station to provide breaks for the other nurses in the afternoon. In an interview with the Director of Nursing (DON) on 09/11/2024 at 2:52 PM, she stated the facility did not hire nurse aides that were not certified. She also stated the facility had an annual competency checkoff that must be completed. She stated she was not aware of any staffing shortages. She stated the facility just hired five new aides who were orienting currently. She stated she was not aware of call light audits indicating response times of over an hour. In an interview with the Administrator on 09/12/2024 at 5:39 PM, she stated it was her expectation the facility provided enough staff to maintain resident care. She stated staffing was a problem on both day and night shift running low. She stated the facility was now maintaining staffing levels. She stated she used an agency and that staff might pick-up three to five shifts per week. She stated some facility staff would pick-up extra shifts per week.

Based on interview, record review, and review of the facility's policies, the facility failed to provide proof of vaccinations or declinations for four out of five sampled residents for immunization, Resident (R) 14, R16, R32, and R60. The findings include: Review of the facility's policy titled, Pneumococcal Vaccination, dated 01/02/2024, revealed the facility would offer this vaccination and each resident would be assessed upon admission for the vaccine. Further review revealed each resident would be offered this vaccine unless contraindicated and would be provided education with benefits and potential side effects. Continued review revealed the resident or representative retained the right to refuse, and information would be documented in the medical record. Review of the facility's policy titled, Influenza Vaccination, dated 01/02/2024, revealed the facility offered annual immunizations from October 1st through March 31st, unless it was medically contraindicated, the resident was already immunized, or the resident refused the vaccine. Continued review revealed education would be provided regarding benefits and potential side effects and would be documented in the resident's medical file. 1. Review of R14's immunization update revealed there was no record of influenza vaccination being given, and the status of the vaccine was not provided by the facility, from R14's admitted [DATE] to the present. Record review revealed R14 had no documented proof of administration or declination of an influenza immunization or declination. 2. Review of R16's medical record revealed R16 had no documented proof of pneumococcal immunization or declination, from R16's admitted [DATE] to the present. 3. Review of R32's medical record revealed no documentation of influenza or pneumococcal vaccines were provided by the facility, from R32's admitted [DATE] to the present. Continued review revealed the Pneumococcal Vaccine Consent Form was signed and dated by the resident representative on 09/03/2024, but there was no documentation R32 had received the pneumococcal vaccination. 4. Review of R60's medical record revealed no documentation of influenza or pneumococcal vaccines were provided by the facility, from R60's admitted [DATE] to the present. Continued review revealed the family refused the influenza vaccination on 09/05/2024. However, further review revealed the Influenza Vaccine Consent Form and the Pneumococcal Vaccine Consent Form were signed and dated on 09/12/2024 by the resident's representative. During interview with the Director of Nursing (DON) on 09/12/2024 at 2:00 PM, she stated after review of their EMRs she could not locate missing vaccination records for R14, R16, R32, and R60, adding she knew the residents had received the vaccinations. She stated the importance of vaccinations was to keep residents and staff safe. During interview with the Administrator on 09/12/2024 at 10:00 AM, she stated all facility guidelines should be followed. During interview with the Medical Director on 09/12/2024 at 10:20 AM, he stated all infection control policies and procedures should be followed because that was why they were in place.

Based on observation, interview, and review of the facility's documents and policies, the facility failed to provide 2 of 42 sampled and supplemental residents, Resident (R) 20 and R59, with a safe, clean, comfortable, and homelike environment. The room that R20 and R59 shared smelled of urine and other unpleasant odors. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, dated 01/02/2024, revealed that in accordance with residents' rights, the facility would provide a safe, clean, comfortable, and homelike environment. Review of the facility's policy titled, Resident Rights, dated October 2019, stated all staff members were to always recognize the rights of residents and residents assumed their responsibilities to enable personal dignity, well-being, and proper delivery of care. Review of the facility's policy titled, Dignity, dated 01/02/2024, revealed that it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintained or enhanced the resident's quality of life by recognizing each resident's individuality. Review of the facility's document Five Step Daily Room Cleaning revealed that the purpose of the document was to teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility. This document stated that the housekeepers were to empty the trash, clean/disinfect horizontal surfaces, spot clean walls, dust mop, and damp mop each room. Observation on 09/08/2024 at 11:06 AM revealed room [ROOM NUMBER], the room shared by R20 and R59, smelled strongly of urine. The room also had another smell the State Survey Agency (SSA) Surveyor could only describe as that of an open wound. Observation on 09/08/2024 at 1:07 PM revealed the door to room [ROOM NUMBER] was open, and the hallway outside of that room smelled of urine and an open wound. Observation on 09/10/2024 at 4:00 PM of room [ROOM NUMBER] revealed the door was closed but the odor of urine and of an open wound could be smelled outside the door and was even stronger inside the room. In an interview with R59 on 09/08/2024 at 11:01 AM, he stated he did not think room [ROOM NUMBER] had an unpleasant odor. In an interview with R20 on 09/08/2024 at 11:06 AM, he stated he had a urostomy (an opening in the abdominal wall created to divert urine away from the bladder and into a collection bag outside the abdominal wall) and a colostomy (an opening in the large intestine to divert feces into a collection bag outside the abdominal wall. He stated his urostomy leaked because the facility had not purchased the correct urostomy bags. He stated he did his own care for his colostomy and urostomy. R20 stated that he had a large sore on his bottom (coccyx, open wound), and he was at the facility for wound management. He stated he did his own showers. In an interview on 09/10/2024 at 10:16 AM with State Registered Nurse Aide (SRNA) 3, she stated R20 did not let staff assist him with bathing or changing his colostomy and urostomy bags; R20 did all his own care. SRNA3 stated that part of the odor in R20's room also came from the wound on his coccyx. She stated R20's urostomy bag leaked. SRNA3 stated R20 refused to let staff change his bed linens. SRNA3 stated when R20 went to the hospital, staff cleaned the room, and the smell went away. She stated the smell was not from R59. In an interview on 09/10/2024 at 10:33 AM with Housekeeper (HK) 1 and the Director of Housekeeping, both stated room [ROOM NUMBER] smelled strongly of urine despite staff cleaning the room daily and using multiple cleaners to try and help with the odor. HK1 stated staff cleaned R20's room multiple times daily, without being successful in ridding the room of the urine and wound odor. The Director of Housekeeping stated the facility had changed out R20's mattress multiple times to help with the odors. Both stated the odor of urine did not constitute a homelike environment. In an interview on 09/10/2024 at 10:37 AM with SRNA2 and her orientee, SRNA4, present, she stated the smell in room [ROOM NUMBER] was from R20's wound drainage and the leaking urostomy that had saturated the mattress topper. She stated she felt he needed a new mattress to help eliminate the odor. SRNA2 stated she had no access to cleaning supplies to clean the mattress, and R20 refused to have his bed linens changed daily. SRNA2 stated R20 often refused to shower. In a telephone interview with SRNA8 on 09/10/2024 at 7:26 PM, she stated R20's room only smelled bad when staff was performing his wound treatments. SRNA8 stated R20 did his own care, and he refused showers and having his bed linens changed. In an interview with Registered Nurse (RN) 1 on 09/10/2024 at 3:20 PM, she stated the odor in room [ROOM NUMBER] was from R20's Stage 4 pressure ulcer on his coccyx and his urostomy and colostomy. RN1 stated R20 often refused to bathe, get his bed linens changed, or allowed staff to wipe off his mattress. In an interview with the Director of Central Supply on 09/11/2024 at 8:43 AM, she stated she was unable to get the correct size urostomy bags for R20 because the supplier had discontinued the ones he used. The Director of Central Supply stated she had ordered different sizes of urostomy bags for R20 to try, and staff was still trying to find a bag that fit and did not leak. In an interview with the Maintenance Director on 09/11/2024 at 8:45 AM, he stated the mattress for R59 had been changed out recently, but the mattress for R20 was an air mattress, from an outside vendor that could not be changed. In an interview with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) on 09/12/2024 at 8:25 AM, both stated the smell in room [ROOM NUMBER] was from R20. The DON stated R20 refused care and treatments, and R20 was care planned for the behavior of refusing care. The ADON and DON stated they tried to encourage R20 to bathe. The DON stated that housekeeping was also cleaning the room more frequently to help with the smell. In an interview with the Administrator on 09/12/2024 at 8:47 AM, she stated the facility had tried multiple things to combat the smell in room [ROOM NUMBER]. She stated R20 refused to pick up things in the room or to have the room cleaned. She stated she had talked with R20 about cleaning up the clutter and allowing housekeeping to clean the room. The Administrator stated she had also interviewed R59 about the odor and the clutter in room [ROOM NUMBER], and R59 had no issues with either and declined to move to another room. The Administrator stated the smell and the clutter in the room were an issue, but she could only suggest cleaning the room to R20 and R59 and could not force them to do it. The Administrator stated R20 did his own ostomy care, and he was messy, which contributed to the room's odor. She stated it was difficult for R20 to accept someone caring for him, even if he did need the assistance.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI), the facility failed in seven days to complete the resident assessment as return anticipated or not anticipated and electronically transmit the discharge assessment within 14 days for 1 of 25 sampled residents, Resident (R) 36. R36's discharge date was 05/28/2024, but R36's Minimum Data Set (MDS) was not submitted until 09/12/2024. The findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/2023, revealed the MDS completion date must be no later than 14 days for a Discharge Assessment - return not anticipated or return anticipated. Review of R36's Face Sheet revealed the facility admitted the resident on 04/16/2024 with diagnoses of protein-calorie malnutrition, hypertension, and atrial fibrillation. Review of R36's MDS, with an assessment reference date (ARD) of 04/23/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R36's Health Progress Note, dated 05/28/2024 at 2:45 PM, revealed the resident was sent to acute care. Review of R36's Health Progress Note, dated 05/28/2024 at 7:08 PM, revealed the resident had been hospitalized . Review of R36's electronic medical record (EMR) revealed the last documented MDS, with an ARD of 05/01/2024, showed a five-day scheduled assessment for Medicare Part A stay. In an interview with the Minimum Data Set Nurse, who was a Registered Nurse (RN), on 09/12/2024 at 2:37 PM, she stated after the resident was out of the facility for 24 hours, she would add discharge (D/C) with anticipated to return or not anticipated to return. She stated she had seven days to complete the assessment and an additional seven days to submit the assessment after completion. She stated the completed resident assessment was submitted within 14 days. She stated she did not add the anticipated to return or not anticipated to return after the resident had not returned within 23 hours. In an interview with the Director of Nursing (DON) on 09/12/20224 at 3:00 PM, she stated the discharged resident assessment was to be submitted timely according to the RAI manual. In an interview with the Administrator on 09/12/2024 at 3:52 PM, she stated she expected the MDS assessment to be submitted on time.

Based on interview, record review, and review of the facility's policy, the facility failed to develop a person centered care plan for each resident, consistent with the resident rights which included measurable objectives, and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 25 sampled residents, Resident (R) 267. Review of R267's Comprehensive Care Plan (CCP) revealed R267 was to be assessed for a bruit and a thrill. However, R267 did not have a fistula to assess, but instead had a dialysis central venous catheter. Further review of R267's CCP revealed the CCP had multiple instances where the resident's name was not documented, and R267 was referred to only by the generic term Resident Name. The findings include: The State Survey Agency (SSA) Surveyor asked the Administrator for a policy on the development and implementation of resident centered care plans on 09/09/2024 at 1:51 PM and on 09/11/2024 at 8:37 AM. On 09/11/2024 at 8:37 AM the Administrator stated the facility did not have a policy for the development and implementation of resident centered care plans. Review of the facility's policy titled, Dialysis, dated 01/02/2024, revealed that it was the facility's policy to provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Further review revealed residents with external dialysis catheters would be assessed every shift to ensure that the catheter dressing was intact and not soiled. Review of R267's Face Sheet revealed the facility admitted the resident on 08/30/2024 with diagnoses of chronic kidney disease without heart failure, with Stage 5 kidney disease or end stage renal disease, and diabetes mellitus type II. Review of R267's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 09/05/2024, revealed R267 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate impaired cognition. Further review revealed R267 was assessed as needing hemodialysis while a resident but was not assessed as having a peripheral, midline, or central intravenous access. Review of R267's CCP, dated 08/31/2024, revealed R267 required hemodialysis due to renal failure. The goal was R267 would be free from complications related to dialysis. The interventions planned to meet this goal was assess bruit and thrill every shift and to not draw blood or take blood pressures in the arm with the graft. Further review revealed 28 instances where the resident's name was to be filled into the blank for a focus or goal, but it only stated (resident name). Review of R267's Orders, dated 09/03/2024, revealed staff was to monitor her right subclavian tunneled catheter site every shift, monitor her dialysis site for signs and symptoms of complications every shift, notify physician and dialysis center of any complications, and that she was to receive dialysis three (3) times per week on Monday, Wednesday, and Friday. In an interview with R267 on 09/08/2024 at 10:33 AM, she stated she still urinated but went to dialysis three times a week also. She stated she had rhabdomyolysis, which had damaged her kidneys. She stated this was why she had a dialysis catheter in her right chest. R267 stated she was told her kidney function was getting better, and she would not need dialysis permanently. In an interview on 09/10/2024 at 3:20 PM with Registered Nurse (RN) 1, she stated R267 had dialysis on Monday, Wednesday, and Friday. She stated she assessed R267's right subclavian dialysis catheter site after she returned from dialysis. The SSA Surveyor asked RN1 how she assessed the bruit and thrill on R267 that was in her CCP. RN1 stated she did not because dialysis catheters did not have a bruit and thrill, only fistulas had a bruit and thrill. The SSA Surveyor asked why it was listed as a care plan intervention, and RN1 stated she did not know. When RN1 was asked if this represented a resident centered care plan, she stated no. In an interview on 09/11/2024 at 8:20 AM with the Minimum Data Set (MDS) Nurse, she stated when a new resident arrived at the facility, a generic care plan was entered for the resident. She stated she had seven days to change the care plan to individualize it for the specific resident. She stated, after this review and unless there was a change in condition or an event such as a fall that occurred, care plans were reviewed quarterly. She stated any changes to the care plan were discussed with the Interdisciplinary Team (IDT, a multidisciplinary group that planned care for the residents). The MDS Nurse stated she was aware there were resident care plans that needed to be updated and individualized, and she was in the process of doing that for all the residents at this time. In an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 09/12/2024 at 8:25 AM, both stated they had the expectation that a resident's care plan should be individualized to that resident, and it should reflect the care and services the facility's staff was providing the resident. When asked how they would assess a thrill or bruit on a dialysis catheter, they stated this assessment was only done for individuals with a fistula. When asked if this intervention care planned for R267 was in individualized, both stated no. Both also stated using the term resident name instead of R267's actual name in the CCP was not considered resident centered. In an interview with the Administrator on 09/12/2024 at 8:47 AM, she stated she did not feel that a care plan with improper or irrelevant interventions were considered a resident centered care plan. She also stated using the term resident name instead of R267's actual name in the CCP was not considered resident centered.

Based on interview, record review, and review of facility's policies, the facility failed to revise the comprehensive care plan after a re-admission for 1 of 25 sampled residents, Resident (R) 167. R167's care plan for nutritional needs and dietary assessment after being readmitted to facility on 08/04/2024 following an acute care hospital stay was not reviewed or revised. The findings include: The State Survey Agency (SSA) Surveyor asked the Administrator for a policy on the revision of resident centered care plans on 09/09/2024 at 1:51 PM and on 09/11/2024 at 8:37 AM. On 09/11/2024 at 8:37 AM the Administrator stated the facility did not have a policy for the revision of resident centered care plans. Review of the facility's policy titled, Dietician Recommendations, dated 01/02/2024, revealed the Registered Dietician (RD) would routinely review the nutritional status of residents and make appropriate recommendations for improved status and or quality of life. Further review revealed the process included the RD to document in the Electronic Medical Record (EMR), on a recommendation health record, and provide it to the Director of Nursing (DON). Continued review revealed the facility would be responsible for review and follow up of the RD recommendations within four business days. However, the policy did not include to add this intervention to the care plan. Review of the facility's policy titled, Interdisciplinary Team (IDT) Risk Review Meeting, dated 01/02/2024, revealed all residents identified with a Risk condition would be reviewed by the IDT weekly with a recommendation for the RD to participant monthly if possible. Further review revealed care planning was not addressed. Review of R167's Face Sheet revealed the facility readmitted the resident on 08/04/2024, with the initial admitted [DATE], with diagnoses to include stoke, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of body), protein-calorie malnutrition, and adult failure to thrive. Review of R167's Comprehensive Care Plan (CCP), with initiation date of 07/02/2024, identified a focus of R167 was at risk for complications due to requiring tube feeding and fluid imbalance due to chronic kidney disease. Interventions placed on 07/02/2024 were for the RD to evaluate quarterly and as needed (PRN), monitor caloric intake, estimate needs, make recommendations to tube feeding as needed, and diet as ordered with revision date of 08/22/2024. Continued review of R167's CCP revealed a focus listed R167 as being at risks of dehydration or nutrition problems. Interventions placed on 07/02/2024 were to notify the physician and dietician for any abnormalities with revision date of 08/22/2024. However no intervention was entered for RD assessment following readmission on 08/04/2024. Review of R167's IDT Care Plan Conference, dated 08/05/2024 at 2:13 PM, revealed to see dietary for nutrition/dietary goals and summary. Further review revealed there were no care plan changes or updates at this time. It stated the resident was a readmission and would continue to be monitor. It was signed and dated by the Social Worker (SW) on 08/07/2024. During an interview with the Minimum Data Set (MDS) Coordinator on 09/12/2024 at 4:30 PM, she stated she had held her position for about six months now and was familiar with R167. She stated the CCP should be updated any time there was a change including after a readmission. She stated, however, if a resident returned to the facility and nothing had changed, then revisions would not be performed. She stated she was not working when R167 was readmitted , and the care plan had not been updated for resident care needs including nutrition. She stated the care plan should have been updated since there were changes, which guided care. She stated, The ball got dropped. She stated this was because she and the Director of Nursing (DON) were not at work for several days after R167 was readmitted . During an interview with the DON on 09/11/2024 at 3:15 PM, she stated for nutritional needs of residents, the RD was consulted. She stated, when asked about the care plan for nutritional needs of R167, there had been a care conference on 08/07/2024, but she was unsure about the revisions to the care plan after readmission on 08/04/2024, since she was not working. During an interview on 09/12/2024 at 10:00 AM with the Administrator, she stated all facility guidelines should be followed.

Based on interview, record review, and review of the facility's Code Status Book, the facility failed to update each resident's Advance Directives in honoring resident wishes for code status to provide basic life support, including cardiopulmonary resuscitation (CPR), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physicians orders and the resident's Advance Directives for 1 of 25 sampled residents, Resident (R) 9. The findings include: Review of R9's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of unspecified atrial fibrillation, type II diabetes mellitus with unspecified complications, and hypertensive urgency. Review of R9's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R9's care plan revealed on [DATE], the facility would honor the decision regarding healthcare choices to be a Full Code. Further review revealed the care plan was revised on [DATE] to indicate R9 wished to have a Do Not Resuscitate (DNR) Advance Directive. However, review of R9's Code Status document dated [DATE], found on [DATE] at 4:27 PM in the Code Status Book located in the A Hall of the facility, incorrectly identified R9's code status as Full Code instead of DNR as indicated in her electronic medical record (EMR) and care plan. In an interview with the Minimum Data Set Nurse on [DATE] at 4:08 PM, she stated R9's care plan had been updated from the previous care plan because R9 wished to be a DNR instead of a full code. She stated when a change was made in the care plan on code status, it was updated in the Code Status Book located in the nurses station of each hall. In an interview with the Director of Nursing (DON) on [DATE] at 2:46 PM, she stated it was her expectation the Code Status Books would be updated each time a new resident was admitted by the nurse. She stated there was not a policy or an assigned person to audit the Code Status Book in each nurses station. She stated if there was a new admission, the team would audit the books in the morning meeting. In an interview with the Administrator on [DATE] at 5:39 PM, she stated her expectation was for the Code Status Books to be accurate and up to date. She stated, I know the books were inaccurate. She stated all code books had now been audited and corrected. She stated the Code Status Books would be monitored weekly.

Based on interview, record review, review of the Registered Dietician's (RD) job description and contract, and review of the facility's policies, the facility failed to perform a comprehensive nutritional assessment by the RD to identify factors that placed the resident at risk for inadequate nutrition and dehydration for one of two sampled residents for nutrition, Resident (R) 167. R167 was readmitted to the facility on [DATE] following an acute care hospital stay for a fall sustained on 07/17/2024. R167, prior to being readmitted on [DATE], was identified as being at risk for inadequate nutrition and hydration. The findings include: Review of the facility's policy titled, Dietician Recommendations, dated 01/02/2024, revealed the RD would routinely review the nutritional status of residents and make appropriate recommendations for improved status and or quality of life. Further review revealed the facility would be responsible for review and follow up of the RD recommendations within four business days. Review of the facility's policy titled, Interdisciplinary Team (IDT) Risk Review Meeting, dated 01/02/2024, revealed all residents identified with a risk condition would be reviewed by the IDT weekly with a recommendation for the RD to participant monthly, if possible. Review of the contracted RD's contract policy titled, Life Care Point Click Care, no date given, revealed resident admissions and readmissions required a full nutritional assessment by day 14 of the admission or readmission. It also stated recommendations would be completed on the RD's recommendations form. However, the facility was unable to find or provide a copy of this form for R167. Review of the Registered Dietician Job Description, dated 03/25/2024, revealed the RD's primary responsibilities included comprehensive assessments for all residents and incorporate nutritional interventions into the individualized interdisciplinary plan of care, provide a written record of recommendations for change in nutrition, and ensure information was appropriately entered. Review of R167's Face Sheet revealed the facility readmitted the resident on 08/04/2024, with an initial admitted [DATE], with diagnoses to include stroke, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of body), protein-calorie malnutrition, and adult failure to thrive. Review of R167's Comprehensive Care Plan (CCP), with initiation date of 07/02/2024, identified a focus as R167 was at risk for complications due to requiring tube feeding. Interventions placed on 07/02/2024 were for the RD to evaluate quarterly and as needed (PRN), with revision date of 08/22/2024. Continued review revealed a focus listed R167 as being at risk of dehydration or nutrition problems. Interventions placed on 07/02/2024 were to notify the physician and dietician for any abnormalities, with a revision date of 08/22/2024. Review of the Speech Therapy Evaluation and Plan, dated 07/01/2024, revealed R167 had severe cognition decline and swallowing skills were within functional limits (WFL) after a clinical bedside assessment of swallowing was performed. Further review revealed recommendations for a diet of regular textures and thin liquids. Review of R167's Nutrition Dietary Enteral Review (NDER) Note, dated 07/04/2024, revealed R167 was at risk for malnutrition with an alternate feeding method via percutaneous endoscopic gastrostomy (PEG) tube. Further review revealed R167 was to receive tube feeding formula four times daily of 240 milliliters (ml) and water flushes of 150 ml and a regular diet. Continued review revealed R167's most recent weight was 100.3 pounds and she was underweight based on the Body Mass Index (BMI). The note stated to consult the RD as needed (PRN). Further review revealed R167, per nursing report, had an oral intake of 0%. Review of R167's Nutrition Interview, dated 07/12/2024, revealed she was high risk nutritionally and was on a regular diet with thin liquids and a supplement order for enteral feed. Further review revealed the information was obtained from the nurse. Review of R167's Discharge Summary from the sending hospital, with a discharge date of [DATE], revealed R167 was admitted to the hospital on 07/18/2024 after sustaining a fall at the facility. Continued review revealed R167 was PEG tube dependent. However no diet order or tube feed orders were listed in the discharge notes, only medications. Review of R167's IDT Care Plan Conference Summary, dated 08/05/2024, revealed to see dietary for nutrition and dietary goals. The summary was dated and signed by the Social Worker (SW) on 08/07/2024. Review of R167's Orders, placed by the provider and dated 08/11/2024, revealed an order for a regular puree diet, follow up with swallow study, and Ensure Plus four times a day to prevent weight loss. Review of R167's Electronic Health Record (EHR) revealed R167 was transferred to the hospital for suspected dehydration on 08/17/2024. Review of a copy of the RD's electronic mail (e-mail) sent to the Director of Nursing (DON), dated 08/20/2024 at 1:28 PM, revealed a diet of regular, puree texture/thin liquid and Ensure would exceed the caloric needs for R167. Review of a copy of the RD's e-mail sent to the DON, dated 09/12/2024, revealed R167's average intake of meals consumed between 08/09/2024 through 08/17/2024 was 58%. During interview with the Complainant on 09/10/2024 at 11:26 AM, who requested anonymity, she stated she had received report from the hospital bedside nurse that R167 had not been receiving tube feedings (TF) at the facility for two weeks, but she had not spoken with the family or seen the resident herself. She stated the emergency medical service (EMS) staff had told the hospital in their report that R167 had not been receiving TF for two weeks, but she was unsure how EMS staff received that information. When asked why she thought the resident was dehydrated and had failure to thrive, she stated it was listed in R167's medical chart. She stated she had spoken with the Director of Nursing (DON) of the facility at time of discharge, and the discharge summary was faxed to the facility on [DATE] at 9:27 AM. However, she stated she was unable to find an order for diet or TF's in the discharge summary. During interview with the contracted RD on 09/10/2024 at 10:59 AM, she stated her tasks included performing dietary assessments on residents who were new admissions, had weight changes, who were high risk for nutritional issues, tube feeding assessments, and dialysis. She stated yes when asked if she performed assessments on readmissions if that resident was flagged as a high risk which R167 was. She stated high risk residents included residents who were, or had been receiving TFs, had wounds, had any significant weight loss, and had dialysis. She stated she remembered the DON calling or texting her about R167 and asking how much R167 would need to consume of her diet for adequate caloric intake, but she was unsure of the date. She stated she thought she had sent an email to the DON stating R167 would need to consume 70% of each meal to reach her daily caloric intake requirement. She stated she should have performed an official dietary assessment on R167 upon her readmission but had failed to do so. She stated she was at another facility and had not looked at R167's information at that time. The RD stated her expectation of the facility's staff was to let her know about R167's weight and history of nutritional needs prior to being dismissed and returned to the facility. During an interview with the DON on 09/11/2024 at 3:15 PM, she stated she was not working at the time of R167's readmission on 08/04/2024 but had reviewed orders upon her return to work on 08/11/2024. She stated she thought she had contacted the RD to ask about the nutritional needs of R167 when she saw there were no diet orders on the hospital discharge summary. She stated the facility's process to follow was for the accepting nurse to review discharge orders, call the provider for verification, and then enter the orders. She stated the nurse had followed that process. She stated the RD should have performed another nutritional assessment upon R167's readmission to assure nutritional needs were met. She stated there had been orders placed for diet and supplements for R167 by the facility's staff. During an interview with Nurse Practitioner (NP) 1 on 09/10/2024 at 10:42 AM, she stated the first time she saw R167 was 07/12/2024, and she appeared in good condition and good spirits. However, she stated, the second time she had rounded on her on 08/09/2024, she seemed thinner and was agitated. She stated she had called back that night, on 08/09/2024, after leaving the facility and placed a verbal order with the nurse for a dietary consult, speech therapy for swallowing consult. She stated she added a nutritional supplement to her diet. She stated she was under the assumption since R167 was on TFs prior to being discharged , the feedings had been reordered. However, she stated she could not recall any TFs infusing at either visit. She stated those visits were the only two times she saw R167, and the other NP had seen her on other visits. She stated she was a little upset that orders had not been placed for the nutrition assessment needs of R167 given the resident's history of having TFs. Interview with NP2 was attempted on 09/10/2024 at 1:36 PM and on 09/11/2024 at 10:57 AM. However, both attempts were not successful. During an interview with the Medical Director on 09/11/2024 at 1:37 PM, he stated there had been some disconnect between the sending hospital and facility concerning the diet order for R167. He stated the facility should have followed up with the sending hospital to verify orders for R167's diet. He stated he thought there had been a conference about the diet order for R167 but could not recall the date. He stated if an order was given, staff should follow that order, including an order for a RD consult. He stated the cause of R167's weight loss, if any that could have occurred, would be hard to determine since R167 had a failure to thrive diagnosis. He stated he knew R167 was getting a food tray and supplements. During an interview with the Administrator on 09/11/2024 at 11:15 AM, she stated she thought there had been a dietician evaluation on R167 upon readmission and would provide a copy; however, a copy was not found. Further, during an interview on 09/12/2024 at 10:00 AM, she stated all facility guidelines should be followed.

Based on observation, interview, record review, and review of facility's policy, the facility failed to ensure a resident who needed respiratory care, was provided such care, for 1 of 25 sampled residents, Resident (R) 55. R55 had orders to receive oxygen (O2) at 3 Liters per minute (L/m) per nasal cannula (n/c); however, observations on 09/08/2024, 09/10/2024 and 09/11/2024 revealed the resident was receiving oxygen at 2 L/m or 2.5 L/m per n/c. The findings include: Review of the facility's policy titled, Oxygen Administration, dated 01/02/2024, revealed oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. Review of R55's Face Sheet revealed the facility admitted the resident on 08/16/2024 with diagnoses of hypertension, heart failure, and chronic kidney disease. Review R55's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/22/2024, revealed the facility assessed R55 to have a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Further review revealed R55 was assessed as having dyspnea when sitting at rest or lying flat. He was also assessed as needing oxygen therapy. Review of R55's Orders, dated 08/16/2024, revealed he was to have his humidification bottle changed every Sunday on night shift, have the head of his bed elevated to help with shortness of breath, his oxygen filter was to be cleaned weekly, and his oxygen was to run at 3 L/m via a n/c. R55 also had orders for his oxygen saturation to be tested on ce weekly and for albuterol nebulizer treatments. Review of R55's Comprehensive Care Plan (CCP), dated 08/16/2024, revealed R55 was care planned for being at a risk for respiratory distress due to pneumonia, being unable to lie flat due to shortness of breath, and a pleural effusion. The goal was for R55 to be free from symptoms of respiratory distress. Interventions were to administer medications as ordered, observe for side effects of the medications, assist resident/family in learning the signs of respiratory compromise, document abnormal findings and notify the Physician, elevate the head of the bed to alleviate shortness of breath caused by lying flat, encourage resident to take deep breaths, utilize pursed lip breathing as needed, take rest breaks as needed, give aerosol or bronchodilators as ordered and observe for adverse side effects, observe for changes in respiratory status, observe for respiratory infection, observe for signs of respiratory distress, administer oxygen as ordered, and obtain vital signs and oxygen saturations as ordered. Observation of R55's oxygen concentrator on 09/08/2024 at 10:15 AM revealed it was set at 2 L/m, and his tubing was not labeled with the date it was last changed. R55 was not short of breath while talking. Observation of R55's oxygen concentrator on 09/10/2024 at 10:53 AM revealed it was set at 2.5 L/m, and his tubing was not labeled with the date it was last changed. R55 appeared calm and was not exhibiting signs of respiratory distress. Observation of R55's oxygen concentrator on 09/11/2024 at 8:24 AM revealed it was set at 2.5 L/m, and his tubing was not labeled with the date it was last changed. In an interview with Licensed Practical Nurse (LPN) 1 on 09/10/2024 at 11:03 AM, she stated a resident's oxygen concentrator setting for oxygen delivered per minute should match the orders in the resident's medical chart. She stated the oxygen tubing was changed weekly, and the oxygen and humidification bottles should be dated. In an interview with Registered Nurse (RN) 1 on 09/10/2024 at 3:20 PM, she stated R55's oxygen should be set at 3 L/m. RN1 stated R55's oxygen was not titrated. She stated each shift she checked to make sure the settings on the oxygen concentrator and the orders matched. She also stated the tubing and the humidification water bottle were changed weekly, and both should be dated when changed. In an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 09/12/2024 at 8:25 AM, both stated oxygen concentrators should be set at the rate designated in the resident's order. Both stated the oxygen concentrator should be checked against the orders to make sure it was set correctly each shift. When asked what could happen to a resident if the oxygen concentrator was set lower than the orders, the DON stated a resident's oxygen saturation could drop because of being under-oxygenated, and the resident could go into respiratory distress. The ADON stated oxygen saturations were checked each shift for residents wearing oxygen, and the oxygen tubing and humidification water bottles were changed weekly. Both stated the tubing and bottle should be dated on the day they were changed. In an interview with the Administrator on 09/12/2024 at 8:47 AM, she stated she expected her nursing staff to follow a resident's care plan and orders when providing care for a resident. In an interview with the Medical Director on 09/12/2024 at 10:20 AM, he stated he expected the physician's orders to be followed. He stated if a nurse felt like R55 was receiving too much oxygen, she could monitor the resident's pulse oxygenation and make sure it remained at 90% or higher when the resident was at a lower rate and request the physician change the orders to a lower flow rate. He stated nurses should not change the rate on their own.

Based on interview, record review and review of facility policy, the facility failed to provide the resident with a discharge summary that included: a recapitulation of the resident's stay; a final summary of the resident's status; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); a post-discharge plan of care that was developed with the participation of the resident and, with the resident's consent, the resident representative. Additionally, the facility failed to ensure transfers and/or discharges were documented in the resident's medical record for eleven (11) of eleven (11) sampled residents, Residents #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29. The findings include: Review of the facility policy titled, Transfer and Discharge, undated revealed for a resident being discharged to the community, a discharge summary and plan of care was to be prepared for the resident. Continued review revealed there was to be documentation in the resident's medical record that written discharge instructions were given to the resident and if applicable the resident's representative. Review revealed a member of the interdisciplinary team (IDT)was to complete relevant sections of the Discharge Summary. Per review of the policy, the nurse caring for the resident at the time of discharge was responsible for ensuring the Discharge Summary was complete and included diagnoses, a final summary of the resident's status, reconciliation of all pre-discharge medications with the resident's post discharge medications, and a post discharge plan of care which had been developed with the participation of the resident and the resident's representative. 1. Review of Resident #19's closed record revealed the facility admitted him/her on 05/18/2023, with diagnoses which included: Traumatic Brain Injury, Fracture of the Body of the Sternum, and Multiple Fractures of the Ribs, Left Side. Review of Resident #19's Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) indicating no cognitive impairment. Review of Resident #19's Electronic Medical Record (EMR) revealed no documented evidence a discharge summary had been completed by facility staff when the resident was discharged from the facility. In an interview on 07/10/2023 at 6:30 PM, Resident #19 stated on 06/14/2023 two (2) aides came into his/her room and began to pack up his/her belongings. Resident #19 stated he/she asked the aides what they were doing and was told he/she was being discharged home after his/her doctor's appointment that morning. The resident stated he/she assumed he/she had lost his/her appeal. Resident #19 stated he/she was transported to his/her scheduled doctor's appointment and from there was transported home. The resident stated once he/she was home he/she called his/her daughter to inform her he/she had been discharged from the facility. Resident #19 stated he/she had not been notified of the discharge or given any information. In an interview on 07/10/2023 at 6:30 PM, Resident #19's daughter stated she had not been notified of the resident's discharge prior to his/her arrival home. She stated they were not given any discharge documentation, nor given any information about home health services, assistive devices/equipment, or the resident's medications. In an interview on 07/12/2023 at 10:21 AM, the Social Services Director (SSD) stated she put the order in for Resident #19's discharge with his/her needed equipment on the day of discharge. She further stated however, she had not spoken to the nurse caring for Resident #19 that day. In an interview on 07/13/2023 at 10:58 AM, Registered Nurse (RN) #1 stated she had not completed a discharge summary for Resident #19. She stated she was not aware a discharge summary needed to have been completed. RN #1 stated she was new to the facility and during orientation there had been no discharges and she had not been trained on the facility's discharge process. In an interview on 07/13/2023 at 12:35 PM, the Executive Director (ED) stated an outcome for Resident #19 of not having his/her discharge completed as per the policy would be not having immediate access to his/her medications. 2. Review of Resident #20's closed record revealed the facility admitted him/her on 05/12/2023, with diagnoses that included Fracture of Unspecified Part of Neck of Left Femur, Personal History of other Malignant Neoplasm of Bronchus and Lung, and Type 2 Diabetes. Review of Resident #20's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Continued review of the MDS Assessment, section Q0300, revealed Resident #20 expected to remain in the facility long term. Review of the Discharge Planning and Evaluation form for Resident #20 dated 06/05/2023, revealed the resident's medications had been listed; however, the form had not been signed by facility staff. Further review of the form revealed no documented evidence Social Services, Activities, Dietary or Therapy staff had completed their required sections of the discharge assessment form as all their fields were blank. Review of Resident #20's Progress Notes dated 06/05/2023, revealed no documented evidence the resident had been discharged from the facility. In an interview on 07/13/2023 at 10:58 AM, RN #1 stated she had not completed a discharge summary for Resident #20 as she had not been aware a discharge summary was to be completed. 3. Review of Resident #21's closed record revealed the facility admitted him/her on 04/04/2023, with diagnoses that included Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD) and Unspecified B-Cell Lymphoma. Review of Resident #21's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15) indicating he/she was cognitively intact. Continued review of the MDS Assessment, section Q0300, revealed Resident #21 expected to be discharged to the community. Review of Resident #21's EMR revealed the facility initiated a Discharge Planning and Evaluation Assessment on 04/05/2023. Continued review revealed however, the assessment had not been completed and was left blank. 4. Review of Resident #22's closed record revealed the facility admitted him/her on 05/18/2023, with diagnoses that included Unspecified Fracture of the Right Femur, Unspecified Dementia, and Hypertension. Review of Resident #22's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of two (2) out of fifteen (15) indicating severe cognitive impairment. Continued review of the MDS Assessment, section Q0300 revealed Resident #22 expected to discharge to the community. Review of Resident #22's EMR revealed no documented evidence the Discharge Planning and Evaluation Assessment had been initiated or completed for the resident. 5. Review of closed record revealed the facility admitted Resident #23 on 04/13/2023 with diagnoses that included Chronic Respiratory Failure with Hypercapnia, Chronic Kidney Disease, Stage 3 and Type 2 Diabetes Mellitus. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. Continued review of the MDS Assessment, section Q0300 revealed Resident #23 expected to discharge to the community. Review of the Discharge Planning and Evaluation form for Resident #23 dated 04/19/2023, revealed no documented evidence Activities, Dietary, or Therapy staff had completed their required sections of the discharge assessment as all their fields were blank. Review of Resident #23's Progress Notes revealed no documented evidence related to the resident being discharged from the facility on 04/23/2023. 6. Review of Resident #24's closed record revealed the facility admitted the resident on 04/20/2023, with diagnoses that included: Acute Cystitis with Hematuria, Chronic Kidney Disease Stage 3, and Chronic Diastolic Heart Failure. Review of Resident #24's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of eleven (11) out of fifteen (15) which indicated moderate cognitive impairment. Continued review of the MDS Assessment, section Q0300 revealed Resident #24 expected to discharge to the community. Review of the Discharge Planning and Evaluation form for Resident #24 dated 05/15/2023, revealed no documented evidence Activities, Dietary, or Therapy staff had completed their required sections of the discharge assessment as all their fields were blank. 7. Review of Resident #25's closed record revealed the facility admitted the resident on 04/13/2023, with diagnoses that included: Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus and Obstructive Sleep Apnea. Review of Resident #25's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS Assessment, section Q0300 revealed Resident #25 expected to discharge to the community. Review of the EMR revealed no documented evidence the Discharge Planning and Evaluation Assessment had been initiated or completed for Resident #25. 8. Review of Resident #26's closed record revealed the facility admitted the resident on 06/01/2023, with diagnoses that included: Acute on Chronic Diastolic Heart Failure, Stenosis of Coronary Artery and Personal History of Malignant Neoplasm of Prostate. Review of Resident #26's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15) which indicated he/she was moderately cognitively impaired. Continued review of the MDS Assessment, section Q0300 revealed Resident #26 expected to discharge to the community. Review of the EMR revealed no documented evidence the Discharge Planning and Evaluation Assessment had been initiated or completed for Resident #26. In an interview on 07/13/2023 at 9:41 AM, Medical Records, who was also a Licensed Practical Nurse (LPN), stated had not completed a discharge summary on Resident #26 because she was not aware it needed to be completed. She stated she printed the medication orders, went over the medications, and had the family member sign. She stated she gave them a copy and the original was scanned into the medical record 9. Review of Resident #27's closed record revealed the facility admitted the resident on 05/05/2023, with diagnoses that included: Malignant Neoplasm of Prostate, Unspecified Atrial Fibrillation and Aphasia. Review of Resident #27's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15) which indicated moderate cognitive impairment. Continued review of the MDS Assessment, section Q0300 revealed Resident #27 expected to discharge to the community. Review of the Discharge Planning and Evaluation form for Resident #27 dated 05/17/2023, revealed no documented evidence Activities, Dietary, or Therapy staff had completed their required sections of the discharge assessment as all their fields were blank. 10. Review of Resident #28's closed record revealed the facility admitted the resident on 06/16/2023, with diagnoses that included: Type 2 Diabetes Mellitus, Alzheimer's Disease with Late Onset, and Chronic Kidney Disease Stage 3. Review of Resident #28's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of ten (10) out of fifteen (15) which indicated moderate cognitive impairment. Continued review of the MDS Assessment, section Q0300 revealed Resident #28 was expected to remain in the facility. Review of the Discharge Planning and Evaluation form for Resident #28 dated 06/19/2023, revealed no documented evidence Activities, Dietary, or Therapy staff had completed their required sections of the discharge assessment as all their fields were blank. 11. Review of Resident #29's closed record revealed the facility admitted the resident on 03/24/2023, with diagnoses that included: Other Fracture of the Second Lumbar Vertebra, Chronic Kidney Disease Stage 3 and Unspecified Osteoarthritis. Review of Resident #29's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) which indicated he/she was cognitively intact. Continued review of the MDS Assessment, section Q0300 revealed Resident #29 expected to return to the community. Review of Discharge Planning and Evaluation form dated 04/11/2023, revealed the facility failed to accurately complete the discharge planning assessment as required per facility policy. In an interview on 07/13/2023 at 9:41 AM, Medical Records/LPN she stated she had not completed a discharge summary on Resident #29 because she was not aware it needed to be completed. She stated she printed the medication orders, went over the medications, and had the family member sign. She stated she gave them a copy and the original was scanned into the medical record. In an interview on 07/12/2023 at 10:21 AM, the Social Services Director (SSD) stated she typically initiated residents' Discharge Planning and Evaluation assessments. She stated staff were aware of residents' discharges and appointments by looking at the dashboard on the computer. In an interview on 07/13/2023 at 9:41 AM, Medical Records stated she had been hired for the Medical Records position about ten (10) months ago. She stated the Executive Director (ED) had made her aware yesterday (07/12/2023) a discharge summary was required to be completed when residents were discharged from the facility, which she had not know before. In an interview on 07/13/2023 at 9:57 AM, the Activity Director (AD) stated she had been the AD for five (5) months. She stated she had just learned this week that activities had a section to complete on the residents' discharge summary and she would be trained on what to do. The AD stated she had not completed discharge summaries on any resident that had been discharged from the facility. During interview on 07/13/2023 at 10:05 AM, the Dietary Manager (DM) stated she had not known until yesterday there was a section of the discharge summary she needed to complete. She further stated she had not completed a discharge summary on any resident who had been discharged from the facility. During interview on 07/13/2023 at 10:23 AM, the Director of Rehab (DOR) stated she had been at the facility for six (6) years. She stated therapy completed their own discharge summaries and she had never completed a discharge summary in the facility's Point Click Care (PCC) system. The DOR stated the ED made her aware on 07/12/2023, that the resident discharge summary had a section for therapy to complete. During an interview on 07/13/2023 at 11:08 AM, LPN #4 stated he was not aware a discharge summary needed to be completed when a resident discharged from the facility. He stated he went over residents' medications and gave them a copy of their medications and a copy went in their medical record. The LPN further stated he could not recall if he had the resident or representative sign the medication list. In an interview on 07/13/2023 at 12:14 PM, the Director of Nursing Services (DNS) stated she had been the DNS since May and was not aware that a discharge summary had to be completed for residents being discharged from the facility. She stated she reviewed the facility's policy and started education with the nurses on the discharge process. The DNS stated it was her expectation the facility's discharge process be followed as per its policy. She stated Physician's orders should be followed for home health, equipment, and any medications. The DNS further stated a progress note saying the resident had been discharged was also a required part of the discharge process. In an interview on 07/13/2023 at 12:35 PM, the Executive Director stated it was his expectation that staff complete the discharge summary at the time of discharge. 46651

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure a resident was not transferred or discharged while an appeal was pending with his/her insurance company for a continued length of stay in the facility for one (1) of twenty-nine (29) sampled residents (Resident #19). Resident #19 was issued a Notice of Medicare Non-Coverage (NOMNC) on 06/08/2023 indicating the date his/her expenses at the facility covered by insurance ended on 06/10/2023. Resident #19's daughter filed an appeal on 06/09/2023 on behalf of the resident with the insurance company and was waiting for notification of approval or denial. However, per Resident #19, on 06/14/2023 two (2) aides came into his/her room and began to pack up his/her belongings, telling the resident he/she was being discharged home after his/her doctor's appointment that morning. Resident #19 was transported to the appointment and then to his/her home where the resident called his/her daughter to tell her he/she had been discharged . Resident #19's daughter received a voice mail from the insurance company, after the resident was discharged home, which stated his/her appeal had been approved. The findings include: Review of the facility policy titled, Transfer and Discharge ., undated, revealed it was the facility's policy not to initiate transfer or discharge a resident from the facility except in limited circumstances. Continued review revealed when a resident exercised his/her right to appeal a transfer or discharge, the facility would not transfer or discharge the resident while the appeal was pending. In addition, review further revealed the facility would provide a transfer/discharge notice to the resident/representative and Ombudsman as indicated. Review of the closed record for Resident #19 revealed the facility admitted the resident on 05/18/2023, with diagnoses to include: Multiple Fractures of the Ribs, Left Side, Fracture of the Body of the Sternum and Traumatic Brain Injury. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #19 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Continued review of section Q0400 A, Discharge Plan, Is there an active discharge plan in place for the resident to return to the community, was answered, Yes. However, further review of Resident #19's electronic medical record (EMR) and Progress Notes dated 06/08/2023 through 06/13/2023, revealed no documented evidence of the resident's discharge or discussion with Resident #19 or his/her daughter regarding guidance for an appeal to his/her insurance for extended stay or the Notice of Medicare Non-Coverage (NOMNC). In a telephone interview on 07/10/2023 at 6:30 PM Resident #19 stated the Business Office Manager (BOM) came into his/her room after he/she had a discussion with the Executive Director (ED) about his/her insurance benefits running out. Resident #19 stated the BOM had him/her sign a piece of paper saying his/her last covered day of stay at the facility was 06/10/2023. The resident stated he/she did not understand there was deadline to file an appeal to be able to stay longer. Resident #19 stated he/she was not confident using the walker, especially since he/she could not use his/her right foot. The resident stated he/she had a doctor's appointment on the morning of 06/14/2023, and two (2) aides came into his/her room before the appointment and started packing up his/her belongings. Resident #19 stated when he/she asked the aides what they were doing, they told him/her they were packing the resident up because he/she was being discharged home right after the doctor's appointment. Per Resident #19, he/she asked if his/her daughter was aware of that information, and the aides told him/her they did not know. Resident #19 stated after the appointment the Transportation Aide (TA) took him/her home. The resident stated it took the TA and his/her grandson about forty (40) minutes to get him/her from the bus into the house because there were steps the resident could not manage with the non-weight bearing restriction to his/her right foot. Resident #19 stated the TA and her son had to use a shower chair to aid in getting the resident up the stairs to his/her home. The resident further stated the TA left the facility's wheelchair for him/her to use until his/her equipment could be delivered. In a telephone interview on 07/10/2023 at 6:30 PM, Resident #19's daughter/caregiver stated the resident had a discussion with the facility Executive Director (ED) on 06/08/2023, regarding his/her insurance benefits running out, with the last covered day being 06/10/2023, and the possibility of filing an appeal. The daughter stated at that time, Resident #19 told the ED he/she was anxious to go home, but wanted to run it by his/her daughter. Resident #19's daughter stated the ED told her Resident #19 could file an appeal with the insurance company; however, it was unlikely the appeal would be won. The daughter stated she had concerns Resident #19 was not ready for discharge and the ED told her he felt like the resident could use more therapy; however, had been told the insurance coverage had run out. Resident #19's daughter stated an appeal was filed directly through the insurance company at approximately 6:00 PM on 06/09/2023. The resident's daughter stated she had called the facility multiple times on 06/09/2023 and had to leave a message; however, no one from the facility called her back. Resident #19's daughter stated the resident had a doctor's appointment on the morning of 06/14/2023, and told her two (2) aides came into his/her room before the appointment and began to pack up his/her belongings. According to Resident #19's daughter, she did not know the resident was being discharged until he/she called her to say he/she had arrived home. She stated she had to leave work early and after she arrived home, a message had been left on her phone by the insurance company telling her Resident #19's appeal had been approved. In an interview on 07/11/2023 at 11:04 AM, the Transportation Aide (TA) stated the Executive Director (ED) told her he would end up eating the last few days of Resident #19's stay since the resident's daughter had not come to pick the resident up on 06/11/2023 as arranged. The TA stated the ED told her to transport Resident #19 directly home after he/she was finished at the doctor's office on the day of discharge. She stated she asked Registered Nurse (RN) #1 and the Director of Nursing Services (DNS) about Resident #19 being able to wait for the results of his/her appeal and was told they did not know anything about that. The TA stated she knew about the appeal because she had encouraged Resident #19 to file the appeal no matter what his/her insurance coverage was. She stated Resident #19 had told her the ED informed him/her that the resident and his/her daughter would not win the appeal. The TA stated she had concerns and did not feel like Resident #19 should have been discharged from the facility, had voiced her concerns to Registered Nurse (RN) #1, the DNS and the ED; however, the resident was discharged anyway. She further stated when they arrived at Resident #19's home they had to use a shower chair to get the resident up the stairs and into his/her house. In an additional interview on 07/12/2023 at 11:16 AM, the Transportation Aide (TA) stated Resident #19's daughter told her on 06/11/2023 they had filed an appeal. The TA stated she had told the ED on 06/12/2023 Resident #19's daughter had called her and told her they had filed an appeal. She stated on 06/14/2023 when she arrived to take Resident #19 to his/her doctor's appointment, the resident's bags were packed, and she was instructed by the ED to take Resident #19 home after the appointment. Review of a document from Resident #19's insurance company faxed to the facility dated 06/14/2023 at 1:20 PM, revealed the resident's appeal to the insurance company for coverage and extension of his/her stay at the facility had been approved from 06/11/2023 through 06/17/2023 or until a NOMNC had been issued. Review of the facility's Discharge Minimum Data Set ( MDS) Assessment for Resident #19 dated 06/14/2023, revealed the facility assessed the resident to have a BIMS score of thirteen (13) out of fifteen (15), indicating he/she continued to have no cognitive impairment. Review of Resident #19's Interdisciplinary Team (IDT) Care Plan Conference Summary (CPCS) document dated 06/13/2023, revealed the MDS Coordinator (MDSC) and the Social Services Director (SSD) were in attendance and Resident #19's daughter participated by phone. Further review of the CPCS document, Section H revealed Resident #19 was under appeal with his/her insurance at that time. In an interview on 07/12/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #2 stated that on 06/10/2023, she knew nothing about an appeal for Resident #19 until after she had spoken to the resident. LPN #2 stated she then called Resident #19's daughter and confirmed an appeal had been filed late that evening. She stated she called the manager on duty (MOD) which was the BOM and was told Resident #19 had filed an appeal; however, it was not the usual kind of appeal so the facility would wait to see what happened. The LPN stated the BOM informed her Resident #19's daughter was scheduled to pick the resident up from the facility on 06/11/2023. LPN #2 stated she was off work for a couple of days and when she returned, Resident #19 was no longer at the facility, so she assumed he/she had lost his/her appeal. The LPN further stated she knew if residents were in the active appeals process they could not be discharged until the appeal decision was made. In an interview on 07/12/2023 at 10:51 AM, the Social Services Director (SSD) stated she had worked at the facility in her current role for seven (7) years and did not understand why Resident #19 was discharged if the facility was aware the resident was in an appeal. She stated she would not have sent Resident #19 home and did not know who made the decision to send the resident home after his/her doctor's appointment, nor how the TA knew to take the resident home after the doctor's appointment, or who ordered Resident #19 to be sent home on the facility bus. The SSD stated she put in the order for Resident #19's wheelchair, bedside commode and a walker based on the order written by the Nurse Practitioner (NP) on 06/08/2023. She stated she did not speak to the nurse caring for Resident #19 the day he/she was discharged . The SSD stated she did not have a process for following up with a resident or their family after discharge to ensure they had all they needed for the resident at home; however, she would start having such a process now. In an interview on 07/11/2023 at 4:29 PM, the Director of Nursing Services (DNS) stated she had been functioning at the facility on an as needed basis for a couple of months, and then took the DNS position on 05/15/2023. The DNS stated she was not involved in the discharge of Resident #19; however, knew any resident in the process of an appeal was not to be discharged from the facility until the appeal decision had been made. In an interview on 07/12/2023 at 4:10 PM, with the Executive Director (ED) and the Regional Nurse Consultant (RNC), the ED stated he had multiple conversations with Resident #19 about an appeal and the resident stated he/she would think about it and speak to his/her daughter. The ED stated the BOM told him on Sunday, 06/11/2023 Resident #19's daughter had filed an appeal and the facility was looking in a Peer Review Organization system (a healthcare management system which assists individuals to remain in the community of their choice) for evidence of a filed appeal and had not seen one. The ED stated if an appeal was filed it was usually through a Peer Review Organization (as it also aided health systems and insurers to manage the care of patients after discharge to keep them from returning to the hospital) and if Resident #19's daughter had filed an appeal the facility was unaware. The ED denied calling Resident #19's daughter to ask where she had filed the appeal. The ED further stated the facility offered to return Resident #19 to the facility on [DATE] for further therapy and the resident declined to do so. 46651 Surveyor: [NAME], [NAME]

Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement an effective discharge planning process which focused on the resident's discharge goals, the preparation of the resident to be an active partner and effectively transition him/her to post-discharge care for one (1) of eleven (11) sampled residents (Resident #19). Resident #19 had a non-weight bearing status to his/her right foot. The facility discharged Resident #19 on 06/14/2023, with that status and without notifying the resident or his/her daughter he/she was being discharged on that day. The facility failed to provide Resident #19 and his/her daughter with any discharge documentation, any information about home health services, assistive devices/equipment, about the resident's medications or how to obtain necessary items/services the resident might require. The findings include: Review of the facility policy titled, Transfer and Discharge, undated, revealed it was the facility's policy to permit each resident to remain in the facility, and not to initiate transfer or discharge of the resident from the facility, except in limited circumstances. Review of closed record for Resident #19 revealed the facility admitted him/her on 05/18/2023, with diagnoses to include: Fracture of the Body of the Sternum; Multiple Fractures of the Ribs, Left Side; and Traumatic Brain Injury. Review of Resident #19's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating he/she was cognitively intact. Continued review of the MDS, section G, revealed the facility assessed Resident #19 as being totally dependent for locomotion; extensive assist for dressing; and as not being able to move from a seated to a standing position without staff assistance for stability; and as not being able to transfer between bed and chair or wheelchair without staff assistance for stability. Review of the discharge order documented by the Nurse Practitioner (NP) dated 06/08/2023 at 2:30 PM, revealed orders for the resident to be discharged from the facility to home with Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat as indicated. Continued review revealed orders noting Resident #19 needed a wheelchair for mobility related to fractures, might take up to thirty (30) Gabapentin (medication used to treat nerve pain) and thirty (30) Oxycodone (narcotic pain medication) home with him/her, might take his/her insulin home with him/her, and all other medications were to be e-scribed (electronically prescribed) to the resident's pharmacy of choice. Continued review of Resident #19's closed medical record to include the electronic medical record (EMR) and Progress Notes dated 06/08/2023 and 06/09/2023 revealed no documented evidence the facility had discussed the resident's discharge with him/her or his/her daughter, or had provided guidance for an appeal or information about the Notice of Medicare Non-Coverage (NOMNC). Further review of Resident #19's closed medical record revealed the Interdisciplinary Team (IDT) Care Plan Conference Summary (CPCS) document dated 06/13/2023, which noted the MDS Coordinator, and Social Services Director (SSD) were in attendance, with Resident #19's daughter participating by phone. Continued review of the CPCS document, Section H revealed Resident #19 was under appeal with his/her insurance at that time. Review of the CPCS document, Section I revealed Resident #19's daughter was noted to have expressed concern regarding the resident's returning home too early and being unable to care for himself/herself. Review of Resident #19's Discharge MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of thirteen (13) indicating he/she was cognitively intact. In an interview on 07/10/2023 at 6:35 PM, Resident #19 stated he felt pushed to be discharged and did not feel confident using his/her walker. Resident #19 stated he/she had no opportunity to object to the discharge. The resident further stated the nurse that discharged him/her told him/her he/she would receive his/her discharge papers in the mail. In an interview on 07/10/2023 at 6:35 PM, Resident #19's daughter stated neither she nor the resident felt like the resident was ready for discharge. Resident #19's daughter stated she did not feel like there had been any Interdisciplinary Team (IDT) approach to her parent's discharge and she did not feel like they had been included in the discharge process. She stated she did not know Resident #19 was being discharged until she got a text from him/her stating he/she was home after the doctor's appointment on 06/14/2023. The daughter stated she had to leave work to go home and meet Resident #19 and had tried to call the facility immediately; however, got no answer. Resident #19's daughter stated they had no opportunity to object to the discharge. She stated she called the facility on Thursday 06/15/2023, Friday 06/16/2023, and Monday 06/19/2023 to obtain some discharge instructions; however, was not able to reach anyone. The daughter stated the phone just rang and rang and was never answered. In an interview on 07/12/2023 at 11:16 AM, the Transportation Aide (TA) stated she had concerns about Resident #19 not being ready to discharge home and had voiced them to the facility's Executive Director (ED) and to the nurse that discharged the resident. She stated being responsible for the transport of residents to and from appointments gave her the opportunity to experience how well residents transferred to and from the bed to the wheelchair and from the wheelchair to the vehicle. The TA stated as Resident #19 was nonweight bearing to his/her right foot/ankle, there had been some issues with his/her stability and with his/her ability to stand and pivot. She stated after transporting Resident #19 from his/her doctor's appointment to his/her home, and assisting the resident from the vehicle had been difficult as the resident had to get up two (2) stairs to get into his/her house. The TA stated it took forty (40) minutes for her and Resident 19's eighteen (18) year old grandson to get the resident from the transportation bus into his/her house. She further stated Resident #19 became tired and had to stop and rest and she and the grandson had to utilize a shower chair for support to get the resident up the stairs into his/her house. In an interview on 07/11/2023 at 1:59 PM, Registered Nurse (RN) #1 stated she had only been employed at the facility for two (2) months, and stated she did not recall Resident #19's discharge. She stated the Social Services Director (SSD) set all a resident's discharge process up. RN #1 stated when Resident #19 was discharged a medication reconciliation should have been done and been documented in the resident's chart. She stated copies of the medication reconciliation and the discharge summary should have been signed by Resident #19 and copies scanned or uploaded into the resident's EMR. RN #1 stated when a resident was discharged , she usually made a progress note in the resident's medical record when the resident left the building. She further stated however, she was not familiar with the discharge processes at this facility. In an interview on 07/12/2023 at 10:21 AM, the Social Services Director (SSD) stated she put the order in for Resident #19's discharge with his/her needed equipment; however, had not spoken to the nurse caring for Resident #19 the day he/she was discharged . She stated usually discharges and appointments were placed on the dashboard/home screen of the computer for staff to see. The SSD stated she did not have a process in place for follow up with residents, but was starting a process now. She stated Resident #19 should have been sent home with all his/her equipment ready to be delivered and in place, with his/her home health services confirmed as in place, and with prescriptions for his/her medications either in hand or e-scribed (electronically prescribed) to the pharmacy of his/her choice. In an interview on 07/11/2023 at 4:29 PM, the Director of Nursing Services (DNS) stated she had been functioning at the facility on an as needed basis for a couple of months and had taken the DNS position on 05/15/2023. She stated she was still learning the facility's discharge process and discharge planning process. The DNS stated right now she pitched in and called in medications as needed, and knew discharge orders should be written and a discharge summary with medication list should go home with each resident. She stated she was not sure about the home health referrals for residents discharging home. The DNS stated she had not been involved in Resident #19's discharge; however, stated the resident should have been provided with a discharge summary. She stated Resident #19 should also have been provided a list of medications as well as instructions for his/her home health equipment and services needed before leaving the facility, and his/her daughter should have been made aware the resident was being transported home. The DNS stated the SSD was responsible for all the discharge planning for residents. She stated she was not aware of any follow up phone calls made to Resident #19, or who would be responsible for doing such phone calls after a resident was discharged to follow up with the resident to make sure the resident had everything they needed. The DNS stated if there had been an active order to send Resident #19 home with medications, equipment, and home health services, she would have expected the resident to have been sent home with all those things. She stated the completion of the Discharge Summary was a team responsibility. The DNS stated she was not aware prior to the event involving Resident #19 the facility had a process failure and it had identified several other residents were also missing their discharge summaries. In an interview on 07/13/2023 at 12:35 PM, the Executive Director stated he was unaware that the discharge process was not being followed. He stated his expectation was that the facility policy be followed regarding the discharge planning and process.

Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident which described the resident's preferences and his/her potential for future discharge, and failed to develop appropriate discharge plans for three (3) of eleven (11) sampled residents (Residents #19, #20 and #21). The facility failed to develop and implement a care plan related to Resident #19's discharge goals and plans. Therefore, the facility discharged Resident #19 without providing notification to the resident and his/her daughter regarding the expected day and time of his/her discharge. In addition, the facility failed to provide Resident #19 and his/her daughter with information regarding discharge instructions such as follow up appointments, medications, how to obtain necessary medical equipment or home health services. The findings include: Review of the facility policy titled, Transfer and Discharge (including AMA), undated, revealed a comprehensive, person centered care plan was to contain a resident's goals for admission and desired outcomes and was to be in alignment with his/her discharge. 1. Review of the closed record for Resident #19 revealed the facility admitted the resident on 05/18/2023, with diagnoses to include: Traumatic Brain Injury, Multiple Fractures of the Ribs, Left Side, and Fracture of the Body of the Sternum. Continued review of the closed record revealed the facility discharged Resident #19 on 06/14/2023. Review of Resident #19's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating he/she was cognitively intact. Review of Resident #19's Comprehensive Care Plan dated 05/19/2023 revealed no documented evidence the facility developed or implemented a care plan related to the resident's discharge goals and plans. Therefore, review of Resident #19's medical record revealed the facility discharged the resident on 06/14/2023, with no documented evidence of the resident or his/her daughter being notified prior to being discharged on that day. Further record review revealed no documented evidence the facility provided Resident #19 and his/her daughter with: any discharge documentation; any information about home health services; assistive devices/equipment; information about the resident's medications; or how to obtain necessary items/services the resident might require. In an interview on 07/13/2023 at 11:28 AM, the MDS Coordinator stated on admission she thought Resident #19 was going to be a long-term resident of the facility and had initiated a long term stay care plan. The MDS Coordinator further stated Resident #19's care plan should have been updated and a discharge plan initiated for him/her. 2. Review of the closed record for Resident #20 revealed the facility admitted the resident on 05/12/2023, with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur; Personal History of other Malignant Neoplasm of Bronchus and Lung; and Type 2 Diabetes. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #20 to have a BIMS score of twelve (12) of fifteen (15) indicating the resident had moderate cognitive impairment. Continued review of the MDS, section Q0300, revealed Resident #20 expected to remain in the facility longterm. Review of Resident #20's Comprehensive Care Plan dated 05/12/2023, revealed no documented evidence the facility developed or implemented a care plan related to the resident's discharge goals and plans. 3. Review of the closed record for Resident #21 revealed the facility admitted the resident on 04/04/2023, with diagnoses which included Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD) and Unspecified B-Cell Lymphoma. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15) indicating Resident #21 was cognitively intact. Continued review of the MDS section Q0300, revealed Resident #21 expected to be discharged to the community. Review of Resident #21's Comprehensive Care Plan dated 04/04/2023, revealed the facility no documented evidence the facility developed and implemented a care plan related to resident's discharge goals and plans. In an interview on 07/13/2023 at 11:28 AM, the Minimum Data Set (MDS) Coordinator stated the baseline care plans were initiated either by her or the admitting nurse. She stated if it was not known what the residents' length of stay goals were, a long term stay care plan was initiated. The MDS Coordinator stated during the seventy-two (72) hour meeting if the resident's goals were to discharge to the community, then the care plan would be updated and revised to reflect that. In an interview on 07/13/2023 at 12:14 PM, the Director of Nursing Services (DNS) stated discharge care plans should be established on a resident's admission and updated and revised if a resident's goals changed. She stated the MDS nurse updated residents' care plans. The DNS further stated it was her expectation for all residents to have a discharge plan of care. In an interview on 07/13/2023 at 12:35 PM, the Executive Director stated it was his expectation that discharge care plans be developed on admission and revised if residents' goals changed. He further stated it was important that residents met their goals prior to being discharged . 46651

Based on interview, record review, and review of the Resident Assessment Instrument Manual, Version 3 it was determined the facility failed to develop and implement care plan interventions for three (3) of sixteen (16) sampled residents (Residents #3, #5, and #2). Residents #3 and #5's care plan interventions were not developed and implemented to prevent escalation of aggressive behaviors, resulting in resident-to-resident abuse. Resident #2 fell at home and was in the hospital prior to transfer to the facility on [DATE]. Resident #2 had a fall on the day of admission to the facility, 02/22/2022, which resulted in a fractured wrist. On 04/07/2022, the resident had a fall without injury. On 05/13/2022, the resident had a third fall which resulted in a fractured hip. Resident #2's care plan interventions were not developed and implemented to prevent additional falls. The findings include: During interview with the Executive Director (ED), on 05/03/2023 at 3:30 PM, he stated the facility did not have a dedicated care plan policy. However, he stated it was his expectation that the facility follow guidance from the Resident Assessment Instrument (RAI) Manual. Review of the RAI Manual Version 3.0, dated 10/2019, revealed the comprehensive care plan must include measurable objectives and time frames to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the care plan was expected to address to what extent the resident's behavior placed others at risk and to address underlying causes to reduce the frequency of problematic behaviors and to minimize resultant harm. 1. Review of Resident #3's Admission Record revealed the facility admitted the resident on 09/12/2017, with diagnoses that included Epilepsy, Severe Intellectual Disabilities, and Generalized Muscle Weakness. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 04/04/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15). This score indicated severe cognitive impairment; and the resident was not interviewable. Review of Resident #3's Care Plan, dated 04/13/2023, revealed the facility assessed the resident, on 09/12/2019, as having a history of aggression towards other residents. Interventions included: anticipating the resident's needs, analyzing triggers, documenting interventions that de-escalated the resident's behaviors, and intervening before behavior escalated. Review of the facility's Investigation Report, dated 04/12/2022, revealed on 04/06/2022, Residents #3 and #4 were sitting in the activity area, when Resident #3 hit Resident #4 on the jaw. Review of the facility's Investigation Report, dated 01/20/2023, revealed on 01/12/2023, State Registered Nurse Aide (SRNA) #10 witnessed Resident #3 swing his/her fist at Resident #5 in the hallway on the B Wing. Further review revealed staff immediately separated the residents and performed a skin assessment on Resident #5, which revealed a reddened area on the resident's cheek from the altercation with Resident #3. During interview with State Registered Nursing Assistant (SRNA) #4, on 05/03/2023 at 4:14 PM, she stated it was not possible to watch Resident #3 all the time. She stated this left periods of time where he/she could become agitated and hit another resident before staff could intervene. SRNA #4 stated this had happened on 04/06/2022 and 01/12/2023. Licensed Practical Nurse (LPN) #4, stated during interview on 05/03/2023 at 10:20 AM, that following the care plan was important because the care plan described which interventions were appropriate for each resident's unique needs. She stated the intervention of providing Resident #3 with headphones to listen to music should be included on the care plan because it was highly effective for calming the resident during periods of agitation. During interview with the MDS Nurse, on 05/05/2023 at 9:12 AM, she stated she should have included providing Resident #3 with a wallet and listening to music with headphones on his/her care plan because those were effective interventions for preventing agitation and aggression for him/her. She stated if Resident #3 was not in his/her room, staff encouraged him/her to be the hall monitor near the nurses' station, which promoted Resident #3's self-esteem and allowed staff to monitor his/her behavior. She also stated it removed Resident #3 from a situation that caused agitation. The MDS Nurse stated the care plan was an important tool for communicating the care each resident needed to achieve his/her best outcome. 2. Review of Resident #5's Admission Record revealed the facility admitted the resident on 11/24/2022 with diagnoses which included Acute Kidney Failure, Encephalopathy, and History of Urinary Tract Infections. Review of Resident #5's Quarterly MDS Assessment, dated 02/28/2023, revealed the facility assessed the resident with a BIMS' score of two (2) of fifteen (15) which indicated severe cognitive impairment. Review of Resident #5's Care Plan, dated 03/06/2023, revealed on 01/05/2023, the facility assessed Resident #5 as displaying aggression towards staff and displaying unspecified verbal and physical behaviors toward other residents. Further review revealed care plan interventions included: approach the resident in a calm and friendly manner, allow the resident to express his/her feelings, and postpone care or activity if the resident became combative. Review of the facility's Investigation Report, dated 04/14/2023, revealed on 04/07/2023, Resident #5 was going through Resident #6's personal belongings; they were roommates. Further review revealed Resident #6 used areacher (a type of adaptive equipment to help residents pick up objects). Resident #5 took the reacher and used it to hit Resident #6 on top of his/her head. The altercation resulted in small skin tears on top of Resident #6's head and right arm. Continued review revealed Resident #5 was moved to a private room on a different hallway from Resident #6. Resident #5 was placed on fifteen (15) minute checks. SRNA #4, stated during interview, on 05/03/2023 at 4:14 PM, that Resident #5 had care plan interventions for wandering and behaviors, but the interventions were not effective, particularly late in the afternoon when the resident's dementia symptoms became worse. She further stated the resident was not re-directable, and it was not possible to provide the level of supervision necessary to prevent the resident from agitating other residents. During interview with Registered Nurse (RN) #4, on 05/04/2023 at 4:08 PM, she stated she worked with Resident #5, and the resident was difficult to redirect as described in the care plan. She further stated it was impossible to provide Resident #5 with adequate supervision while caring for other residents. RN #4 stated she told the former DNS about the lack of supervision of Resident #5, and the former DNS told her to just do your best. The Executive Director (ED), stated during interview on 05/04/2023 at 3:30 PM, that it was his expectation that relevant interventions be added to the care plan after a resident-to-resident altercation. 3. Review of Resident #2's clinical record revealed the facility admitted the resident on 02/22/2022 with diagnoses of Dementia, Hip Fracture, and Sleep Disorders. The facility transferred Resident #2 to the hospital after the fall, on 02/22/2022. The hospital diagnosed the resident with a fractured wrist. The facility readmitted Resident #2 on 02/23/2022. Review of Resident #2's Admission MDS Assessment, completed on 03/02/2022, revealed a BIMS' examination was conducted. The facility assessed the resident to have a score of four (4) of fifteen (15) which indicated the resident was not interviewable and had severe cognitive impairment. Review of Resident #2's Admission Comprehensive Care Plan revealed a plan was developed on 02/22/2022 with updated goals on 05/16/2022 and a target date for 09/09/2022. The problem stated the resident was at risk for falls. The goal stated the resident would have reduced risk for falls and fall injury. The approaches directed the staff to monitor for changes in functional status and environmental and situational hazards daily to ensure a safe environment was provided. Review of Resident #2's record revealed the resident had an unwitnessed fall on the day of admission, 02/22/2022. Resident #2 was found in his/her room on the floor beside the door, holding his/her left wrist. Further review revealed the resident had been ambulating without assistance. Upon assessment, a small skin tear was noted to the resident's left eyebrow. The facility sent the resident to the hospital for an overnight stay. The resident was diagnosed with a fractured left wrist. Further review revealed predisposing situation factors were the resident was admitted within the last seventy-two (72) hours and was ambulating without assistance. Review of Resident #2's care plan revealed it was not developed to address the resident ambulating without assistance. Record review revealed Resident #2 suffered a second fall, which was witnessed, on 04/07/2022. Review of the 04/07/2022 Fall Note revealed Licensed Practical Nurse (LPN) #6 was called to the room by the resident's roommate. The resident was on the floor, confused and unable to explain what happened, and just said, I'm all right. Resident #2 denied any pain and was assessed for injuries; no injuries were found. Per the record, the root cause analysis determined that the resident was ambulating without assistance. Review of Resident #2's care plan revealed again it was not developed to address the resident being up without assistance, even though this was identified as a predisposing factor for the first and second fall. Continued review of Resident #2's record revealed the resident had a third fall on 05/13/2022. Resident #2's roommate, Resident #10, called out to the nurse. Resident #2 stated he/she was going to the bathroom. The resident was sent to the hospital and was admitted with a fractured left hip and had it surgically repaired. Resident #2 was discharged from the hospital to the facility on [DATE]. Review of Resident #2's care plan revealed on 05/20/2022, care plan approaches were revised, and a bed and chair alarm were placed to notify staff if the resident got up without assistance. In addition, hourly checks were started. SRNA #12, stated during interview on 05/04/2023 at 2:31 PM, that if she noticed a change in a resident's behavior she notified the nurse and completed a Stop and Watch form which detailed the change in the resident. During interview with the Social Service Director/Admission Coordinator (SSD/AC), on 05/05/2023 at 8:31 AM, she stated the Admission Liaison (AL) went to the hospital prior to admission and evaluated all the residents. She stated the AL then discussed the resident with the Case Manager and the Director of Nursing Services (DNS). The SSD/AC stated she and the MDS Coordinator set up the seventy-two (72) hour care plan. She stated the MDS Coordinator went over the hospital Discharge Summary and then went over the care plan with the DNS and the nurse accepting the resident. The MDS Coordinator, stated during interview, on 05/05/2023 at 9:19 AM, that her role during the admission process was to receive the information about the resident prior to admission. She stated she reviewed the discharge summary; and it was emailed to everyone. She stated she reviewed the summary and set up the admission and five (5) day assessment. The MDS Coordinator stated, when the nurse did the evaluation the baseline care plan was there. She stated, on the baseline care plan there was an evaluation that needed to be completed in forty-eight (48) hours. Further, she stated she assured the care plan was person centered by getting to know the resident and the family. The MDS Coordinator stated for a resident who had dementia and was a fall risk, she implemented interventions to prevent falls with the dementia in consideration. She stated she assessed almost all residents for an increased risk for falls due to their new environment. The MDS Coordinator stated she might care plan for increased supervision if needed. However, the facility did not admit residents who required a staff member to be with them at all times. Additionally, she stated staff would revise the care plan if a resident fell and had a fracture in an attempt to prevent another fall. She stated the MDS Coordinator was part of the Interdisciplinary Team (IDT), and the IDT had a meeting after each fall. She stated the IDT updated the care plan with interventions that were specific to the resident. During interview with the Interim Director of Nursing Services (DNS), on 05/04/2023 at 3:27 PM, she stated her expectation for staff, if a resident was admitted with a known fall history, was to do a full assessment and implement appropriate interventions. Further, she stated she expected staff to follow the recommendations from the hospital discharge summary. The DNS stated, if a resident had a fall in the facility, staff did a full evaluation to determine the root cause. She stated each fall was discussed the next morning, and the IDT determined the most appropriate interventions. The DNS stated it was her expectation for staff to follow care plans because they described the appropriate, person-centered care each resident needed. The ED stated during interview, on 05/04/2023 at 2:16 PM and 3:30 PM, that the IDT met the following day after each fall. He stated the IDT looked at the predisposing, environmental, and physiological factors that might have contributed to the fall. The ED stated the IDT determined the most appropriate interventions to prevent further falls. He further that it was his expectation for staff to follow the care plans.

Based on observation, interview, record review, review of the facility's investigative reports, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents received supervision to prevent accidents for one (1) of six (6) sampled residents (Resident #2). The facility admitted Resident #2 with a history of falls. Resident #2 had a fall at home and in the hospital before his/her admission to the facility. Resident #2 had a fall on 02/22/2022, the day of admission to the facility, when staff left him/her alone in his/her room. This fall resulted in a fractured wrist. On 04/07/2022, the resident had a fall without injury. On 05/13/2022, the resident had a third fall which resulted in a fractured hip. The findings include: Review of the facility's policy titled, Fall Management, dated 10/2019, revised 01/2023, revealed a resident's fall risk would be assessed upon admission, quarterly, and with a significant change. In addition, a resident's care plan would be developed at the time of admission with specific care plan interventions to address each resident's fall risk factors. Per the policy, post fall, any resident experiencing a fall would be assessed immediately by the charge nurse for possible injuries and necessary treatment would be provided. Further review of the policy, revealed all falls would be discussed by the Interdisciplinary Team (IDT) at the first IDT meeting. Review of Resident #2's clinical record revealed the facility admitted the resident on 02/22/2022 with diagnoses of Dementia, Hip Fracture, and Sleep Disorders. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, completed on 06/02/2022, revealed a Brief Interview for Mental Status (BIMS) examination was conducted. The facility assessed the resident to have a score of four (4) of fifteen (15). This score indicated the resident had severe cognitive impairment and was not interviewable. Review of Resident #2's Comprehensive Care Plan revealed a plan was started on 02/22/2022 with updated goals on 05/16/2022 and a target date for 09/09/2022. The problem stated the resident was at risk for falls. The goal stated the resident would have reduced risk for falls and fall injuries. The approaches directed the staff to monitor for changes in functional status and environmental and situational hazards daily to ensure a safe environment was provided. Review of a Nursing Note, dated 02/22/2022 at 6:33 PM, revealed Resident #2's roommate alerted staff that Resident #2 was on the floor in his/her room. Review of the facility's Investigative Report, dated 02/22/2022 at 6:30 PM, revealed Resident #2's fall was not witnessed. Continued review revealed Resident #2 was found in his/her room on the floor beside the door, holding his/her left wrist. Upon assessment, a small skin tear was noted to his/her left eyebrow, and the left wrist appeared curved with a raised area on top and a small skin tear to the lateral side of his/her wrist. Per the report, Resident #2 stated, I hit my head and hurt my wrist. When the nurse asked the resident why he/she was walking without assistance, the resident stated, I'm getting out of here and going home. Further review revealed the resident had a numerical pain score of ten (10) the highest pain level, was alert, and was able to ambulate with assistance. The report revealed there were no predisposing environmental factors. The predisposing physiological factors were that the resident was confused, had a gait imbalance, and impaired memory. Predisposing situation factors revealed the resident was admitted within the last seventy-two (72) hours and was ambulating without assistance. Continued review of Resident #2's medical record revealed the resident had a second fall on 04/07/2022. Review of the Investigative Report, dated 04/07/2022 at 9:15 PM, revealed the resident's roommate called the nurse into their room. The resident was lying in the doorway of the room on his/her left side. Resident #2 denied any pain and was assessed with no injuries. The resident was oriented to person only. Per the report, there were no predisposing environmental factors. The predisposing physiological factors were that the resident was confused, incontinent, and had a gait imbalance and impaired memory. The root cause analysis determined that the resident was ambulating without assistance. Review of Resident #2's care plan revealed no new interventions were developed to address the root cause of the first and second fall: the resident was up and ambulating without assistance. Continued review of Resident #2's medical record revealed the resident experienced a third fall on 05/13/2022. The Investigative Report, dated 05/13/2022 at 8:30 AM, revealed Resident #2's roommate called out to the nurse. The nurse found Resident #2 sitting on the floor. Resident #2 stated he/she was going to the bathroom, and the resident was holding his/her left hip. The facility transferred Resident #2 to the emergency room . Resident #2 was diagnosed with a left hip fracture, and was admitted to the hospital. Per the record, Resident #2 had an Open Reduction and Internal Fixation of the left femur (broken bones surgically repaired) on 05/13/2022. Per the record, Resident #2 was discharged back to the facility on [DATE]. Review of Resident #2's care plan revealed on 05/20/2022, his/her care plan approaches were further developed, and a bed and chair alarm were placed to alert staff when the resident got out of bed or out of the chair without assistance. In addition, hourly checks were started. During interview with State Registered Nursing Assistant (SRNA) #12, on 05/04/2023 at 2:31 PM, she stated if she noticed a change in a resident's behavior she notified the nurse and got a Stop and Watch form (a document that listed the resident's behaviors). She stated the form was completed and put in the Director of Nursing Services' (DNS) mailbox. SRNA #12 stated she found the daily needs of the resident by looking at the care plan. SRNA #5, stated during interview on 05/04/2023 at 2:37 PM, that she reported to the nurse if she saw a resident acting differently or having a decline in transferring. She stated she learned about the resident's needs by looking at the care plan. Licensed Practical Nurse (LPN) #4, stated during interview, on 05/04/2023 at 2:41 PM, if she noticed a change in a resident's condition she evaluated the resident. She stated there was an evaluation program to use to evaluate the resident. LPN #4 stated there was also a fall's program to evaluate the resident, which was under risk management. She stated she learned what the resident's care needs were by looking at the care plan because it detailed how the resident transferred, along with all his/her needs. The Interim Director of Nursing Services (DNS), stated during interview, on 05/04/2023 at 3:27 PM, she expected the nurse to do a full assessment after each fall. Further, she stated she expected the nurse to follow all instructions in a hospital discharge summary if a resident was admitted to the hospital after a fall. She stated the nurse implemented appropriate interventions in the care plan based on the assessment. The DNS stated the Discharge Summary usually did not recommend that a staff member be with the resident at all times, but if this was in the Discharge Summary, she would follow the recommendations. She stated her process to prevent falls was to investigate what caused the falls. The DNS stated, after a fall, she would usually put a fall mat on the floor, do more frequent rounds, and follow the care plan that had interventions that were specific to the resident. She stated some interventions might be to redirect, interact with the resident, and involve the resident in an activity they enjoyed. The DNS stated she expected the nurse to notify the provider first, and then family, the DNS, and the ED after any fall. She stated, to prevent falls, she made a copy of the root cause of a fall and put it at each nurses' station. During interview with the Social Service Director/Admission Coordinator (SSD/AC), on 05/05/2023 at 8:31 AM, she stated the Admission Liaison (AL) went to the hospital and evaluated all the residents who were admitted to the facility. She stated the AL then discussed the resident with the Case Manager, the DNS, and Business Office staff. Further, part of the AL's task was going over the admission packet with the family and the resident. The SSD/AC stated she and the MDS Coordinator set up the seventy-two (72) hour care plan. She stated, when a resident came to her with a fracture for rehabilitation, staff tried to put the resident close to the nurses' station. She stated the MDS Coordinator went over the Discharge Summary and then went over the care plan with the DNS and the nurse accepting the resident. The SSD/AC stated the MDS Coordinator, DNS, and the nurse accepting the resident went over every new admission. Further interview revealed the SSD/AC knew Resident #2. She stated Resident #2 was at the nurses' station most of the time, and liked to work on puzzles. During a telephone interview with the Corporate Central Intake Director, on 05/05/2023 at 9:01 AM, she stated she received resident information from the hospital through a phone call or the hospital referral process. She stated, after she received the information, the AL looked at the resident and gave the resident a red, yellow, or green score. The Corporate Central Intake Director stated green indicated the resident was clinically approved; red meant the facility was not going to admit the resident for some reason; and yellow meant the facility had to investigate further prior to admission. She stated she remembered Resident #2 because the daughters toured the facility more than once, and Resident #2 was green and was accepted for admission. The Corporate Central Intake Director stated she would not do anything differently than the facility did for admitting a resident with a history of falls. She stated she recognized the importance of implementing interventions for a resident who had previous falls. During the interview, she stated she sent detailed information to the facility about a resident who had experienced a fall. She stated the facility implemented appropriate interventions, such as putting a low bed in the room against the wall, with a mat placed at the side of the bed. During the telephone interview with the Corporate Admission Coordinator, on 05/05/2023 at 9:02 AM, she stated she was an LPN. She stated she checked for insurance and looked at the paperwork; and then gave the resident a green, yellow, or red sign for admission. She stated the process for a resident who was a fall risk was in the green area. The Corporate Admission Coordinator stated, if a resident required a staff member to be with them at all times, the resident would be classified as red. She stated the facility could not accept a resident who required a staff member to be with him/her at all times. The MDS Coordinator, in an interview on 05/05/2023 at 9:19 AM, stated her role during the admission process was to receive the information about the resident prior to admission. She stated she reviewed the discharge summary; and, emailed it to everyone. The MDS Coordinator stated she reviewed it and started the admission and set up the five (5) day assessments. She stated, when the nurse did the evaluation, the baseline care plan was developed. The Coordinator stated on the baseline care plan, there was an evaluation that needed to be completed in forty-eight (48) hours. She stated, for a resident who had dementia and was a fall risk, she developed and implemented interventions to prevent falls with the dementia in consideration. The Coordinator stated she assessed almost all residents for an increased risk for falls due to the new environment they were in. The MDS Coordinator stated she might care plan for increased supervision if needed, but she would not put that resident with a staff member present at all times. She stated the facility did not admit a resident who required a staff member to be with the resident at all times. Additionally, she stated staff would revise the care plan if a resident fell and had a fracture in an attempt to prevent another fall. Further interview revealed the MDS Coordinator was part of the Interdisciplinary Team (IDT), who had a meeting after each resident fall. She stated, at this meeting, the IDT, which consisted of the Executive Director, DNS, MDS Coordinator, Social Services Director, Activities Director, and staff nurse, updated the care plan with interventions that were specific to the resident. During the interview with LPN #4, on 05/05/2023 at 9:49 AM, she stated the care plan for new admissions was person centered by getting to know the resident. She stated, when she got an admission, she always asked in report if the resident had fallen and tried to implement interventions that would prevent the resident from having another fall. She stated, for new admissions, staff educated the resident to ask for assistance prior to getting up. LPN #4 stated, if she had concerns about a resident falling, she monitored the resident every fifteen (15) minutes during her shift. She stated she made sure the call light was in reach and alerted the nursing assistant if the resident was at risk for falls. She stated, if a resident continued to try to get up without assistance, the resident was moved close to the nurses' station. The LPN stated there was a program in the computer to document what happened after a fall: what the resident said and other specific items about the environment. She stated this program alerted the DNS and the ED about the fall, and the IDT had a meeting about the fall the next day. LPN #4 stated, after a fall, either she or the MDS Coordinator updated the resident's care plan. Interview with the former DNS, who was present at the time of the falls, was attempted on 05/03/2023 at 11:57 AM and 12:00 PM and on 05/04/2023 at 1:35 PM. These attempts were unsuccessful. A voice message was left requesting a return call, but no call was received. The ED, in an interview on 05/04/2023 at 2:16 PM, stated he received notification by the Fall's Program Note, dated 02/22/2022 at 6:30 PM, that Resident #2 had fallen. He stated the note addressed finding the resident on the floor. The ED stated the resident was taken to the hospital and had an injury to the left wrist. He stated the resident was alert and oriented to person. During continued interview the ED stated the IDT looked at the predisposing environmental factors and found none. He stated the IDT looked at the physiological factors and found the resident was confused, had a gait imbalance, and had impaired memory. The ED stated the IDT evaluated the predisposing factors and found the resident was admitted within the last seventy-two (72) hours and was ambulating without assistance. He stated the IDT looked for witnesses, but there were none. The ED further stated he was a member of the IDT. He stated, after each fall, the IDT reviewed the factors that contributed to the fall, and developed interventions to prevent further falls.

Based on interview, record review, review of the facility's Job Description, and review of the facility's policies, it was determined the facility failed to ensure the resident's Advanced Practice Registered Nurse (APRN) #1 reviewed the resident's total program of care, including medications and treatments at each visit for one (1) of four (4) sampled residents (Resident #1). On [DATE] at approximately 2:30 PM, the facility admitted Resident #1 from an acute care facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital's Infectious Disease (ID) Specialist ordered the resident to have the antibiotic [MEDICATION(S)], six hundred (600) milligrams (mg) every twelve (12) hours to treat the infection, and continue it through [DATE]. Based on documentation in the medical record, APRN #1 did not follow through with continuing the ID Specialist's antibiotic ([MEDICATION(S)]) order. The APRN discontinued the [MEDICATION(S)] without documenting a clinical rationale or addressing the resident's total program of care related to the UTI. On [DATE], APRN #1 performed a telehealth visit with Resident #1. Review of the visit notes revealed APRN #1 acknowledged the resident's UTI with MRSA. However, there was no documented evidence APRN #1 reviewed the resident's current list of medications, as she only documented to see the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . APRN #1 failed to include [MEDICATION(S)] in the current plan as related to the UTI. On [DATE], Resident #1's daughter inquired about Resident #1 receiving the ordered antibiotic for the UTI and was informed Resident #1 was not receiving the medication. The facility contacted the Medical Director (MD) who ordered an in-and-out catheterization to obtain the specimen and re-ordered [MEDICATION(S)], along with two (2) other antibiotics. However, by then, Resident #1 had missed eleven (11) doses of [MEDICATION(S)]. On [DATE], Resident #1 exhibited vomiting, complaints of shortness of air, and chilling; Resident #1 was sent to the hospital. Review of Resident #1's Hospital Discharge Summary, revealed Resident #1 expired, on [DATE], and the cause of death was listed as UTI, Ischemic [CONDITION(S)], Lactic Acidosis, and Acute Kidney Injury. The facility's failure to ensure Resident #1's Physician/APRN reviewed the resident's total program of care, including medications and treatments, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE], at 42 CFR §483.30 (b) Physicians Visits (F711). The facility was notified of the Immediate Jeopardy on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE], alleging removal of the Immediate Jeopardy, and to be in substantial compliance, on [DATE]. The State Survey Agency validated the AoC, on [DATE], and determined the facility implemented corrective actions and was in compliance on [DATE], as alleged, prior to the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's Advanced Practice Registered Nurse (APRN) Job Description, undated, revealed a nurse practitioner provided primary and specialty healthcare, and like a Physician, he or she assessed and diagnosed patients; ordered laboratory tests, prescribed medications, and managed health conditions. The job description stated as primary healthcare providers, nurse practitioners helped patients maintain good health and treated their illnesses. In addition, this required taking into account their health histories and any symptoms they were experiencing. Per the job description, responsibilities included reviewing medical histories, hospital discharge summaries, and other electronic medical record (EMR) documents to effectively develop a plan of care and coordinate with Physicians. Furthermore, it stated providers would coordinate with the Physician when seeing acute care and new admissions. Review of the facility's policy titled, Attending Physician Responsibilities, revised [DATE], revealed the Attending Physician would seek, provide, and analyze information regarding a resident's status, recent history, and medications and treatments to enable safe, effective continuing care and to support the facility's compliance with regulations and care standards. In addition, it stated the Attending Physician or a covering practitioner would authorize timely admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per policy, based on the results, the Physician would explain the medical rationale for subsequent interventions or decisions not to intervene, especially when the basis was not readily apparent. Further review of the policy revealed the Physician would periodically review all medications prescribed for his/her patients and would monitor for continuing indications and for possible adverse drug reactions. Review of the facility's policy titled, Medication Therapy Policy, dated 2001 and revised 2007, revealed each medication regimen would include only those medications necessary to treat existing conditions and address significant risks. It stated medication use would be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. In addition, appropriate care processes and practices would support all medication orders. Per policy, upon or shortly after admission, and periodically after that, staff and practitioner (assisted by the Consultant Pharmacist) would review an individual's current medication regimen to identify whether a) there was a clear indication for treating that individual with the medication; b) the dosage was appropriate; c) the frequency of administration and duration of use was appropriate; and d) potential or suspected side effects were present. Review of Resident #1's closed medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Baseline Care Plan, initiated [DATE], revealed a focus of improving functional status and a goal of returning to the community. There was an additional focus of being at risk for complications related to medical conditions, medications and treatments. Further review revealed the goal stated the resident would be free from adverse effects of medications and treatments. In addition, care plan interventions included to document abnormal findings, labs as ordered, medications and treatments per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Five (5) day Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility, transfer, and toileting. Continued review of the assessment revealed the facility assessed the resident as requiring extensive assistance of two (2) or more persons for personal hygiene and dressing. Further review revealed the MDS assessed the resident as always incontinent of urine and frequently incontinent of bowel. Review of Resident #1's Hospital Discharge Summary, dated [DATE] at 12:14 PM, revealed a laboratory culture and sensitivity report of a catheterized urine specimen collected, on [DATE], and reported, on [DATE], was positive for, or grew, Staphylococcus Aureus resistant to [MEDICATION(S)] (MRSA). Continued review of the Hospital Discharge Summary revealed Resident #1 had a urinary tract infection (UTI) present on admission to the hospital and was seen by an Infectious Disease Specialist and a Consultant Urologist, with a plan to continue [MEDICATION(S)] orally, through [DATE]. Further review revealed the resident would then follow-up with the Infectious Disease Specialist, in a clinic setting. Review of the Discharge Summary revealed a list of medications Resident #1 was to continue taking, but [MEDICATION(S)] was not listed as one of those medications. However, in the body of the Discharge Summary, it stated to continue [MEDICATION(S)] for MRSA in the urine, but the dosage, frequency, and stop date was not stated. Interview with the Director of Nursing (DON), on [DATE] at 5:16 PM, revealed she did not know why the Discharge Summary did not list [MEDICATION(S)] with all the other medications. She stated staff should have discussed with APRN #1 the drug dosage and frequency. The DON stated there should have been a complete order given from the APRN, including medication, dosage, frequency, and stop date. Approximately thirty (30) to forty (40) minutes later, the DON presented the State Survey Agency Surveyor a page of the Hospital Discharge Summary that had not been scanned into the medical record. This page contained the order for [MEDICATION(S)] 600 mg every twelve (12) hours. The DON stated this page perhaps was left out of the discharge summary when scanned into the medical record. Review of the Admission Assessment performed via telehealth by APRN #1, on [DATE], and electronically signed, on [DATE], revealed APRN #1 acknowledged the resident's UTI with MRSA. However, there was no documented evidence APRN #1 reviewed the current medications. The APRN documented to see the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed APRN #1 failed to include the [MEDICATION(S)] in the resident's current plan as related to the UTI. Review of Resident #1's admission medication orders hand written on a three-part admission form titled admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed there was no stop date indicated on the order. Review of Resident #1's admission medication orders, entered electronically into the medical record on [DATE] at 2:30 PM, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. Further review revealed Pharmacy requested an order clarification, on [DATE], informing the facility the maximum daily dose was two (2) tablets, and every shift interpretation by Pharmacy was three times a day (three (3) tablets per day), not every twelve hours (two (2) tablets per day) as the order was intended. In addition, a clarification was needed because there was no stop date. Continued review revealed, on [DATE] at 2:45 PM, LPN #1 inputted into the EMR (electronic medical record) a verbal order, obtained from APRN #1, to cancel the [MEDICATION(S)], with a rationale that Resident #1's urine results did not indicate treatment per APRN #1. Review of Resident #1's Progress Notes, dated [DATE] at 12:10 PM, revealed Resident #1's family member called the facility and reported Resident #1 was to be on an antibiotic for a UTI when he/she discharged from the hospital. Per notes and interview with RN#1, on [DATE] at 7:45 PM, Registered Nurse (RN) #1 contacted APRN #1, who stated Resident #1 had been on [MEDICATION(S)]; however, his/her urine results did not indicate the need for antibiotic therapy on admission to the facility. Continued review revealed because the resident was exhibiting confusion, APRN #1 ordered to collect a urine sample via in-and-out catheterization, to be done the PM of [DATE], and to be sent to the lab on Monday ([DATE]) to determine the need for antibiotics. Further review revealed Resident #1 refused the in-and-out catheterization on [DATE]. Review of Resident #1's Progress Notes, dated [DATE] at 3:20 AM, revealed RN #1 notified the on-call APRN about Resident #1 regarding obtaining a chest x-ray due to desaturation (low oxygen level) and a positive in-house COVID swab. The on-call APRN gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2 received orders from the MD (Medical Director) to collect a urine specimen and send it to the lab for a urinalysis and culture and sensitivity, if indicated. The MD ordered to notify him of the urinalysis results. On [DATE] at 6:06 PM, results of the chest x-ray showed a slight right upper lobe infiltrate. The nurse notified the MD, who gave antibiotic orders for [MEDICATION(S)] 500 mg daily for ten (10) days, [MEDICATION(S)] 500 mg every day for five (5) days, and [MEDICATION(S)] 600 mg orally every twelve (12) hours for ten (10) days. Record review revealed Resident #1 was transferred to a hospital. Review of Resident #1's Hospital's Readmission Note, on [DATE] at 5:28 PM, revealed Resident #1 presented to the Emergency Department (ED) by Emergency Medical Service (EMS) with reports of general decline. Continued review of the Note revealed Resident #1 discharged from the hospital to the long-term care facility on [DATE]; he/she had a positive urine culture for MRSA and received [MEDICATION(S)], but this seemed ineffective. Continued review of the admission assessment revealed the resident's urine was grossly abnormal. Resident #1 expired on [DATE] at 2:38 PM. Per the record, the resident's official cause of death and any directly related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview with APRN #1, on [DATE] at 12:22 PM, revealed she no longer worked at the facility, effective [DATE], adding when the new company took over, they used their APRN's. Per the interview, APRN #1 stated she vaguely remembered details of Resident #1 and did not remember why she did not continue the Zyxox as ordered. APRN #1 stated the antibiotic was more expensive than other comparable drugs, and the facility focused a lot on saving money. She stated she thought she recalled the administration asking if there was another drug to prescribe that had comparative effectiveness but was less costly. Continued interview revealed she was going to look into it, but she could not recall what happened six (6) months ago. APRN #1 stated [MEDICATION(S)] was not in the facility's contingency medication supply inventory. Additional telephone interview with APRN #1, on [DATE] at 1:56 PM, revealed she did not remember giving a verbal order to stop the [MEDICATION(S)], unless the facility had called her to stop the medication, perhaps due to the cost of the drug. She stated she thought the drug cost about six hundred ($600) dollars per pill. APRN #1 stated that an antibiotic typically needed to be taken its entire prescribed course to treat the infection effectively by destroying all bacteria. She added it would not have been her intent to discontinue the antibiotic. Also, APRN stated ordinarily, she continued whatever medications the resident was on, as long as he/she was supposed to be on it. She repeated she had no idea why she would have given an order to discontinue the antibiotic. Per APRN #1, If I did give an order to discontinue the medication, I don't know why I would have; it doesn't make sense. APRN #1 accessed Resident #1's medical record remotely and reviewed her documentation in Resident #1's Progress Notes. She noted documentation in the Progress Notes that said the nursing staff contacted APRN #1 after receiving a call from Resident #1's daughter inquiring about the antibiotic. She stated the documentation revealed APRN #1 said Resident #1's urine did not appear to need the antibiotic. APRN #1 stated, This documented dialogue occurred on day three (3) of Resident #1's admission and did not explain why the antibiotic would have been discontinued on admission, and the facility had not collected another urine specimen. Continued interview revealed she had a telehealth visit with Resident #1 on day three (3) of his/her admission to the facility. APRN #1 stated she had no explanation as to why she would have discontinued the medication. Additional telephone interview with APRN #1, on [DATE] at 12:38 PM, revealed during the admission process with new admits and readmits, she usually went over medications and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The APRN stated the facility did not fax the Discharge Summary to her unless she specifically requested it. Continued review revealed the nurses were supposed to call her for approval before putting the orders into the EMR. APRN #1 stated her Summary Note, on [DATE], said the hospital planned to continue Resident #1 on [MEDICATION(S)] for positive MRSA in his/her urine for seven (7) more days. Further interview revealed she must not have known the drug was discontinued because she documented, in the Admission Summary, the plan was to continue [MEDICATION(S)]. She also stated because the resident had MRSA in his/her urine, she would have given additional clinical data concerning the urine results to support why it was unnecessary to leave the resident on the antibiotic. Per interview, APRN #1 stated it was not normal protocol for her to reference the MAR for current medications in the Admission Summary Report; but, it was typical for her to list all the medications in the report. She stated she could not understand why she did not specifically list all the medications. She stated her telehealth visit, on [DATE], was for a new admission visit, as she had to see the resident within twenty-four (24) to forty-eight (48) hours of admission. APRN #1 acknowledged the Hospital Discharge Summary revealed Resident #1 had a UTI, and the follow-up plan of care included [MEDICATION(S)] and follow-up appointments with his/her Urologist and Infectious Disease Specialist. In addition, APRN #1 stated she did not remember, from the call on [DATE], the dialogue about why she discontinued the [MEDICATION(S)], adding she usually did not ask nurses to read a urinalysis or a culture report from the hospital discharge record. She also stated she did not recall having a conversation with the MD regarding discontinuing the [MEDICATION(S)]. Telephone interview with the Director of Quality Assurance Pharmacist at the contracted Pharmacy, on [DATE] at 11:22 AM, revealed Pharmacy received an order, on [DATE] at 2:40 PM Eastern Standard Time (EST, the Pharmacy is on Central Standard Time (CST)), from the facility for [MEDICATION(S)] 600 mg, one (1) tablet every shift, and there was no end date specified. Further interview revealed the therapeutic dosage was 600 mg twice a day. She stated this medication also required a stop date. The Pharmacist stated the Pharmacy received an electronic request, on [DATE] at 2:45 PM, from LPN #1 to discontinue [MEDICATION(S)]. Continued interview revealed there was no other order submitted for [MEDICATION(S)], until [DATE] at 6:15 PM. She stated the pharmacy dispensed the medication to the facility on [DATE], adding she was not sure why Pharmacy did not send the drug to the facility on that evening's medication delivery run. In addition, she stated [MEDICATION(S)] was not in the facility's contingency medication supply inventory. Telephone interview with LPN #1, on [DATE] at 2:37 PM, revealed she left the facility in [DATE]. She stated she vaguely remembered Resident #1 but thought she recalled an issue with the medication cost, adding, I cannot say I paid much attention to that conversation or who besides APRN #1 was involved. LPN #1 stated [MEDICATION(S)] was not in the contingency medication supply. Continued interview revealed she was the assigned nurse the day the facility admitted Resident #1. She stated she could not recall much detail about the admission as it was almost six (6) months ago. Additional telephone interview with LPN #1, on [DATE] at 11:58 AM, revealed she submitted the [MEDICATION(S)] order, on [DATE] at 2:40 PM, and the discontinuation order, on [DATE] at 2:45 PM, the day Resident #1 was admitted . She stated she believed she faxed the Hospital Discharge Summary to APRN #1, and they reviewed it together. She stated she did not remember if APRN #1 told her to discontinue [MEDICATION(S)]. She stated she thought APRN #1 told her the urine specimen she was reviewing in the medical record did not indicate [MEDICATION(S)] was needed. She stated there had been no discussion about a medication error related to [MEDICATION(S)] before she left employment at the facility. LPN #1 stated she did not question the order to discontinue [MEDICATION(S)] because the point of calling APRN #1 was to confirm the Hospital Discharge Summary orders, and it was the provider's responsibility to continue or discontinue orders. LPN #1 stated, for new orders, nurses were taught to call the APRN first, before the MD, to discuss hospital discharge orders. In addition, she said this process did not change before she left the facility. She stated it was important for residents to complete their entire course of ordered antibiotic therapy to clear the infection and not have it return. Per interview, LPN #1 stated follow-up appointments mentioned in the Hospital Discharge Summary were usually made before the resident left the hospital; if the appointments were not made by the hospital, another staff member in the facility coordinated with family about the appointments. She stated it was not a floor nurse's responsibility to arrange follow-up appointments. Telephone interview with the Infection Prevention/Staff Development Coordinator (IPSD), on [DATE] at 5:01 PM, employed four (4) years at the facility, revealed her primary role was to provide staff education, and she also assisted staff in whatever capacity they needed. She stated, per documentation, she assisted LPN #1 in admitting Resident #1 to the unit, but could not recall details and might have helped the nurse enter orders or other tasks. She stated the new admission process began by staff receiving a discharge summary that included the resident's current treatments and medications. Then, she stated it was reviewed by the Administrator, DON, Medical Records, and the Primary Nurse; the nurse called the MD and reviewed all medications and treatments; the provider verified whether to continue or discontinue current treatments and medications; the nurse wrote the orders on a three-part admission order form; and then entered the orders into the computer, linked automatically to the Pharmacy. Per interview, the top page of the form stayed on the chart under physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview with RN #1, on [DATE] at 7:45 PM, revealed she quit working at the facility approximately five (5) months ago and acknowledged she briefly remembered Resident #1. She recalled receiving a late night phone call from Resident #1's daughter asking if her parent was still receiving the antibiotic he/she was getting at the hospital for a UTI. She stated she informed the daughter he/she was not, and RN #1 called APRN #1. Per RN #1's recall, APRN #1 stated the urine results were unremarkable, but APRN #1 asked RN #1 to read he urine results to her. RN #1 stated the urinalysis report in the chart, and the one read to APRN #1, was the one sent from the hospital. RN #1 stated APRN #1 said she did not want the family to be upset, so she ordered another urinalysis to see if Resident #1 needed to be on the antibiotic. RN #1 said she recalled the report she read to APRN #1 was a urinalysis report, not one for culture and sensitivity. RN #1 stated she thought there was mention of MRSA in another urine report; however, she remembered only reading the urinalysis report to APRN #1 because that was what APRN #1 requested. RN #1 stated she knew [MEDICATION(S)] was an antibiotic, and if one did not finish the entire course of an antibiotic as ordered, symptoms could worsen, and the infection not be eradicated. Telephone interview with the facility's Medical Director (MD), on [DATE] at 4:33 PM, revealed he never saw Resident #1. He stated the resident was only at the facility for six (6) days or so, and APRN #1 handled the admission. The MD stated he received a call from the facility, around [DATE] or [DATE], concerning Resident #1's [MEDICATION(S)] antibiotic. He stated he reviewed the hospital discharge medications and noticed [MEDICATION(S)] was not listed in the discharge medications list. However, he stated, upon further examination, in the body of the summary, the discharging Physician had written the resident was to continue [MEDICATION(S)]. He stated he contacted APRN #1 to inquire why she had not continued Resident #1's [MEDICATION(S)] on admission to the facility. Per the MD, APRN #1 stated she was not aware of MRSA in Resident #1's urine. He stated staff was following APRN #1's decisions and directions, concerning the [MEDICATION(S)] order on Resident #1's admission. Continued interview with the MD, on [DATE] at 4:33 PM, revealed when staff called him about the antibiotic, Resident #1 was beginning to experience symptoms of behavioral changes and respiratory issues. He stated he gave an order to collect a urine specimen for culture and sensitivity, and the on-call APRN had earlier requested a chest x-ray. The MD stated he decided to restart the [MEDICATION(S)] and add two (2) additional antibiotics because the urine specimen culture grew Escherichia Coli (E. Coli) bacteria. Per interview, the incident with the [MEDICATION(S)] order for Resident #1 and APRN #1's actions prompted concerns from the facility, and consequently, changes were made to the process regarding how admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, he stated around the same time as the process change, the facility contracted with another APRN group. In addition, the MD stated he was not aware, for Resident #1's readmission, the hospital believed the resident had remained on [MEDICATION(S)] while in the facility; and thus, had stated the [MEDICATION(S)] was apparently ineffective for Resident #1. Per interview, the MD stated the [MEDICATION(S)] mishandling was discussed in the Quality Assurance Process Improvement (QAPI) team meeting, and this was when the process was created and implemented. Also, the MD stated after the [MEDICATION(S)] incident, during his July facility visits, he reviewed all the new admits or re-admit residents' orders and discharge summaries for medication and treatment accuracy and completeness. Interview with the Director of Nursing (DON), on [DATE] at 5:16 PM, revealed she had been the DON since [DATE]. According to the DON, nurses received notice that the facility had accepted a new resident, and the facility received the discharge summary before the new resident's arrival. The Interdisciplinary Team (IDT) (DON, ADON, Medical Records, and Primary Nurse) would review the discharge summary, and medications were faxed to the Pharmacy and were placed in a hold status before the resident arrived. Per interview, upon the resident's arrival to the facility, the nurse faxed or gave the discharge summary to the practitioner for review; this was the previous process before the [MEDICATION(S)] order in [DATE]. She stated, in [DATE], after the [MEDICATION(S)] incident, the facility began using a new contracted APRN group, and the process for verifying new orders changed. In addition, she stated the new APRN group would now verify all new orders for both new admits and transfers with the MD. Per interview, the DON revealed she had no idea about an issue with the cost of [MEDICATION(S)]. Further, she stated she was not aware of a problem with the dosage and frequency of the [MEDICATION(S)] order sent to the Pharmacy, adding that staff would call the practitioner to clarify the order, but she did not know if this occurred. The DON stated the [MEDICATION(S)] order was never put in the computer because when the facility nurse reconciled hospital discharge medications with APRN #1, the APRN did not order the medication. She also stated [MEDICATION(S)] was in the unit contingency medication inventory; however, both the Pharmacy and staff nurses said the drug was not in their contingency medication inventory. The contingency medication inventory supplied from the Pharmacy did not list this medication as being in the facility's inventory. Continued interview revealed the DON expected nurses to review discharge medications with the MD and make sure they had the correct medication list. Also, she stated the standard process was medical records went through the record and did the checks and balances to ensure everything on the discharge summary reflected the computer's orders. Additional interview with the DON, on [DATE] at 2:00 PM, revealed, on [DATE], staff informed her Resident #1's daughter had called the facility, on [DATE], asking if her parent was still getting the antibiotic he/she was receiving at the hospital before the transfer. She stated this was the first she had heard anything about the [MEDICATION(S)] order. Further, upon inquiry, she learned APRN #1 discontinued [MEDICATION(S)] on [DATE]. She stated when the MD became involved, he gave an order to collect a urine sample and send it to the lab for a urinalysis and culture and sensitivity. In addition, she said the MD remarked he would go ahead and re-order the [MEDICATION(S)] for the daughter's sake, along with the other two (2) antibiotics. Additional interview with the DON, on [DATE] at 11:05 AM, revealed the MD validated all medication and treatment orders for both new admits and readmits, not the APRN, and this would happen at all times and at all hours. She stated the facility's new owners also assigned a new APRN to the facility who consistently visits residents two (2) to three (3) times a week. Per interview, the APRN kept up with residents' labs, x-rays, and changes in condition. Continued interview revealed the facility had a liaison between the hospital and the facility whose responsibility was to get the resident ready to transition from the hospital to the nursing home. The DON stated the liaison worked with hospital case managers to ensure everything was in place before the resident left the hospital. In addition, she stated new orders were scanned to the DON and a hard copy placed in a binder on B Wing and a wall bin on A Wing. Further, she stated this additional order review allowed all new orders a second look, so nothing was missed. She stated she did not do audits on the revised process because nothing changed in the process except all new medications were now called to the MD and not the APRN. Also, she revealed that she changed the existing admission summary form. The DON explained it was not a change, but staff started using a form that already existed that had not been used. She stated she re-instituted the form because it was a more complete and intuitive form that fostered gathering complete information. However, it was noted that the form currently being used was the same form that was being used in July when the [MEDICATION(S)] incident occurred. Interview with the DON, on [DATE] at 11:05 AM, revealed she expected nurses to transcribe orders into the EMR exactly as the provider gave them. She stated it would be acceptable for the nurse to enter the medication into the EMR as every shift when it was ordered every twelve (12) hours beca

Based on interview, record review and review of the Centers for the Medicare and Medicaid Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of ten (10) sampled residents (Resident #4). Record review revealed Resident #4 had a history of [REDACTED]. This incident was investigated by the State Survey Agency during the facility's standard survey concluded on [DATE]. Resident #4's Behavior Comprehensive Care Plan (CCP) was revised on 08/28/19, related to sexually inappropriate behaviors towards other residents with an intervention for every fifteen (15) minute checks; however, this intervention was discontinued on 08/30/19. Interview and record review revealed the resident's CCP was not further revised with interventions related to his/her sexually inappropriate behaviors towards other residents, in an attempt to prevent recurrence, and staff was unaware of Resident #4's sexual behaviors. On 12/15/19, at approximately 2:00 PM, Resident #4 was witnessed to have his/her hand on Resident #5's breast, and staff immediately separated the two (2) residents. Resident #4's Behavior Comprehensive Care Plan (CCP), revised on [DATE], revealed no reference to the incident that occurred on 12/15/19, nor was the CCP revised with interventions for continued monitoring of Resident #4 due to his/her history of sexually inappropriate behaviors towards other residents. Staff interviews conducted on 01/02/2020 revealed Resident #4 was not currently receiving increased monitoring or supervision for inappropriate sexual behaviors. (Refer to F-[AGE]0) The facility's failure to ensure the Comprehensive Care Plan was revised with interventions to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/03/2020 and was determined to exist on 12/15/19. The facility provided an acceptable credible Allegation of Compliance (AOC) on 01/13/2020, alleging removal of the Immediate Jeopardy on 01/06/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE]20 prior to exit on [DATE]20 with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Interview with the Minimum Data Set (MDS) Coordinator, on 01/03/2020 at 5:00 PM, revealed the facility had no policy related to revising Care Plans, and utilized the RAI Manual. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #4's medical record revealed the facility admitted the resident on 10/06/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 11/21/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) of three (3) out of fifteen (15) indicating severe cognitive impairment. Continued review revealed the facility assessed the resident as having no presence or frequency of delusions, hallucinations, physical or verbal behavioral symptoms toward others e.g. screaming, cursing, pushing or hitting or sexually inappropriate behaviors. The facility further assessed the resident as having functional limitations in ROM of one (1) lower extremity. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for bed mobility, dressing, and toileting; limited assistance of one (1) person for transfers, and locomotion on and off the unit; and as using a wheelchair. Resident #4's Behavior Comprehensive Care Plan (CCP) was revised on 09/10/19, with the facility's new computerized electronic record system. Review of the Behavior CCP revealed the resident had a history of [REDACTED]. The goal stated the resident would have fewer episodes of behaviors and would have no behavior problems. Interventions included: administer medications as ordered/monitor for side effects and effectiveness; discuss the resident's options for appropriate channeling of anger; praise the resident for demonstrating desired behavior; immediately remove the resident from public area or away from other residents when behavior was disruptive or unacceptable; mental health consult PRN (as needed), reinforce with the resident unacceptable behaviors of verbal/physical abuse; and, social services to visit with resident. All of the above interventions were initiated on 09/10/19. However, the information from the previous CCP, related to the incident of inappropriate sexual behavior that occurred on 08/28/19, was not included on this computerized CCP in order for staff to be aware of the resident's history of past inappropriate sexual behaviors. Review of the facility Long Term Care Facility-Self Reported Incident Form/Initial and Combined Report/Investigation, faxed to the Office of Inspector General (OIG) on 12/15/19 at 3:47 PM, revealed there was an incident of sexual abuse on 12/15/19 at the B-Wing back hall, which involved Resident #4 and Resident #5. SRNA #2 and SRNA #3 reported Resident #4 had his/her left hand in Resident #5's shirt, and SRNA #3 stated Resident #4 was manipulating Resident #5's right breast. Per the investigation, Resident #4 was placed on one on one (1:1) monitoring while out of bed. Further review of Resident #4's Behavior CCP, initiated 09/10/19, revised [DATE], revealed no reference to the incident of inappropriate sexual behavior that occurred on 12/15/19, and no documented evidence the CCP was revised with interventions related to Resident #4's history of sexually inappropriate behaviors towards other residents in an attempt to prevent further occurrences. Interview conducted with the Assistant Director of Nursing (ADON) on 01/02/2020, at 2:00 PM, revealed this was the current Care Plan used by the clinical staff. Review of Resident #4's Kardex Report, (reference used by the State Registered Nurse Aides (SRNAs) in providing care to residents ), undated, reviewed by the State Agency Representative on 01/02/2020, revealed there were no interventions related to preventing inappropriate sexual behaviors and no interventions related to monitoring the resident related to his/her history of sexually inappropriate behaviors towards other residents. Interview with SRNA #3, on 01/02/2020 at 2:00 PM, revealed she had not witnessed, nor was she aware of any prior instances of Resident #4 touching or exhibiting sexually inappropriate behaviors towards other residents before 12/15/19, and she normally worked the B- Wing where Resident #4 resided. Per interview, she had not been instructed to watch Resident #4 closely or to monitor him/her for inappropriate touching of other residents prior to the 12/15/19 incident, and to her knowledge staff had not been closely monitoring Resident #4 after 12/15/19. Additionally, SRNA #3 stated the Kardex was the reference the SRNAs used in providing care, and after reviewing Resident #4's Kardex, she stated there were no interventions related to closely monitor Resident #4's whereabouts. Interview with SRNA #2, on 01/02/2020 at 2:10 PM, revealed she was not aware of any further sexually inappropriate touching/behaviors by Resident #4 after 12/15/19, nor was she aware of previous incidences of this nature. Further interview revealed she was not instructed to watch Resident #4 closely or to monitor him/her for inappropriate touching of other residents prior to the 12/15/19 incident or after that date. She verified Resident #4 was not currently receiving close monitoring, and she was frequently assigned to the resident. Interview, on 01/02/2020 at 3:00 PM, with SRNA #1 revealed she was unaware of staff currently providing increased supervision to Resident #4. Interview with LPN #1, on 01/02/2020 at 2:40 PM, revealed she did not recall being instructed to ensure staff closely monitored Resident #4 prior to the incident on 12/15/19 or after 12/15/19. She further stated Resident #4 was currently not on frequent monitoring or observation. Interview with the Assistant Director of Nursing (ADON), on 01/02/2020 at 2:00 PM, revealed the Interdisciplinary Team (IDT), which consisted of the Administrator, MDS Coordinator, Scheduler, ADON, DON, Social Worker, Therapy and Medical Records, discussed the 08/28/19 incident and the IDT felt close monitoring of Resident #4 could be discontinued on 08/30/19, as the resident was not exhibiting further sexual behaviors. However, she stated in hindsight Resident #4's Behavior CCP should have been had revised with interventions related to monitoring his/her whereabouts ongoing to prevent further sexual advances towards other residents. Per interview, this may have prevented the incident involving Resident #4 and Resident #5. Further interview with the ADON, on 01/13/19 at 4:45 PM, revealed when Resident #4 presented with sexually inappropriate resident-to-resident behavior towards Resident #5 on 12/15/19, frequent monitoring was re-implemented and there was discussion in IDT related to the incident. She stated, although close monitoring of Resident #4 was discontinued after a short interval, the resident's Behavior CCP should have been revised with interventions for ongoing monitoring. She stated prior to 01/03/2020, the MDS Coordinator revised the Care Plans based on the IDT's input during the IDT meeting, and staff nurses did not revise the CCP. Additional interview with the ADON, revealed it was not identified until 01/03/2020, that Resident #4's Care Plan which was in use on that date, did not reference the 08/28/19 incident of sexual behavior towards another resident. She stated this was partly related to the new computerized Point of Care (electronic medical record) did not carry forward information from the previous Care Plan. Per interview, after this discovery, on 01/03/2020, additional steps to the Care Plan process were implemented to ensure incidents of new and old behaviors were documented on the Care Plan in order for staff to be aware of past and present behaviors. She stated it was her expectation that care plans were person-centered and revised, with problems, goals, and necessary interventions to keep residents safe. Interview with the Minimum Data Set (MDS) Coordinator on 01/03/2020 at 5:00 PM, revealed she was responsible for developing, and revising care plans in conjunction with the IDT staff during the IDT meetings. She acknowledged Resident #4's current Behavior CCP did not reference the 08/28/19 incident of sexual behavior towards another resident. Per interview, the new computerized Point of Care (electronic medical record) did not carry forward the information from the previous Care Plan. She further stated Resident #4's current Behavior CCP, revised [DATE], did not reference the 12/15/19 incident of sexual behavior towards Resident #5. She acknowledged Resident #4's Behavior CCP should have been revised related to sexually inappropriate behaviors and interventions to prevent these behaviors such as frequent checks and monitoring. Further, she stated the SRNAs should also be aware of Resident #4's sexual behavior via the Kardex, and there should have been interventions on the Kardex related to monitoring Resident #4 after incidents of inappropriate sexual behaviors. Interview with the Director of Nursing (DON), on 01/02/2020 at 4:00 PM, revealed it was the responsibility of the facility to ensure residents with sexually abusive behaviors were care planned with interventions for close monitoring in order to prevent abuse towards other residents. She stated Resident #4's Behavior CCP should have been revised with interventions for ongoing monitoring of the resident after the 08/28/19 incident in order for staff to be aware of the resident's whereabouts and ensure he/she was not in isolated areas of the facility with high-risk vulnerable residents. Further interview with the DON, revealed she was informed of the allegation of abuse between Resident #4 and Resident #5 on 12/15/19, shortly after it happened. Additional interview revealed Resident #4's Behavior CCP, was replaced on 09/10/19, due to the facility's new computerized electronic record system. Per interview, the CCP initiated 09/10/19 and revised [DATE], was the current CCP and did not reference the incidents of inappropriate sexual behavior that occurred on 08/28/19 or 12/15/19, in order for staff to be aware of the resident's history of inappropriate sexual behaviors towards residents. Additional interview with the DON revealed the IDT reviewed and discussed allegations of abuse and resident-to-resident altercations. IDT team meetings were held Monday through Friday and all team members provided input based on their expertise. The DON stated the MDS Coordinator developed and revised the Care Plans during these meeting with interventions to prevent further incidents of the same nature. Continued interview revealed the IDT did meet on [DATE], to discuss the allegation of sexual abuse involving Resident #4 and Resident #5, which staff reported the previous day. However, she stated Resident #4's current Care Plan was not revised related to interventions for close monitoring or increased supervision. Further, the resident's Kardex did not specify the need to closely monitor Resident #4 related to sexual behaviors towards other residents. Interview with the Administrator, on 01/02/2020 at 4:30 PM, revealed there was an IDT meeting for discussion and input from the team, when an incident involving a resident occurred. He stated Care Plans were to be revised related to recommendations based on the team's input. He stated it was his expectation interventions implemented after an incident of a resident-to-resident altercation or allegation of sexual abuse would include frequent monitoring of the residents as recommended by the clinical staff. Further interview with the Administrator, on 01/13/2020 at 8:15 AM, revealed the IDT should have ensured Resident #4's Behavior CCP was revised with interventions for necessary supervision and monitoring after Resident #4's inappropriate sexual behaviors on 08/28/19, in order to prevent recurrence. He stated it was his expectation that incidents such as inappropriate sexual behaviors were documented on the CCP in order for staff to be aware of past resident behaviors to ensure appropriate monitoring of residents. He stated there could be negative consequences for residents if necessary supervision and monitoring was not implemented for residents with behaviors. Interview with the Senior Executive Director Consultant, on [DATE]20, at 12:55 PM, revealed he had recently reviewed the Abuse Neglect and Misappropriation Policy and incidents involving Resident #4. He stated on 01/04/2020, after Surveyor intervention, there was corrective action by the facility to include frequent monitoring of Resident #4, and there was initiation of education for staff related to development, implementation, and revision of Care Plans. He stated these actions should have been implemented as early as 08/28/19, when the first incident related to sexual abuse occurred involving Resident #4 and another resident. The facility provided an acceptable credible Allegation of Compliance (AoC) on 01/13/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/06/2020. Review of the AoC revealed the facility implemented the following: 1. On 01/03/2020, after notification by the Office of Inspector General (OIG) Surveyor of the specific allegations at 7:00 PM, the Administrator and Director of Nursing (DON) placed Resident #4 on one on one (1:1) monitoring when up out of bed and every fifteen (15) minute checks while in bed. 2. On 01/04/2020, Resident #4 was placed on one on one (1:1) monitoring. 3. On 01/04/2020, the Physician ordered [MEDICATION NAME] 0.05 mg patch related to inappropriate behaviors for Resident #4. The patch arrived from the pharmacy and the nurse applied the patch at 6:00 AM on 01/04/2020. 4. On 01/04/19, Resident #4's Comprehensive Care Plan was updated to reflect new interventions by the MDS Coordinator. 5. On 01/04/2020 and 01/05/2020, the DON, Assistant Director of Nursing (ADON), MDS Coordinator, Registered Nurse (RN), or Licensed Practical Nurse (LPN), audited all Comprehensive Care Plans to ensure interventions were in place for residents with high-risk behaviors, and reviewed the Care Plans for accuracy and thoroughness related to behaviors. Nine (9) residents had their behavioral Care Plans modified to address past and current behaviors with patient centered interventions. 6. On 01/04/2020 and 01/05/2020, the Administrator, DON, ADON, MDS Coordinator, RN or LPN interviewed all interviewable residents with a Brief Interview for Mental Status (BI[CONDITION]) of eight (8) or higher to determine if they had experienced any sexual abuse, or abuse in any form. Residents with BI[CONDITION] of seven (7) or below had their responsible parties contacted and interviewed. On 01/05/2020, a full skin assessment was conducted for residents in which the responsible parties could not be contacted. These skin assessments were conducted by the DON, ADON, MDS Coordinator, RN, or LPN. 7. On 01/05/2020, the DON, ADON, MDS Coordinator, RN, or LPN interviewed thirty-three (33) team members out of sixty-eight (68) to ensure there had not been resident behaviors that Administrative staff was not aware of either because staff thought Administrative staff was aware of the behaviors or because staff thought it was the resident's normal behavior. Any team member who was not interviewed due to leave of absence or who did not work on 01/05/2020 would not be allowed to have direct resident contact or report to their workstation until the interview was completed. 8. On 01/05/2020, the Vice President (VP) of Clinical Services Consultant reviewed all allegations of abuse, neglect, and exploitation, occurring since 09/01/19 to ensure investigations were thorough, including team member interviews. This produced no negative findings. 9. On 01/05/2020, the Senior Executive Director Consultant provided the Administrator one on one (1:1) education on abuse, investigating and reporting abuse, including preventing further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress using the Abuse policy. 10. On 01/05/2020, the Administrator, DON, or ADON, in-serviced thirty-three (33) team members regarding Abuse, Neglect and Exploitation. The education included identifying residents who were at high risk for abuse and how to monitor their whereabouts and ensure they were kept away from unsafe situations. Thirty-three (33) team members completed post-tests to ensure their understanding of the education provided. Any team member who did not complete the abuse training and post-test due to leave of absence or who did not work on 01/05/2020 would not be allowed to have direct resident contact or report to their workstation until abuse training is completed. 11. All new hire nursing staff and agency staff will be educated on Abuse and how to identify residents at risk of abuse, by the DON, ADON or LPN Scheduler, Medical Records, or the MDS Coordinator. 12. On 01/05/2020, the Regional MDS Coordinator Consultant in-serviced IDT members on the requirements to up-date the comprehensive care plan for new, worsening and increased behaviors. 13. On 01/05/2020, the DON, ADON, MDS Coordinator, RN or LPN, or Regional MDS Coordinator Consultant in-serviced nine (9) out of sixteen (16) licensed nurses related to documentation of behaviors, including documenting on the Twenty-four (24) Hour Report. Any licensed nurse team members who did not receive this education due to leave of absence or who did not work on 01/05/2020 would not be allowed to have direct resident contact or report to their workstation until their training was completed. 14. On 01/05/2020, the DON, ADON, MDS Coordinator, RN or LPN in-serviced twelve (12) out of twenty-six (26) State Registered Nurse Aides (SRNA) on documenting behaviors in Point of Care (POC) (computerized electronic record). SRNAs not provided the in-service on 01/05/2020 would receive the same in-service prior to working on their next scheduled day. 15. The Interdisciplinary Team (IDT) Members including the DON, ADON, MDS Coordinator, Medical records, and Social Services Director (SSD) will review 100% of residents for signs and symptoms of new, worsening and increased behaviors Monday through Friday, with Saturday and Sunday reviewed on Monday, and identify high risk residents with a behavior mood tracking system. High-risk behaviors will be addressed with seventy-two ([AGE]) hour follow up and referral to Psych services pending behavior. The MDS Coordinator or the ADON will update the care plan with any new interventions. 16. On 01/05/2020, an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON and Medical Director. During the meeting, there was a review of the actions, education, and audits performed by the Center after the 01/03/2020 alleged deficiency. The facility will review any actions or findings of the resident, and/or team member interviews and post-tests after 01/05/2020, in the monthly QAPI meeting, which includes the Administrator, Medical Director, DON and at least three (3) other department heads. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the facility's assignment sheets for B-Wing dated 01/03/2020, revealed SRNA #4 was assigned one-on-one (1:1) monitoring of Resident #4, from 7:00 PM until 11:00 PM shift. Interview with SRNA #4, on 01/13/19, at 9:45 AM, revealed she worked her regular hours from 7:00 AM until 7:00 PM on 01/03/19, and upon request, she sat at the bedside with Resident #4 from 7:00 PM through 11:00 PM. 2. Interview with the Director of Nursing (DON) and Administrator, on 01/13/2020 at 8:15 AM, revealed after the Surveyor's visit on 01/03/2020, staffing was arranged to provide one on one (1:1) monitoring of Resident #4, indefinitely. Observations of Resident #4, 01/13/2020 through [DATE]20, revealed a staff member was sitting at his/her bedside when in his/her room, or was pushing him/her in a wheelchair in the hall. Review of staffing sheets revealed a staff member was assigned for one on one (1:1) monitoring of Resident #4 each shift, which started 01/04/2020. 3. Review of Resident #4's Physician Orders, dated 01/04/2020, revealed orders for [MEDICATION NAME] Patch; apply 0.05 mg, [MEDICATION NAME] one (1) time weekly. Per the Medication Administration Record [REDACTED]. ([MEDICATION NAME] is a female hormone ([MEDICATION NAME]) which is sometimes used to treat sexual inappropriateness of long-term care residents with Dementia) 4. Review of Resident #4's Comprehensive Care Plan, revealed new interventions to observe resident for any signs/symptoms of increased sexual behaviors; one on one (1:1) staff monitoring; notify Physician and psyche services for increases/changes in behavioral symptoms, and maintain a safe environment for resident. These interventions were added to the care plan on 01/04/2020. Interview with the MDS Coordinator, on 01/13/2020 at 11:30 AM, revealed she updated Resident #4's Care Plan with new behavioral interventions on 01/04/2020. 5. Review of the Comprehensive Behavior Care Plan Audit, dated 01/04/2020 and 01/05/2020, revealed nine (9) residents had their behavioral Care Plans modified to address past and current behaviors with person-centered interventions. Nine (9) residents had their behavioral Care Plans modified to address past and current behaviors with patient centered interventions by 01/05/2020. Interview with the ADON, on [DATE]20 at 4:45 PM, verified that on 01/04/2020 and 01/05/2020, the IDT team audited all Care Plans to ensure interventions were in place for residents with high-risk behaviors, and reviewed the Care Plans for accuracy and thoroughness related to behaviors. 6. Review of the Resident Interview Audit, dated 01/04/2020, revealed residents with a BI[CONDITION] of eight (8) or higher were interviewed. All indicated they had not experienced any sexual abuse or abuse of any form. Interview with the DON, on 01/14/2020 at 3:00 PM, revealed all residents in the facility with BI[CONDITION] of eight (8) or higher were interviewed by either the DON, ADON, MDS Coordinator, RN or LPN. Per interview, residents with BI[CONDITION] of seven (7) or less were not interviewed; however, if their families were available, they were interviewed. Review of the full Skin Assessment Audits, conducted 01/04/2020 and 01/05/2020 by the DON, revealed all residents were examined for any undocumented skin issue or injury of unknown origin. No skin issues or injuries of unknown origin were noted. Interview with the DON, on [DATE]20 at 8:30 AM, revealed she made the decision to conduct full skin assessments on all facility residents and she performed the skin assessments on all residents on 01/04/2020 and 01/05/2020. 7. Review of the Behavior Education sheets, dated 01/05/2020, revealed thirty-three (33) team members were interviewed and the interviews were witnessed. The interviews revealed there had not been resident behaviors the facility was unaware of because either staff thought the facility knew of the behaviors or staff thought it was the resident's normal. Interview with the DON, on [DATE]20 at 8:30 AM, revealed staff members were interviewed related to resident behaviors to ensure the IDT was aware of all resident behaviors. Per interview, any team member who was not interviewed due to leave of absence or who did not work on 01/05/2020 was not allowed to have direct resident contact or report to their workstation until the interview was completed. Interviews with SRNA #4 on 01/15/19 at 9:45 AM; Registered Nurse (RN) #1 at 10:38 AM; SRNA #5 at 2:30 PM; LPN #1 at 3:35 PM; and, SRNA #3 at 3:42 PM, revealed they had been interviewed related to resident behaviors. 8. Review of the Reportable Incident Review for the Center Audit, completed by the Regional Vice President of Clinical Services, (undated), revealed there had been eleven (11) reported resident incidents, dating 07/24/19 to 01/02/2020, with no issues identified. Phone interview with the Regional VP of Clinical Services, on [DATE]20 at 12:15 PM, revealed she reviewed all the facility's reportable incident files from July 24, 2019, to January 2, 2020, checking for issues. She further stated she reviewed medical records, employee statements, and reporting requirements, and identified no issues 9. Review of the education sign-in sheet, dated 01/05/2020, revealed the Senior Executive Director Consultant provided education to the facility's DON and Administrator, in regards to the Abuse Policy. The education included recognizing and reporting abuse, and steps to follow during the investigation. Interview with the DON and the Administrator, on 01/13/2020, at 8:30 AM, revealed they both received education related to the facility's Abuse Policy from the Senior Executive Director Consultant, on 01/05/2020. Interview with the Senior Executive Director Consultant, on [DATE]20, at 12:55 PM, revealed he educated the DON and the Administrator on 01/05/2020, regarding the facility's Abuse Policy. 10. Review of the facility Education Sign in Sheets, dated 01/05/2020, revealed thirty-three (33) team members were educated regarding Abuse, Neglect and Exploitation. The education included identifying residents who were at high risk for abuse and how to monitor their whereabouts and ensure they were kept away from unsafe situations. The education also covered discussion on behavior reporting and comprehensive personalized care-plan. Post-tests were completed with no concerns. Interview with the DON, on 01/14/2020 at 3:00 PM, revealed she and the ADON provided abuse education to thirty-three (33) team members on 01/05/2020 and as of 01/06/2020 seventy-two ([AGE]) facility staff received the education. Per interview, the education included identifying high-risk residents for abuse, and monitoring their whereabouts; behavior reporting and implementing the care plan. The DON stated any staff member who did not receive the education on 01/05/2020, had to receive the education prior to working. Interviews with SRNA #4 on 01/15/19 at 9:45 AM; RN #1 at 10:38 AM; SRNA #5 at 2:30 PM; LPN #1 at 3:35 PM; and, SRNA #3 at 3:42 PM; revealed they received re-education on Abuse by the DON and ADON on 01/05/2020 or 01/06/2020. The interviews revealed the education included identifying high-risk residents for abuse and monitoring their whereabouts, behavior reporting and implementing the care plan. Further, interviews revealed if they did not receive the education on 01/05/2020, they were not allowed to work until they had received the education. 11. Review of the In-service Attendance Record of New Hires, dated [DATE]20, revealed the ADON provided education to two (2) new hires, one (1) LPN and one (1) SRNA, related to Abuse, Comprehensive Care Plan, Point of Care, and Documentation. 12. Review of education dated 01/05/2020, revealed the Regional MDS Coordinator Consultant, in-serviced IDT members related to the requirements to up-date the comprehensive care plan for new, worsening and increased behaviors. Interview with the MDS Coordinator, on 01/13/2020 at 11:30 AM, revealed she received education on 01/04/2020, from the Regional MDS Coordinator Consultant regarding requirements for updating the comprehensive care plan for new, worsening and increased behaviors. Interview with the DON on [DATE]20 at 8:30 AM, and the ADON on [DATE]20 at 4:45 PM, revealed they received education on requirements for updating the comprehensive care plan for new, worsening and increased behaviors from the Regional MDS Coordinator Consultant. 13. Review of in-service education conducted on 01/05/2020, revealed nine (9) licensed nurses received training on documentation of behaviors, including documenting on the Twenty-four (24) Hour Report. Those unable to attend on 01/05/2020, were educated prior to working their next shift. Interview with LPN #2 on 01/14/2020 at 2:00 PM; LPN #1 01/14/2020 at 4:20 PM; and RN #1 on [DATE]20 at 10:38 AM, revealed they received education from the Nurse Scheduler in regards to documentation of behaviors, including documenting on the Twenty-four (24) Hour Re

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for one (1) of ten (10) sampled residents (Residents #5). Record review revealed Resident #4 had a history of [REDACTED]. This incident was investigated by the State Survey Agency during the facility's standard survey concluded on [DATE]. Although Resident #4's Comprehensive Care Plan was initially revised on 08/28/19 related to sexually inappropriate behaviors towards other residents with an intervention for every fifteen (15) minute checks, this intervention was discontinued on 08/30/19. Interview and record review revealed the resident's Comprehensive Care Plan was not further revised with interventions, related to his/her sexually inappropriate behaviors towards other residents, in an attempt to prevent recurrence, and staff was unaware of Resident #4's sexual behaviors. On 12/15/19, at approximately 2:00 PM, Resident #4 was witnessed to have his/her hand on Resident #5's breast, and staff immediately separated the two (2) residents. Resident #4 was placed on fifteen (15) minute checks while in his/her room and one to one (1:1) monitoring while out of the room; however, this was only for the remainder of the shift until 7:00 PM. There was no documented evidence of continued monitoring of Resident #4 related to the resident's history of sexually inappropriate behaviors towards other residents. Staff interviews on 01/02/2020, revealed Resident #4 was not currently receiving increased monitoring or supervision for inappropriate sexual behaviors. (Refer to F-657) The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 01/03/2020 and was determined to exist on 12/15/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 01/13/2020 alleging removal of the Immediate Jeopardy on 01/06/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE]20, prior to exit on [DATE]20, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed the purpose of the policy is to prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment, and involuntary seclusion) in accordance with Federal and State Laws. Continued review revealed the Policy describes sexual abuse as non-consensual sexual contact of any type with a resident/patient. If an alleged violation is verified, the center should oversee the implementation of corrective action and evaluate whether it is effective. The Director of Nursing (DON) in conjunction with other clinical team members shall initiate or revise the plan of care to reflect the resident's condition and measures taken to prevent a recurrence, where appropriate. Review of Resident #4's medical record revealed the facility admitted the resident on 10/06/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 11/21/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) of three (3) out of fifteen (15) indicating severe cognitive impairment. Resident #4's Behavior Comprehensive Care Plan (CCP) was revised on 09/10/19, with the facility's new computerized electronic record system. However, the information from the previous CCP, related to the incident of inappropriate sexual behavior that occurred on 08/28/19, was not included on this computerized CCP in order for staff to be aware of the resident's history of past inappropriate sexual behaviors. Review of the facility's Long Term Care Facility-Self Reported Incident Form/Initial and Combined Report/Investigation, faxed to the Office of Inspector General (OIG) on 12/15/19 at 3:47 PM, revealed there was an incident of sexual abuse on 12/15/19, at the B wing back hall involving Resident #4 and Resident #5. State Registered Nurse Aide (SRNA) #2 and SRNA #3 alleged Resident #4 had his/her left hand in Resident #5's shirt, and SRNA #3 stated Resident #4 was manipulating Resident #5's right breast. SRNA #3 removed Resident #4's hand and immediately separated the residents. A full skin assessment was completed for Resident #5 and no new issues were noted. Resident #4 was placed on one on one (1:1) monitoring while out of bed. Resident #5 was singing during the alleged incident, continued to sing, and appeared in no distress after the incident. Further review revealed Psych services saw Resident #4 after the incident and recommended increasing [MEDICATION NAME] to 125 mg three (3) times a day and adding [MEDICATION NAME] 400 mg daily ([MEDICATION NAME] is classified as a stomach acid reducer, but is also used to treat sexually inappropriate behavior in persons with Dementia). Further review of Resident #4's medical record revealed a Nurse's Progress Note, dated 12/15/19, at 2:46 PM, which stated the resident was up in his/her wheelchair propelling self in the hallway. Per the Note, the resident was seen sitting beside a female resident in the hallway with his/her left hand underneath the female resident's shirt. Staff reported Resident #4's hand was underneath the female resident's shirt and placed on his/her breast. Staff approached Resident #4 and removed his/her hand from the female resident's breast. Both residents were removed from the situation immediately. Resident #4 attended staff supervised smoke break and then was assisted back to bed. The Advanced Practice Registered Nurse (APRN) was notified with no new orders at this time. Licensed Practical Nurse (LPN) #1 signed this Note. Review of SRNA #3's Statement obtained by the facility on 12/15/19, revealed she and SRNA #2 were in the hallway when they observed Resident #4 had his/her hand up Resident #5's shirt with breast in hand. SRNA #3 then ran to both residents and told Resident #4 that it wasn't nice, then pushed Resident #5 to his/her room. Interview with SRNA #3, on 01/02/2020 at 2:00 PM, revealed on 12/15/19 at approximately 2:00 PM, she looked down the hall and noticed Resident #4's hand under Resident #5's shirt. She stated both residents were sitting in their wheelchairs at the end of the hallway. She further stated she then clapped her hands together loudly and ran toward both residents. Per interview, she physically removed Resident #4's hand from Resident #5's breast, firmly telling Resident #4 not to do this again. SRNA #3 stated she separated both residents and transported Resident #5 to his/her room via wheelchair while Resident #4 self-propelled himself/herself back to his/her room via wheelchair. Further interview with SRNA #3, revealed she immediately notified LPN #1 of the incident. Per interview, she was then instructed to monitor Resident #4 every fifteen (15) minutes while in his/her room and to ensure he/she received one to one (1:1) monitoring while out of the room for the remainder of the shift which ended at 7:00 PM. SRNA #3 stated she had not witnessed nor was she aware of any prior instances of Resident #4 touching or exhibiting sexually inappropriate behaviors towards other residents before 12/15/19. Per interview, she had not been instructed to watch Resident #4 close or to monitor him/her for inappropriate touching of other residents prior to the 12/15/19 incident, and to her knowledge staff had not been closely monitoring Resident #4 after 12/15/19. Additionally, SRNA #3 stated the Kardex was the reference the SRNAs used in providing care, and after reviewing Resident #4's Kardex, she stated there were no interventions related to the need to closely monitor Resident #4's whereabouts. Review of SRNA #2's Statement, obtained by the facility on 12/15/19, revealed she and SRNA #3 were in the hallway when they observed Resident #4 using his/her left hand to touch Resident #5's right breast under Resident #5's shirt. SRNA #2 and SRNA #3 immediately confronted Resident #4 and moved Resident #5 out of the hallway into his/her room. Interview with SRNA #2, on 01/02/2020 at 2:10 PM, revealed she witnessed the incident with Resident #4 and Resident #5, which occurred on 12/15/19 at approximately 2:00 PM in the back hallway of B-Wing. Per interview, she was standing in the hallway by the nurse's station talking to SRNA #3 when she saw Resident #4 with his/her hand up Resident #5's shirt. SRNA #2 stated she and SRNA #3 ran toward the back of the hall where both residents were sitting in their wheelchairs, and SRNA #3 removed Resident #4's hand from under Resident #5's shirt. Further interview revealed both SRNA #2 and SRNA #3 notified the charge nurse (LPN #1) of the incident. Continued interview with SRNA #2, revealed staff assisted Resident #5 to bed and Resident #4 returned to his/her room. Further, LPN #1 instructed staff to check on Resident #4 every fifteen (15) minutes while he/she was in his/her room and to monitor the resident one to one (1:1) when he/she was out of the room. SRNA #2 stated she was not aware of any previous incidences of this nature. Further interview revealed she was not instructed to watch Resident #4 close or to monitor him/her for inappropriate touching of other residents prior to the 12/15/19, incident or after that date. She stated Resident #4 was not on frequent monitoring after 12/15/19. Interview with LPN #1, on 01/02/2020 at 2:40 PM, who was assigned to Resident #4 on 08/28/19, revealed Resident #4 had a prior history of sexual inappropriate touching/behaviors with other residents before the incident on 12/15/19, but she could not remember the details. Further interview with LPN #1, revealed SRNA #2 and SRNA #3 reported on 12/15/19, while they were standing at the B-Wing nurses' station, they observed Resident #4 had his/her hand up Resident #5's shirt, and Resident #4's hand was attached to Resident #5's breast. Per interview, the incident occurred on 12/15/19, at approximately 2:00 PM. LPN #1 stated SRNA #3 removed Resident #4's hand and immediately separated both residents. Further interview revealed after the incident, Resident #4 went to his/her room and SRNA #3 assisted Resident #5 to his/her room. LPN #1 stated she performed skin assessments on both residents, with no injuries, noted. Per interview, Resident #4 was placed on every fifteen (15) minute checks while in bed and one to one (1:1) monitoring when out of his/her room, although the flowsheet only indicated fifteen (15) minute checks were done. Additionally, LPN #1 stated she notified the facility's Administrator, Director of Nursing, APRN and families of both residents of the incident. Additional interview revealed she did not recall being directed to watch or closely monitor Resident #4 prior to the incident on 12/15/19, or after 12/15/19. Additionally, she stated Resident #4 was currently not on frequent monitoring or observation. Interview, on 01/02/2020 at 3:00 PM, with SRNA #1 revealed she was aware of the sexually inappropriate behavior exhibited by Resident #4 on 12/15/19 towards Resident #5, although she did not witness the incident. She stated she was unaware of staff currently providing increased supervision to Resident #4. Review of Resident #4's Nurse's Progress Note, dated 12/15/19 at 2:55 PM, revealed Resident #4 self transferred from the bed to the wheelchair. Staff to sit with resident one-to-one (1:1) at this time. Further review of the Note, revealed the nurse spoke with the resident's responsible party regarding the incident with the female resident. Per the Note, the Administrator and DON were aware of the incident. This Note was signed by LPN #1. Review of the Fifteen (15) Minute Check flowsheet, revealed the resident was monitored every fifteen (15) minutes on 12/15/19 from 2:30 PM, until 7:00 PM. This flowsheet stated the resident was to be provided one on one (1:1) monitoring until in the bed; however, only the fifteen (15) minute checks were documented. Further review of Resident #4's Comprehensive Care Plan, initiated 09/10/19, revised [DATE], revealed there was no reference to the incident of inappropriate sexual behavior that occurred on 12/15/19, and no documented evidence the Care Plan was revised with interventions for continued monitoring of the resident related to his/her history of sexually inappropriate behaviors towards other residents in an attempt to prevent recurrence. Review of Resident #4's Kardex Report, (undated) reviewed by the State Agency Representative on 01/02/2020, revealed no interventions related to preventing inappropriate sexual behaviors, and no interventions related to monitoring the resident related to his/her history of sexually inappropriate behaviors towards other residents in an attempt to prevent recurrence. The State Agency Representative attempted conversation with Resident #4 on 01/03/2020 and 01/14/2020, which was unsuccessful, as the resident, did not speak. Review of Resident #5's medical record revealed the facility admitted the resident on 07/02/19 with diagnoses, which included [MEDICAL CONDITION], Abnormal Posture, [MEDICAL CONDITION], Dementia with Behavioral Disturbances, Generalized Muscle Weakness, [MEDICAL CONDITION] and Transient Cerebral Ischemic Attack. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 10/01/19, revealed the facility assessed the resident as having a BI[CONDITION] of three (3) out of fifteen (15), which indicated severe cognitive impairment. The State Agency Representative attempted conversation with Resident #5 on 01/13/2020 at 10:49 AM, which was unsuccessful, as the resident responded to questions with indecipherable responses, often repeating the same question. Interview with the Assistant Director of Nursing (ADON), on 01/02/2020 at 2:00 PM, revealed the Interdisciplinary Team (IDT), which consisted of the Administrator, MDS Coordinator, Scheduler, ADON, DON, Social Worker, Therapy and Medical Records, met Monday through Friday, and reviewed and discussed incidents such as abuse and resident-to-resident altercations. Per interview, she was aware of the 08/28/19 incident involving Resident #4 and another resident. She stated after the incident the IDT felt close monitoring of Resident #4 could be discontinued on 08/30/19, as the resident was not exhibiting further sexual behaviors. However, she stated in hindsight there should have been further interventions in place to allow for monitoring of Resident #4's whereabouts to prevent further sexual advances by him/her towards other vulnerable residents. The ADON stated if staff had a heightened awareness of Resident #4's whereabouts and ensured close monitoring for potential inappropriate sexual behaviors towards residents, this may have prevented the incident involving Resident #4 and Resident #5. Additional interview with the ADON, on 01/13/19 at 4:45 PM, revealed when Resident #4 presented with sexually inappropriate resident-to-resident behavior towards Resident #5 on 12/15/19, frequent monitoring was re-implemented and there was discussion related to the incident in IDT; however, close monitoring of Resident #4 was discontinued after a short period of time. She stated there were no further interventions implemented for close monitoring of Resident #4 in an attempt to prevent further occurrences of inappropriate sexual behaviors toward residents after 12/15/19. Interview with the APRN, on 01/03/2020 at 10:00 AM, revealed she was not aware of the incident involving Resident #4 and the other resident on 08/28/19, as another Medical Provider had been notified of that incident. However, she stated the facility notified her of Resident #4's sexually inappropriate behavior on 12/15/19. The APRN stated she had already ordered a Psychiatric consult for Resident #4's reported physically aggressive behaviors prior to the 12/15/19 incident. The APRN revealed the clinical staff did not take Resident #4's behaviors seriously and just laughed when talking about his/her comments and behaviors, which were sexual in nature. When discussing if the facility should have continued increased supervision for Resident #4 after the 12/15/19 incident, she stated, Maybe so. Interview with the Director of Nursing (DON), on 01/02/2020 at 4:00 PM, revealed she was not employed at the facility in August 2019 when the incident involving Resident #4 and another resident occurred and was unaware of what interventions were placed after this incident to prevent further occurrences of the same nature. However, she acknowledged it was the responsibility of the facility to ensure residents with abusive behaviors were monitored appropriately to prevent abuse towards other residents. She stated this would include staff being aware of Resident #4's whereabouts and ensuring he/she was not in isolated areas of the facility with high-risk vulnerable residents. Further interview with the DON, revealed LPN #1 informed her of the allegation of abuse between Resident #4 and Resident #5 on 12/15/19, shortly after it happened. She gave directions for LPN #1 to notify the two (2) residents' families, perform an assessment of Resident #5, and document the incident on a Progress Note. Further, she stated she told LPN #1 to ensure every fifteen (15) checks were conducted on Resident #4 while in his/her room and provide one to one (1:1) monitoring when he/she was out of the room. However, she did not recall how long the one on one (1:1) monitoring and fifteen (15) minute checks were in place. Further, she was unaware the one on one (1:1) monitoring was not documented as completed after this incident. She stated currently Resident #4 was not on every fifteen (15) minutes checks when in his/her room, nor was there one to one (1:1) monitoring of the resident when he/she was out of the room. Per interview, there were no current interventions in place to closely monitor the resident's whereabouts to ensure he/she was not isolated with a vulnerable resident. Further, Resident #4's current Kardex, which was the reference used by the SRNAs to provide resident care, did not specify the need to closely monitor the resident related to sexual behaviors towards other residents. Additional interview with the DON, on 01/13/2020 at 10:00 AM, revealed on 01/03/2020 at 7:00 PM, after Surveyor intervention, Resident #4 was placed on one on one (1:1) observation around the clock, indefinitely. Per interview, facility staff and contracted agency staff provided coverage. The DON stated there could be negative consequences if residents were not monitored as necessary related to sexual behaviors towards other residents. Per interview, it was her expectation residents were monitored as necessary in order to be free from abuse. Interview with the Administrator, on 01/02/2020 at 4:30 PM, revealed his role at the facility was to make sure residents were safe and not exposed to inappropriate and unsafe behaviors. He stated if inappropriate resident behavior occurred, it was his responsibility to address the behavior, report, investigate and ensure interventions were in place to mitigate the problem and prevent further problems. Per interview, there was an IDT meeting for discussion and input from the team, when an incident involving a resident occurred. He stated recommendations and interventions were implemented based on the team's input. He further stated interventions to be implemented after an incident of a resident-to-resident altercation or allegation of sexual abuse would include frequent monitoring of the residents as recommended by the clinical staff. Continued interview with the Administrator, revealed it was his expectation that incidents such as inappropriate sexual behaviors were communicated to not only the IDT, but to direct care staff and nurses in order for staff to be aware of past resident behaviors to ensure appropriate monitoring of residents. Additional interview revealed it was his expectation the facility responds to resident behaviors in a manner that meets all regulatory standards in order to ensure residents were free from abuse. Interview with the Senior Executive Director Consultant, on [DATE]20, at 12:55 PM, revealed he had been with the organization since the acquisition in August 2019. Per interview, he recently reviewed the Abuse Neglect and Misappropriation Policy with the Administrator and the DON and looked at what the facility could have done differently regarding incidents involving Resident #4. He stated on 01/04/2020, after Surveyor intervention, there was corrective action to include frequent monitoring of Resident #4, and there was initiation of education for staff related to development and revision of Care Plans. He revealed these actions should have been implemented as early as 08/28/19, when the first incident related to sexual abuse occurred involving Resident #4 and another resident. He stated it was his expectation the facility handled incidences of sexual abuse such as this in an aggressive manner in order to prevent further incidents of sexual abuse. The facility provided an acceptable credible Allegation of Compliance (AoC) on 01/13/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/06/2020. Review of the AoC revealed the facility implemented the following: 1. On 01/03/2020, after notification by the Office of Inspector General (OIG) Surveyor of the specific allegations at 7:00 PM, the Administrator and Director of Nursing (DON) placed Resident #4 on one on one (1:1) monitoring when up out of bed and every fifteen (15) minute checks while in bed. 2. On 01/04/2020, Resident #4 was placed on one on one (1:1) monitoring. 3. On 01/04/2020, the Physician ordered [MEDICATION NAME] 0.05 mg patch related to inappropriate behaviors for Resident #4. The patch arrived from the pharmacy and the nurse applied the patch at 6:00 AM on 01/04/2020. 4. On 01/04/19, Resident #4's Comprehensive Care Plan was updated to reflect new interventions by the MDS Coordinator. 5. On 01/04/2020 and 01/05/2020, the DON, Assistant Director of Nursing (ADON), MDS Coordinator, Registered Nurse (RN), or Licensed Practical Nurse (LPN), audited all Comprehensive Care Plans to ensure interventions were in place for residents with high-risk behaviors, and reviewed the Care Plans for accuracy and thoroughness related to behaviors. Nine (9) residents had their behavioral Care Plans modified to address past and current behaviors with patient centered interventions. 6. On 01/04/2020 and 01/05/2020, the Administrator, DON, ADON, MDS Coordinator, RN or LPN interviewed all interviewable residents with a Brief Interview for Mental Status (BI[CONDITION]) of eight (8) or higher to determine if they had experienced any sexual abuse, or abuse in any form. Residents with BI[CONDITION] of seven (7) or below had their responsible parties contacted and interviewed. On 01/05/2020, a full skin assessment was conducted for residents in which the responsible parties could not be contacted. These skin assessments were conducted by the DON, ADON, MDS Coordinator, RN, or LPN. 7. On 01/05/2020, the DON, ADON, MDS Coordinator, RN, or LPN interviewed thirty-three (33) team members out of sixty-eight (68) to ensure there had not been resident behaviors that Administrative staff was not aware of either because staff thought Administrative staff was aware of the behaviors or because staff thought it was the resident's normal behavior. Any team member who was not interviewed due to leave of absence or who did not work on 01/05/2020 would not be allowed to have direct resident contact or report to their workstation until the interview was completed. 8. On 01/05/2020, the Vice President (VP) of Clinical Services Consultant reviewed all allegations of abuse, neglect, and exploitation, occurring since 09/01/19 to ensure investigations were thorough, including team member interviews. This produced no negative findings. 9. On 01/05/2020, the Senior Executive Director Consultant provided the Administrator one on one (1:1) education on abuse, investigating and reporting abuse, including preventing further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress using the Abuse policy. 10. On 01/05/2020, the Administrator, DON, or ADON, in-serviced thirty-three (33) team members regarding Abuse, Neglect and Exploitation. The education included identifying residents who were at high risk for abuse and how to monitor their whereabouts and ensure they were kept away from unsafe situations. Thirty-three (33) team members completed post-tests to ensure their understanding of the education provided. Any team member who did not complete the abuse training and post-test due to leave of absence or who did not work on 01/05/2020 would not be allowed to have direct resident contact or report to their workstation until abuse training is completed. 11. All new hire nursing staff and agency staff will be educated on Abuse and how to identify residents at risk of abuse, by the DON, ADON or LPN Scheduler, Medical Records, or the MDS Coordinator. 12. On 01/05/2020, the Regional MDS Coordinator Consultant in-serviced IDT members on the requirements to up-date the comprehensive care plan for new, worsening and increased behaviors. 13. On 01/05/2020, the DON, ADON, MDS Coordinator, RN or LPN, or Regional MDS Coordinator Consultant in-serviced nine (9) out of sixteen (16) licensed nurses related to documentation of behaviors, including documenting on the Twenty-four (24) Hour Report. Any licensed nurse team members who did not receive this education due to leave of absence or who did not work on 01/05/2020 would not be allowed to have direct resident contact or report to their workstation until their training was completed. 14. On 01/05/2020, the DON, ADON, MDS Coordinator, RN or LPN in-serviced twelve (12) out of twenty-six (26) State Registered Nurse Aides (SRNA) on documenting behaviors in Point of Care (POC) (computerized electronic record). SRNAs not provided the in-service on 01/05/2020 would receive the same in-service prior to working on their next scheduled day. 15. The Interdisciplinary Team (IDT) Members including the DON, ADON, MDS Coordinator, Medical records, and Social Services Director (SSD) will review 100% of residents for signs and symptoms of new, worsening and increased behaviors Monday through Friday, with Saturday and Sunday reviewed on Monday, and identify high risk residents with a behavior mood tracking system. High-risk behaviors will be addressed with seventy-two ([AGE]) hour follow up and referral to Psych services pending behavior. The MDS Coordinator or the ADON will update the care plan with any new interventions. 16. On 01/05/2020, an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON and Medical Director. During the meeting, there was a review of the actions, education, and audits performed by the Center after the 01/03/2020 alleged deficiency. The facility will review any actions or findings of the resident, and/or team member interviews and post-tests after 01/05/2020, in the monthly QAPI meeting, which includes the Administrator, Medical Director, DON and at least three (3) other department heads. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the facility's assignment sheets for B-Wing dated 01/03/2020, revealed SRNA #4 was assigned one-on-one (1:1) monitoring of Resident #4, from 7:00 PM until 11:00 PM shift. Interview with SRNA #4, on 01/13/19, at 9:45 AM, revealed she worked her regular hours from 7:00 AM until 7:00 PM on 01/03/19, and upon request, she sat at the bedside with Resident #4 from 7:00 PM through 11:00 PM. 2. Interview with the Director of Nursing (DON) and Administrator, on 01/13/2020 at 8:15 AM, revealed after the Surveyor's visit on 01/03/2020, staffing was arranged to provide one on one (1:1) monitoring of Resident #4, indefinitely. Observations of Resident #4, 01/13/2020 through [DATE]20, revealed a staff member was sitting at his/her bedside when in his/her room, or was pushing him/her in a wheelchair in the hall. Review of staffing sheets revealed a staff member was assigned for one on one (1:1) monitoring of Resident #4 each shift, which started 01/04/2020. 3. Review of Resident #4's Physician Orders, dated 01/04/2020, revealed orders for [MEDICATION NAME] Patch; apply 0.05 mg, [MEDICATION NAME] one (1) time weekly. Per the Medication Administration Record [REDACTED]. ([MEDICATION NAME] is a female hormone ([MEDICATION NAME]) which is sometimes used to treat sexual inappropriateness of long-term care residents with Dementia) 4. Review of Resident #4's Comprehensive Care Plan, revealed new interventions to observe resident for any signs/symptoms of increased sexual behaviors; one on one (1:1) staff monitoring; notify Physician and psyche services for increases/changes in behavioral symptoms, and maintain a safe environment for resident. These interventions were added to the care plan on 01/04/2020. Interview with the MDS Coordinator, on 01/13/2020 at 11:30 AM, revealed she updated Resident #4's Care Plan with new behavioral interventions on 01/04/2020. 5. Review of the Comprehensive Behavior Care Plan Audit, dated 01/04/2020 and 01/05/2020, revealed nine (9) residents had their behavioral Care Plans modified to address past and current behaviors with person-centered interventions. Nine (9) residents had their behavioral Care Plans modified to address past and current behaviors with patient centered interventions by 01/05/2020. Interview with the ADON, on [DATE]20 at 4:45 PM, verified that on 01/04/2020 and 01/05/2020, the IDT team audited all Care Plans to ensure interventions were in place for residents with high-risk behaviors, and reviewed the Care Plans for accuracy and thoroughness related to behaviors. 6. Review of the Resident Interview Audit, dated 01/04/2020, revealed residents with a BI[CONDITION] of eight (8) or higher were interviewed. All indicated they had not experienced any sexual abuse or abuse of any form. Interview with the DON, on 01/14/2020 at 3:00 PM, revealed all residents in the facility with BI[CONDITION] of eight (8) or higher were interviewed by either the DON, ADON, MDS Coordinator, RN or LPN. Per interview, residents with BI[CONDITION] of seven (7) or less were not interviewed; however, if their families were available, they were interviewed. Review of the full Skin Assessment Audits, conducted 01/04/2020 and 01/05/2020 by the DON, revealed all residents were examined for any undocumented skin issue or injury of unknown origin. No skin issues or injuries of unknown origin were noted. Interview with the DON, on [DATE]20 at 8:30 AM, revealed she made the decision to conduct full skin assessments on all facility residents and she performed the skin assessments on all residents on 01/04/2020 and 01/05/2020. 7. Review of the Behavior Education sheets, dated 01/05/2020, revealed thirty-three (33) team members were interviewed and the interviews were witnessed. The interviews revealed there had not been resident behaviors the facility was unaware of because either staff thought the facility knew of the behaviors or staff thought it was the resident's normal. Interview with the DON, on [DATE]20 at 8:30 AM, revealed staff members were interviewed related to resident behaviors to ens

Based on observation, interview, record review, and review of the facility Controlled Substances Accountability Guideline, it was determined the facility failed to provide medications to meet the needs of the residents and failed to implement procedures for acquiring, receiving, dispensing, documenting and administering medications for seven (7) of ten (10) sampled residents (Resident #1 #5 #6 #7 #8 #9 and #10). Resident #5 had active physician's orders [REDACTED]. However, review of the Controlled Drug Record (CDR), revealed the resident did not receive the scheduled [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches on 03/04/19. Also, Resident #5 had active physician's orders [REDACTED]. However, review of the Electronic Medication Administration Record (EMAR), revealed the resident missed ten (10) doses of [MEDICATION NAME] between 03/01/19 and 03/07/19. The facility was unable to account for the CDR for review, for [MEDICATION NAME] 50 mg from 03/01/19 until 03/07/19. In addition, per the EMAR, the resident received [MEDICATION NAME] 7.5-325 mg tablet, one (1) tablet on 03/01/19 at 2:25 PM; on 03/03/19 at 1:25 PM; on 03/04/19 at 3:49 PM and 10:21 PM; on 03/05/19 at 3:37 PM and 8:22 PM; and on 03/10/19 at 9:08 PM. However, the facility was unable to account for the CDR from 02/22/19 until 03/12/19, for the [MEDICATION NAME]. In addition, Resident #1 had active physician's orders [REDACTED]. Pharmacy delivered a total of two hundred forty (240) [MEDICATION NAME] HCL 4 mg tablets from 01/2019 through 03/07/19; however, the EMAR for the same time period, revealed only fourteen (14) tablets were administered. The facility could not account for the CDR for the [MEDICATION NAME] HCL 4 mg tablets for the timeframe of 01/04/19 through 03/12/19. Also, observation on 03/13/19 of the narcotic count revealed there was no [MEDICATION NAME] HCL 4 mg tablets in the medication cart to count for Resident #1 and no CDR for the missing medication. The Director of Nursing (DON) was unaware the [MEDICATION NAME] HCL 4 mg tablets and the CDR were missing until it was brought to her attention by the State Agency Representative. Also, Resident #1 had active physician's orders [REDACTED]. Review of the CDR from 01/04/19 through 02/07/19, revealed the last dose was signed out on 02/07/19 at 10:00 PM; and review of the facility pharmacy shipment forms revealed [MEDICATION NAME] was not delivered in (MONTH) 2019 for this resident. The (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 300 mg was not signed as administered for fifteen (15) days. The EMAR, further revealed [MEDICATION NAME] was signed as administered on 02/08/19, 02/11/19, 02/13/19, and 02/19/19, even though according to the CDR, the last dose of this medication was signed out on 02/07/19. Additionally, review of the EMAR revealed [MEDICATION NAME] 300 mg was not signed out as administered on 03/01/19, 03/04/19, and 03/05/19. However, the EMAR revealed the [MEDICATION NAME] was signed as administered on 03/02/19, and 03/03/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Additionally, review of Resident #8's Admission physician's orders [REDACTED]. However, per the (MONTH) 2019 EMAR, the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, indicating the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered. Review of the CDR, revealed the medication was signed out on 03/11/19 and 03/14/19; however, the facility could not account for the CDR for the [MEDICATION NAME]es, prior to 03/11/19. Moreover, Resident #6 had active physician's orders [REDACTED].#3, give one (1) tablet every eight (8) hours, scheduled at 6:00 AM, 2:00 PM, and 10:00 PM, with a start date of 10/12/18. Review of the (MONTH) and (MONTH) 2019 EMARs, revealed the Tylenol with [MEDICATION NAME] #3 was signed as administered as scheduled for (MONTH) 2019 and through the review period of 03/14/19. However, there were discrepancies noted related to the doses of medications administered per the EMAR, as compared with the CDR. Review of the CDR, revealed the medication was not signed out as scheduled in (MONTH) for two (2) doses and was not signed out in (MONTH) for three (3) doses, revealing the resident did not receive the medication as ordered. Further review of the CDR, revealed there were four (4) doses signed out on 03/12/19, revealing an extra dose was signed out between 2:00 PM and 10:00 PM, which was not ordered. In addition, the labels on the CDR for the Tylenol with [MEDICATION NAME] #3, delivered 02/06/19, 02/27/19, and 03/11/19, stated [MEDICATION NAME]-[MEDICATION NAME] 300 mg-30 mg (Tylenol with [MEDICATION NAME] #3), give one (1) tablet by mouth every eight (8) hours as needed for pain. Therefore, the CDR label was inaccurate as the medication was ordered scheduled. Furthermore, Resident #7 had active physician's orders [REDACTED]. The Pharmacy Proof of Delivery, revealed [MEDICATION NAME] 5 mg tablets, thirty (30) tablets were delivered on 02/02/19 and twelve (12) tablets were ordered on [DATE], for a total of forty-two (42) tablets. However, review of the (MONTH) 2019 and (MONTH) 2019 EMARs, revealed the resident only received [MEDICATION NAME] 5 mg, one (1) tablet on 03/09/19 at 7:46 AM and one (1) tablet on 03/09/19 at 2:29 PM, for the timeframe reviewed through 03/14/19. The facility could not account for the resident's CDR for the [MEDICATION NAME] tablets prior to 03/09/19. Additionally, Resident #9 had physician's orders [REDACTED]. Review of the Pharmacy's Proof of Delivery, revealed the facility received one hundred-twenty (120) tablets from 01/25/19 until 02/14/19 for four (4) different delivery dates. However, review of the EMAR for (MONTH) 2019 through 03/14/19, revealed the resident only received nine (9) doses of [MEDICATION NAME] 5-325 mg for this same timeframe. Furthermore, the facility was unable to account for the CDR for [MEDICATION NAME] 5-325 mg, prior to 03/11/19. Moreover, Resident #10 had active physician's orders [REDACTED]. Although the EMAR dated (MONTH) 2019, revealed only one (1) dose of [MEDICATION NAME] HCL 5 mg tablet was administered for the for the timeframe reviewed, 02/28/19 through 03/14/19; the CDR revealed twenty-four (24) doses were signed out indicating a significant discrepancy. (Refer to F-602 and F-697) The findings include: Review of the facility's Controlled Substances Accountability Guideline, undated, revealed Controlled Substances-medications included in the Drug Enforcement Administration (DEA) classification as controlled substances by state law are subject to special ordering, receipt, and record keeping requirements in accordance with federal and state laws and regulations. The Director Nursing Services (DNS), in collaboration with consultant pharmacist, shall maintain and ensure center's compliance with all federal and state laws and regulations in the handling of all controlled substance medications. Each individual controlled substance medication shall have its own individual resident controlled substance record. Nurse and witness (licensed nurse or certified medication technician - if allowed by state law) shall login received controlled substance medications onto the change of shift reconciliation log with controlled substance medications being immediately placed into secure storage. For Change of Shift Reconciliation, two (2) licensed nurses are required to conduct the reconciliation of patient specific controlled substances and sign a signature log attesting to the completion and accuracy of the count. Controlled Substances Count Sheets indicating records of usage shall be maintained in sufficient detail to allow reconciliation. The DNS shall reconcile all controlled substances count sheets upon completion of supply and/or destruction subsequent to discontinuation of a controlled substance order or upon resident discharge. 1. Review of Resident #5's clinical record revealed the facility admitted the resident on 08/18/17 with [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 physician's orders [REDACTED]. Additional review revealed orders for [MEDICATION NAME] 12 mcg/hr patch (narcotic pain medication), apply [MEDICATION NAME] every three (3) days (every seventy-two hours) and [MEDICATION NAME] 25 mcg/hr patch apply every three (3) days (every seventy-two hours) for a total of 37 mcg/hr, with a start date of 12/13/18. Further review revealed (MONTH) 2019 physician's orders [REDACTED]. Additional review of Resident #5's (MONTH) 2019 physician's orders [REDACTED]. Review of the (MONTH) 2019 Electronic Medication Administration Record (EMAR), revealed [MEDICATION NAME] 50 mg Capsule one (1) orally every eight (8) was scheduled at 6:00 AM, 2:00 PM and 10:00 PM. However, further review of the EMAR, revealed the medication was not signed out to indicate it was administered on 03/01/19 at 2:00 PM; 03/02/19 at 2:00 PM and 10:00 PM; 03/03/19 at 2:00 PM; 03/04/19 at 10:00 PM; 03/05/19 at 6:00 AM and 10:00 PM; 03/06/19 at 6:00 AM and 2:00 PM; and 03/07/19 at 2:00 PM. Review of the Controlled Drug Record (CDR), revealed the last dose of [MEDICATION NAME] 50 mg capsules was administered on 03/01/19 at 6:00 AM. The facility was unable to account for the CDR for review, for [MEDICATION NAME] 50 mg from 03/01/19 until 03/07/19. Registered Nurse (RN) #2 signed the (MONTH) 2019 EMAR as not administering the [MEDICATION NAME] on 03/04/19 at 10:00 PM, 03/05/19; at 6:00 PM and 10:00 PM; and 03/06/19 at 6:00 AM. Interview with RN #2, on 03/20/19 at 12:30 PM, revealed the [MEDICATION NAME] 50 mg was unavailable for administration on these dates and she failed to follow up to order the medication for the resident. She further stated she was fairly new to the facility and did not remember being educated on re-ordering medication or what to do if a medication was unavailable for administration during orientation at the facility. Continued review of the (MONTH) 2019 EMAR, revealed the resident was ordered [MEDICATION NAME] 7.5-325 mg tablet, one (1) tablet by mouth every four (4) hours PRN (as needed) for moderate to severe pain, starting 03/01/19. Review of the EMAR, revealed the resident received the [MEDICATION NAME] 7.5-325 mg tablet, one (1) tablet on 03/01/19 at 2:25 PM; on 03/03/19 at 1:25 PM; on 03/04/19 at 3:49 PM and 10:21 PM; on 03/05/19 at 3:37 PM and 8:22 PM; and on 03/10/19 at 9:08 PM. However, the facility was unable to account for the CDR for review, from 02/22/19 until 03/12/19, for the [MEDICATION NAME]. Review of Resident #5's (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed as applied on 03/04/19, by Licensed Practical Nurse (LPN) #1. However, review of the CDR, revealed the [MEDICATION NAME] was not signed out on 03/04/19. Further review of the CDR, revealed the [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed out on 03/01/19, and were not signed again until 03/07/19. This revealed the resident went six (6) days between application of the [MEDICATION NAME]es, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. Review of the Resident Incident Report dated 03/07/19, completed by the Director of Nursing (DON), revealed LPN #1 signed the EMAR to indicate the [MEDICATION NAME]es were administered to Resident #5, but failed to apply the patches to the resident on 03/04/19. Interview with LPN #1, on 03/15/19 at 3:00 PM, revealed he did not administer Resident #5's [MEDICATION NAME]es on 03/04/19. He stated although he did sign the patches out on the EMAR, he did not pull them from the narcotic drawer and they could still be accounted for on the CDR. He stated he was unaware of the mistake until the DON talked to him about it later, on 03/07/19. Interview with the DON, on 03/20/19 at 4:00 PM, revealed Resident #5 should have received the [MEDICATION NAME]es and [MEDICATION NAME] medication as prescribed. She stated RN #1 had notified her on 03/07/19, that Resident #5 had not received the [MEDICATION NAME] on 03/04/19. She stated she ensured there was a full facility pain assessment completed for all residents on 03/08/19, by the MDS Nurse, after it was discovered Resident #5 did not receive the [MEDICATION NAME]es as ordered. Per interview, on 03/07/19, there was also a facility wide medication cart audit completed for all medications, and it was discovered narcotics and controlled medications were not available for administration due to the failure to order medications timely for residents, as was the reason Resident #5 did not receive the [MEDICATION NAME] as ordered. Per interview, the facility was unable to locate CDR sheets for Resident #5 related to [MEDICATION NAME] 50 mg from 03/01/19 until 03/07/19; or the PRN [MEDICATION NAME] for the timeframe of 02/22/19 until 03/12/19. 2. Review of Resident #1's clinical record revealed the facility admitted the resident on 08/26/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Monthly (MONTH) 2019 physician's orders [REDACTED]. Further review revealed an active order with a start date of 01/04/19, for [MEDICATION NAME] (medication used to treat nerve pain-controlled substance in Kentucky) 300 mg tablet at nighttime for pain. Review of the pharmacy's shipment of medications for the month of (MONTH) 2019, revealed thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 01/04/19; thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 01/14/19; thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 01/20/19; and thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 01/29/19. This was a total of one hundred twenty (120) doses delivered to the facility in the month of (MONTH) 2019. Review of Resident #1's EMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] HCL 4 mg was administered on 01/14/19 at 10:27AM; 01/15/19 at 9:35 AM; 01/18/19 at 10:54 PM; 01/24/19 at 1:44 PM; 01/25/19 at 1:34 PM and 3:23 PM; and 01/27/19 at 9:29 PM. Although there was one hundred twenty (120) doses of the medication delivered to the facility for the month of (MONTH) 2019; review of the EMAR revealed only seven (7) doses were documented as administered for the month of (MONTH) 2019. Review of the pharmacy's shipment of medications for the month of (MONTH) 2019, revealed thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered to the facility on [DATE]; and thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 02/20/19; for a total of sixty (60) doses delivered to the facility for the month of (MONTH) 2019. Review of the EMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] HCL 4 mg was signed as administered on 02/03/19 at 4:58 PM; 02/18/19 at 5:30 AM; 02/22/19 at 4:50 PM; 02/25/19 at 1:57 PM; and 02/26/19 at 9:53 AM. Although sixty (60) doses of the medication was delivered to the facility for the month of (MONTH) 2019, review of the EMAR revealed only five (5) doses were signed as administered for the month of (MONTH) 2019. Review of the pharmacy's shipment of medications for the month of (MONTH) 2019, revealed thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 03/01/19; and thirty (30) doses of [MEDICATION NAME] HCL 4 mg tablets were delivered on 03/07/19; for a total of sixty (60) doses delivered to the facility from 03/01/19 through 03/07/19. Review of the EMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] HCL 4 mg was signed as administered on 03/02/19 at 11:45 AM and 03/09/19 at 2:54 PM. Although sixty (60) doses of the medication was delivered to the facility from 03/01/19 through 03/07/19, review of the EMAR, revealed there was only two (2) doses signed as administered from the beginning of (MONTH) 2019 until the review period of 03/14/19. Although the pharmacy delivered a total of two hundred forty (240) [MEDICATION NAME] HCL 4 mg tablets from (MONTH) 2019 through 03/07/19 to the facility; the EMARs for the same time frame, revealed only fourteen (14) tablets were administered. The facility was unable to locate the CDR, to compare with the EMARs for the [MEDICATION NAME] HCL 4 mg tablets for the timeframe of 01/04/19 through 03/12/19. Observation on 03/13/19 at 3:30 PM, of the narcotic count on the Therapy Hall, where Resident #1 resided, revealed there was no [MEDICATION NAME] HCL 4 mg tablets in the cart to count and no CDR for the medication to review. Interview with the DON, on 03/20/19 at 4:00 PM, revealed when she completed the audit of the narcotics in the building on 03/07/19, by checking each medication cart with the EMAR to ensure the narcotic medications prescribed were available for the residents, she identified Resident #1 did have [MEDICATION NAME] HCL 4 mg tablets available. However, she stated she did not write down the number of tablets that were in the cart with her audit or compare the pill count with the CDR. She further stated the facility had not identified there were missing [MEDICATION NAME] HCL 4 mg tablets and a missing CDR for the medication until this was brought to her attention by the State Agency Representative. Continued interview revealed the resident was not at the facility at present, as the resident had been hosptalized on [DATE], and was still in the hospital. Review of the Pharmacy Proof of Delivery for the month of (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE]. Review of the EMAR dated (MONTH) 2019, revealed the [MEDICATION NAME] 300 mg was signed as administered from 01/04/19 through 01/31/19 as ordered. Review of the Controlled Drug Record for the timeframe of 01/04/19 through 02/07/19, revealed [MEDICATION NAME] 300 mg, was signed out for all thirty (30) doses of medication, with the last dose signed out on 02/07/19 at 10:00 PM. Review of the Refill Reorder Form, dated 02/04/19, completed by Registered Nurse (RN) #2, revealed a refill was requested for [MEDICATION NAME] 300 mg tablets. However, review of the pharmacy's shipment of medications to the facility for the month of (MONTH) 2019, revealed the facility did not receive a shipment of [MEDICATION NAME] for Resident #1. Review of the EMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 300 mg was not documented as administered on the 9th, 10th, 12th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 23rd, 25th, 26th, 27th and the 28th of the month, fifteen (15) days. However, the medication was documented as administered on the 8th, 11th, 13th, and 19th, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the EMAR dated (MONTH) 2019, revealed [MEDICATION NAME] 300mg was not documented administered on the 1st, 4th and 5th of the month. However, the medication was documented as administered on 03/02/19, and 03/03/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the Pharmacy Proof of Delivery for the month of (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE]. Interview with Registered Nurse (RN) #2, on 03/20/19 at 12:30 PM, revealed in (MONTH) 2019, she did send a refill request to the pharmacy for Resident #1's [MEDICATION NAME]. She stated she was aware Resident #1 went a long time without the [MEDICATION NAME] available to administer during the following shifts she worked. Further interview revealed she informed the day shift nurses the medication was unavailable;however, they did not follow up. Per the EMAR, RN #2 signed she did not administer [MEDICATION NAME] for Resident #1 on 02/09/18, 02/10/19, 02/14/19, 02/16/29, 02/17/19, 02/18/19, 02/20/19, 02/21/19, 02/25/19, 02/26/19, 02/27/19, 03/04/19, and 03/05/19. Per the staffing sheets, RN #3 was the other nurse assigned to the resident during the nights in which the resident did not receive [MEDICATION NAME] as ordered for (MONTH) and (MONTH) 2019. The State Agency Representative phoned RN #3 on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM; and left messages to return the call; however, there was no return call. Interview with LPN #1, on 03/19/19 at 2:00 PM, revealed he was assigned to Resident #1 on day shift for most days in (MONTH) and (MONTH) 2019; however, he did not remember RN #2 asking him or other nurses to re-order [MEDICATION NAME] for Resident #1, and he was unaware the resident did not receive this medication as ordered. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she was unaware Resident #1 had not received [MEDICATION NAME] as scheduled in (MONTH) and (MONTH) 2019 until the facility completed the audit related to narcotics and controlled medications on 03/14/19. She further stated the nurses should have re-ordered the [MEDICATION NAME] prior to the medication running out. Continued interview revealed she was unaware a total of two hundred forty (240) [MEDICATION NAME] HCL 4 mg tablets were delivered from (MONTH) 2019 through 03/07/19 to the facility; and the EMAR revealed only fourteen (14) tablets were administered during this time period until she was notified of this by the State Agency Representative, on 03/14/19. 3. Review of Resident #8's clinical record revealed the facility admitted the resident on 02/27/19 with [DIAGNOSES REDACTED]. Review of Resident #8's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #8's ARNP Note, dated 03/05/19, revealed the resident had increased back pain, and would like a pain patch as he/she had been on the [MEDICATION NAME] for quite some time. Will go ahead and order [MEDICATION NAME]. Continued review of the Note, under the Medications Ordered Section, revealed [MEDICATION NAME] 25 (mcg)/per hour, one (1) patch today and one (1) patch every seventy-two (72) hours, starting 03/05/19, for low back pain. However, the facility could not locate a physician's orders [REDACTED]. Review of Resident #8's EMAR, dated (MONTH) 2019, revealed the resident was to receive [MEDICATION NAME] 25 mcg/hr mcg every seventy-two (72) hours with an order date of 02/27/19, and start date of 03/02/19. The EMAR was signed to indicate the [MEDICATION NAME] 25 mcg patch was applied on 03/02/19; however, the EMAR was not signed to indicate the patch was applied on 03/05/19. In addition, the facility could not account for the CDR for the [MEDICATION NAME] 25 mcg/hr patch to review in order to verify if the medication was signed out for 03/02/19 and 03/05/19. Review of the EMAR, dated (MONTH) 2019, revealed the Admission physician's orders [REDACTED]. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was re-ordered on [DATE], with a start date of 03/07/19, and stop date of 03/14/19, with no instructions on how often the patch was to be administered. Per the EMAR, the [MEDICATION NAME] 25 mcg/hr patch was applied on 03/07/19 at 10:00 PM, by RN #3. However, there was no documented evidence of a new physician's orders [REDACTED]. Also, there was no documented evidence of a CDR to review to verify the [MEDICATION NAME] was signed out on 03/07/19. Furthermore, the facility was unable to account for a CDR for Resident #8's [MEDICATION NAME]es from 02/27/19 through 03/11/19. The State Agency Representative phoned RN #3, on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM; however, a message could not be left for the RN to return the call. Review of Telephone Orders dated 03/11/19, revealed orders for [MEDICATION NAME] 25 mcg patch, apply and change every seventy-two (72) hours. Review of the Pharmacy's Proof of Delivery, revealed five (5) [MEDICATION NAME] 25 mcg patches were delivered to the facility on [DATE] at 7:52 PM. Review of the CDR for the [MEDICATION NAME] 25 mcg/hr patches delivered on 03/11/19, revealed a [MEDICATION NAME] 25 mcg/hr patch was signed out on 03/11/19 at 8:00 PM by RN #3. However, review of the EMAR revealed the [MEDICATION NAME] 25 mcg/hr patch was not signed to indicate the medication was applied on 03/11/19 by RN #3. Further review of the EMAR, revealed [MEDICATION NAME] 25 mcg/hr patch was signed out on 03/07/19, and was not signed out again until 03/14/19, seven (7) days later. Per the Admission physician's orders [REDACTED].#8 should have received the [MEDICATION NAME] 25 mcg/hr patch on 03/02/19, 03/05/19, 03/08/19, 03/11/19, and 03/14/19. However, per the EMAR, the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, revealing the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered. Review of the CDR, revealed the medication was signed out on 03/11/19 and 03/14/19; however, the facility could not account for the CDR to review for the [MEDICATION NAME]es prior to 03/11/19. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she could not locate and was unable to account for the CDR sheet for the [MEDICATION NAME]es for Resident #8 prior to 03/11/8. Continued interview revealed she was unable to find a physician's orders [REDACTED]. Further interview revealed there was discrepancies in the EMAR and the CDR related to the [MEDICATION NAME]es being signed out as administered for Resident #8, which indicated the resident did not receive the medication as ordered. 4. Review of Resident #6's clinical record revealed the facility admitted the resident on 02/10/18 with [DIAGNOSES REDACTED]. Review of Resident #6's (MONTH) 2019 physician's orders [REDACTED].#3, (narcotic pain medication) one (1) tablet every eight (8) hours, at 6:00 AM, 2:00 PM and 10:00 PM, with an order date of 10/11/18 and start date of 10/12/18. The order did not specify milligrams for the medication in the physician's orders [REDACTED].>In addition, the labels on the CDR for the Tylenol with [MEDICATION NAME] #3, delivered 02/06/19, 02/27/19, and 03/11/19, stated [MEDICATION NAME]-[MEDICATION NAME] 300 mg-30 mg (Tylenol with [MEDICATION NAME] #3), give one (1) tablet by mouth every eight (8) hours as needed for pain. Therefore, the CDR label was inaccurate as the medication was ordered scheduled and not PRN. Review of the (MONTH) and (MONTH) 2019 EMARs, revealed Tylenol with [MEDICATION NAME] #3, one (1) tablet every eight (8) hours, was scheduled for 6:00 AM, 2:00 PM, and 10:00 PM. Per the EMAR, the medication was signed out as administered per this schedule for (MONTH) and (MONTH) 2019. However, there were discrepancies in the doses of medications administered per the EMAR, as compared with the CDR. Review of the CDR for [MEDICATION NAME]-[MEDICATION NAME] 300 mg-30 mg (Tylenol with [MEDICATION NAME] #3), revealed the medication was not signed out for the following scheduled doses: 02/05/19 at 6:00 AM; 02/28/19 at 6:00 AM; 03/05/19 at 6:00 AM dose; 03/07/19 at 10:00 PM or 03/08/19 at 6:00 AM dose (could not decipher due to illegible). Further review revealed there were four (4) doses signed out on the CDR for 03/12/19 with illegible times, revealing an extra dose was signed out between 2:00 PM and 10:00 PM, which was not ordered. Also, the medication was not signed out on the CDR on 03/13/19 for the 6:00 AM dose. Although RN #4 signed the EMAR to indicate the medication was administered on 02/05/19 at 6:00 AM; and 02/28/19 at 6:00 AM; RN #4 did not sign out the medication on the CDR for the Tylenol with [MEDICATION NAME] #3, on 02/05/19 at 6:00 AM; and 02/28/19 at 6:00 AM. The State Agency Representative phoned RN #4 for interview on 03/14/19 at 12:30 PM; 03/15/18 at 12:10 PM; and 03/16/19 at 11:39 AM; and left a message; however, there was no return phone call. RN #3 signed the EMAR to indicate the medication was administered on 03/05/19 at 6:00 AM, but did not sign the CDR for the Tylenol with [MEDICATION NAME] #3, on 03/05/19 at 6:00 AM. The State Agency Representative attempted to interview RN #3 via phone, on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM. However, the RN was unable to be reached by phone. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she was not informed of the discrepancy related to the physician's orders [REDACTED].#3 for Resident #6, and stated this should have been corrected. Continued interview revealed Resident #6 should have received the Tylenol with [MEDICATION NAME] #3 pain medication in (MONTH) and (MONTH) 2019 as scheduled, and an extra dose should not have been signed out on the CDR, on 03/12/19. She stated there should not have been discrepancies in comparing the EMAR with the CDR for Resident #6's Tylenol with [MEDICATION NAME] #3. 5. Review of Resident #10's medical record revealed the facility admitted the resident on 02/27/19 with the [DIAGNOSES REDACTED]. Review of the Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #10's EMAR, revealed one (1) dose of [MEDICATION NAME] HCL 5 mg tablet was administered for the month of (MONTH) 2019, and this dose was administered on 03/14/19 at 4:40 AM, by RN #2. However, review of the CDR, revealed [MEDICATION NAME] HCL 5 mg tablet, one (1) tablet was administered on 03/01/19 at 5:30 AM; 03/02/19 at 8:00 PM; 03/03/19 at 2:00 AM; 03/04/19 at 2:00 AM, 3:00 AM, 10:19 AM, and 9:00 PM; 03/06/19 at 12:10 PM and 10:00 PM; 03/07/19 at 9:34 AM and 5:37 PM; 03/08/19 at 3:05 PM; 03/09/19 at 7:40 AM and 5:27 PM; 03/10/19 at 9:20 AM; 03/11/19 at 9:30 AM, and 10:15 PM; an illegible date and time; 03/12/19 at 9:44 AM and 8:00 PM; 03/13/19 at 2:30 AM and 11:25 AM; and 03/14/19 at 4:30 AM and 2:40 PM. This was a total of twenty-four (24) doses signed out on the CDR through the review date of 03/14/19. Although signatures on the CDR were illegible, RN #3 was assigned to the medication cart for these dates and times in which the [MEDICATION NAME] HCL 5 mg tablet was signed out for Resident #10: 0

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to ensure residents were free from significant medication errors related to narcotic and controlled pain medications for four (4) of ten (10) sampled residents (Residents #1 #5 #6 and #8). Resident #5 was receiving Palliative Care for pain management; however, the resident did not receive the scheduled [MEDICATION NAME] 25 micrograms per hour (mcg/hr) and [MEDICATION NAME] 12 mcg/hr (narcotic medication for severe pain) [MEDICATION NAME] as ordered on [DATE]. Therefore, the resident went six (6) days between application of the [MEDICATION NAME]es, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. In addition, Resident #5 missed ten (10) doses of the scheduled [MEDICATION NAME] 50 mg Capsule (medication to treat nerve damage) between 03/01/19 and 03/07/19. On 03/05/19, Resident #5 started complaining of nausea and vomiting, and the Provider was notified. New orders were received for [MEDICATION NAME] (medication for nausea and vomiting). On 03/07/19, when the [MEDICATION NAME]es were applied as ordered, staff interview revealed the resident's symptoms of nausea and vomiting subsided within approximately thirty (30) minutes, indicating the resident was having withdrawal symptoms from not receiving pain medications as ordered. Interview with Resident #5, revealed he/she suffered with flu like symptoms and had increased pain the first week of (MONTH) 2019. In addition, Resident #1 was receiving Hospice Care, and per the Controlled Drug Record (CDR), the resident received the last dose of [MEDICATION NAME] 300 mg (medication used to treat nerve pain) which was scheduled every night for pain, on 02/07/19. Review of the Pharmacy Proof of Delivery forms, revealed there was no [MEDICATION NAME] delivered for this resident in (MONTH) 2019, and the medication was not delivered to the facility until 03/06/19. The Electronic Administration Record (EMAR) revealed the medication was not signed out for fifteen (15) days in (MONTH) 2019 and was not signed out as administered on 03/02/19, and 03/03/19. However, the medication was signed out as administered on the EMAR on 02/08/19, 02/11/19, 02/13/19, and 02/19/19, 03/01/19, 03/04/19, and 03/05/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Additionally, Resident #8's Admission physician's orders [REDACTED]. However, review of the (MONTH) 2019 EMAR, revealed the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, indicating the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered. Review of the CDR, revealed the medication was signed out on 03/11/19 and 03/14/19; however, the facility could not locate the CDR to review for the [MEDICATION NAME]es, prior to 03/11/19. The Nurse's Note dated 03/06/19, written by the Minimum Data Set (MD) Nurse, revealed the resident was in pain at a level of eight (8) out of ten (10) constantly through his/her upper body and legs; and the Palliative Provider Notes, dated 03/11/19, revealed the resident complained of bad pain that started at the lower back and extended into both lower extremities. Furthermore, Resident #6 had active physician's orders [REDACTED].#3, one (1) tablet every eight (8) hours, at 6:00 AM, 2:00 PM, and 10:00 PM, with a start date of 10/12/18. Although review of the (MONTH) and (MONTH) 2019 EMARs, revealed the medication was signed as administered for the scheduled times, review of the CDR, revealed the medication was not signed out as scheduled in (MONTH) for two (2) doses and was not signed out in (MONTH) for three (3) doses, revealing the resident did not receive the medication as ordered. Interview with Resident #6, revealed when he/she requested his/her scheduled pain medication, the nurse would tell him/her it had already been administered. Substandard Quality of Care (SQC) with actual harm was identified related to the facility's failure to ensure residents are free from significant medication errors. (Refer to F-602, F-697, and F-755) The findings include: Review of the facility's Medication-Related Errors Policy, dated 12/01/07, revealed the facility should notify pharmacy of any possible dispensing occurrence; and notify physician/prescriber to obtain further instructions and/or orders. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 08/18/17 with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the facility assessed the resident's pain management for the past five (5) days as the resident receiving scheduled and PRN (as needed) pain medications, as the resident having pain rarely, and as the resident having mild pain. Review of Resident #5's Comprehensive Care Plan (CCP), with a problem initiated 09/12/13, revealed the resident had chronic pain issues (low back, arthritis, left shoulder pain, right hip pain, gout and history of migraines), and was receiving palliative care for pain management. The goal revealed the resident would have an acceptable comfort level through 04/20/19. There were several approaches including: observe for pain including type, intensity, duration, location, alleviating and aggravating factors; administer pain medications as ordered and observed for effectiveness; offer/assist with repositioning during Certified Nursing Assistant (CNA) rounds and as needed; report uncontrolled pain to the physician; observe for side effects such as stomach pain, nausea, constipation, and dizziness; labs as ordered; refer to rehab as warranted; apply patches for pain as ordered, observe for side effects and adverse reactions; and correlate all pain management with palliative care for appropriate pain interventions. Review of Resident #5's (MONTH) 2019 physician's orders [REDACTED]. Further review of the (MONTH) 2019 physician's orders [REDACTED]. Continued review of Resident #5's (MONTH) 2019 physician's orders [REDACTED]. Review of the (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed as applied on 03/04/19 by Licensed Practical Nurse (LPN) #1; however, review of the CDR, revealed there were no patches signed out on 03/04/19. Review of the CDR, revealed the [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed out on 03/01/19, and were not signed again until 03/07/19. This revealed the resident went six (6) days between application of the [MEDICATION NAME]es, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. Continued review of Resident #5's (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 50 mg Capsule one (1) orally every eight (8) was scheduled at 6:00 AM, 2:00 PM and 10:00 PM. However, the medication was not signed out to indicate it was administered on 03/01/19 at 2:00 PM; 03/02/19 at 2:00 PM and 10:00 PM; 03/03/19 at 2:00 PM; 03/04/19 at 10:00 PM; 03/05/19 at 6:00 AM and 10:00 PM; 03/06/19 at 6:00 AM and 2:00 PM; and 03/07/19 at 2:00 PM. Review of the CDR, revealed the last dose of [MEDICATION NAME] 50 mg capsules was administered on 03/01/19 at 6:00 AM. The facility was unable to locate the CDR for [MEDICATION NAME] 50 mg from 03/01/19 until 03/07/19. Registered Nurse (RN) #2 signed the EMAR as not administering the [MEDICATION NAME] as scheduled on 03/04/19 at 10:00 PM, 03/05/19 at 6:00 PM and 10:00 PM; and 03/06/19 at 6:00 AM. Interview with RN #2, on 03/20/19 at 12:30 PM, revealed the [MEDICATION NAME] 50 mg was not available for administration on these dates and she did not ensure the medication was re-ordered for Resident #5, as she was fairly new at the facility and did not understand the procedure to re-order medications. Further review of the (MONTH) 2019 EMAR, revealed the resident received [MEDICATION NAME] 7.5-325 mg tablet, one (1) tablet PRN on 03/01/19 at 2:25 PM; on 03/03/19 at 1:25 PM; on 03/04/19 at 3:49 PM and 10:21 PM; 03/05/19 at 3:37 PM and 8:22 PM; and on 03/10/19 at 9:08 PM. The facility was unable to locate a CDR for review from 02/22/19 until 03/12/19 for the [MEDICATION NAME]. Interview with Resident #5, on 03/15/19 at 2:30 PM, revealed he/she did not receive his/her [MEDICATION NAME] at the beginning of (MONTH) and staff also failed to change his/her [MEDICATION NAME]es. He/she stated he/she requested additional [MEDICATION NAME] for increased pain during this time. Resident #5 further stated when he/she did not receive the medication as scheduled, it felt like he/she was coming down with the flu. Further interview revealed he/she suffered from nausea and vomiting which started around 03/05/19. Review of Resident #5's Progress Note, dated 03/05/19 at 4:25 PM, completed by RN #1, revealed the resident complained of nausea and vomiting, and the Advanced Registered Nurse Practitioner (ARNP) was available to assess the resident. Further review of the Note, revealed new orders were received for [MEDICATION NAME] 4 mg by mouth every six (4) hours as needed for nausea. Review of the ARNP Note, dated 03/05/19, revealed the patient complained of nausea and chills, denied any vomiting or diarrhea, had been afebrile, and would like something to help with nausea. Review of the Resident Incident Report dated 03/07/19, completed by the Director of Nursing (DON), revealed LPN #1 signed the EMAR to indicate the [MEDICATION NAME]es were administered; however, failed to apply the patch to the resident on 03/04/19. Interview with LPN #1, on 03/15/19 at 3:00 PM, revealed he did not administer Resident #5's [MEDICATION NAME]es on 03/04/19. Per interview, he did sign as administering the patches on the EMAR, but did not pull the medication from the narcotic drawer and the patches could still be accounted for on the CDR. He revealed this was an oversight and he was unaware of the mistake until the DON talked to him about it later, on 03/07/19. Interview with RN #1, on 03/15/19 at 1:19 PM, revealed she was assigned to Resident #5 on 03/05/19, and on that date the resident complained of nausea and vomiting. Per interview, the ARNP was at the facility and she asked the ARNP to assess the resident. Further, the ARNP wrote a new order for [MEDICATION NAME] 4 mg every six (6) hours PRN for nausea. Per interview, to her knowledge, Resident #5 never vomited and his/her vital signs were normal; however, the resident just kept complaining of not feeling well, and the [MEDICATION NAME] helped. She stated she checked Resident #5's patch on 03/07/19, prior to administering a new [MEDICATION NAME] and identified the old patch was dated 03/01/19. Per interview, she then contacted the DON to inform her of this. RN #1 stated the new [MEDICATION NAME] was applied to the resident on 03/07/19 and his/her symptoms of nausea and vomiting subsided within approximately thirty (30) minutes. RN #1 further stated the resident acted as though he/she was having withdrawal symptoms from not receiving the medication. Interview with the ARNP, on 03/14/19 at 11:30 AM, revealed she assessed Resident #5 on 03/05/19, and the resident had no fever, but was complaining of nausea, vomiting and chills at the time of her assessment. She stated, with a [MEDICAL CONDITION] infection a person would typically have a fever with nausea, vomiting and or diarrhea. However, she further stated with withdrawal symptoms, a person would have similar symptoms and would typically have shaking, nausea and vomiting, yet no fever. Additional interview with the ARNP, on 03/20/19 at 1:20 PM, revealed she was unaware Resident #5 went without his/her [MEDICATION NAME]es being applied as ordered and was unaware the resident was not receiving the ordered dosages of [MEDICATION NAME] for nerve pain during this same timeframe. She stated she was unaware the resident did not receive the pain medication as ordered until this interview. Review of Resident #5 Palliative ARNP Note, dated 03/11/19 at 1:00 PM, revealed the resident told her his/her [MEDICATION NAME] had not been not been changed for six (6) days and his/her pain increased from a seven (7) out of ten (10) compared to the usual three (3) to four (4) out of ten (10) when he/she routinely received the [MEDICATION NAME]. According to the Note, the resident was having pain in the right lateral and posterior hip. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed she assessed Resident #5 on 03/11/19; however, at that time she was unaware the resident went without the [MEDICATION NAME] from 03/01/19 until 03/07/19, until the resident notified her. Further interview revealed she was unaware the resident had not received the [MEDICATION NAME] medication as ordered 03/01/19 through 03/07/19. Per interview, it was her expectation all medications be administered as prescribed. Interview with the DON, on 03/20/19 at 4:00 PM, revealed Resident #5 did not receive the [MEDICATION NAME] as scheduled on 03/04/19, and this was a significant medication error. She further stated Resident #5 also did not receive the [MEDICATION NAME] as ordered for several doses in the beginning of (MONTH) 2019, which was also a significant medication error. Per interview, it was discovered Resident #5 was having withdrawal symptoms from not receiving the pain medications as ordered. 2. Review of Resident #1's medical record revealed the facility admitted the resident on 08/26/14 with diagnoses, which included Chronic Diastolic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Review of the CCP initiated 04/04/17, revealed the resident was at risk for altered comfort and pain and was currently receiving hospice care related to a history of generalized aches and the resident was able to make needs known; request PRN (as needed) pain medication when needed and relate effectiveness of the pain medication. The goal revealed the resident would remain comfortable throughout hospice care and the resident would not have any unidentified pain thorough 05/01/19. There were several approaches which included: coordinate the resident's care with the hospice team; coordinate with the hospice team to assure the resident experiences as little pain as possible; observe pain if occurring for type, intensity, duration, location, and alleviating and aggravating factors; report uncontrolled pain to the Physician; encourage to elevate feet as much as possible; and administer pain medication as ordered, observing for effectiveness and for adverse reactions/side effects. Review of the Annual MDS Assessment, dated 02/07/19, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed Resident #1's pain management for the past five (5) days as the resident having a scheduled pain medication regimen; receiving PRN pain medications; and having frequent pain making it hard to sleep at night. Further review revealed on a numeric scale of zero (0) to ten (10), the resident's pain was a ten (10). Additional review of the MDS Assessment revealed the facility assessed the resident as receiving Opioid Medication seven (7) days out of seven (7) days; and as receiving Hospice Care. Review of the Monthly (MONTH) 2019 physician's orders [REDACTED]. Further review revealed an active order with a start date of 01/04/19, for [MEDICATION NAME] (controlled substance in Kentucky) 300 mg tablet at nighttime for pain. Review of the Pharmacy Proof of Delivery for (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE]. Review of the EMAR dated (MONTH) 2019, revealed [MEDICATION NAME] 300 mg was documented as administered from 01/04/19 through 01/31/19 as ordered. Review of the CDR for 01/04/19 through 02/07/19, revealed [MEDICATION NAME] 300 mg, was signed out for all thirty (30) doses of medication, with the last dose signed out on 02/07/19 at 10:00 PM. Review of the Refill Reorder Form, dated 02/04/19, completed by RN #2, revealed a refill was requested for [MEDICATION NAME] 300 mg tablets. Review of the pharmacy's shipment of medications for the month of (MONTH) 2019, revealed the pharmacy did not deliver any shipments of [MEDICATION NAME] for Resident #1. Review of the EMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 300 mg was not signed as administered on the 9th, 10th, 12th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 23rd, 25th, 26th, 27th and the 28th of the month, a total of fifteen (15) days. However, the [MEDICATION NAME] 300 mg was signed out as administered on the 8th, 11th, 13th, and 19th, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the EMAR dated (MONTH) 2019, revealed [MEDICATION NAME] 300 mg was not signed out as administered on the 1st, 4th and 5th of the month. However, [MEDICATION NAME] 300 mg was signed out as administered on 03/02/19, and 03/03/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the pharmacy's shipment for the month of (MONTH) 2019, revealed thirty (30) doses of [MEDICATION NAME] 300 mg tablets, were delivered to the facility on [DATE]. Interview with RN #2, on 03/20/19 at 12:30 PM, revealed in (MONTH) 2019, she did send a refill request to the pharmacy for Resident #1's [MEDICATION NAME]. She stated she was aware Resident #1 went a long time without the [MEDICATION NAME] available to administer during the following shifts she worked. Per interview, she had informed the day shift nurses the medication was unavailable, thinking they would follow up and ensure the medication was obtained from pharmacy. Per Resident #1's (MONTH) 2019 EMAR, RN #2 signed as not administering the [MEDICATION NAME] 300 mg, on 02/09/18, 02/10/19, 02/14/19, 02/16/19, 02/17/19, 02/18/19, 02/20/19, 02/21/19, 02/25/19, 02/26/19, 02/27/19, 03/04/19, and 03/05/19. Review of the staffing sheets, revealed RN #3 was the other nurse assigned to the resident during the nights in which the resident did not receive [MEDICATION NAME] as ordered. The State Agency Representative attempted interview via phone with RN #3, on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM; and left messages to return the call; however, there was no return phone call. Interview with LPN #1, on 03/19/19 at 2:00 PM, revealed he was assigned to Resident #1 on day shift for most days in (MONTH) and (MONTH) 2019; however, he did not recall RN #2 asking him or other nurses to re-order [MEDICATION NAME] for Resident #1, and he was not aware the resident did not receive this medication as ordered. Interview with Resident #1, on 03/19/19 at 12:30 PM, revealed he/she was not currently in pain. The resident stated he/she could not recall if he/she had any concerns with pain medications being administered while at the facility. Interview with the Hospice Physician, on 03/13/19 at 1:30 PM, revealed he increased Resident #1's pain medication on 01/04/19, and he felt like the resident's pain was under control when he assessed the resident on 03/06/19. However, he stated he had only written a prescription for thirty (30) tablets on 01/04/19 for the [MEDICATION NAME]. Per interview, he was unaware the resident had not received this medication as ordered in (MONTH) and March, and he should have been notified of the need for a new prescription for [MEDICATION NAME], prior to the resident running out of the medication. Per interview, this medication was ordered for the resident's nerve pain, and it was important for the resident to receive the medication as ordered. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she was unaware Resident #1 had not received [MEDICATION NAME] as scheduled in (MONTH) and (MONTH) 2019 until the facility completed the audit related to narcotics and controlled medications on 03/14/19. Further interview revealed the nurses should have re-ordered the [MEDICATION NAME] by pulling the bar code re-order label off the blister pack of medication and placing it on the Refill-Re-order Form and faxing it to pharmacy prior to the medication running out. 3. Review of Resident #8's medical record revealed the facility admitted the resident on 02/27/19 with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan, dated 02/27/19, revealed a problem of Pain, and the Care Plan stated the resident would remain comfortable and as free of pain as was possible. The interventions included: administer pain medications as ordered; monitor for effectiveness and document results; and notify the Physician for additional interventions. Review of Resident #8's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) which indicated moderate cognitive impairment. Additional review revealed the facility assessed the resident's pain management for the past five (5) days as receiving a scheduled pain medication regimen; as receiving no PRN pain medications; as having almost constant pain; as pain affecting the resident's ability to sleep at night and limiting the resident's day to day activities; and as pain presence of an eight (8) on a numeric scale of zero (0) to ten (10). Review of the Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #8's ARNP Note, dated 03/05/19, revealed the resident had increased back pain, and would like a pain patch as he/she had been on the [MEDICATION NAME] for quite some time. Will go ahead and order [MEDICATION NAME]. Additional review of the Note, under the Medications Ordered Section, revealed [MEDICATION NAME] 25 (mcg)/per hour, one (1) patch today and one (1) patch every seventy-two (72) hours, starting 03/05/19, for low back pain. However, the facility could not locate a physician's orders [REDACTED]. Review of Resident #8's (MONTH) 2019 EMAR, revealed the resident was to receive [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours with an order date of 02/27/19, and a start date of 03/02/19. Further review of the EMAR, revealed the [MEDICATION NAME] 25 mcg/hr patch was applied on 03/02/19; however, the EMAR was not signed to indicate the patch was applied on 03/05/19. Additionally, the facility could not locate the CDR for Resident #8's [MEDICATION NAME] 25 mcg patch to review in order to verify if the medication was signed out for 03/02/19 and 03/05/19. Review of the Nurse's Notes, dated 03/06/19 at 4:45 PM, completed by the MDS Nurse, revealed Resident #8 complained to the MDS Nurse during the admission pain assessment, stating he/she had pain at a level of eight (8) out of ten (10) constantly through his/her upper body and legs. There was no subsequent follow up note related to the resident's pain on that date. (Refer to F-697) Further review of the (MONTH) 2019 EMAR, revealed the admission order for [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours with an order date of 02/27/19, and a start date of 03/02/19, was discontinued on 03/07/19. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was also re-ordered on [DATE], with a start date of 03/07/19, and a stop date of 03/14/19, with no instructions on how often the patch was to be administered. Further review of the EMAR, revealed the patch was applied on 03/07/19 at 10:00 PM, by RN #3. However, there was no documented evidence of a new physician's orders [REDACTED]. Also, there was no documented evidence of a CDR to review to verify the [MEDICATION NAME] was signed out on 03/07/19. Additionally, the facility was unable to submit for review, a CDR for Resident #8's [MEDICATION NAME]es from 02/27/19 until 03/11/19 to review for dates the [MEDICATION NAME] was signed out. The State Agency Representative attempted to interview RN #3 via phone, on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM; however, the RN was unable to be reached. Review of Resident #8's Palliative Provider Notes, dated 03/11/19, revealed the resident complained of bad pain that started at the lower back and extended into both lower extremities- the left much worse than the right. Additional review revealed the resident noted his/her [MEDICATION NAME] was due to be changed yesterday, yet there was no script available for refill. Review of Telephone Orders dated 03/11/19 revealed a new order for [MEDICATION NAME] 25 mcg/hr patch, apply and change every seventy-two (72) hours. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed when a resident was admitted to the facility there would be a brief lapse until palliative could come to the facility to assess a new resident, and until then there was an agreement that the Medical Director would cover the patients until palliative could assess the resident, including ensuring pain medication was ordered with scripts available for refills as needed. She stated she did come to the facility on [DATE] to assess Resident #8 and to write a prescription for [MEDICATION NAME]es to help control his/her pain. She further stated she was not notified until this interview, the [MEDICATION NAME] had not been signed out on the EMAR as administered on 03/05/19. Review of the Pharmacy's Shipment Summary, revealed five (5) [MEDICATION NAME] 25 mcg/hr patches were delivered to the facility on [DATE] at 7:52 PM. Review of the CDR for the [MEDICATION NAME] 25 mcg/hr patches delivered on 03/11/19, revealed a patch was signed out on 03/11/19 at 8:00 PM by RN #3. However, review of the EMAR revealed the [MEDICATION NAME] 25 mcg/hr patch was not signed as applied on 03/11/19 by RN #3. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was signed out on 03/07/19, and was not signed out again until 03/14/19, seven (7) days later. Per Resident #8's Admission physician's orders [REDACTED]. However, per the EMAR, the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, indicating the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered for pain. The CDR revealed the medication was signed out on 03/11/19 and 03/14/19; however, there was no documented evidence of a CDR to review for the [MEDICATION NAME]es prior to 03/11/19. Interview with the DON, on 03/20/19 at 4:00 PM, confirmed she was unable to account for the CDR sheet for the [MEDICATION NAME]es for Resident #8 prior to 03/11/19. Additionally, she stated she was unable to find a physician's orders [REDACTED]. Further, there was discrepancies in the EMAR and the CDR related to the [MEDICATION NAME]es being signed out as administered for Resident #8, which indicated the resident did not receive the medication as ordered. Per interview, it was a significant medication error for Resident #8 not to receive the [MEDICATION NAME]es as ordered. Per interview, the resident suffered from pain as indicated in the Nurse's Notes and the Provider Notes. 4. Review of Resident #6's medical record revealed the facility admitted the resident on 02/10/18 with diagnoses, which included Unspecified Cyst of the Bone, and End Stage [MEDICAL CONDITION]. Review of the CCP, dated 02/18/18, revealed a problem of being at risk for or having the presence of pain. The goal revealed the resident's pain level would not inhibit quality of life or activity tolerance. There were several approaches including: observe resident's pain daily using one to ten (1-10) scale with prompt pain management as ordered; administer resident's pain medication as ordered with observation of effectiveness to ensure relief; assist resident with diversional activity; resident prefers to rest in bed after receiving pain medication; assist resident to change positions slowly; observe for worsening symptoms and report to the physician, and observe for verbal/nonverbal indicators of pain. Review of the Annual MDS Assessment, dated 02/16/19, revealed the facility assessed Resident #6 having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Additional review revealed the facility assessed the resident's pain management for the past five (5) days as being on a scheduled pain regimen; not receiving any PRN pain medications; and as having no symptoms of pain or pain presence. Review of the (MONTH) 2019 physician's orders [REDACTED].#3, (narcotic pain medication) one (1) tablet every eight (8) hours, at 6:00 AM, 2:00 PM and 10:00 PM, with an order date of 10/11/18 and a start date of 10/12/18. (There was no milligram noted for the medication per the physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) 2019 EMARs, revealed Tylenol with [MEDICATION NAME] #3, one (1) tablet every eight (8) hours, was scheduled to be administered at 6:00 AM, 2:00 PM, and 10:00 PM. Per the EMAR, the medication was administered as scheduled for (MONTH) and (MONTH) 2019. However, there were discrepancies in the doses of medications administered per the EMAR, as compared with the CDR. Review of the CDR for [MEDICATION NAME]-[MEDICATION NAME] 300 mg-30 mg (Tylenol with [MEDICATION NAME] #3), revealed the medication was not signed out for the following scheduled doses: 02/05/19 at 6:00 AM; 02/28/19 at 6:00 AM; 03/05/19 at 6:00 AM dose; 03/07/19 at 10:00 PM or 03/08/19 at 6:00 AM dose (could not decipher due to illegible). Further review revealed there was also four (4) doses signed out on 03/12/19 with illegible times, revealing an extra dose was signed out between 2:00 PM and 10:00 PM, which was not ordered. In addition, the medication was not signed out on 03/13/19 for the 6:00 AM dose. RN #3 did not sign the CDR for the Tylenol with [MEDICATION NAME] #3, on 03/05/19 for the 6:00 AM dose. The State Agency Representative attempted interview via phone with RN #3, on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM. However, the RN could not be reached. RN #4 did not sign the CDR for the Tylenol with [MEDICATION NAME] #3, on 02/05/19 at 6:00 AM; and 02/28/19 at 6:00 AM. The State Agency Representative attempted interview via phone with RN #4 on 03/14/19 at 12:30 PM; 03/15/18 at 12:10 PM; and 03/16/19 at 11:39 AM and left a message; however, there was no return phone call. Interview with Resident #6, on 03/15/19 at 2:10 PM, revealed he/she often times would request pain medication when it was due, and the nurse would tell him/her it had already been administered. P

Based on interview, record review, review of the Director of Nursing and Administrator's Job Descriptions and review of the Plan of Correction (P[NAME]) for the Recertification Survey/ Abbreviated Survey, dated 08/30/18, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. The facility submitted an acceptable Plan of Correction (P[NAME]) in response to the deficiency cited related to pharmacy services on the Recertification/Abbreviated Survey concluded on 08/30/18, with a compliance date of 10/13/18. However, the facility failed to maintain substantial compliance as it was identified during the Abbreviated/Partial Extended Survey concluded on 03/20/19, the facility to implement procedures for acquiring, receiving, dispensing, documenting and administering medications to meet the needs of its residents. Substandard Quality of Care (SQC) with Actual Harm was identified related to the facility's systemic failure. This failure affected seven (7) of ten (10) sampled residents (Resident #1 #5 #6 #7 #8 #9 and #10). The findings include: Review of the facility's Job Description for Administrator, undated, revealed the Administrator reports to the Regional Vice President. The Administrator directs, oversees and manages the 24/7 day to day operations of the Diversicare post-acute care center. Further review revealed the Administrator's Key Responsibilities included: ensures the patient and resident is at the center of every decision made; ensures compliance with State and Federal Regulations; ensures adoption of Diversicare policies, guidelines and standards; ensures quality care and services are provided to all patients, residents and that it meets the satisfaction of the patient, resident, family, physicians and other partners. Review of the facility's Job Description for Director of Nursing (DON), undated, revealed the DON reports to the Administrator. The DON manages the Department of Nursing in accordance with policy and procedure, and state and federal regulations to promote high quality care and service to the facility and community. Further review revealed the DON's Key Responsibilities included: assumes responsibility of facility in absence of Administrator; ensures positive outcomes are accomplished for residents; responsible to develop systems and work schedules that respect resident's lifestyle and ensure the resident reaches the highest attainable level of functioning; makes rounds at least daily; follows up daily on each shift to ensure changes in status are reported and recorded; deals with families and residents when issues arise and handles complaints; and provides education regarding care as needed. Review of the DON's training record revealed Acknowledgment of Receipt of the Facility's On 08/30/18, a Recertification Survey/Abbreviated Survey was conducted at the facility and deficient practice was determined to exist at 42 CFR 483.45 Pharmacy Services related to the facility's failure to ensure a prescription for [MEDICATION NAME] (controlled anti-anxiety medication) to the Electronic physician's orders [REDACTED]. During the Abbreviated/Partial Extended Survey concluded on 03/20/19, it was identified residents did not receive narcotic and controlled substance pain medications as ordered; narcotic and controlled substance medications were not available for administration; there were discrepancies in the EMAR and the CDR related to medications signed out as administered; CDRs could not be accounted for; there were significantly more narcotic or controlled substance medications delivered from pharmacy as compared with the medications administered; staff was unaware of the procedure for ordering narcotic/controlled substance medications; and there was drug diversion at the facility. Interview with the DON on 03/20/19 at 4:00 PM, revealed it was her job to implement policies and procedures with follow-up and supervision of staff to ensure compliance. She further stated it was her job to follow up and supervise nursing staff, and to provide adequate oversight to the staff in regards to the facility's controlled drug system. Per interview, there was a system failure related to acquiring, receiving, documenting and administering narcotic pain medication and controlled pain medications. Further interview revealed residents did not receive pain medications as ordered for their pain management, causing concern related to negative outcomes for the residents. Interview with the Regional Nurse of Operations, on 03/20/19 at 6:45 PM, revealed the facility's controlled system had not been effective as residents had not received pain medications as ordered. She stated the current issues found on this Survey were due to a huge disconnect in the system. Interview with the Administrator, on 03/20/19 at 5:24 PM, revealed he realized there were discrepancies in the medications signed out on EMAR and the CDR and residents were not receiving pain medications as ordered. He further stated there was new staff hired which may not have been educated related to the controlled drug system. Further interview revealed there were missing narcotics as well as missing CDR sheets which could not be accounted for, as well as there was significantly more controlled drugs delivered from pharmacy than were signed as administered per the EMAR and the CDR which indicated drug diversion. Continued interview revealed he was ultimately responsible for what occurred in the facility and it was his job to provide oversight. He stated there was a huge system failure in regards to narcotic pain medication, a failure for A to Z.

Based on observation, interview, record review, review of the facility's Guidelines, and review of the Plan of Correction (P[NAME]) for the Recertification Survey/Abbreviated Survey, dated 08/30/18, it was determined the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) Program that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies from the Abbreviated/Partial Extended Survey conducted on 03/20/19, related to pharmacy services. Although deficient practice was cited on the 08/30/18 Recertification Survey/Abbreviated Survey related to pharmacy services, it was identified during the Abbreviated/Partial Extended Survey concluded on 03/20/19, the facility to implement procedures for acquiring, receiving, dispensing, documenting and administering medications to meet the needs of its residents. Substandard Quality of Care (SQC) with Actual Harm was identified related to the facility's systemic failure. This failure affected seven (7) of ten (10) sampled residents (Resident #1 #5 #6 #7 #8 #9 and #10). The findings include: Review of the facility's Quality Assurance and Process Improvement Meeting Guidelines, Template 2014, revealed the mission of the Quality Assessment and Process Improvement (QAPI) was to improve every life touched by providing exceptional healthcare and exceeding expectations. Further review revealed the purpose was to monitor core processes to identify trends and variations through appropriate analysis of data from multiple data sources. Continued review revealed a Performance Improvement Project (PIP) was a concentrated effort on a particular problem in one area of the facility or facility wide; it involved gathering information systematically to clarify issues or problems, and intervening for improvements. Additional review revealed the facility would conduct PIPs to examine and improve care or services in areas that the facility identified as needing attention. Continued review revealed the guidelines addressed utilizing Infection Control Surveillance Documents for Patterns and Trends. Review of the facility's Controlled Substances Accountability Guideline, undated, revealed Controlled Substances-medications included in the Drug Enforcement Administration (DEA) classification as controlled substances by state law are subject to special ordering, receipt, and record keeping requirements in accordance with federal and state laws and regulations. The Director Nursing Services (DNS), in collaboration with consultant pharmacist, shall maintain and ensure center's compliance with all federal and state laws and regulations in the handling of all controlled substance medications. Each individual controlled substance medication shall have its own individual resident controlled substance record. Nurse and witness (licensed nurse or certified medication technician - if allowed by state law) shall login received controlled substance medications onto the change of shift reconciliation log with controlled substance medications being immediately placed into secure storage. For Change of Shift Reconciliation, two (2) licensed nurses are required to conduct the reconciliation of patient specific controlled substances and sign a signature log attesting to the completion and accuracy of the count. Controlled Substances Count Sheets indicating records of usage shall be maintained in sufficient detail to allow reconciliation. The DNS shall reconcile all controlled substances count sheets upon completion of supply and/or destruction subsequent to discontinuation of a controlled substance order or upon resident discharge. Based on observation, interview and record review, it was determined the facility failed to implement procedures for acquiring, receiving, dispensing, documenting and administering medications to meet the needs of its residents. This was a repeat deficiency for the facility which was cited 08/30/18 related to the facility's failure to transcribe a prescription for [MEDICATION NAME] (anti-anxiety medication) to the Electronic physician's orders [REDACTED]. Review of the facility's Plan of Correction (P[NAME]), with a compliance date of 10/13/18, revealed education was provided to all licensed nurses and Kentucky Medication Aides (KMAs) on ensuring prescriptions were written as physician's orders [REDACTED]. The inservices were completed by 10/11/18, and going forward all newly hired licensed nurses and agency would be inserviced on the EMAR and Narcotic Count Sheet documentation process. The CDR sheets would be turned into the Director of Nursing (DON), who would validate administration and provide to the Health Information Management's Coordinator for filing. Additional review of the P[NAME], revealed an audit would be conducted to validate there were no discrepancies in narcotics documented in comparing the EMAR and the CDR. In daily clinical start up the Interdisciplinary Team (IDT) would compare physician's orders [REDACTED]. The audits would be conducted on ten (10) records daily for four (4) weeks, then three (3) times weekly for four (4) weeks, then weekly for four (4) weeks. The results of the audits would be presented to the QAPI committee in the October, (MONTH) and (MONTH) (YEAR) meetings and continued audits would be determined by the QAPI committee. During this survey it was identified Resident #5 did not receive the scheduled [MEDICATION NAME] 25 micrograms per hours (mcg/hr) and [MEDICATION NAME] 12 mcg/hr patches (narcotic pain medication) on 03/04/19, and did not receive ten (10) doses of the prescribed [MEDICATION NAME] 50 milligrams (mg) Capsule (scheduled V controlled substance) between 03/01/19 and 03/07/19. On 03/05/19, the resident complained of nausea and vomiting indicating he/she was suffering from withdrawal symptoms from not receiving the medication as ordered. The facility was unable to account for the [MEDICATION NAME] CDR from 03/01/19 until 03/07/19 and was also was unable to account for the CDR from 02/22/19 until 03/12/19, for the prescribed [MEDICATION NAME] (narcotic medication). Actual Harm was identified. Also, pharmacy delivered a total of two hundred forty (240) [MEDICATION NAME] HCL 4 mg tablets from 01/2019 through 03/07/19 for Resident #1; however, the EMAR for the same time period, revealed only fourteen (14) tablets were administered and the facility could not account for the CDR for the [MEDICATION NAME] HCL 4 mg tablets for the timeframe of 01/04/19 through 03/12/19. In addition, observation on 03/13/19, of the medication cart narcotic count, revealed there was no [MEDICATION NAME] HCL 4 mg tablets in the medication cart to count for Resident #1 and the CDR was also missing; however, the facility was unaware the medication and CDR were missing. Also, per the CDR, Resident #1's last dose of [MEDICATION NAME] 300 mg was signed out on 02/07/19, and per the pharmacy's shipment of medication, the medication was not delivered to the facility until 03/06/19, revealing the resident did not receive the prescribed [MEDICATION NAME] 300 mg tablet at nighttime. Additionally, record review revealed Resident #8 should have received the ordered [MEDICATION NAME] 25 mcg/hr patch on 03/02/19, 03/05/19, 03/08/19, 03/11/19, and 03/14/19. However, per the (MONTH) 2019 EMAR, the medication was only signed as administered on 03/02/19, 03/07/19, and 03/14/19. The medication was signed out on the CDR for 03/11/19 and 03/14/19; however, the facility could not account for the CDR for the [MEDICATION NAME]es, prior to 03/11/19. Moreover, there were discrepancies noted related to the doses of medications administered per the EMAR, as compared with the CDR for Resident #6 for the prescribed scheduled Tylenol with [MEDICATION NAME] #3 (narcotic pain medication). The (MONTH) and (MONTH) 2019 EMARs, revealed the Tylenol with [MEDICATION NAME] #3 was signed as administered as scheduled for (MONTH) 2019 and through the review period of 03/14/19. However, the CDR, revealed the medication was not signed out as scheduled in (MONTH) for two (2) doses and was not signed out in (MONTH) 2019 for three (3) doses, revealing the resident did not receive the medication as ordered. Further review of the CDR, revealed there were four (4) doses signed out on 03/12/19, revealing an extra dose was signed out between 2:00 PM and 10:00 PM, which was not ordered. Furthermore, the Pharmacy Proof of Delivery, revealed [MEDICATION NAME] 5 mg tablets, thirty (30) tablets were delivered on 02/02/19 and twelve (12) tablets were ordered on [DATE], for a total of forty-two (42) tablets for Resident #7. However, review of the (MONTH) 2019 and (MONTH) 2019 EMARs, revealed the resident only received two (2) tablets 02/2019 through the timeframe reviewed of 03/14/19. The facility could not account for the resident's CDR for the [MEDICATION NAME] tablets prior to 03/09/19. Additionally, the Pharmacy's Proof of Delivery, revealed the facility received one hundred-twenty (120) tablets total from 01/25/19 until 02/14/19 during four (4) different delivery dates for [MEDICATION NAME] 5-325 mg for Resident #9; however, review of the EMAR for (MONTH) 2019 through 03/14/19, revealed the resident only received nine (9) doses of [MEDICATION NAME] 5-325 mg during this same timeframe. Furthermore, the facility was unable to account for the CDR for [MEDICATION NAME] 5-325 mg, prior to 03/11/19. In addition, Although Resident #10's EMAR dated (MONTH) 2019, revealed only one (1) dose of [MEDICATION NAME] HCL 5 mg tablet was administered for the timeframe reviewed, 02/28/19 through 03/14/19; the CDR revealed twenty-four (24) doses were signed out indicating a significant discrepancy. Interview with the Director of Nursing (DON), on 03/20/19 at 4:00 PM, revealed during this survey the same issues were identified that were occurring in (MONTH) (YEAR), such as discrepancies in narcotics and controlled medications signed out on the EMAR as compared to the CDR. She further stated education was presented related to the controlled drug system after the survey in (MONTH) (YEAR) for the licensed nurses and the KMAs; however, she was not sure if new hires received the education which was presented after the (MONTH) (YEAR) survey. Continued interview revealed the facility performed audits to compare medication signed out on the EMAR with the CDR as per the P[NAME] for three (3) months, and during the last month of audits there were no concerns noted. The DON stated the QAPI committee felt like the audits could end after (MONTH) (YEAR). and therefore there was no further auditing of the CDR system after the month of December. Continued interview revealed when it was reported Resident #5 did not receive the [MEDICATION NAME] as ordered on [DATE], additional audits were completed and the facility identified there were discrepancies again in signing out narcotics and controlled medications per the CDR and the EMARs, and the facility also identified narcotics and controlled medications were not available for administration as prescribed due to the failure to re-order the medications. Further interview with the DON, revealed the process for licensed nursing staff to receive narcotic and controlled medication when delivered from pharmacy, was for the nurse to obtain the medication card blister pack containing the medications and compare it to the CDR to ensure accuracy; sign the CDR to verify who received the medication; sign the pharmacy delivery slip and place it in the DON's mailbox; and immediately place the narcotic medication into the locked narcotic box on the medication cart and place the CDR into the narcotic count sheet book. Additional interview revealed the facility was unaware there were missing narcotics and missing CDR sheets until this survey when it was brought up by the Surveyor that two hundred forty (240) [MEDICATION NAME] HCL 4 mg tablets were delivered from 01/2019 through 03/07/19 to the facility; and the EMAR revealed only fourteen (14) tablets were administered during this same time period for Resident #1, indicating drug diversion. The DON stated, if the nurse receiving the narcotics from the person delivering the medications from pharmacy kept the medication, the CDR, and the delivery slip there would be no way of knowing the medication had been delivered. Further interview with the DON, revealed there was a system failure. She stated continued audits may have help to catch some of the issues noted during this survey such as drug diversion, unaccounted for CDR sheets, and the fact that residents were not receiving medications as prescribed. Interview with the Regional Nurse of Operations, on 03/20/19 at 6:45 PM, revealed she was not in charge of this facility during the time of the last survey in (MONTH) (YEAR) when the facility was cited related to pharmacy services. Further interview revealed she did not think the implemented plan of action to correct the deficiency after the (MONTH) (YEAR) survey would have caught some of the issues identified during this survey. She stated there was a huge disconnect in the system. Interview with the Administrator, on 03/20/19 at 5:24 PM, revealed the facility performed audits and monitoring of the controlled drug system up until (MONTH) (YEAR). He stated if there had been continued monitoring of the controlled drug system including comparing the EMAR and the CDR, as well as monitoring of documents related to pharmacy shipment of narcotics/controlled medications, the facility may have recognized there was significantly more narcotic medications delivered from pharmacy than were administered, and residents were not receiving medications as ordered. He further stated there should have been effective monitoring of the controlled drug system and this may have prevented the drug diversion.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure pain management is provided to residents who require such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for four (4) of ten (10) sampled residents (Residents #1 #5 #6 and #8). Resident #5 was receiving Palliative Care for pain management and had active physician's orders [REDACTED]. However, review of the Controlled Drug Record (CDR), revealed the resident did not receive the scheduled [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches on 03/04/19. In addition, Resident #5 had active physician's orders [REDACTED]. However, review of the Electronic Medication Administration Record [REDACTED]. On 03/05/19, Resident #5 complained of nausea and vomiting, the Provider was notified, and new orders were received for [MEDICATION NAME] medication. On 03/07/19, when the [MEDICATION NAME]es were applied as ordered, the resident's symptoms of nausea and vomiting subsided within approximately thirty (30) minutes, indicating the resident was having withdrawal symptoms from not receiving pain medications as ordered. Interview with Resident #5, revealed he/she suffered with flu like symptoms and had increased pain the first week of (MONTH) 2019. In addition, Resident #1 was receiving Hospice Care, and had active physician's orders [REDACTED]. Review of the CDR from 01/04/19 through 02/07/19, revealed the last dose was signed out on 02/07/19 at 10:00 PM. Review of the facility pharmacy shipment forms revealed there was no [MEDICATION NAME] delivered in (MONTH) 2019 for this resident. Review of the EMAR, revealed [MEDICATION NAME] 300 mg was not signed as administered fifteen (15) days in (MONTH) 2019. Also, review of the EMAR, revealed the medication was signed as administered on 02/08/19, 02/11/19, 02/13/19, and 02/19/19, even though according to the CDR, the last dose was signed out on 02/07/19. In addition, review of the EMAR revealed [MEDICATION NAME] 300 mg was not signed out as administered on 03/01/19, 03/04/19, and 03/05/19. However, the medication was signed out as administered on 03/02/19, and 03/03/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Additionally, review of Resident #8's Admission physician's orders [REDACTED]. However, per the EMAR, the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, indicating the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered. Review of the CDR, revealed the medication was signed out on 03/11/19 and 03/14/19; however, there was no documented evidence of a CDR to review for the [MEDICATION NAME]es, prior to 03/11/19. The Nurse's Note dated 03/06/19, written by the Minimum Data Set (MD) Nurse, revealed the resident was in pain at a level of eight (8) out of ten (10) constantly through his/her upper body and legs and she had notified the floor nurse; however, there was no documented evidence the floor nurse followed up to assess the resident related to his/her pain. Furthermore, Resident #6 had active physician's orders [REDACTED].#3, one (1) tablet every eight (8) hours, scheduled at 6:00 AM, 2:00 PM, and 10:00 PM, with a start date of 10/12/18. Review of the (MONTH) and (MONTH) 2019 EMARs, revealed the medication was signed administered as scheduled for (MONTH) and (MONTH) 2019. However, there were discrepancies in the doses of medications administered per the EMAR, compared with the CDR. Review of the CDR, revealed the medication was not signed out as scheduled in (MONTH) for two (2) doses and was not signed out in (MONTH) for three (3) doses, revealing the resident did not receive the medication as ordered. Interview with Resident #6, revealed when he/she requested his/her pain medication, the nurse would tell him/her it had already been administered. Substandard Quality of Care (SQC) with actual harm was identified related to the facility's failure to ensure pain management was provided. (Refer to F-600, F-655, F-656, F-755, and F-760) The findings include: Review of the facility's Policy, titled Pain Management dated (MONTH) (YEAR), revealed the purpose is to provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life. Further review revealed ongoing pain monitoring and effectiveness of interventions is noted in the electronic medical record through the EMAR (Electronic Medication Administration Record) system and progress notes. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 08/18/17 with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) revealing moderate cognitive impairment. Further review revealed the facility assessed the resident's pain management for the past five (5) days as the resident receiving scheduled and PRN (as needed) pain medications, as the resident having pain rarely, and as the resident having mild pain. Review of Resident #5's Comprehensive Care Plan, with a problem onset date of 09/12/13, revealed the resident had chronic pain issues (low back, arthritis, left shoulder pain, right hip pain, gout and history of migraines), and was on palliative care for pain management. The goal stated the resident would have an acceptable comfort level through 04/20/19. The approaches included: observe for pain including type, intensity, duration, location, alleviating and aggravating factors; administer pain medications as ordered and observed for effectiveness; offer/assist with repositioning during Certified Nursing Assistant (CNA) rounds and as needed; report uncontrolled pain to the physician; observe for side effects such as stomach pain, nausea, constipation, and dizziness; labs as ordered; refer to rehab as warranted; apply patches for pain as ordered, observe for side effects and adverse reactions; and correlate all pain management with palliative care for appropriate pain interventions. Review of Resident #5's (MONTH) 2019 physician's orders [REDACTED]. Further review revealed orders for [MEDICATION NAME] 12 microgram mcg/hr patch (narcotic pain medication), apply [MEDICATION NAME] every three (3) days (every seventy-two hours) and [MEDICATION NAME] 25 mcg/hr patch apply every three (3) days (every seventy-two hours) for a total of 37 mcg, with a start date of 12/13/18. Additional review revealed (MONTH) 2019 physician's orders [REDACTED]. Continued review of Resident #5's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #5's (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 50 mg Capsule one (1) orally every eight (8) was scheduled at 6:00 AM, 2:00 PM and 10:00 PM. However, the medication was not signed out to indicate it was administered on 03/01/19 at 2:00 PM; 03/02/19 at 2:00 PM and 10:00 PM; 03/03/19 at 2:00 PM; 03/04/19 at 10:00 PM; 03/05/19 at 6:00 AM and 10:00 PM; 03/06/19 at 6:00 AM and 2:00 PM; and 03/07/19 at 2:00 PM. Per the CDR, the last dose of [MEDICATION NAME] 50 mg capsules was administered on 03/01/19 at 6:00 AM. The facility was not able to locate the CDR for [MEDICATION NAME] 50 mg for the timeframe of 03/01/19 through 03/07/19. Registered Nurse (RN) #2 signed the EMAR as not administering the [MEDICATION NAME] on 03/04/19 at 10:00 PM; 03/05/19 at 6:00 PM and 10:00 PM; and 03/06/19 at 6:00 AM. Interview with RN #2, on 03/20/19 at 12:30 PM, revealed the [MEDICATION NAME] 50 mg was not available for administration on these dates and she failed to ensure the medication was re-ordered for the resident. Per interview she was fairly new at the facility at the time and did not understand how to re-order medications. Additional review of the (MONTH) 2019 EMAR, revealed the resident was ordered [MEDICATION NAME] 7.5-325 mg tablet, one (1) tablet by mouth every four (4) hours PRN (as needed) for moderate to severe pain, starting 03/01/19. Per the EMAR, [MEDICATION NAME] 7.5-325 mg tablet, one (1) tablet was administered on 03/01/19 at 2:25 PM for a pain level of six (6) out of ten (10) on a numeric scale of zero (0) to ten (10) with ten (10) being the highest level of pain. Further review of the EMAR, revealed [MEDICATION NAME] 7.5-325 mg one (1) tablet was administered on 03/03/19 at 1:25 PM for a pain level of five (5); one (1) tablet was administered on 03/04/19 at 3:49 PM for a pain level of four (4) and one (1) tablet was administered at 10:21 PM for a pain level of six (6); one (1) tablet was administered on 03/05/19 at 3:37 PM for a pain level of seven (7), and one (1) tablet was administered at 8:22 PM for a pain level of six (6); and one (1) tablet was administered on 03/10/19 at 9:08 PM for a pain level of six (6). However, the facility could not submit a CDR for review from 02/22/19 until 03/12/19 for the [MEDICATION NAME]. Review of the (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed as applied on 03/04/19 by Licensed Practical Nurse (LPN) #1. However, review of the CDR revealed there were no patches signed out on 03/04/19. Per review of the CDR, the [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed out on 03/01/19, and were not signed again until 03/07/19. This indicated the resident went six (6) days between application of the [MEDICATION NAME]es, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. Interview with Resident #5, on 03/15/19 at 2:30 PM, revealed he/she went a week without receiving his/her [MEDICATION NAME] at the beginning of (MONTH) and staff also failed to change his/her [MEDICATION NAME]es. Per interview, he/she requested additional [MEDICATION NAME] for increased pain during this time. Resident #5 stated when he/she did not receive the medication as scheduled, he/she felt like he/she was coming down with the flu. Per interview, he/she suffered from nausea and vomiting which started around 03/05/19. Review of Resident #5's Progress Note, dated 03/05/19 at 4:25 PM, completed by RN #1, revealed the resident complained of nausea and vomiting, and the Advanced Registered Nurse Practitioner (ARNP) was here to assess the resident. Per the Note, new orders were received for [MEDICATION NAME] 4 mg by mouth every six (4) hours as needed for nausea (medication used for nausea and vomiting). Review of the ARNP Note, dated 03/05/19, revealed the patient complains of nausea and chills, denies any vomiting or diarrhea and had been afebrile, and would like something to help with nausea. Review of the Resident Incident Report dated 03/07/19, completed by the Director of Nursing (DON), revealed LPN #1 signed the EMAR to indicate the [MEDICATION NAME]es were administered, but failed to apply the patch to the resident on 03/04/19. Interview with LPN #1, on 03/15/19 at 3:00 PM, revealed he failed to administer Resident #5's [MEDICATION NAME]es on 03/04/19. He stated he did sign the patches out on the EMAR, yet he did not pull them from the narcotic drawer and they could still be accounted for on the CDR. He stated he just forgot. Further interview revealed his job was very hectic and often times he would get busy and had very little time to complete what was expected of him. He stated he was unaware of the mistake until the DON talked to him about it later, on 03/07/19. Interview with RN #1, on 03/15/19 at 1:19 PM, revealed when she worked on 03/05/19, Resident #5 was complaining of nausea and vomiting. She stated the ARNP was in the building and she had the ARNP assess the resident. Per interview, the ARNP wrote a new order for [MEDICATION NAME] 4 mg every six (6) hours as needed for nausea. She stated to her knowledge, Resident #5 never vomited and his/her vital signs were normal; however, the resident just kept complaining of not feeling well, and the [MEDICATION NAME] did help. She further stated she checked Resident #5's patch on 03/07/19, prior to administering a new [MEDICATION NAME] and noticed the old patch was dated 03/01/19. Per interview, she then contacted the DON to make her aware. Further interview revealed the Incident Report was completed by the DON, and the Medical Director was notified the resident had not received the [MEDICATION NAME] by the DON. Further, RN #1 stated she did not notify the resident's Palliative ARNP that the resident had not received the [MEDICATION NAME] as ordered. RN #1 stated the new patch was applied to the resident on 03/07/19 and his/her symptoms of nausea and vomiting subsided within approximately thirty (30) minutes. RN #1 further stated it was like the resident was having withdrawal symptoms from not receiving the medication. Interview with the ARNP, on 03/14/19 at 11:30 AM, revealed there was [MEDICAL CONDITION] going around at the facility which involved complaints of nausea and vomiting and when she assessed Resident #5 on 03/05/19, she assumed this was the reason for the resident's symptoms. She stated Resident #5 had no fever and was complaining of nausea, vomiting and chills at the time of her assessment. Per interview, with a [MEDICAL CONDITION] infection a person would typically have a fever with nausea, vomiting and or diarrhea. However, she stated with withdrawal symptoms, a person would have similar symptoms and would typically have shaking, nausea and vomiting, yet no fever. Further interview with the ARNP, on 03/20/19 at 1:20 PM, revealed she was unaware Resident #5 went without his/her [MEDICATION NAME]es being applied as ordered and was unaware the resident was not receiving adequate dosages of [MEDICATION NAME] for nerve pain during this same timeframe. She stated this was only brought to her attention during this interview. Review of the Palliative ARNP Note, dated 03/11/19 at 1:00 PM, revealed Resident #5 told her his/her [MEDICATION NAME] had not been not been changed for six (6) days and his/her pain increased from a seven (7) out of ten (10) compared to the usual three (3) to four (4) out of ten (10) when he/she routinely received the [MEDICATION NAME]. Per the Note, the pain was in the right lateral and posterior hip. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed she assessed Resident #5 on 03/11/19; however, at that time she was unaware the resident went without the [MEDICATION NAME] from 03/01/19 until 03/07/19, until the resident informed her. Further interview revealed she was unaware the resident had not received the [MEDICATION NAME] medication as ordered 03/01/19 through 03/07/19 and stated this was probably due to staff failing to re-order the medication timely. She stated it was her expectation all narcotic and controlled medications be ordered timely and administered as prescribed. Interview with the DON, on 03/20/19 at 4:00 PM, revealed Resident #5 should have received his/her [MEDICATION NAME] and [MEDICATION NAME] medication as prescribed. She stated RN #1 had notified her on 03/07/19, that Resident #5 had not received the [MEDICATION NAME] on 03/04/19. She stated a full facility pain assessment was completed for all residents on 03/08/19, by the MDS Nurse after it was discovered Resident #5 was having withdrawal symptoms from not receiving the [MEDICATION NAME]. Per interview, on 03/07/19, there was also a facility wide medication cart audit for all medications, and it was discovered narcotics and controlled medications were not available for administration due to the failure to order medications timely, as was the reason Resident #5 did not receive the [MEDICATION NAME] as ordered. 2. Review of Resident #1's medical record revealed the facility admitted the resident on 08/26/14 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan initiated 04/04/17, revealed Resident #1 was at risk for altered comfort and pain and was currently on hospice care related to a history of generalized aches and the resident was able to make needs known; request PRN (as needed) pain medication when needed and relate effectiveness of the pain medication. The goal stated the resident would remain comfortable throughout hospice care and the resident would not have any unidentified pain thorough 05/01/19. There were several approaches including: coordinate the resident's care with the hospice team; coordinate with the hospice team to assure the resident experiences as little pain as possible; observe pain if occurring for type, intensity, duration, location, and alleviating and aggravating factors; report uncontrolled pain to the Physician; encourage to elevate feet as much as possible; and administer pain medication as ordered, observing for effectiveness and for adverse reactions/side effects. Review of Resident #1's Annual MDS Assessment, dated 02/07/19, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident's pain management for the past five (5) days as the resident having a scheduled pain medication regimen; receiving PRN (as needed) pain medications; and having frequent pain making it hard to sleep at night. Further review revealed on a numeric scale of zero (0) to ten (10), the resident's pain was a ten (10). Continued review of the MDS Assessment, revealed the facility assessed the resident as receiving Opioid Medication seven (7) days out of seven (7) days; and as receiving Hospice Care. Review of Resident #1's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the pharmacy's shipment for the month of (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE]. Review of the EMAR dated (MONTH) 2019, revealed the [MEDICATION NAME] 300 mg was documented as administered from 01/04/19 through 01/31/19 as ordered. Review of the CDR from 01/04/19 through 02/07/19, revealed [MEDICATION NAME] 300 mg, was signed out for all thirty (30) doses of medication, with the last dose signed out on 02/07/19 at 10:00 PM. Review of the facility's Refill Reorder Form, dated 02/04/19, completed by Registered Nurse (RN) #2, revealed a refill was requested for [MEDICATION NAME] 300 mg tablets. Review of the pharmacy's shipment of medications to the facility for the month of (MONTH) 2019, revealed the facility did not receive any shipments of [MEDICATION NAME] for Resident #1. Review of the EMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 300 mg was not signed as administered on the 9th, 10th, 12th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 23rd, 25th, 26th, 27th and the 28th of the month, fifteen (15) days. However, the medication was signed out as administered on the 8th, 11th, 13th, and 19th, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the EMAR dated (MONTH) 2019, revealed [MEDICATION NAME] 300 mg was not signed out as administered on the 1st, 4th and 5th of the month. However, the medication was signed out as administered on 03/02/19, and 03/03/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the pharmacy's shipment for the month of (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE]. Interview with Registered Nurse (RN) #2, on 03/20/19 at 12:30 PM, revealed in (MONTH) 2019, she did send a refill request to the pharmacy in regards to Resident #1's [MEDICATION NAME]. She further stated she was aware Resident #1 went a long time without the [MEDICATION NAME] available to administer during the following shifts she worked. Further interview revealed she had informed the day shift nurses the medication was unavailable, thinking they would follow up. Per the EMAR, RN #2 signed as not administering the [MEDICATION NAME] for Resident #1 on 02/09/18, 02/10/19, 02/14/19, 02/16/19, 02/17/19, 02/18/19, 02/20/19, 02/21/19, 02/25/19, 02/26/19, 02/27/19, 03/04/19, and 03/05/19. Per the staffing sheets, RN #3 was the other nurse assigned to the resident during the nights in which the resident did not receive [MEDICATION NAME] as ordered. The State Agency Representative phoned RN #3 on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM; and left messages to return the call; however, there was no return phone call. Interview with LPN #1, on 03/19/19 at 2:00 PM, revealed he was assigned to Resident #1 on day shift for most days in (MONTH) and (MONTH) 2019; however, he did not remember RN #2 asking him or other nurses to re-order [MEDICATION NAME] for Resident #1, and he was unaware the resident did not receive this medication. Observation and interview with Resident #1, on 03/19/19 at 12:30 PM, revealed he/she was sitting at the bedside eating lunch. He/she stated he/she was not in pain. Per interview, the resident could not recall if he/she had any concerns with pain medications being administered while at the facility. Interview with the Hospice Physician, on 03/13/19 at 1:30 PM, revealed he increased Resident #1's pain medication on 01/04/19, and he felt like the resident's pain was under control when he assessed the resident on 03/06/19. However, per interview, he had only written a prescription for thirty (30) tablets on 01/04/19 for the [MEDICATION NAME]. He stated he was unaware the resident had not received this medication as ordered in (MONTH) and March, and he should have been notified of the need for a new prescription for [MEDICATION NAME], prior to the resident running out of the medication. Further interview revealed this medication was ordered for the resident's nerve pain, and it was important for the resident to receive the medication as ordered. Interview with the DON, on 03/20/19 at 4:00 PM, revealed the facility had completed audits in the past to compare the EMAR with the CDR to ensure there were no discrepancies in the doses signed out as administered and to ensure medication was being signed out to indicate it was administered as ordered; however, the last audit was completed in (MONTH) (YEAR). Continued interview revealed she was unaware Resident #1 had not received [MEDICATION NAME] as scheduled in (MONTH) and (MONTH) 2019 until the facility completed the audit related to narcotics and controlled medications on 03/14/19. She stated the nurses should have re-ordered the [MEDICATION NAME] by pulling the bar code re-order label off the blister pack of medication and placing it on the Refill-Re-order Form and faxed it to pharmacy prior to the medication running out. 3. Review of Resident #8's medical record revealed the facility admitted the resident on 02/27/19 with [DIAGNOSES REDACTED]. Review of Resident #8's Baseline Care Plan, dated 02/27/19, revealed a problem of Pain, and per the Care Plan, the resident would remain comfortable and as free of pain as was possible. The interventions included: administer pain medications as ordered; monitor for effectiveness and document results; and notify Physician for additional interventions. Review of Resident #8's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Continued review revealed the facility assessed the resident's pain management for the past five (5) days as receiving a scheduled pain medication regimen; as receiving no PRN pain medications; as having almost constant pain; as pain affecting the resident's ability to sleep at night and limiting the resident's day to day activities; and as pain presence of an eight (8) on a numeric scale of zero (0) to ten (10). Review of Resident #8's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the ARNP Note, dated 03/05/19, revealed the resident had increased back pain, and would like a pain patch as he/she had been on the [MEDICATION NAME] for quite some time. Will go ahead and order [MEDICATION NAME]. Further review of the Note, under the Medications Ordered Section, revealed [MEDICATION NAME] 25 mcg/per hour, one (1) patch today and one (1) patch every seventy-two (72) hours, starting 03/05/19, for low back pain. However, the facility could not submit for review, a physician's orders [REDACTED]. Review of Resident #8's EMAR, dated (MONTH) 2019, revealed the resident was to receive [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours with an order date of 02/27/19, and a start date of 03/02/19. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was applied on 03/02/19; however, the EMAR was not signed to indicate the patch was applied on 03/05/19. Also, the facility could not locate the CDR for Resident #8's [MEDICATION NAME] 25 mcg/hr patch to review in order to verify if the medication was signed out. Review of the Nurse's Notes, dated 03/06/19 at 4:45 PM, completed by the MDS Nurse, revealed the resident complained to the MDS Nurse during the admission pain assessment, stating he/she had pain at a level of eight (8) out of ten (10) constantly through his/her upper body and legs. Per the Note, the MDS Nurse reported the pain to the nurse on the floor to follow up. Interview with the MDS Nurse, on 03/20/19 at 1:15 PM, revealed she passed Resident #8's complaints of pain along to RN#7 who was assigned to the resident that day. However, there was no documented evidence of a follow up assessment of Resident #8 on 03/06/19. Interview with RN #7 on 03/20/19 at 2:30 PM, who was assigned to Resident #8 on 03/06/19 at the time of the MDS Nurse's assessment, revealed she could not remember the MDS Nurse informing her Resident #8 was in pain on 03/06/19. Per interview, if there was no documentation of an assessment on that date by her, then she could not say she had followed up to assess the resident. Review of the EMAR, dated (MONTH) 2019, revealed the admission order for [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours with an order date of 02/27/19, and a start date of 03/02/19, was discontinued on 03/07/19. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was re-ordered on [DATE], with a start date of 03/07/19, and a stop date of 03/14/19, with no instructions on how often the patch was to be administered. Per the EMAR, the patch was applied on 03/07/19 at 10:00 PM, by RN #3. However, there was no documented evidence of a new physician's orders [REDACTED]. In addition, there was no documented evidence of a CDR to review to verify the [MEDICATION NAME] was signed out on 03/07/19. Furthermore, the facility was unable to submit for review, a CDR for Resident #8's [MEDICATION NAME]es from 02/27/19 until 03/11/19. The State Agency Representative phoned RN #3, on 03/13/19 at 8:59 AM; 03/14/19 at 2:14 PM; and 03/15/19 at 10:00 AM; however, the RN was unable to be reached. Review of Resident #8's Palliative Provider Notes, dated 03/11/19, revealed the resident stated he/she was having bad pain that started at the low back and extended into both lower extremities- the left much worse than the right. Further review revealed the resident noted his/her [MEDICATION NAME] was due to be changed yesterday, yet there was no script available for refill. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed when a resident was admitted to the facility there would be a brief lapse until palliative could come to assess the resident, and until then there was an agreement the Medical Director would cover the patients until palliative could assess the resident. She stated she came to the facility on [DATE] to assess Resident #8 and to write a prescription for [MEDICATION NAME]es to help control his/her pain. She further stated the resident was in a lot of pain that day, and she was unaware the [MEDICATION NAME] was not signed out on the EMAR to indicate the medication had been administered on 03/05/19. Review of Telephone Orders dated 03/11/19 revealed a new order for [MEDICATION NAME] 25 mcg/hr patch, apply and change every seventy-two (72) hours. Review of the Pharmacy's Shipment Summary, revealed five (5) [MEDICATION NAME] 25 mcg/hr patches were delivered to the facility on [DATE] at 7:52 PM. Review of Resident #8's physician's orders [REDACTED]. Review of the Controlled Drug Record for the [MEDICATION NAME] 25 mcg/hr patches delivered on 03/11/19, revealed a patch was signed out on 03/11/19 at 8:00 PM by RN #3. However, review of the EMAR revealed the [MEDICATION NAME] 25 mcg/hr patch was not signed as applied on 03/11/19 by RN #3. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was signed out on 03/07/19, and was not signed out again until 03/14/19, seven (7) days later. Per record review of the Admission physician's orders [REDACTED].#8 should have received the [MEDICATION NAME] 25 mcg/hr patch on 03/02/19, 03/05/19, 03/08/19, 03/11/19, and 03/14/19. However, per the EMAR, the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, indicating the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered. Review of the CDR, revealed the medication was signed out on 03/11/19 and 03/14/19; however, there was no documented evidence of a CDR to review for the [MEDICATION NAME]es prior to 03/11/19. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she was unable to account for the CDR sheet for the [MEDICATION NAME]es for Resident #8 prior to 03/11/19. Further interview revealed she was unable to find a physician's orders [REDACTED]. She further stated the EMAR was not signed to indicate the [MEDICATION NAME] was applied as ordered in (MONTH) 2019. Continued interview revealed the resident suffered from pain as indicated in the Nurse's Notes and the Provider Notes. Furthermore, she revealed Resident #8 should have been assessed by the nurse assigned after the MDS Nurse informed her the resident was having significant pain on 03/06/19. 4. Review of Resident #6's medical record revealed the facility admitted the resident on 02/10/18 with [DIAGNOSES REDACTED]. Review of Resident #6's Comprehensive Care Plan, dated 02/18/18, revealed a problem of being at risk for or having the presence of pain. The goal stated the resident's pain level would not inhibit quality of life or activit

Based on interview, record review, and review of facility policy, it was determined the facility failed to consult with the resident's Hospice or Palliative Provider when residents did not receive medications as ordered for three (3) of ten (10) sampled residents (Residents #1 #5 and #8). Although Resident #5 was receiving Palliative Care for pain management, there was no documented evidence the Palliative Provider was notified the resident went from 03/01/19 until 03/07/19, six (6) days between application of [MEDICATION NAME] 25 micrograms per hour (mcg/hr) and [MEDICATION NAME] 12 mcg/hr patches, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. In addition, there was no documented evidence of notification to the Palliative Provider that the resident missed ten (10) doses of [MEDICATION NAME] 50 milligrams (mg) Capsules between 03/01/19 and 03/07/19. Additionally, although Resident #1 was receiving Hospice Care, there was no documented evidence the Hospice Provider was notified the resident did not receive the prescribed [MEDICATION NAME] 300 milligram (mg) at night for pain during (MONTH) and (MONTH) 2019. Per the Controlled Drug Record (CDR), the last dose of [MEDICATION NAME] 300 mg was signed out on 02/07/19, and per the pharmacy's shipment of medication, the medication was not delivered to the facility until 03/06/19. Furthermore, although Resident #8 was receiving Palliative Care, there was no documented evidence the Palliative Provider was notified the resident did not receive the ordered [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours as ordered. According to the Admission physician's orders [REDACTED]. However, per the Electronic Medication Administration Record [REDACTED]. (Refer to F-655, F-656, F-697, F-755, and F-760) The findings include: Review of the facility's Notification of Patient/Resident Change Policy, dated 11/01/16, revealed the center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient/resident's legal representative or an interested family member when there is an acute illness or a significant change in the resident's physical, mental, or psychosocial status. Review of the facility's Medication-Related Errors Policy, dated 12/01/07, revealed the facility should notify pharmacy of any possible dispensing occurrence; and notify the physician/prescriber and obtain further instructions and/or orders. 1. Resident #5's clinical record revealed the facility admitted the resident on 08/18/17 with [DIAGNOSES REDACTED]. Review of Resident #5's Monthly (MONTH) 2019 physician's orders [REDACTED]. Further review revealed active orders for [MEDICATION NAME] 25 micrograms per hour (mcg/hr) and [MEDICATION NAME] 12 mcg/hr [MEDICATION NAME] every seventy-two (72) hours, starting 12/13/18 (narcotic pain medication). Review of the Controlled Drug Record (CDR), revealed the scheduled [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed out on 03/01/19; however, were not signed again until 03/07/19. This revealed Resident #5 went six (6) days between application of the [MEDICATION NAME]es, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. Also, Resident #5's Monthly (MONTH) 2019 physician's orders [REDACTED]. However, review of the Electronic Medication Administration Record [REDACTED]. Interview with Resident #5, on 03/15/19 at 2:30 PM, revealed he/she went a week without receiving his/her [MEDICATION NAME] at the beginning of (MONTH) and also the [MEDICATION NAME] was not applied that week. Additional interview revealed when he/she did not receive the medication as scheduled, he/she felt like he/she was coming down with the flu and suffered from nausea and vomiting which started around 03/05/19. Review of Resident #5's Nurse's Notes, dated 03/05/19 at 4:25 PM, signed by Registered Nurse (RN) #1 revealed the resident complained of nausea and vomiting, and the Advanced Registered Nurse Practitioner (ARNP) was here to assess the resident. Per the Note, new orders were received for [MEDICATION NAME] 4 mg by mouth every six (4) hours as needed for nausea (medication used for nausea and vomiting). The ARNP Note, dated 03/05/19, revealed Resident #5 complained of nausea and chills, denied any vomiting or diarrhea and had been afebrile, and would like something to help with nausea. Interview with Licensed Practical Nurse (LPN) #1, on 03/15/19 at 3:00 PM, verified he did not administer Resident #5's [MEDICATION NAME]es on 03/04/19. He stated he signed the EMAR to indicate he had applied the patches, but failed to pull them from the narcotic drawer and they could still be accounted for on the CDR. Further, he was unaware of the mistake until the Director of Nursing (DON) talked to him about it later, on 03/07/19. Interview with RN #1, on 03/15/19 at 1:19 PM, revealed on 03/05/19, Resident #5 complained of nausea and vomiting and she asked the ARNP to assess the resident. She stated the ARNP wrote an order for [REDACTED].#5's patch on 03/07/19, prior to administering a new [MEDICATION NAME] and noticed the old patch was dated 03/01/19. Per interview, the new patch was applied to the resident on 03/07/19 and the resident's symptoms of nausea and vomiting subsided within approximately thirty (30) minutes. RN #1 stated it was like the resident was having withdrawal symptoms from not receiving the medication. Review of the Palliative ARNP Note, dated 03/11/19 at 1:00 PM, revealed Resident #5 told her his/her [MEDICATION NAME] had not been changed for six (6) days and his/her pain increased from a seven (7) out of ten (10) compared to the usual three (3) to four (4) out of ten (10) when he/she routinely received the [MEDICATION NAME]. Further review revealed the resident's pain was in the right lateral and posterior hip. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed when she assessed Resident #5 on 03/11/19; she did not know the resident went without the [MEDICATION NAME] from 03/01/19 until 03/07/19, until the resident informed her. Further interview revealed she was unaware the resident had not received the [MEDICATION NAME] medication as ordered 03/01/19 through 03/07/19. Per interview, it was her expectation all narcotic and controlled medications be ordered timely and administered as prescribed and that facility staff confer with her regarding any concerns related to pain medications and pain management. Interview with the DON, on 03/20/19 at 4:00 PM, confirmed Resident #5 did not receive his/her [MEDICATION NAME] and [MEDICATION NAME] medication as prescribed for pain. Per interview, RN #1 notified her on 03/07/19, Resident #5 had not received the [MEDICATION NAME] on 03/04/19 and she ensured a full facility pain assessment was completed for all residents on 03/08/19, by the after it was discovered Resident #5 was having withdrawal symptoms from not receiving the [MEDICATION NAME]. Additional interview revealed on 03/07/19, there was also a facility wide medication cart audit for all medications, and it was discovered narcotics and controlled medications were not available for administration due to failure to order medications timely, as was the reason Resident #5 did not receive the [MEDICATION NAME] as ordered. Further interview revealed the Palliative ARNP was not informed Resident #5 did not receive the [MEDICATION NAME]es and [MEDICATION NAME] as ordered. 2. Resident #8's clinical record revealed the facility admitted the resident on 02/27/19 with [DIAGNOSES REDACTED]. Review of the Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the (MONTH) 2019 EMAR, revealed orders for [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours with an order date of 02/27/19, and a start date of 03/02/19. The EMAR was signed to indicate the [MEDICATION NAME] 25 mcg/hr patch was applied on 03/02/19; however, the EMAR was not signed to indicate the patch was applied on 03/05/19; and the facility could not account for the CDR for Resident #8's [MEDICATION NAME] 25 mcg/hr patch to review in order to verify if the medication was signed out on 03/02/19 and 03/05/19. Review of the Nurse's Notes, dated 03/06/19 at 4:45 PM, completed by the MDS Nurse, revealed Resident #8 complained to the MDS Nurse during the admission pain assessment, of having pain at a level of eight (8) out of ten (10) constantly through his/her upper body and legs. (Refer to F-697) Further review of the EMAR, dated (MONTH) 2019, revealed the admission order for [MEDICATION NAME] 25 mcg/hr patch every seventy-two (72) hours with an order date of 02/27/19, and a start date of 03/02/19, was discontinued on 03/07/19. Per the EMAR, [MEDICATION NAME] 25 mcg/hr patch was re-ordered on [DATE], with a start date of 03/07/19, and a stop date of 03/14/19, with no instructions on how often the patch was to be administered. However, there was no documented evidence of a physician's orders [REDACTED]. RN #3 signed as applying the patch on 03/07/19 at 10:00 PM; however, the facility could not account for the CDR to review to verify the [MEDICATION NAME] was signed out on 03/07/19. Also, the facility was unable to account for a CDR for Resident #8's [MEDICATION NAME]es from 02/27/19 until 03/11/19. (Refer to F-755) Review of the Palliative Provider Notes, dated 03/11/19, revealed the resident complained of having bad pain that started at the low back and extended into both lower extremities- the left much worse than the right. Review of Resident #8's Telephone Orders, dated 03/11/19, revealed a new order for [MEDICATION NAME] 25 mcg/hr patch, apply and change every seventy-two (72) hours. The Pharmacy's Shipment Summary, revealed five (5) [MEDICATION NAME] 25 mcg/hr patches were delivered to the facility on [DATE] at 7:52 PM. Review of the CDR for the [MEDICATION NAME] 25 mcg/hr patches delivered on 03/11/19, revealed a patch was signed out on 03/11/19 at 8:00 PM by RN #3; however, the EMAR revealed the [MEDICATION NAME] 25 mcg/hr patch was not signed as applied on 03/11/19 by RN #3. Additional review of the EMAR, revealed [MEDICATION NAME] 25 mcg/hr patch was signed out on 03/07/19, and was not signed out again until 03/14/19, seven (7) days later. Record review of the Admission physician's orders [REDACTED].#8 should have received the [MEDICATION NAME] 25 mcg/hr patch on the following dates: 03/02/19, 03/05/19, 03/08/19, 03/11/19, and 03/14/19. However, review of the EMAR, revealed the resident only received the medication on 03/02/19, 03/07/19, and 03/14/19, indicating the resident did not receive the [MEDICATION NAME] every seventy-two (72) hours as ordered. Review of the CDR, revealed the [MEDICATION NAME] 25 mcg/hr patch was signed out on 03/11/19 and 03/14/19; however, the facility could not account for a CDR to review to verify if the [MEDICATION NAME]es were signed out, prior to 03/11/19. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed she was at the facility on 03/11/19 to assess Resident #8 and to write a prescription for [MEDICATION NAME]es to help control his/her pain. The Palliative ARNP stated the resident was in a lot of pain that day, and she was unaware the [MEDICATION NAME] was not signed out on the EMAR to indicate the medication had been administered on 03/05/19. Continued interview revealed she was unaware the resident did not receive the [MEDICATION NAME]es as ordered in (MONTH) prior to 03/11/19. Further interview with the DON, on 03/20/19 at 4:00 PM, revealed Resident #8's EMAR was not signed to indicate the [MEDICATION NAME] was applied as ordered in (MONTH) 2019 and she could not locate the CDR sheet to verify if the resident actually received the [MEDICATION NAME]es for Resident #8 prior to 03/11/19. Further interview revealed the resident did suffer from pain as indicated in the Nurse's Notes and the Provider Notes. However, continued interview revealed the Palliative ARNP was not notified that the (MONTH) 2019 EMAR indicated the resident's pain medication was not administered as ordered. 3. Resident #1's clinical record revealed the facility admitted the resident on 08/26/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the Controlled Drug Record (CDR) from 01/04/19 through 02/07/19, revealed the last dose of [MEDICATION NAME] was signed out on 02/07/19 at 10:00 PM. Review of the facility pharmacy shipment forms revealed there was no [MEDICATION NAME] delivered in (MONTH) 2019 for Resident #1. Review of the (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 300 mg was not signed as administered on the 9th, 10th, 12th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 23rd, 25th, 26th, 27th and the 28th of the month, a total of fifteen (15) days. However, review of the EMAR, revealed the medication was signed as administered on 02/08/19, 02/11/19, 02/13/19, and 02/19/19, although according to the CDR, the last dose was signed out on 02/07/19. Additionally, review of the EMAR revealed [MEDICATION NAME] 300 mg was not signed out as administered on 03/01/19, 03/04/19, and 03/05/19. However, the medication was signed out as administered on 03/02/19, and 03/03/19, although the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the pharmacy's shipment for the month of (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE] for Resident #1. Interview with Resident #1, on 03/19/19 at 12:30 PM, revealed he/she was not currently in pain, and could not recall if he/she had any concerns with pain medications being administered while at the facility. Interview with the Hospice Physician, on 03/13/19 at 1:30 PM, revealed he was unaware the resident had not received pain medication as ordered in (MONTH) and March, and stated he should have been notified of the need for a new prescription for [MEDICATION NAME], before the resident ran out of the medication. Additional interview revealed [MEDICATION NAME] medication was ordered for the resident's nerve pain, and therefore it was important for the resident to receive the medication as ordered. Continued interview revealed he should have been notified the resident did not receive the [MEDICATION NAME] as ordered. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she was unaware Resident #1 had not received [MEDICATION NAME] as prescribed in (MONTH) and (MONTH) 2019 until the facility completed the audit related to narcotics and controlled medications on 03/14/19. She stated the nurses should have re-ordered the [MEDICATION NAME] or obtained a prescription as needed before the resident ran out of medication. Additional interview revealed the Hospice Physician was not notified Resident #1 did not receive the [MEDICATION NAME] as ordered in (MONTH) and (MONTH) 2019. Additional interview with the DON, revealed she had not contacted the Hospice and Palliative Providers related to Resident #1, #5 and #8's pain medications not being administered as prescribed, and she should have ensured they had been notified. She further stated she expected the nurses to notify the physician when medications were going to be administered late or were not administered. Interview with the Regional Nurse of Operations, on 03/20/19 at 6:45 PM, revealed the resident's Hospice or Palliative Providers should be notified when resident's miss any medication, especially narcotic pain medication because they were responsible for managing the residents' care and pain management. Interview with the Administrator on 03/20/19 at 5:24 PM revealed it was his expectation the resident's Hospice or Palliative Providers be contacted in regards to missed pain medications because they prescribed the residents' pain medications.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for three (3) of ten (10) sampled residents, (Resident #1, #5 and #6). Resident #5's Comprehensive Care Plan, with a problem onset date of 09/12/13, was not implemented related to interventions to administer pain medications as ordered, apply patches ([MEDICATION NAME]) patches as ordered and correlate all pain management with palliative care. The resident did not receive the prescribed [MEDICATION NAME] 25 micrograms per hour (mcg/hr) and [MEDICATION NAME] 12 mcg/hr [MEDICATION NAME] every seventy-two (72) hours, as evidenced by the resident missing the 03/04/19 scheduled dose. In addition, the resident missed ten (10) doses of the scheduled [MEDICATION NAME] between 03/01/19 and 03/07/19. Furthermore, the Palliative Advanced Registered Nurse Practitioner (ARNP) was not informed of the resident not receiving medication as ordered for pain management the first week of (MONTH) 2019. Interview with Resident #5, revealed he/she had flu like symptoms and had increased pain the first week of (MONTH) 2019. In addition, Resident #1's Comprehensive Care Plan, initiated 04/04/17, was not implemented related to interventions to administer pain medications as ordered and to coordinate the resident's care with the hospice team. Review of the Controlled Drug Record (CDR) from 01/04/19 through 02/07/19, revealed the last dose of [MEDICATION NAME] 300 milligram (mg) was signed out on 02/07/19 at 10:00 PM; and review of the facility pharmacy shipment forms revealed there was no [MEDICATION NAME] delivered in (MONTH) 2019 for this resident. The Electronic Medication Administration Record [REDACTED]. In addition, review of the EMARs, revealed the medication was signed as administered on 02/08/19, 02/11/19, 02/13/19, 02/19/19, 03/02/19, and 03/03/19, even though according to the CDR, the last dose was signed out on 02/07/19 and there was not another shipment of the medication delivered to the facility until 03/06/19. Furthermore, interview with the Hospice Physician, revealed he was not informed of the resident not receiving medication as ordered for pain management in (MONTH) and (MONTH) 2019. Furthermore, Resident #6's Comprehensive Care Plan, dated 02/18/18, was not implemented related to administering pain medications as ordered. Tylenol with [MEDICATION NAME] #3, one (1) tablet every eight (8) hours was prescribed scheduled at 6:00 AM, 2:00 PM, and 10:00 PM, with a start date of 10/12/18. However, review of the CDR, revealed the medication was not signed out as scheduled in (MONTH) 2019 for two (2) doses and was not signed out in (MONTH) 2019 for three (3) doses, revealing the resident did not receive the medication as ordered. Interview with Resident #6, revealed when he/she requested his/her pain medication, the nurse would tell him/her it had already been administered. (Refer to F-697, and F-755) The findings include: Interview with the Director of Nursing (DON) on 03/20/19 at 4:00 PM, revealed the facility utilized the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0 for guidance related to developing and implementing the Comprehensive Care Plan. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Resident #5's medical record revealed the facility admitted the resident on 08/18/17 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, with a problem onset date of 09/12/13, revealed Resident #5 had chronic pain issues (low back, arthritis, left shoulder pain, right hip pain, gout and history of migraines), and was on palliative care for pain management. The goal revealed the resident would have an acceptable comfort level through review date of 04/20/19. The interventions included: observe for pain including type, intensity, duration, location, alleviating and aggravating factors; administer pain medications as ordered and observed for effectiveness; offer/assist with repositioning during Certified Nursing Assistant (CNA) rounds and as needed; report uncontrolled pain to the physician; observe for side effects such as stomach pain, nausea, constipation, and dizziness; labs as ordered; refer to rehab as warranted; apply patches for pain as ordered, observe for side effects and adverse reactions; and correlate all pain management with palliative care for appropriate pain interventions. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/18, revealed the facility assessed Resident #5 as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) revealing moderate cognitive impairment. Additional review of the MDS Assessment, revealed the facility assessed the resident's pain management for the past five (5) days as the resident receiving scheduled and PRN (as needed) pain medications, as the resident having pain rarely, and as the resident having mild pain. Review of Resident #5's Monthly (MONTH) 2019 physician's orders [REDACTED]. However, review of the CDR, revealed the scheduled [MEDICATION NAME] 25 mcg/hr and [MEDICATION NAME] 12 mcg/hr patches were signed out on 03/01/19, and were not signed again until 03/07/19. This indicated Resident #5 went six (6) days between application of the [MEDICATION NAME]es, even though the [MEDICATION NAME]es were ordered to be applied every three (3) days. In addition, Resident #5 had active physician's orders [REDACTED]. However, review of the EMAR, revealed the resident missed ten (10) doses of [MEDICATION NAME] between 03/01/19 and 03/07/19. Interview with Resident #5, on 03/15/19 at 2:30 PM, revealed he/she went a week without receiving his/her [MEDICATION NAME] at the beginning of (MONTH) and also the [MEDICATION NAME] was not applied as ordered. Further interview revealed when he/she did not receive the medication as scheduled, he/she felt like he/she was coming down with the flu and he/she suffered from nausea and vomiting which started around 03/05/19. Review of Resident #5's Nurse's Notes, dated 03/05/19 at 4:25 PM, completed by Registered Nurse (RN) #1 revealed the resident complained of nausea and vomiting, and the Advanced Registered Nurse Practitioner (ARNP) was here to assess the resident. New orders were received for [MEDICATION NAME] 4 mg by mouth every six (4) hours as needed for nausea (medication used for nausea and vomiting). The ARNP Note, dated 03/05/19, revealed the patient complains of nausea and chills, denies any vomiting or diarrhea and had been afebrile, and would like something to help with nausea. Interview with Licensed Practical Nurse (LPN) #1, on 03/15/19 at 3:00 PM, revealed he did not administer Resident #5's [MEDICATION NAME]es on 03/04/19. Per interview, he did sign the patches out on the EMAR, yet he did not pull them from the narcotic drawer and they could still be accounted for on the CDR. Per interview, he was unaware of the mistake until the DON talked to him about it later, on 03/07/19. Interview with RN #1, on 03/15/19 at 1:19 PM, revealed when she worked on 03/05/19, Resident #5 was complaining of nausea and vomiting and she asked the ARNP to assess the resident. Per interview, the ARNP wrote an order for [REDACTED].#5's patch on 03/07/19, prior to administering a new [MEDICATION NAME] and noticed the old patch was dated 03/01/19. RN #1 stated the new patch was applied to the resident on 03/07/19 and the resident's symptoms of nausea and vomiting subsided within approximately thirty (30) minutes. RN #1 further stated it was like the resident was having withdrawal symptoms from not receiving the medication. Review of the Palliative ARNP Note, dated 03/11/19 at 1:00 PM, revealed Resident #5 told her his/her [MEDICATION NAME] had not been changed for six (6) days and his/her pain increased from a seven (7) out of ten (10) compared to the usual three (3) to four (4) out of ten (10) when he/she routinely received the [MEDICATION NAME]. Per the Note, the pain was in the right lateral and posterior hip. Interview with the Palliative ARNP, on 03/20/19 at 11:20 AM, revealed she assessed Resident #5 on 03/11/19; however, at that time she did not know the resident went without the [MEDICATION NAME] from 03/01/19 until 03/07/19, until the resident informed her. Additional interview revealed she was unaware the resident had not received the [MEDICATION NAME] medication as ordered 03/01/19 through 03/07/19. Per interview, it was her expectation all narcotic and controlled medications be ordered timely and administered as prescribed. Interview with the DON, on 03/20/19 at 4:00 PM, revealed Resident #5 did not receive his/her [MEDICATION NAME] and [MEDICATION NAME] medication as prescribed for pain, as per the Care Plan. She stated RN #1 had notified her on 03/07/19, Resident #5 had not received the [MEDICATION NAME] on 03/04/19 and she ensured a full facility pain assessment was completed for all residents on 03/08/19, by the MDS Nurse after it was discovered Resident #5 was having withdrawal symptoms from not receiving the [MEDICATION NAME]. Further interview revealed on 03/07/19, there was also a facility wide medication cart audit for all medications, and it was discovered narcotics and controlled medications were not available for administration due to the failure to order medications timely, as was the reason Resident #5 did not receive the [MEDICATION NAME] as ordered. Further, the Palliative ARNP was not informed of the resident's missed pain medication and therefore the Care Plan was not implemented related to correlating all pain management with palliative care. 2. Resident #1's medical record revealed the facility admitted the resident on 08/26/14 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 04/04/17, revealed Resident #1 was at risk for altered comfort and pain and was currently on hospice care related to a history of generalized aches and the resident was able to make needs known; request pain medication when needed and relate effectiveness of the pain medication. The goal revealed the resident would remain comfortable throughout hospice care and the resident would not have any unidentified pain thorough 05/01/19. There were several interventions including: coordinate the resident's care with the hospice team; coordinate with the hospice team to assure the resident experiences as little pain as possible; observe pain if occurring for type, intensity, duration, location, and alleviating and aggravating factors; report uncontrolled pain to the Physician; encourage to elevate feet as much as possible; and administer pain medication as ordered, observing for effectiveness and for adverse reactions/side effects. Review of the Annual MDS Assessment, dated 02/07/19, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Per the MDS Assessment, the facility assessed the resident's pain management for the past five (5) days as the resident having a scheduled pain medication regimen; receiving PRN (as needed) pain medications; and having frequent pain making it hard to sleep at night. Per the MDS Assessment, on a numeric scale of zero (0) to ten (10), the resident's pain was a ten (10). Additional review of the MDS Assessment, revealed the facility assessed the resident as receiving Opioid Medication seven (7) days out of seven (7) days; and as receiving Hospice Care. Review of Resident #1's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the CDR from 01/04/19 through 02/07/19, revealed the last dose of [MEDICATION NAME] was signed out on 02/07/19 at 10:00 PM. Review of the facility pharmacy shipment forms revealed there was no [MEDICATION NAME] delivered in (MONTH) 2019 for this resident. Review of the (MONTH) 2019 EMAR, revealed [MEDICATION NAME] 300 mg was not signed as administered on the 9th, 10th, 12th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 23rd, 25th, 26th, 27th and the 28th of the month, fifteen (15) days. However, review of the EMAR, revealed the medication was signed as administered on 02/08/19, 02/11/19, 02/13/19, and 02/19/19, even though according to the CDR, the last dose was signed out on 02/07/19. Also, review of the EMAR revealed [MEDICATION NAME] 300 mg was not signed out as administered on 03/01/19, 03/04/19, and 03/05/19. However, the medication was signed out as administered on 03/02/19, and 03/03/19, even though the last dose of [MEDICATION NAME] was signed out on the CDR on 02/07/19, and there was not another shipment of the medication delivered to the facility until 03/06/19. Review of the pharmacy's shipment for the month of (MONTH) 2019, revealed [MEDICATION NAME] 300 mg tablets, thirty (30) doses were delivered to the facility on [DATE]. Observation and interview with Resident #1, on 03/19/19 at 12:30 PM, revealed he/she was sitting at the bedside eating lunch. Per interview, he/she was not currently in pain, and he/she could not recall if he/she had any concerns with pain medications being administered while at the facility. Interview with the Hospice Physician, on 03/13/19 at 1:30 PM, revealed he was unaware the resident had not received pain medication as ordered in (MONTH) and March, and stated he should have been notified of the need for a new prescription for [MEDICATION NAME], prior to the resident running out of the medication. Further interview revealed [MEDICATION NAME] medication was ordered for the resident's nerve pain, and it was important for the resident to receive the medication as ordered. Interview with the DON, on 03/20/19 at 4:00 PM, revealed she was unaware Resident #1 had not received [MEDICATION NAME] as scheduled in (MONTH) and (MONTH) 2019 until the facility completed the audit related to narcotics and controlled medications on 03/14/19. Per interview, the nurses should have re-ordered the [MEDICATION NAME] before the resident ran out of medication. She stated the resident should have received the [MEDICATION NAME] medication as prescribed as per the Care Plan. Further interview revealed staff should have informed the Hospice Physician Resident #1 did not receive the [MEDICATION NAME] as ordered in (MONTH) and (MONTH) 2019, as per the Care Plan. 3. Resident #6's medical record revealed the facility admitted the resident on 02/10/18 with [DIAGNOSES REDACTED]. Review of Resident #6's Comprehensive Care Plan, dated 02/18/18, revealed a problem of being at risk for or having pain. The goal revealed the resident's pain level would not inhibit quality of life or activity tolerance. The interventions included: observe resident's pain daily using one to ten (1-10) scale with prompt pain management as ordered; administer resident's pain medication as ordered with observation of effectiveness to ensure relief; assist resident with diversional activity; resident prefers to rest in bed after receiving pain medication; assist resident to change positions slowly; observe for worsening symptoms and report to the physician, and observe for verbal/nonverbal indicators of pain. Resident #6's Annual MDS Assessment, dated 02/16/19, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Per the MDS Assessment, the facility assessed the resident's pain management for the past five (5) days as being on a scheduled pain regimen; not receiving any PRN pain medications; and as having no symptoms of pain or pain presence. Review of Resident #6's (MONTH) 2019 physician's orders [REDACTED].#3, (narcotic pain medication) one (1) tablet every eight (8) hours, at 6:00 AM, 2:00 PM and 10:00 PM, with an order date of 10/11/18 and start date of 10/12/18. (There was no milligram noted for the medication in the physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) 2019 EMARs, revealed Tylenol with [MEDICATION NAME] #3, one (1) tablet every eight (8) hours, was scheduled at 6:00 AM, 2:00 PM, and 10:00 PM. Per the EMAR, the medication was signed as administered as scheduled for the months of (MONTH) and (MONTH) 2019. However, review of the CDR for [MEDICATION NAME]-[MEDICATION NAME] 300 mg-30 mg (Tylenol with [MEDICATION NAME] #3), revealed the medication was not signed out for the following doses which were scheduled: 02/05/19 at 6:00 AM; 02/28/19 at 6:00 AM; 03/05/19 at 6:00 AM dose; 03/07/19 at 10:00 PM or 03/08/19 at 6:00 AM dose (could not decipher due to illegible); and 03/13/19 for the 6:00 AM dose. Interview with Resident #6, on 03/15/19 at 2:10 PM, revealed often times when he/she asked for his/her pain medication at the time it was due, the nurse would tell him/her it had already been administered. Per interview, he/she would feel uncomfortable at times. Interview with the DON, on 03/20/19 at 4:00 PM, revealed Resident #6 should have received the Tylenol with [MEDICATION NAME] #3 pain medication in (MONTH) and (MONTH) 2019 as prescribed for (MONTH) and (MONTH) 2019 as per the Care Plan. Interview with the Regional Nurse of Operations, on 03/20/19 at 6:45 PM, revealed Resident #1, #5 and #6's Comprehensive Care Plans should have been implemented related to pain management; and administering medications as ordered. Interview with the Administrator, on 03/20/19 at 5:24 PM, revealed it was important for all interventions on the Care Plans to be implemented related to pain management to ensure residents do not have unnecessary pain.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for one (1) of eight (8) sampled residents (Resident #1). Per staff interview Certified Nurse Aide (CNA) #1, and other staff witnessed verbal abuse on 02/18/17 at approximately 4:25 PM when Licensed Practical Nurse (LPN) #1 was in Resident #1's face yelling it's not happening today. I'm not doing it LPN #1 then told the resident he/she was lying about smoking after the resident requested a smoke break. CNA #1 immediately reported this to the Director of Nursing Service (DNS). The DNS immediately questioned LPN #1, who denied the allegation, stating she had to talk loudly because Resident #1 had his/her radio turned up loud and ear buds in at the time. However, staff interviews revealed Resident #1 was not listening to the radio and did not have ear buds in at the time of the incident. The DNS counseled the nurse on the resident smoking policy; however, did not further investigate the allegation. Subsequently, per staff interview, CNA #2 and other staff witnessed verbal abuse again on 02/18/17 at approximately 5:00 PM between LPN #1 and Resident #1. CNA #2 pushed Resident #1 via wheelchair to the nurses' station per the resident's request. LPN #1 then yelled in front of the resident (he/she) can't sit here with all this stuff! I don't want (him/her) here. I don't want to see (his/her) face. LPN #1 then told CNA #2 in front of Resident #1, I don't care if it's (his/her) home or not, it's not happening. CNA #2 immediately went to the DNS to report the incident. However, the DNS only interviewed CNA #1, CNA #2 and LPN #1 after the incidents, and failed to question any additional employees or residents who may have been witnesses. Also, the DNS failed to report the incidents to the facility's Administrator. On 02/18/17 at approximately 8:00 PM, CNA #1 reported the two (2) incidents she and CNA #2 had witnessed to the facility's Administrator and the Corporate Care Line (Hotline) via phone conversation. On 02/21/17, the Governing Body representatives arrived at the facility related to a Human Resource issues and reviewed CNA #1's Statement related to LPN #1's behavior towards Resident #1 and also transcribed a statement from the DNS related to the incidents. However, the governing body representatives failed to recognize the allegations as potential abuse. (Refer to F-225, F-226, and F-493) The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/03/17, and was determined to exist on 02/18/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 alleging removal of the Immediate Jeopardy on 03/06/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/06/17, prior to exit on 03/09/17, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse Policy (Policy # N-A-045) dated 11/20/16, revealed all allegations of abuse were reported immediately to the Administrator. Further review of the policy revealed the definition of verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Review of the facility's Abuse Investigations and Reports on 02/27/17, revealed no documented evidence of an investigation related to allegations of verbal abuse by LPN #1 towards Resident #1, which were reported by CNA #1 and CNA #2, on 02/18/17. On 02/28/17 the State Survey Agency Representative received from the facility written statements from LPN #1 dated 02/18/17, CNA #1 dated 02/19/17, the DNS Statement transcribed by the Corporate Division President dated 02/21/17 and the DNS written Statement dated 03/01/17. However, there was no further documented evidence an investigation was completed. Review of Resident #1's medical record, revealed the facility admitted the resident on 01/26/12, and readmitted the resident on 06/23/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of three (03) out of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #1's Comprehensive Care Plan, dated 02/04/12, with next review date of 05/01/17, revealed a problem related to disorganized thoughts, easily irritated and impatient related to [DIAGNOSES REDACTED]. The goal stated the resident would not have any unnoticed declines and would have less than weekly occurrence of verbally abusive behavior through 05/01/17. The interventions included: approach the resident from the front in a calm, unhurried manner; talk with the resident in a calm voice when behavior was disruptive; maintain a calm manner with interactions; and allow the resident to verbalize thoughts and feelings and validate them when resident was confused or anxious. Observation on 02/27/17 at 9:00 AM, 11:00 AM, 2:00 PM and 4:00 PM of Resident #1, and other residents who smoked, revealed the residents were supervised by one (1) staff member at the posted scheduled smoking times. Continued observation of Resident #1 revealed the resident was sitting in a wheelchair and had no difficulty communicating with staff and was making needs known. On 02/27/17 at 10:00 AM, interview was conducted with Resident #1 and when asked if anyone had been mean or yelled at him/her at the facility, the resident looked side to side and whispered, sometimes. However, when questioned further the resident did not answer the questions and changed the subject. During the conversation the resident was observed to have three (3) small plastic bottles, which the resident kept in his/her jacket pocket and placed on the table. The resident shuffled the bottles around, talked about the bottles, and read out loud the label on top of one of the bottles which said, hold tab down and turn. The resident also had a small pocket radio with ear buds/ear phones in his/her jacket pocket. Review of CNA #1's written Statement, dated 02/19/17, revealed on 02/18/17 she and CNA #2 responded to Resident #1 when they observed LPN #1 bent down in the resident's face yelling and arguing with the resident about the smoke break. Per the Statement, CNA #2 supervised the resident while CNA #1 reported the incident to the DNS. Phone interview with CNA #1, on 02/27/17 at 2:30 PM, revealed she witnessed verbal abuse by LPN #1 towards Resident #1, on 02/18/17 at approximately 4:25 PM which took place near the exit door to the residents' outside smoking area. CNA #1 revealed Dietary Aide #1, was nearby and also witnessed part of the interaction between LPN #1 and Resident #1. She stated the residents' 2:00 PM smoke break had been delayed until 3:00 PM due to activities and Resident #1 smoked during the 3:00 PM smoke break. However, she stated that didn't change the time of the next scheduled smoke break which was scheduled for 4:00 PM. CNA #1 stated she witnessed LPN #1 in Resident #1's face yelling it's not happening today; I'm not doing it and then told the resident he/she was lying about smoking. CNA #1 further stated she made sure Resident #1 was okay, and out on smoke break with CNA #2, and then went to the DNS's office and reported what she had witnessed. CNA #1 stated after she reported the allegation to the DNS, the DNS verified Resident #1 was supposed to have a smoke break at 4:00 PM. CNA #1 stated the DNS told her she would take care of it. CNA #1 stated the DNS then spoke with LPN #1; however, CNA #1 was not in on that conversation. Phone interview with CNA #2, on 02/27/17 at 6:41 PM, revealed she witnessed verbal abuse towards Resident #1 by LPN #1 on 02/18/17 at approximately 4:25 PM. She stated Resident #1 was waiting at the door for the smoke break and LPN #1 was yelling and arguing with the resident saying he/she couldn't go on a smoke break. CNA #2 further revealed on 02/18/17 when Bingo was over, the Activities staff took the residents to smoke; however, the 2:00 PM smoke break was delayed by the activity until 3:00 or 3:30 PM. She stated there were no other residents waiting to smoke at the time and CNA #1 said she would take Resident #1 to smoke. Per interview, LPN #1 acted mad, and said something to CNA #1 which CNA #2 could not hear. Per interview, CNA #1 asked CNA #2 to supervise Resident #1's smoke break while CNA #1 went to the DNS office. CNA #2 stated she stayed with the resident while he/she smoked. Phone Interview with CNA #9 on 03/01/17 at 1:15 PM, revealed on 02/18/17 she observed activity staff take the residents, including Resident #1, out to smoke around 3:00-3:30 PM. She stated at about 4:00 PM, Resident #1 was at the exit door for the next scheduled smoke break; however, she did not hear the resident stating smoke time. She revealed she heard CNA #1 say to LPN #1 it was the resident's right to smoke, and she was taking the resident out. CNA #9 revealed she walked away and didn't hear LPN #1's response. Phone Interview with CNA #12, on 03/02/17 at 9:00 AM, revealed on 02/18/17 at approximately 3:45 PM, she went to the pop machine by the exit smoke break door, and Resident #1 was there and asked her to get him/her a Pepsi. She stated because the resident was on a fluid restriction, and the resident's supply of Pepsi was locked in the nourishment room, she told the resident she would check with the nurse. CNA #12 further stated she told LPN #1 the resident asked for a Pepsi and LPN #1 replied the resident would have to wait. Continued interview revealed at that time the resident was calm, and was probably there waiting on the 4:00 PM smoke break, but wasn't saying anything about the smoke break. CNA #12 stated she did not hear the resident hollering or talking loudly saying smoke break. She stated the resident did not have his/her radio on, and there were no ear buds in his/her ears. Further interview revealed the resident was not hard of hearing and did not like loud voices. CNA #12 stated the resident could be easily agitated and therefore the resident had to be approached calmly. She further revealed the batteries were dead in the resident's radio when she last worked with the resident on Thursday (02/16/17). She stated the resident was supposed to get more batteries on Friday 02/17/17, but the batteries were not changed until CNA #12 changed the batteries on Monday 02/20/17. Phone interview with CNA #5, on 02/28/17 at 7:50 AM, revealed she could not recall the exact day, but she had observed LPN #1 lean down in Resident #1's face and say, I don't really care what you say, or who you tell, resident care comes first. CNA #5 further stated she had no idea what the comment was about, but the tone LPN #1 used was really rude. Continued interview revealed the resident did not respond and she did not report the incident. Further interview with CNA #1, on 02/27/17 at 2:30 PM, revealed the DNS called CNA #1 back into the office between 4:30 PM and 5:00 PM. CNA #1 stated the DNS then justified the actions of LPN #1 being in the resident's face as getting on the resident's level, which they teach in nursing school. Per CNA #1's interview, LPN #1 had pointed her finger in Resident #1's face while arguing with the resident and she told the DNS, You're not supposed to point your finger at them or argue with them. When I went to school, they taught us to let them be and you don't argue with them. Review of LPN #1's written Statement, dated 02/18/17, revealed at 4:30 PM, Resident #1 was sitting by the dining room, yelling out in a loud tone smoke time, smoke time. Continued review revealed LPN #1 walked to the resident who had ear buds in his/her ears and a radio playing; and requested the resident take out the ear buds. Per the Statement, the resident refused and continued to yell out. Further review revealed LPN #1 stooped on her knees to maintain eye contact with the resident and explained the resident had just went out to smoke at 3:30 PM; all staff were in rooms providing care; and the resident could go out the next smoke time. Per the Statement, LPN #1 then walked back to the nurse's station at which time CNA #1 stated she would take the resident outside to smoke. Continued review, revealed LPN #1 told CNA #1 to continue to provide other residents' care and CNA #1 refused, and took Resident #1 outside, along with CNA #2. Additional review of the Statement, revealed LPN #1 went to the DNS's office to report CNA #1's insubordination. Interview with LPN #1, on 02/27/17 at 4:00 PM, and 03/03/17 at 3:30 PM, revealed Resident #1 was totally aware of smoke break times and would get very verbal and let staff know fifteen (15) minutes ahead of time, it was time to smoke. Continued interview revealed on 02/18/17 at 3:30 PM, the Activities person said the residents were allowed to make up the 2:00 PM smoke break and took the resident's out to smoke about 3:00 PM including Resident #1. She revealed on 02/18/17 about 4:00 PM, she walked out of the nurses station and saw Resident #1 sitting at the back exit door yelling, time to smoke; take me out to smoke. She stated the resident was agitated and shouting and the resident's pocket radio was on very loud and the resident had ear phones in his/her ears. She further stated she got down on eye level and had to talk loud and the resident didn't hear her. She further revealed she kept saying, you can't go out right now, it will be a few minutes, you just went out to smoke. She stated CNA #1 came out of a resident's room and said she was going to take the resident to smoke. Per interview, LPN #1 wanted to talk to the DNS first and make sure the resident was allowed to take another smoke break. LPN #1 revealed CNA #1 took the resident out to smoke, then CNA #2 stayed with the resident while CNA #1 went to the DNS's office. Per interview, there may have been a dietary worker, in the hallway at the time of her interaction with Resident #1. Phone interview with Dietary Aide (DA) #1, on 02/27/17 at 3:00 PM, revealed the DA witnessed verbal abuse towards Resident #1 by LPN #1, on 02/18/17 at about 4:20 PM. Per interview, the resident was waiting at the exit door to smoke and the DA witnessed LPN #1 walking down the hall, with a dirty look, and said in reference to Resident #1, (He/she) is off the chain! The DA revealed LPN #1 seemed to be aggravated, talked loudly to the resident, and said, It's not time! You just went out! Continued interview with the DA, revealed LPN #1 spoke to the resident in a rude manner which was verbal abuse according to their abuse training. DA #1 further stated residents shouldn't be talked to that way and they should be treated with the utmost respect. Additional interview revealed DA #1 didn't report the verbal abuse because the DA knew CNA #1 had reported LPN #1 yelling and arguing with the resident to the DNS which occurred during the same timeframe. Additional interview revealed no one, including the DNS, had asked if the DA had seen or heard anything. Review of the DNS's Statement, transcribed on 02/21/17 by the Corporate Division President, revealed CNA #1 reported to the DNS on 02/18/17, she was upset because LPN #1 was in Resident #1's face yelling at and arguing with the resident. Continued review of the DNS's Statement revealed there were only three (3) individuals involved who witnessed the incident, which were Resident #1, CNA #1 and LPN #1. Per the Statement, there were no other witnesses and the resident was not interviewable. Further review revealed Resident #1 wanted to smoke and was yelling. Per the Statement, LPN #1 denied yelling at the resident, but stated that it may have seemed loud because the resident had refused to remove the ear buds with the radio playing and LPN #1 had to bend down to make eye contact with the resident. Additional review of the Statement, revealed the DNS did not find anything unusual about this interaction. Per the Statement the allegation of yelling and arguing was investigated, and a credible explanation was obtained. Review of the DNS's Statement written on 03/01/17, revealed CNA #1 came to her office on 02/18/17 upset because LPN #1 had told Resident #1 he/she could not go out for the 4:00 PM smoke break and LPN #1 was argumentative with the resident. Further review revealed the DNS went to speak with LPN #1 who was already on her way to the DNS's office. Per the Statement, LPN #1 told her Resident #1 had ear plugs in so she was speaking to be heard and had gotten down to make eye contact. The Statement further revealed the DNS went to assess Resident #1 who was sitting outside with CNA #1 and was happy and smoking. Per the Statement, the DNS asked CNA #1 to return to her office when finished, at which time the DNS told CNA #1 that LPN #1 had been informed the smokers' schedule did not change and LPN #1 needed to make eye contact and get down on resident's level for therapeutic communication, as taught in nursing school. Review of the conclusion of the DNS written statement revealed she did not see, after talking with involved persons, that LPN #1 had incorrectly implemented the smoking policy. LPN #1 was not aware when a scheduled smoke break was delayed due to an activity, the next scheduled smoke break time was not affected. Per the Statement the DNS provided immediate counseling regarding the smoking policy to LPN #1 and determined there was no willful action to cause the resident harm. Interview with the DNS, on 02/27/17 at 5:10 PM, and on 03/02/17 at 3:25 PM, revealed on 02/18/17 about 4:30 PM, CNA #1 came to her office upset because LPN #1 was yelling and arguing with Resident #1 and wouldn't let the resident go for a smoke break. Per interview, CNA #1 told the DNS she was sick and tired of LPN #1 telling the residents they couldn't smoke and LPN #1 was in the resident's face. The DNS further revealed she talked with LPN #1 and the nurse revealed she was not argumentative with Resident #1, but she was incorrect not to let the resident smoke at the scheduled time. She further stated LPN #1 had to talk loudly because Resident #1 had his/her radio turned up loud and ear buds in at the time. Continued interview with the DNS, revealed she did not perceive CNA #1's report of LPN #1 yelling and arguing with the resident to be an allegation of abuse because CNA #1 didn't say LPN #1 cursed and didn't say what she witnessed was verbal abuse. The DNS further stated there was no intent of verbal abuse. Continued interview with the DNS revealed arguing with a resident constituting verbal abuse was all individual perception and an argument to one individual might be a discussion to another. Further interview revealed yelling would be verbal abuse unless the person was hearing impaired, or unless the person had ear buds in and had to be talked to loudly over the music, which would not be yelling. Further review of CNA #1's written Statement, dated 02/19/17, revealed CNA #1 was in the DNS office when CNA #2 came in and reported LPN #1 got nose to nose with CNA #2, yelling about Resident #1 wanting to sit at the nurse's station. Continued review revealed the DNS said she would take care of it, and CNA #1 and CNA #2 proceeded to the dining room. Continued interview with CNA #1, on 02/27/17 at 2:30 PM, revealed while she was still in the DNS's office, CNA #2 came in very upset, ready to go home, and reported LPN #1 had gotten nose to nose with her over letting Resident #1 sit at the nurse's station desk. Per interview with CNA #1, CNA #2 revealed LPN #1 stated in front of Resident #1, she didn't want him/her there; and didn't want to see his/her face. CNA #1 stated LPN #1 had moved the resident to a bedside table away from the nurse's station where the resident sat until dinner trays arrived. CNA #1 revealed Resident #1 routinely sat at the nurse's station desk before dinner, especially when other nurses were on duty. She stated the resident liked to sit at one corner of the nurse's desk, put his/her collection of three (3) little bottles on the desk, where he/she sometimes had a Diet Pepsi, laughed, and listened to his/her pocket radio with ear buds. However, CNA #1 stated the resident didn't have a radio or ear buds during the 4:30 PM smoke break or while at the nurses' station desk on 02/18/17 during the interactions with LPN #1. Continued interview with CNA #2, on 02/27/17 at 6:41 PM, revealed after Resident #1 had the smoke break, she asked the resident where he/she wanted to go and he/she said to the nurse's station. CNA #2 further revealed the resident liked to sit there with his/her little plastic bottles and drinking cup; and sometimes the resident listened to his/her radio with ear plugs. However, CNA #2 stated the resident didn't have the radio on during the smoke break or at the nurses' station that day. CNA #2 further stated when other LPNs worked Resident #1 always put the bottles and cup on the nurses' station desk because it was his/her routine. CNA #2 stated as soon as LPN #1 saw her push the resident in the wheelchair up to the desk at approximately 5:00 PM she stated in front of the resident, (he/she) can't sit here with all this stuff! I don't want (him/her) here. I don't want to see (his/her) face. CNA #2 stated she replied to LPN #1, you can't tell (him/her) (he/she) can't sit here. It's (his/her) home! CNA #2 stated, LPN #1 then got in her (CNA #2's) face and said, I don't care if it's (his/her) home or not, it's not happening. Take it up with the DNS. Additional interview with CNA #2, revealed instead of letting Resident #1 sit at the desk, LPN #1 moved the resident in the hallway across from the nurses' station and gave him/her a bedside table. CNA #2 revealed she went straight to the DNS and reported the incident because she was so upset and told the DNS this was the second time that day the DNS had received a report about the way LPN #1 treated Resident #1, and she was tired of the nurse treating the resident badly. CNA #2 stated the DNS told her to calm down and she would talk to LPN #1. Continued interview with CNA #9, on 02/27/17 at 3:00 PM, revealed after the smoke break, when CNA #2 pushed Resident #1 in his/her wheelchair to the nurse's station desk, LPN #1 said, No, no, no! We're not doing this. (He/she) is not going to sit here. It's not happening. (He/she) can't be here. CNA #9 further revealed Resident #1 sat there every day and it was never a problem because the resident never bothered anyone. She stated when LPN #1 said that in front of the resident it broke (his/her) heart. CNA #9 said the resident looked sad and dropped his/her head down. CNA #9 further revealed CNA #2 stated to LPN #1 she wasn't having this argument in front of the resident, and CNA #2 walked away. Further interview revealed at the time of the incident, LPN #1 moved the resident to a bedside table in the hall. CNA #9 stated she did not report this to anyone because she had reported events before to the Corporate Hotline and nothing was done. Additional interview with LPN #1, on 02/27/17 at 4:00 PM, revealed right after the smoke break, Resident #1 was pushed to the nurse's desk by CNA #2, and CNA #2 put the resident's food on the nurse's station. She stated there was charts, paperwork, which could be a HIPAA concern at the nurse's station. (HIPAA refers to the Health Insurance Portability and Accountability Act, a 1996 Federal law that restricts access to individuals' private medical information). LPN #1 further stated she tried to explain about HIPAA in simple terms the CNA could understand and told her the resident could not eat there. She stated CNA #2 responded it was the resident's right, it was his/her house, and he/she could sit anywhere he/she wanted. LPN #1 stated she obtained a bedside table and put it beside the nurses' station, set the resident's food on it, and the resident ate his/her dinner. LPN #1 stated CNA #2 got mad and went to the DNS's office. Continued interview with LPN #1, revealed she did recall the DNS coming to the unit on 02/18/17 around dinner time and she recalled speaking to the DNS, but could not remember what they talked about. Additional interview with the DNS on 03/02/17 at 4:20 PM, revealed CNA #2 came into her office screaming, but due to her screaming it was hard to understand what the CNA was telling her. The DNS stated CNA #2 told her she was walking out, and she (DNS) told CNA #2 when she calmed down, she would listen to what she was saying. The DNS further revealed CNA #2 quit yelling and screaming, and said she pushed Resident #1 up to the desk and LPN #1 said, oh, no, not today. The DNS stated she followed up awhile later with LPN #1 who told her she said the resident was not going to eat at the nurses' desk due to papers, charting/HIPAA, and relocated the resident to a bedside table which was more appropriate. The DNS further stated when she observed Resident #1, the resident was eating at the bedside table. Continued interview with the DNS revealed she was not aware, and did not ask, if there were any other witnesses to the incident to gain additional information. Further interview revealed lots of residents sit at the desk routinely, including Resident #1. The DNS revealed she had no knowledge of LPN #1 stating in front of Resident #1, I don't want to see (his/her) face, as this was not conveyed to her by CNA #2. However, the DNS stated CNA #2 said a lot of things while screaming that she may not have heard. The DNS stated if LPN #1 had said this, it would have been considered abuse. The DNS stated she had never read the Statement written by CNA #1 and she did not remember CNA #1 giving her the Statement. Further interview with CNA #1, on 02/27/17 at 2:30 PM, revealed she called the Administrator on 02/18/17 at 8:00 PM and told the Administrator, everything that had happened that day regarding LPN #1 yelling in Resident #1's face it's not happening today; I'm not doing it and also that LPN #1 told the resident he/she was lying about smoking after the resident requested a smoke break. She further stated she told the Administrator that she (CNA #1) immediately reported this to the DNS. She further stated she told the Administrator that while she was in the DNS's office, CNA #2 came in told her she (CNA #2) had parked the resident in his/her wheelchair at the nurses's station per the resident's request and LPN #1, in front of the resident stated, (he/she) can't sit here with all this stuff! I don't want (him/her) here. I don't want to see (his/her) face. She stated the Administrator told her to write a Statement related to this. CNA #1 then stated she also called the Corporate Hotline and spoke with the Division President and told him the entire story. Interview with the Medical Director on 03/09/17 at 12:30 PM revealed yelling at a resident could be considered verbal abuse; it depended on the context of the situation. Further interview revealed if the staff reporting the incidents related to Resident #1 on 02/18/17 felt it was abuse, it should have been looked into in order to find out if there were any witnesses, and this should have been investigated thoroughly. Interview with Administrator, on 02/27/17 at 12:00 PM, revealed she received a call from CNA #1 on 02/18/17 late evening, stating LPN #1 didn't let CNA #1 take the resident out to smoke and talked to the resident loudly. Per interview with the Administrator, CNA #1 went on and took the resident out to smoke anyway. Continued interview revealed to her knowledge the DNS had talked to LPN #1 about it, and informed the LPN about the make-up smoke break schedule. Further interview revealed the Administrator was led to believe there wasn't any abuse allegation. Additional interview revealed if a staff member used a rude tone and said a resident was off the chain it would be verbal abuse. Per interview, if it was said in a care area, where other family members or residents might hear, it would be something that should be investigated further. She stated she was unaware of that allegation. The Administrator stated the DNS did not report any allegations of abuse to her. Further interview with the Administrator, on 03/01/17 at 5:45 PM, regarding incidents on 02/18/17 which involved alleged verbal abuse allegations towards Resident #1, revealed it was one person's word against the other. Per interview, LPN #1 said Resident #1 was hollering smoke time, smoke time, had ear buds in, and she had to speak loud for the resident to hear her. Continued interview and review of CNA #1's and the DNS' written statements with the Administrator, revealed it was a concern for LPN #1 to be in Resident #1's face yelling and arguing with the resident. Additional interview revealed if LPN #1 stated in front of Resident #1, It's not happening. (He/she's) not sitting here. I don't want to see (his/her) face, this was berating the resident and even if the resident had a BIMS score of three (03), this was not okay to say. She stated she was not aware of CNA #1's Statement or the DNS's Statements related to verbal abuse towards Resident #1 until this interview and had not interviewed staff related to these allegations because she had been ill from 02/18/17 until 02/21/17, and when Corporate came in on 02/21/17, they took over. Interview with the Regional Vice President, on 02/27/17 at 10:45 AM, revealed she had read CNA #1, LPN #1, and the DNS statements and did not identify any abuse occurred with review of the statements. She stated the DNS never filed an abuse allegation related to the incidents on 02/18/17 regarding Resident #1 because the DNS interviewed LPN #1 and was told the nurse talked loud to the resident because the resident had ear buds in and music was loud, and the nurse bent down on the resident's level to say no smoke break. Further interview revealed the DNS determined the nurse was speaking loudly, but there was no verbal abuse. Continued interview revealed regarding the second incident, CNA#2 was told by LPN #1 it was not appropriate for Resident #1 to sit or eat at the nurses station because of HIPAA. She stated LPN #1 told CNA #1 not to take the resident out to smoke, and she took the resident out anyway. She stated LPN #1 told CNA #2 it was not appropriate for the resident to eat dinner at the nurses' station and CNA #2 argued with the nurse. Interview with the Division President, on 03/02/17 at 6:00 PM, revealed she had read Statements written by CNA #1, LPN #1, and the DNS and also took a Statement from the DNS. Continued interview revealed the DNS was in the facility, spoke to the individuals including CNA #1, CNA #2 and LPN #1, and determined there was no abuse. Per interview, a report of yelling and arguing with a resident could be an allegation of abuse or potential abuse. However, she stated in Resident #1's situation, yelling was not yelling when the resident was wearing ear buds. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 that alleged removal of the Immediate Jeopardy (IJ) on 03/06/17. Review of the AOC revealed the facility implemented the following. 1) Resident #1 (BIMS of 3) was interviewed on 03/03/17, using the Resident Interview Tool, by the Regional Director of Nursing Management Services. A physical assessment of Resident #1 was completed on 03/03/17, by the Regional Director of Nursing Management Se

Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to have an effective system to ensure its abuse policy and procedures were implemented for one (1) of eight (8) sampled residents (Resident #1). On 02/18/17 at between 4:20 PM and 5:00 PM, two (2) allegations of abuse were reported to the Director of Nursing Services (DNS) by two (2) Certified Nursing Assistants (CNA) who witnessed what they identified as verbal abuse by Licensed Practical Nurse (LPN) #1 toward Resident #1. Per staff interviews at 4:25 PM, CNA #1 and CNA #2, witnessed LPN #1 bent down in Resident #1's face, yelling at and arguing with the resident about going out for a scheduled smoke break which CNA #1 described as verbal abuse. CNA #1 immediately reported the allegation to the DNS. Although the DNS counseled LPN #1 on the smoking policy, the DNS failed to report the allegation to the Administrator, failed to remove the alleged perpetrator/LPN #1 from resident care to protect the residents, and failed to investigate the allegation further per the facility's policy and procedures. Subsequently, on 02/18/17 at 5:00 PM, CNA #2 pushed Resident #1 via wheelchair, per the resident's request, to the nurse's station. Per staff interviews, LPN #2 stated in front of the resident, he/she wasn't going to sit there, and she did not want to see his/her face. CNA #2 immediately reported the allegation to the DNS. However, the DNS only questioned CNA #1, CNA #2, and LPN #1 after the incidents, and did not question Resident #1, additional employees or residents who may have been witnesses. The DNS again did not notify the Administrator of the allegation, and did not remove LPN #1 from resident care per the facility's policy and procedures. On 02/21/17, the Corporate representatives arrived at the facility related to Human Resource issues after CNA #1 reported the two (2) allegations to the facility Administrator and the Corporate Care Line (Hotline) via phone conversation on 02/18/17 at approximately 8:00 PM. The governing body representatives reviewed CNA #1's Statement related to LPN #1's behavior towards Resident #1 and also transcribed a statement from the DNS related to the allegations; however, failed to identify the allegations as abuse and failed to implement the facility's Abuse Policy related to reporting, investigating, and protecting. LPN #1 continued to work the remainder of the shift on 02/18/17, and worked as scheduled on 02/19/17, 02/20/17, 02/21/17, 02/26/17 and 02/27/17. (Refer to F-223, F-225 and F-493) The facility's failure to implement its policy and procedures regarding protecting, reporting and thoroughly investigating alleged incidents of verbal abuse; and failing to immediately report the alleged incidents to the State Agencies, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/03/17, and was determined to exist on 02/18/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 alleging removal of the Immediate Jeopardy on 03/06/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/06/17, prior to exit on 03/09/17, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse Policy (Policy # N-A-045) dated 11/20/16, revealed all allegations of abuse would be reported immediately to the Administrator to State Agencies and law enforcement in accordance with existing state law. The Administrator would direct a thorough investigation of each alleged violation and was responsible for reporting the results of all investigations to the State Agencies. Results of the investigation would be reported to the appropriate State Agencies in accordance with existing State Law through established procedures immediately, which meant as soon as possible, but ought not to exceed twenty-four (24) hours after discovery of the incident. The results of all investigations must be reported within five (5) working days of the alleged violation. Continued review of the facility's Policy revealed employees who were alleged to have committed abuse were suspended pending outcome of an investigation. Further review of the Policy revealed the definition of verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Anytime there was an allegation of abuse, the Center must not only report the alleged violation to the Administrator, the Chief Compliance Officer and other officials, but also initiate an immediate investigation and prevent further abuse. All investigations shall be conducted by the Administrator, Director of Nursing or subject matter expert. The investigation shall include interviews of team members, visitors, patients/residents, volunteers and vendors who may have knowledge of the alleged incident. Written statements from involved parties should not be requested, as all information will be documented on the investigation form or state required form. Federal law requires evidence of investigations of alleged violations. The investigation form or state required form, shall be completed after the investigation is complete and provided to survey agencies when requested or required by state and federal law. All alleged violations shall be recorded. Review of the Office of Inspector Reports on 02/27/17, revealed the State Survey Agency (SSA) had not received a report from the facility of the alleged abuse related to Resident #1. Review of the facility's Abuse Investigations and Reports on 02/27/17, revealed no documented evidence of an investigation related to allegations of verbal abuse by LPN #1 related to Resident #1, which were reported by CNA #1 and CNA #2, on 02/18/17. On 02/28/17 the facility submitted to the State Survey Representative written statements from LPN #1 dated 02/18/17, CNA #1 dated 02/19/17, DNS Statement transcribed by the Corporate Division President dated 02/21/17, and the DNS written Statement dated 03/01/17 related to the allegations. However, there facility provided no further evidence of an investigation related to the verbal abuse allegations. Interview with the DNS on 03/02/17 at 3:25 PM, revealed she did not perceive CNA #1's report of LPN #1 yelling and arguing with the resident was an allegation of abuse because CNA #1 did not say LPN #1 cursed and did not say what she witnessed was an allegation of abuse. She further revealed she did not consider LPN #1's actions as verbal abuse because it was not an act purposefully done that resulted in harm. Per interview, later when CNA #2 came into her office the CNA was upset and screaming and she did understand that LPN #1 was stating in front of Resident #1, I don't want to see (his/her) face. Per the DNS, if LPN #1 had said this, it would have been considered abuse. The DNS stated she did ask everybody involved including CNA #1, CNA #2 and LPN #1 to write statements and turn them in by 02/20/17. The DNS revealed in hind-site she failed to implement the Abuse Policy when she did not immediately assess the resident after CNA #2 reported a problem; did not report either incidents as allegations of abuse to the Administrator or to State Agencies, did not protect the residents by allowing LPN #1 to continue working and did not do a thorough investigation which would have included interviewing additional witnesses. The DNS acknowledged she independently made the determination there was no abuse, as she was not authorized to do, and she took making this decision away from the Administrator. Interview with the Administrator, on 02/27/17 at 4:00 PM, and 03/02/17 at 4:30 PM, revealed when CNA #1 and CNA #2 went to the DNS office and reported what they considered verbal abuse of Resident #1 on 02/18/17, it warranted further investigation and should have been reported per the facility's Abuse Policy to herself, and to State Agencies as well as thoroughly investigated in order to protect the residents. She acknowledged a statement of a staff member in a resident's face yelling and arguing could be verbal abuse. Per interview, the DNS failed to follow the facility's Abuse Policy process when she solely made the decision that no abuse had occurred Related to Resident #1. Interview with the Medical Director on 03/09/17 at 12:30 PM revealed yelling at a resident could be verbal abuse; it depended on the context of the situation. He further stated all allegations of all types of abuse are reportable, and the statutes regarding reporting, protecting and investigating should be referenced and the Abuse Policy followed. Interview with the Regional Vice President, on 02/27/17 at 10:45 AM, on 03/02/17 at 5:30 PM, revealed you have a he said she said, and there was no reportable allegation of abuse. However, further interview revealed she had not interviewed any staff including CNA #1, CNA #2, or LPN #1 related to the allegations related to Resident #1 and did not investigate the allegations after reading the DNS Statement. Interview with the Division President (DP), on 03/02/17 at 6:00 PM, revealed all allegations of abuse were to be reported to the Administrator and to other State Agencies, a thorough investigation was to be completed, and residents were to be protected during the investigation as per facility Policy. Per interview, CNA #1 called the Corporate Care Line and reported a nurse was loud and argumentative with a resident, but there was a lot of other concerns reported which corporate considered Human Resources issues. She also stated since a staff member being loud and argumentative with a resident did not automatically equate abuse to her; she responded to the Care Line call and just looked at how it involved Human Resources and did not look at it as an abuse investigation. There was no documented evidence the Corporate representatives implemented the facility Abuse policy related to reporting the verbal abuse allegations to the State Agency, completing a thorough investigation to interview other witnesses to the incidents in order to gain additional information, and protecting the residents as they allowed LPN #1 to continue working in resident care areas after the allegations were reported. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 that alleged removal of the Immediate Jeopardy (IJ) on 03/06/17. Review of the AOC revealed the facility implemented the following. 1) Resident #1 (BIMS of 3) was interviewed on 03/03/17, using the Resident Interview Tool, by the Regional Director of Nursing Management Services. A physical assessment of Resident #1 was completed on 03/03/17, by the Regional Director of Nursing Management Services, using the Resident Body Audit Tool. The responsible party and attending physician were notified by the administrator of the allegation on 03/03/17. 2) All alert and oriented residents (BIMS greater than 8) were interviewed utilizing the Resident Interview Tool, by the Regional Director of Nursing Management Services or the Regional Vice President by 03/04/17. Physical assessments of non-interviewable residents (BIMS less than 8) were conducted by the DNS, ADNS, or House Supervisor by 03/05/17, using the Resident Body Audit Tool. 3) The facility submitted an Initial Allegation of Abuse Report to OIG, dated 03/03/17. Per the report, APS (adult protective service), the local Ombudsman and the Police were notified on 03/03/17. The involved LPN was placed on administrative leave on 03/03/17. A thorough investigation was completed by the Divisional Senior Director of Clinical Operations to ensure evidence of completion including reporting to proper authorities in acceptance with State law. This review was completed by 03/05/17. 4) The Director of Clinical Operations and/or the Regional Vice President will be notified by the Administrator and/or DNS any time there is a report of any incident that could possibly be construed as an allegation of abuse in order to assist in determining appropriate investigation and reporting. 5) Education was provided to the Division President and the Region Vice President. This education was presented by the Senior Director of Clinical Operation and completed on 03/03/17. The education included a review of the facility's Abuse Policy to include a Staff Abuse Questionnaire to demonstrate learning. 6) Education was provided to the Administrator, Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) by the Director of Clinical Operations. This education was completed on 03/03/17 and also emphasized that yelling and/or arguing with a resident should be considered an allegation of abuse. A Staff Abuse Questionnaire was completed by each on 03/03/17, to demonstrate learning. 7) Education was provided to all licensed nursing team members which included Registered Nurses (RN) and Licensed Practical Nurses (LPN) to include a review of the facility's Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was developed by the Director of Clinical Operations and presented by the DNA, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 8) Education was provided to all non-licensed team members including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry to include a review of the Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was provided by the DNS, ADNS, Regional Director of Clinical Operations or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 9) Educational material regarding Abuse was included in the facility's orientation materials to be completed with future new hires and will be presented by the Director of Nursing Services or a designated Registered Nurse prior to providing direct care to residents. All team members will receive additional education related to abuse reporting at least twice a year. 10) All learning with current full time facility team members was completed by 03/05/17. Any team member not completing the education by 03/05/17 will not be allowed to work until the education has been completed and competency determined. The facility does not employ any agency staff. 11) Resident #1's care plan was reviewed for communication needs by the MDS coordinator on 03/02/17. The special communication needs were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station. This was completed by 03/5/17. 12) All resident care plans were reviewed for special communication needs by 03/05/17. Any identified special communication needs of the resident were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station and completed on 03/05/17. 13) The Individualized Communication Preference Guide Book, containing each resident within the center's communication needs, was placed at each nursing station on 03/05/17. Education presented to all staff was completed by 03/05/17 by the Administrator, DNS, ADNS, Director of Clinical Operations, Regional Director of Nursing Management Services and the Regional Director of Rehabilitation. 14) The Administrator, Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Regional Director of Clinical Operations, Senior Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Vice President will complete fifteen (15) Communication Preference Questionnaire forms weekly for eight (8) weeks. These will be conducted on all shifts and all department staff. 15) The Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations, or Divisional Senior Director of Clinical Operations will conduct fifteen (15) staff interviews per week for eight (8) weeks utilizing the Staff Abuse Questionnaire, regarding the facility's abuse policy and aspects of resident abuse to ensure continued and thorough understanding of the policy. These interviews will continue until determined by the facility's QA team that compliance is sustained. 16) The Administrator, DNS and/or ADNS will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe in the center and to allow a platform where the residents are encouraged to express and report any concerns regarding behaviors or actions displayed by team members, resident, family members or visitors. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. Minutes from these meetings will also be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) The Director of Clinical Operations and/or Regional Vice President will review all Resident Concerns (Grievance) Forms weekly for four (4) weeks and monthly thereafter to ensure any possible allegations have been investigated and reported per the facility policy. Resident Council Meeting minutes will be reviewed weekly for four (4) weeks to ensure that any possible allegations have been investigated and reported per the facility policy. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. 18) The facility's Governing Body, consisting of the Regional Vice President, the Regional Director of Clinical Operations, the Regional Clinical Reimbursement Specialist, and the Regional Director of Nursing Management Services will be present at the facility five (5) times each week for the next forty-five (45) days and visit weekly thereafter to ensure the facility maintains compliance with state and federal rules and regulations by reviewing the facility's staffing pattern, concern log, Resident Council Meeting minutes and the QAPI meeting minutes. The facility's Vice President of Clinical Operations and Chief Operating Officer will oversee the Governing Body to ensure the facility, administrator, and DNS receive the support needed to sustain compliance with state and federal rules and regulations, by review of quality indices and feedback reports from the Governing Body. 19) Oversight will be completed by the Administrator using the information from daily floor rounds, chart reviews, staff and resident interviews. As the QAPI leader, the Administrator will utilize the information to identify and correct non-compliance with state and federal regulations. The Administrator will review any allegations of abuse to ensure a thorough investigation and reporting per state law. The Regional Vice President and/or Regional Director of Clinical Operations will ensure the Administrator is investigating allegation of abuse according to policy and in accordance with state law. 20) On 03/05/17, a QAPI meeting was held with the Administrator, DNS and Medical Director. This meeting reviewed the actions and audits taken by the center effective 03/05/17. Findings of the audits and actions taken after 03/05/17 will be reviewed at the monthly QAPI meeting, by the QAPI team. The QAPI team includes the Medical Director, Administrator, DNS and at least three (3) other departmental leaders. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the Resident Interview Tool, dated 03/03/17, completed by the Regional Director of Nursing Management Services, revealed she had conducted an interview with Resident #1. Review of a Nurses Note, dated 03/03/17 at 9:02 PM, revealed she had conducted an interview with the resident. Review of a Resident Body Audit Tool for assessing the resident, revealed an assessment was completed by the Regional Director of Nursing Management Services on 03/03/17. Interview with the Regional Director of Nursing Management Services on, 03/09/17 at 5:40 PM, confirmed she had completed the interview, performed the assessment and had notified Resident #1's responsible party as well as the Physician. 2) Review of the Resident Interview Tool, revealed the Regional Director of Nursing Management Services or the Regional Vice President completed the interviews by 03/04/17. Review of the Resident Interview Tool, revealed there were forty (40) Resident Interview Tools completed by 03/04/17. Interviews with the Regional Director of Nursing Management Services, on 03/09/17 at 5:40 PM, and the Regional Vice President, on 03/09/17 at 5:30 PM, revealed they had performed the interviews and completed them by 03/04/17. Review of the Resident Body Audit Tool, revealed the assessments were completed by 03/05/17 by the Director of Nursing Services, Assistant Director of Nursing Services or the House Supervisor. Review of the Resident Body Audit Tool, revealed there were twenty-one (21) Resident Body Audits completed by 03/05/17. Interviews with the Director of Nursing Services, on 03/09/17 at 6:14 PM, the Assistant Director of Nursing Services, on 03/09/17 at 7:08 PM, revealed they had performed the Body Audits and completed them on 03/05/17. 3) Review of the Resident Abuse Investigation Report Form, dated 03/03/17 and electronically signed by the Administrator, revealed the investigation into alleged verbal abuse of Resident #1 on 02/18/17, was initiated on 03/03/17, as per the AOC. Review of the form revealed LPN #1 was placed on administrative leave on 03/03/17. Per the facility's Final Report, dated 03/07/17, the facility's investigation revealed the nurse was not witnessed to be using an argumentative tone with the resident. Interview with the Administrator and Senior Director of Clinical Operations, on 03/08/17 at 4:30 PM, revealed an initial report was submitted by the facility on 03/03/17 and a final report was submitted by the facility on 03/07/17. Both confirm notifications were made to the Ombudsman and police as well as LPN #1 being placed on ongoing administrative leave. 4) Interview with the Director of Clinical Operations, on 03/09/17 at 5:55 PM, revealed the facility has an Event Escalation process. Further interview revealed, the process was for the Administrator or DNS to call all potential allegations to the Director of Clinical Operations or the Director of Nursing Services Management. The notification is to be made at the time of the potential allegation of abuse. Further interview revealed, they would listen to the concerns and advise staff of further needed actions. 5) Review of the education provided to the Division President and the Regional Vice President revealed the education was provided by the Senior Director of Clinical Operations and completed on 03/03/17 to include a post-test. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, revealed she did present the education. Interview with the Division President, on 03/09/17 at 5:47 PM and the Regional Vice President, on 03/09/18 at 5:30 PM, revealed they did receive the education and post-test. 6) Review of the education provided to the Administrator, Director of Nursing Service (DNS) and the Assistant Director of Nursing Services (ADNS), revealed the education was provided by the Director of Clinical Operations and completed on 03/03/17 to include a post-test. Interview with the Administrator, on 03/09/17 at 6:32 PM, confirmed the education was provided to her, the DNS and ADNS on 03/03/17 that included a post-test. Further interview revealed the education emphasized yelling and/or arguing with a resident should be considered an allegation of abuse. Interview with the DNS, on 03/09/17 at 6:14 PM, confirmed the education was provided to her, the Administrator and ADNS on 03/03/17, that did include a post-test for learning comprehension. Further interview with the DNS revealed, the education emphasized yelling and/or arguing with a resident should be considered an allegation of abuse. 7) Review of the education provided to all licensed nursing team members, which included Registered Nurses (RN) and Licensed Practical Nurses (LPN), revealed the education was completed on 03/05/17. Those unable to attend by 03/05/17 were educated prior to working their next shift. Further review revealed, the education was presented by the DNS, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. Interview on 03/09/17 with RN #2 at 7:00 AM, LPN #7 at 9:50 AM, LPN #8 at 3:30 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, revealed they had received education on abuse. Further interview revealed, they had received the education by 03/05/17 and prior to their working the shift. Continue interview revealed they were required to complete a post-test for learning comprehension prior to working. 8) Review of the education provided to all non-licensed staff including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry, revealed the education was completed on 03/05/17. Staff unable to attend by 03/05/17 were educated prior to working their next shift. Further review revealed, the education was presented by the DNS, ADNS, Regional Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Director of Rehabilitation. Interview on 03/09/17 with CNA #14 at 7:46 AM, CNA#15 at 8:00 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, CNA #16 at 3:30 PM, CNA #6, CNA #5 at 3:34 PM, Physical Therapy Staff #3 at 2:16 PM, Housekeeping staff #18 at 3:20 PM, Laundry staff #15 at 3:25 PM, and Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, and Medical Records staff #16 at 3:40 PM, confirmed they had received education on abuse. Further interviews revealed, they had received the education by 03/05/17 and prior to working their shift. Continued interview revealed, they were required to complete a post-test for learning comprehension prior to working. 9) The facility's new hire orientation information and education was reviewed and revealed it included the abuse education and post-test. Interview with the Senior Director of Clinical Services, on 03/09/17 at 2:53 PM, revealed the facility's new hire orientation included the abuse education and post-test and would go into effect, as per the AOC. 10) The facility's abuse in-service material and post-tests were reviewed and checked against the master list of current employees. Review of the facility's master list of current employees revealed all staff disciplines were educated regarding the facility's abuse policy. The facility does not employ any agency staff. Interview on 03/09/17 with RN #2 at 7:00 AM, CNA #14 at 7:46 PM, CNA #15 at 8:00 AM, LPN #7 at 9:50 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, Housekeeping Staff #18 at 3:20 PM, Laundry Staff #15 at 3:25 PM, Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, LPN #8 at 3:30 PM, CNA #16 at 3:30 PM, CNA#6 at 3:30 PM, CNA #5 at 3:40 PM, Medical Record Staff #17 at 3:40 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, revealed they had all been educated on the facility's abuse policy and procedure and had taken a post-test. 11) Review of Resident #1's care plan for communication needs was completed on 03/02/17. Further review of the care plan, revealed goals were in place with a target date of 05/01/17. Continued review revealed, there were several approaches staff could utilize for communicating with Resident #1. Review of the Individualized Communication Preferences Guide Book, revealed Resident #1's care plan was in this book. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, confirmed the MDS nurse evaluated Resident #1's care plan for communication. Further interview revealed the care plan for Resident #1 was placed in the facility's Individualized Communication Preferences Guide Book, located at each nurse's station. 12) Review of the Individual Communication Preferences Guide Book revealed the residents had been assessed for communication needs the care plans placed in this book. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, confirmed the MDS nurse evaluated each of the facility's residents for their individual communication needs. Further interview revealed the care plans were placed in the facility's Individualized Communication Preferences Guide Book, located at each nurse's station. 13) Reviewed the Individualized Communication Preference Guide Book containing each resident within the center's communication needs. Interview on 03/09/17 with RN #2 at 7:00 AM, CNA #14 at 7:46 PM, CNA #15 at 8:00 AM, LPN #7 at 9:50 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, Housekeeping Staff #18 at 3:20 PM, Laundry Staff #15 at 3:25 PM, Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, LPN #8 at 3:30 PM, CNA #16 at 3:30 PM, CNA #6 at 3:30 PM, CNA #5 at 3:40 PM, Medical Record Staff #17 at 3:40 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, confirmed they had received education on the facility's Communication Preference Guide Book. 14) Review of completed Communication Preferences Questionnaire, revealed the questionnaires had been completed by appropriate staff. Further review revealed, as of 03/09/17, there were nine (9) completed for the week of 03/05/17 to 03/12/17. Interview with the Senior Director of Clinical Operations on 03/09/17 at 2:53 PM, the Regional Director of Clinical Operations, on 03/09/17 at 5:55 PM and the Administrator, on 03/09/17 at 6:32 PM, confirmed the facility had been completing the questionnaires per the AOC. 15) Review of the facility's Staff Abuse Questionnaire revealed the Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations or the Senior Director of Clinical Operations have conducted at least fifteen (15) Staff Abuse Questionnaire forms per week, per the AOC. Interview on 03/09/17 with Regional Director of Nursing Management Services at 5:40 PM and the Regional Director of Clinical Operations at 5:55 PM, confirmed they had conducted the Staff Abuse Questionnaire forms. Further interview revealed they perform at least fifteen (15) per week per the AOC. 16) Review of the Resident Council Meeting minutes, conducted on 03/07/16, revealed the meeting was conducted with the Administrator present and concerns were followed up on by the Administrator and the Regional Director of Nursing Management Services on 03/07/17. Interview with the Administrator on 03/09/17 at 6:32 PM, revealed she had conducted the Resident Council Meeting on 03/07/17 and had a meeting scheduled for 03/14/17, 03/21/17 and 03/28/17. Interview with the Regional Director of Nursing Management Services on 03/09/17 at 5:40 PM, revealed she had reviewed the Resident Council Meeting minutes and followed up with the resident concerns on 03/07/17. Interview with both staff report the minutes of the meeting will be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) Review of the Governing Body Review Form revealed concerns were reviewed by the Regional Director of Clinical Operations. Interview with the Regional Director of Clinical Operations, on 03/09/17 at 5:55 PM, confirmed she had reviewed the resident concerns and the Resident Council Meeting minutes of 03/07/17. Further interview revealed this will be done on a weekly basis for four (4) weeks and then monthly to ensure any possible allegations have been in

Based on observation, interview, record review, review of the facility's smoking policy and procedures, and review of the Centers for the Medicare and Medicaid Resident Assessment Instrument (RAI) Version 3.0 Manual, it was determined the facility failed to ensure services were provided in accordance with each resident's written Plan of Care for one (1) of eight (8) sampled residents, Resident #1. Resident #1's Comprehensive Plan of Care, dated 02/04/12, revealed interventions to provide structured daily routine, approach the resident in a calm manner, and talk in a calm voice. However, on 02/18/17 at 4:20 PM, per staff interviews, when the resident was waiting for his/ her routine 4:00 PM smoke break, Licensed Practical Nurse (LPN) #1 was witnessed to be in the resident's face yelling and arguing over the smoke break. Subsequently, on 02/18/17 at 5:00 PM, Certified Nursing Aide (CNA) #2 pushed the resident to the nurses' station per the resident's request and daily routine. Per staff interviews, LPN #1 stated in front of the resident, (He/she) can't sit here. I don't want to see (his/her) face, and LPN #1 moved the resident to a bedside table in the hall across from the nurses' station. (Refer to F-223) The facility's failure to ensure the Comprehensive Care Plan was followed has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/03/17, and was determined to exist on 02/18/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 alleging removal of the Immediate Jeopardy on 03/06/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/06/17, prior to exit on 03/09/17, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Interview with the Administrator on 03/03/17 at 4:25 PM revealed the facility had no policy related to following the care plan, and utilized the RAI Manual. Review of the Centers for the Medicare and Medicaid Resident Assessment Instrument (RAI) Version 3.0 Manual, dated July 2010, chapter four (4.7), revealed the Comprehensive Care Plan was an interdisciplinary communication tool, and must include measurable objectives and time frames and must describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed services provided or arranged must be consistent with resident's written plan of care. Review of the facility's Resident Smoking Policy, dated 07/01/08 revealed residents may only smoke in the designated smoking area, and supervised smokers may only smoke with a staff member present in the smoking area. Review of the facility's Resident Smoking Schedule revealed residents were allowed smoke breaks supervised by staff at 9:00 AM, 11:00 AM, 2:00 PM, 4:00 PM, 7:30 PM and 9:15 PM. Review of Resident #1's medical record revealed the facility admitted the resident on 01/26/12, and readmitted the resident on 06/23/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of three (03) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further review of the MDS, Section G, indicated the resident required extensive assistance of one (1) person for transfers and most activities of daily living, except eating, and the resident was non-ambulatory and used a wheelchair for mobility. Review of Resident #1's Comprehensive Care Plan, dated 02/04/12, with next review date of 05/01/17, revealed a problem of disorganized thoughts, irritated easily and impatient related to Cognitive Deficits, Senile [MEDICAL CONDITIONS] and Anxiety Disorders. The Goal stated the resident would not have any unnoticed declines in cognitive ability and the resident would have less than weekly occurrences of verbally abusive behavior through 05/01/17. The interventions included: approach the resident from the front in a calm, unhurried manner; talk with the resident in a calm voice when behavior was disruptive; maintain a calm manner with interactions; allow the resident to verbalize thoughts and feelings and validate them when resident was confused or anxious; and provide daily structured routine. Further review of the Comprehensive Care Plan, dated 02/04/12, with next review date of 03/01/17, revealed a problem of potential for injury related to smoking. The Goal stated the resident was to be injury free daily when engaging in smoke breaks through 03/01/17. The interventions included staff supervising the resident for safety during smoking privileges as per the resident's smoking assessment. Review of the Departmental Notes (DN) dated 02/21/17, signed by the Activities Director, revealed the resident continued to self-initiate own activity of interest as with routine collection of money each morning for two (2) Diet Pepsi, listened to music on radio via ear plugs related to [DIAGNOSES REDACTED]. Observations made on 02/27/17 at 9:00 AM, 11:00 AM, 2:00 PM and 4:00 PM of Resident #1, and other residents who smoked, revealed the residents were supervised by one (1) staff member at the posted scheduled smoking times. Continued observation of Resident #1 on 02/27/17 revealed he/she attended all the scheduled smoke breaks, except at 11:00 AM, at which time the resident stated to a staff member he/she didn't want to go smoke. Additional observations of Resident #1 on 02/27/27 at 9:30 AM, 10:30 AM, 11:20 AM, 12:15 PM, and 2:15 PM revealed the resident did not display behavior problems, and had no difficulty communicating with staff and making his/her needs known. At these same observation times, the resident did not have his/her pocket radio turned on and did not have ear phones in ears. Per these observation times the resident was observed to spend the day in the front lobby except at 12:15 PM and 5:30 PM when the resident went to the dining room to eat. On 02/27/17 at 10:00 AM, interview was conducted with Resident #1 and when the resident was asked if anyone had been mean or yelled at him/her at the facility, the resident looked side to side and whispered, sometimes. However, when questioned further the resident did not answer the questions and changed the subject. During the conversation the resident was observed to have three (3) small plastic bottles, which the resident kept in his/her jacket pocket and placed on the table. The resident shuffled the bottles around, talked about the bottles, and read out loud the label on top of one of the bottles which said, hold tab down and turn. The resident also had a small pocket radio with ear buds/ear phones in his/her jacket pocket. Interviews with CNA #3 on 02/27/17 at 1:20 PM; CNA #4 at 1:30 PM; CNA #1 on 02/27/17 at 2:30 PM; CNA #2 on 02/27/17 at 6:41 PM; CNA #5 on 02/28/17 at 8:00 AM; CNA #14 on 03/01/17 at 8:00 AM; CNA #9 on 03/01/17 at 10:00 AM; CNA #12 on 03/02/17 at 9:00 AM; LPN #1 on 03/03/17 at 3:30 PM; and LPN #2 on 03/08/17 at 2:35 PM; all revealed Resident #1's routine was to smoke at each scheduled smoke break, and the resident often reminded the staff it was time to smoke. The staff interviewed further revealed the resident would request to be pushed to the B-wing nurse's station desk, and would sit there daily with his/her collection of little plastic bottles, one (1) or two (2) clear drinking cups with straws, and pocket radio with ear phones. Per staff interviews, the resident would sometimes eat snacks at the nurse's station desk and occasionally would eat dinner there. The CNAs interviewed who had worked the longest stated Resident #1 had been sitting at the nurse's station desk daily for years and described it as the resident's comfort zone, where the resident liked to socialize, laugh and interact with other residents and nursing staff. Phone Interview with CNA #12, on 03/02/17 at 9:00 AM, revealed on 02/18/17 at 3:45 PM, Resident #1 was waiting at the exit door for smoke break and asked her to get him/her a Pepsi. She stated the resident was on a fluid restriction, and the supply of Pepsi was kept locked in the nourishment room. She further stated she told LPN #1 the resident asked for a Pepsi and the nurse stated the resident would have to wait. CNA #12 stated she did not hear the resident holler, talk loud or say smoke break. Continued interview revealed CNA #12 did not see the resident's radio or ear phones, on 02/18/17. Further interview revealed the resident was not hard of hearing, did not like loud voices, and could be easily agitated; therefore, the resident had to be talked to in a quiet, calm voice. She further revealed the batteries in the resident's radio were dead when she last worked with the resident on Thursday (02/16/17). She further stated the resident was supposed to get more batteries on Friday 02/17/17, but CNA #12 changed the batteries herself on Monday 02/20/17. Phone interview with CNA #1, on 02/27/17 at 2:30 PM, revealed on 02/18/17 at 4:25 PM she witnessed LPN #1 bent down in Resident #1's face yelling and arguing smoke break wasn't happening, she wasn't doing it, and told the resident he/she was lying about smoking. Continued interview revealed the resident did not have his/her radio on or ear phones in before or during the smoke break, and even if he/she did have the radio on, it was no excuse for LPN #1 to yell. She further stated the resident did not have any problems hearing, and loud voices agitated the resident. She stated everybody that worked there was aware of this. Further interview revealed the resident was very regimented, OCD ([MEDICAL CONDITION]) in daily routines and became agitated if his/her needs and requests were not given attention quickly and calmly. Phone Interview with CNA #2, on 02/27/17 at 6:41 PM, she witnessed on 02/18/17 at approximately 4:25 PM, LPN #1 yell and argue with Resident #1 about a smoke break. She stated LPN #1 acted mad and said something she could not hear to CNA #1 who had taken the resident out to smoke. CNA #2 further revealed after the resident had the smoke break, she asked the resident where he/she wanted to go and the resident said to the nurse's station. CNA #2 further revealed it was the resident's routine to sit at the nurse's station desk with his/her little plastic bottles and drinking cup and sometimes the resident listened to his/her radio with ear plugs. CNA #2 stated as soon as LPN #1 saw her push the resident via the wheelchair up to the desk, she said in front of the resident, (He/she) can't sit here with all this stuff! I don't want( him/he)r here. I don't want to see (his/her) face. CNA #2 stated she replied to LPN #1, You can't tell (him/her) (he/she) can't sit here. It's (his/her) home! Per interview with CNA #2, LPN #1 then got in CNA #2's face and said, I don't care if it's (his/her) home or not, it's not happening. Take it up with the DNS. CNA #2 further revealed instead of letting the resident sit at the desk, LPN #1 found a bedside table and moved the resident in the hallway across from the nurses' station. CNA #2 verified Resident #1 did not have ear buds or the radio on during these incidents with LPN #1. Interview with CNA #9, on 03/01/17 at 1:15 PM, revealed on 02/18/17, she observed activity staff take the residents, including Resident #1, out to smoke around 3:00-3:30 PM. She stated at 4:00 PM, Resident #1 was at the exit door for the next scheduled smoke break; however, she did not hear the resident saying, smoke time. She revealed she heard CNA #1 say to LPN #1 it was the resident's right to smoke, and she was taking the resident out to smoke. CNA #9 revealed she walked away and didn't hear LPN #1's response. Continued interview with CNA #9, revealed after the smoke break, when CNA #2 pushed Resident #1 in his/her wheelchair to the nurse's station desk, LPN #1 said, No, no, no! We're not doing this. (He/she) is not going to sit here; it's not happening; (he/she) can't be here. CNA #9 further revealed Resident #1 sat there every day and it was never a problem because the resident didn't bother anyone. She stated when LPN #1 said that in front of the resident it broke (his/her) heart because the resident looked sad and dropped his/her head down. Further interview revealed at the time of the incident, the resident was moved to a bedside table. Additional interview revealed the resident was allowed to sit at the nurse's station desk when any of the other nurses besides LPN #1 was there, and the resident would laugh and talk with staff. Interview with LPN #1, on 02/27/17 at 4:00 PM, and on 03/03/17 at 3:30 PM, revealed Resident #1 was totally aware of smoke break times, was like an alarm clock, and would get very verbal and let staff know fifteen (15) minutes ahead when it was smoke time. Continued interview revealed on 02/18/17 at 3:30 PM, the Activities person said the residents were allowed to make up the 2:00 PM smoke break delayed by activities. She stated the residents were out there about fifteen to twenty (15-20) minutes. LPN #1 further stated after that smoke break, at approximately 4:25 PM she heard the resident yelling, smoke time, smoke time, and the resident was agitated. She further stated the resident's pocket radio was on very loud and ear phones were in his/her ears. Per interview, she didn't want to yell, and she got down on eye level and had to talk loud, but the resident still didn't hear her. She further revealed she kept saying you can't go out right now, it will be a few minutes because you just went to smoke. Additional interview revealed she denied yelling at the resident, and denied arguing with the resident. Continued interview with LPN #1, revealed right after the smoke break, on 02/18/17, Resident #1 was pushed to the nurse's desk by CNA #2, and CNA #2. LPN #1 stated there were charts, paperwork, which could be a HIPAA concern at the nurse's station. (HIPAA refers to the Health Insurance Portability and Accountability Act, a 1996 Federal law that restricts access to individuals' private medical information). LPN #1 further stated she tried to explain to CNA #2 about HIPAA and told her the resident could not eat there. LPN #1 stated she obtained a bedside table and assisted the resident to the bedside table near the nurse's station desk. Additional interview with LPN #1, revealed she was usually familiar with residents' care plans; however, quite often they changed and they were not always accessible in the computer due to lock-outs. She further revealed it had been hard for her to pull them up from the computer lately, but there was also Care Plans behind the nurses' desk which she could review. Continued interview revealed as for Resident #1, she was not sure what his/her care plan said about approaches due to cognitive status, Anxiety and [MEDICAL CONDITION] Disorders or approaches related to daily routine. However, LPN #1 denied displaying behavior which would have been contradictory to the resident's Plan of Care to maintain a calm manner and speak with a calm voice on on 02/18/17. Further interview with LPN #1 revealed it was Resident #1's routine to sit at the nurse's station desk but the evening of 02/18/17 she had charts out and was busy working at the desk. She stated she asked the resident if he/she would mind moving to the bedside table and the resident was agreeable to this. Phone interview with CNA #5, on 02/28/17 at 7:50 AM, revealed she could not recall the exact day, but she had observed LPN #1 lean down in Resident #1's face during a supervised smoke break and heard her say, I don't really care what you say, or who you tell, resident care comes first. CNA #5 further stated she had no idea what the comment was about, but the tone in which LPN #1 stated it was really rude. Continued interview revealed the resident did not respond. Further interview revealed CNA #5 never had to be loud with Resident #1. She stated the resident did better when staff paid attention to what he/she said, listened, talked nice and didn't get rushed. She further stated the resident did not have a hearing problem, and there was no reason to get close to his/her face. Additional interview revealed if the resident had the ear phones in, she simply tapped the resident on the shoulder, gestured to the resident to take them out, and he/she would without being argumentative. Interview with CNA #14, on 03/01/17 at 8:00 AM, revealed she was familiar with Resident #1's care plan and knew how to interact with the resident. She stated the resident didn't like to be talked to in a loud voice, and this would actually upset the resident and make him/her more anxious. Continued interview revealed if the resident had ear phones in, staff would have to get closer, but there was no need to yell, because the resident could hear well even with the ear phones in and the music on. Further interview revealed if the resident was asked nicely, he/she would take them out to listen and she had never had any problems communicating with Resident #1. Additional interview, revealed she had observed Resident #1 sitting at the nurse's station desk and the resident seemed content there. She further stated the facility was the resident's home and he/she should be allowed to sit wherever the resident wanted as long as it wasn't disturbing others. She also stated his/her bedside table would be provided in the hall if the resident wanted it; however, she had observed the resident usually wanted to sit at the nurse's station desk and he/she interacted with staff and other residents there. Interview with LPN #8, on 03/08/17 at 2:35 PM, revealed it was Resident #1's routine to sit at the nurse's station desk with the bottles, drinking cups, straws, Diet Pepsi and radio. She further revealed the resident's places of choice were the nurse's station desk, the front lobby and at the end of B-wing hall near the pop machine. Further interview with LPN #8 revealed the resident was care planned for cognitive changes and anxiety, and as long as the resident's needs were met fairly quickly when he/she asked, the resident did not become agitated. Phone interview with the Social Services Director, on 02/27/17 at 11:00 AM, revealed residents were supposed to be taken out for smoke breaks as close to the scheduled times as possible. She further stated sitting at the nurse's station desk was definitely part of Resident #1's daily routine with the bottles and the radio. She further stated it was the resident's right to sit at the nurse's station desk and she had observed Resident #1 sitting at the front nurse's station desk and eating there several times as well. She further revealed the medical charts were kept in the back of the nurse's station, where most nurses did their charting, and the front nurse's desk was usually clear. Further interview revealed it was important to follow all the residents' care plans and provide them structure in their daily routines. Interview with the Director of Nursing Services (DNS), on 03/02/17 at 4:25 PM, revealed the nurses had access to the residents' Care Plans each time they logged into the computer and charted. Review of Resident #1's printed Care Plan with the DNS, revealed it was initiated 02/04/12 with interventions to maintain a calm manner, and a calm voice when the resident's behavior was disruptive; and provide structured daily routine for the resident. When questioned about the incidents related to Resident #1 and LPN #1 on 02/18/17, the DNS revealed CNA #1 reported on 02/18/17 around 4:30 PM, LPN #1 was yelling and arguing with Resident #1, and she immediately checked on the resident by looking at the resident through the glass door and the resident was happy and smoking. The DNS further stated, later the same day, CNA #2 reported she had pushed the resident to the nurse's station via wheelchair and LPN #1 said, oh no, not today and moved the resident to a bedside table in the hall. Per interview, the DNS went to the unit later and observed the resident eating dinner, with no problems, at the bedside table away from the nurse's station. Further interview with the DNS, revealed she was not sure if LPN #1 followed the resident's Care Plan on 02/18/17 related to interacting with the resident in a calm manner because she did not witness the interactions between Resident #1 and LPN #1 on that date. She further stated LPN #1 had told her she had to talk loud in order for the resident to hear because his/her radio was on. However, she stated if the nurse was arguing and yelling at the resident as per interview with CNA #1 on 02/18/17, the nurse would not be following the Care Plan. Further interview revealed on 02/18/17 at approximately 4:30 PM, when CNA #1 made the allegation, the DNS did not look to see if the resident had ear phones in or the radio on. She stated the resident didn't ever let the batteries go down; however, if the resident didn't have the radio and ear phones on, there really would be no reason for the nurse to be talking loudly to him. Additional interview with the DNS regarding the resident's structured daily routine, revealed Resident #1 was allowed to sit at the nurses' station routinely, and if LPN #1 did not allow the resident to sit there on 02/18/17, the nurse did not follow the resident's care plan related to a consistent routine. Interview with the Administrator on 03/01/17 at 5:45 PM, revealed if Resident #1 was care planned to be approached in a calm manner and with a calm voice, staff were to follow the care plan. She stated staff had witnessed LPN #1 yelling and arguing with Resident #1 on 02/18/17 which was not okay and the care plan was not followed. Further interview revealed if Resident #1 was care planned to be provided structured daily routine, and had a routine of sitting at the nurse's station desk, LPN #1 should have allowed the resident to sit at the nurse's station desk on 02/18/17. She stated the resident's routine should be followed to the extent possible. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 that alleged removal of the Immediate Jeopardy (IJ) on 03/06/17. Review of the AOC revealed the facility implemented the following. 1) Resident #1 (BIMS of 3) was interviewed on 03/03/17, using the Resident Interview Tool, by the Regional Director of Nursing Management Services. A physical assessment of Resident #1 was completed on 03/03/17, by the Regional Director of Nursing Management Services, using the Resident Body Audit Tool. The responsible party and attending physician were notified by the administrator of the allegation on 03/03/17. 2) All alert and oriented residents (BIMS greater than 8) were interviewed utilizing the Resident Interview Tool, by the Regional Director of Nursing Management Services or the Regional Vice President by 03/04/17. Physical assessments of non-interviewable residents (BIMS less than 8) were conducted by the DNS, ADNS, or House Supervisor by 03/05/17, using the Resident Body Audit Tool. 3) The facility submitted an Initial Allegation of Abuse Report to OIG, dated 03/03/17. Per the report, APS (adult protective service), the local Ombudsman and the Police were notified on 03/03/17. The involved LPN was placed on administrative leave on 03/03/17. A thorough investigation was completed by the Divisional Senior Director of Clinical Operations to ensure evidence of completion including reporting to proper authorities in acceptance with State law. This review was completed by 03/05/17. 4) The Director of Clinical Operations and/or the Regional Vice President will be notified by the Administrator and/or DNS any time there is a report of any incident that could possibly be construed as an allegation of abuse in order to assist in determining appropriate investigation and reporting. 5) Education was provided to the Division President and the Region Vice President. This education was presented by the Senior Director of Clinical Operation and completed on 03/03/17. The education included a review of the facility's Abuse Policy to include a Staff Abuse Questionnaire to demonstrate learning. 6) Education was provided to the Administrator, Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) by the Director of Clinical Operations. This education was completed on 03/03/17 and also emphasized that yelling and/or arguing with a resident should be considered an allegation of abuse. A Staff Abuse Questionnaire was completed by each on 03/03/17, to demonstrate learning. 7) Education was provided to all licensed nursing team members which included Registered Nurses (RN) and Licensed Practical Nurses (LPN) to include a review of the facility's Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was developed by the Director of Clinical Operations and presented by the DNA, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 8) Education was provided to all non-licensed team members including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry to include a review of the Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was provided by the DNS, ADNS, Regional Director of Clinical Operations or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 9) Educational material regarding Abuse was included in the facility's orientation materials to be completed with future new hires and will be presented by the Director of Nursing Services or a designated Registered Nurse prior to providing direct care to residents. All team members will receive additional education related to abuse reporting at least twice a year. 10) All learning with current full time facility team members was completed by 03/05/17. Any team member not completing the education by 03/05/17 will not be allowed to work until the education has been completed and competency determined. The facility does not employ any agency staff. 11) Resident #1's care plan was reviewed for communication needs by the MDS coordinator on 03/02/17. The special communication needs were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station. This was completed by 03/5/17. 12) All resident care plans were reviewed for special communication needs by 03/05/17. Any identified special communication needs of the resident were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station and completed on 03/05/17. 13) The Individualized Communication Preference Guide Book, containing each resident within the center's communication needs, was placed at each nursing station on 03/05/17. Education presented to all staff was completed by 03/05/17 by the Administrator, DNS, ADNS, Director of Clinical Operations, Regional Director of Nursing Management Services and the Regional Director of Rehabilitation. 14) The Administrator, Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Regional Director of Clinical Operations, Senior Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Vice President will complete fifteen (15) Communication Preference Questionnaire forms weekly for eight (8) weeks. These will be conducted on all shifts and all department staff. 15) The Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations, or Divisional Senior Director of Clinical Operations will conduct fifteen (15) staff interviews per week for eight (8) weeks utilizing the Staff Abuse Questionnaire, regarding the facility's abuse policy and aspects of resident abuse to ensure continued and thorough understanding of the policy. These interviews will continue until determined by the facility's QA team that compliance is sustained. 16) The Administrator, DNS and/or ADNS will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe in the center and to allow a platform where the residents are encouraged to express and report any concerns regarding behaviors or actions displayed by team members, resident, family members or visitors. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. Minutes from these meetings will also be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) The Director of Clinical Operations and/or Regional Vice President will review all Resident Concerns (Grievance) Forms weekly for four (4) weeks and monthly thereafter to ensure any possible allegations have been investigated and reported per the facility policy. Resident Council Meeting minutes will be reviewed weekly for four (4) weeks to ensure that any possible allegations have been investigated and reported per the facility policy. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. 18) The facility's Governing Body, consisting of the Regional Vice President, the Regional Director of Clinical Operations, the Regional Clinical Reimbursement Specialist, and the Regional Director of Nursing Management Services will be present at the facility five (5) times each week for the next forty-five (45) days and visit weekly thereafter to ensure the facility maintains compliance with state and federal rules and regulations by reviewing the facility's staffing pattern, concern log, Resident Council Meeting minutes and the QAPI meeting minutes. The facility's Vice President of Clinical Operations and Chief Operating Officer will oversee the Governing Body to ensure the facility, administrator, and DNS receive the support needed to sustain compliance with state and federal rules and regulations, by review of quality indices and feedback reports from the Governing Body. 19) Oversight will be completed by the Administrator using the information from daily floor rounds, chart reviews, staff and resident interviews. As the QAPI leader, the Administrator will utilize the information to identify and correct non-compliance with state and federal regulations. The Administrator will review any allegations of abuse to ensure a thorough investigation and reporting per state law. The Regional Vice President and/or Regional Director of Clinical Operations will ensure the Administrator is investigating allegation of abuse according to policy and in accordance with state law. 20) On 03/05/17, a QAPI meeting was held with the Administrator, DNS and Medical Director. This meeting reviewed the actions and audits taken by the center effective 03/05/17. Findings of the audits and actions taken after 03/05/17 will be reviewed at the monthly QAPI meeting, by the QAPI team. The QAPI team includes the Medical Director, Administrator, DNS and at least three (3) other departmental leaders. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the Resident Interview Tool, dated 03/03/17, completed by the Regional Director of Nursing Management Services, revealed she had conducted an interview with Resident #1. Review of a Nurses Note, dated 03/03/17 at 9:02 PM, revealed she had conducted an interview with the resident. Review of a Resident Body Audit Tool for assessing the resident, revealed an

Based on interview, record review, and review of the facility's Job Description for Divisional President, the facility's Job Description for Regional Vice President and review of the facility's policy and procedures, it was determined the facility's Governing Body failed to ensure the facility's Policy related to Abuse Prohibition was implemented for one (1) of eight (8) sampled residents (Resident #1). Certified Nursing Assistant (CNA) #1 reported to the Director of Nursing Services (DNS) on 02/18/17, Licensed Practical Nurse (LPN) #1 had yelled and argued with Resident #1 over a scheduled smoke break. Subsequently, the same day CNA #2 reported to the Director of Nursing Services (DNS), that when she pushed Resident #1 to the nurse's station desk at the resident's request, LPN #1 stated in front of the resident he/she could not sit there; it wasn't going to happen; and she didn't want to see the resident's face. Although the DNS immediately interviewed CNA #1, CNA #2, and LPN #1 after the allegations, the DNS failed to immediately report the allegations to the Administrator, and the Administrator was not made aware of the incidents until CNA #1 reported the incidents to the Administrator via phone conversation on 02/18/17 at approximately 8:00 PM. These two (2) abuse allegations related to Resident #1 were not reported to other officials (including the State Survey Agency) by either the DNS or the Administrator. In addition, the the facility failed to conduct a comprehensive investigation related to the allegations and the the facility's Administration failed to ensure residents were protected from potential abuse during the investigation. Although the facility's Administration was notified on 02/18/17 of the alleged abuse which occurred on 02/18/17, LPN #1 was allowed to work and care for the residents the rest of the shift on 02/18/17 and worked as scheduled on 02/19/17, 02/20/17, 02/21/17, 02/26/17 and 02/27/17. Also, on 02/18/17 at approximately 8:00 PM, CNA #1 called the Corporate Care Line (Hotline) and reported the two (2) allegations related to Resident #1 and also reported verbal arguments between LPN's and CNA's. Corporate representatives arrived at the facility on 02/21/17 to investigate Human Resource issues related to CNA #1's concerns. Although the Corporate representatives reviewed CNA #1's Statement related to LPN #1's behavior towards Resident #1, and also transcribed a statement from the DNS related to the allegations; Corporate failed to identify the allegations as abuse and failed to implement the facility Abuse Policy related to reporting, investigating, and protecting. (Refer to F-223, F-225, F-226 and F-490) The facility's failure to have an effective Governing Body to ensure the facility's policies were implemented related to abuse allegations has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 03/03/17 and determined to exist on 02/18/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 alleging removal of the Immediate Jeopardy on 03/06/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/06/17, prior to exit on 03/09/17, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Divisional President, dated October 2015, revealed the Divisional President was to provide direction, oversight, and support for the day to day operations of segments of the Diversicare Portfolio. Further review revealed the Essential Job Duties included: ensures the resident is at the center of every decision; ensures compliance with State and Federal Regulations; ensures that quality care and services is provided to all residents and that it meets the satisfaction of the patient, resident, family, physicians, and partner; ensures an effective workforce management program is in pace including but not limited to orientation, training, and Team Member engagement; and supports and provides guidance to the Regional Vice Presidents. Review of the facility's Job Description for Regional Vice President, dated October 2015, revealed the Regional Vice President was to direct and oversee the 24/7 day to day operation of the Diversicare post-acute care centers. Further review revealed the Essential Job Duties included: ensures the resident is at the center of every decision; ensures compliance with State and Federal Regulations; ensures adoption of Diversicare policies, guidelines, standards; ensures that quality care and services is provided to all residents and that it meets the satisfaction of the patient, resident, family physicians, and partners; ensures an effective workforce management program is in pace including but not limited to orientation, training, and Team Member engagement; supports, provides guidance, and manages the Administrators. Review of the facility's Governing Body Policy, effective 11/01/16, revealed as required by law, the Center shall have a Governing Body that is legally responsible for establishing and implementing policies regarding management and operation of the Center. The Governing Body shall consist of Regional Vice President, Administrator, and Director of Nursing. Review of the facility's Abuse Policy (Policy # N-A-045) dated 11/20/16, revealed all allegations of abuse are reported immediately to the Administrator to State Agencies and law enforcement in accordance with existing state law. The Administrator will direct a thorough investigation of each alleged violation and was responsible for reporting the results of all investigations to the State Agencies. Results of the investigation are reported to the appropriate State Agencies in accordance with existing State Law through established procedures immediately, which means as soon as possible, but ought not to exceed twenty-four (24) hours after discovery of the incident. The results of all investigations must be reported within five (5) working days of the alleged violation. Continued review of the facility's Policy revealed employees who were alleged to have committed abuse were suspended pending outcome of an investigation. Further review of the Policy revealed the definition of verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Anytime there is an allegation of abuse, the center must not only report the alleged violation to the Administrator, the Chief Compliance Officer and other officials, but also initiate an immediate investigation and prevent further abuse. All investigations shall be conducted by the Administrator, Director of Nursing or subject matter expert. The investigation shall include interviews of team members, visitors, patients/residents, volunteers and vendors who may have knowledge of the alleged incident. Written statements from involved parties should not be requested, as all information will be documented on the investigation form or state required form. Federal law requires evidence of investigations of alleged violations. The investigation form or state required form, shall be completed after the investigation is complete and provided to survey agencies when requested or required by state and federal law. All alleged violations shall be recorded. Review of the facility's Abuse Investigations and Reports on 02/27/17, revealed no documented evidence of an investigation related to allegations of verbal abuse by LPN #1 towards Resident #1, which were reported on 02/18/17, by CNA #1 and CNA #2. On 02/28/17, the State Survey Representative received from the facility written statements from LPN #1 dated 02/18/17, CNA #1 dated 02/19/17, DNS Statement transcribed by the Corporate Division President dated 02/21/17, and the DNS written Statement dated 03/01/17 related to the allegations of verbal abuse for Resident #1. However, the facility failed to provide further evidence of an investigation related to the verbal abuse allegations. Additionally interviews with CNA #1 on 02/27/17 at 2:30 PM, LPN #1 on 02/27/17 at 4:00 PM, CNA #2 on 02/27/17 at 6:41 PM and LPN #2 on 02/28/16 at 6:30 AM revealed on the evening of 02/18/17 the four (4) staff had a heated verbal altercation related to staff assignments. Per interview LPN #1 asked CNA #1 and #2 to leave the building and she and LPN #2 called the Administrator and reported CNA #1 and CNA #2 being insubordinate and left a voicemail for the DNS. CNA #1 and CNA #2 stated they left the building and called the DNS from the car and reported everything that happened related to the staff argument. Interview with the DNS, on 03/02/17 at 3:25 PM, revealed she did not immediately report either incidents as allegations of abuse to the Administrator or to State Agencies, did not protect the residents by allowing LPN #1 to continue working, and did not investigate the allegations further which would have included interviewing additional witnesses. The DNS acknowledged she independently made the determination there was no abuse. Interview with the Administrator, on 02/27/17 at 4:00 PM, and 03/02/17 at 4:30 PM, revealed the DNS should have reported the allegations to her and to State Agencies as well as conducted a thorough investigation in order to protect the residents. Per interview, CNA #1 did call her the evening of 02/18/17; however, she was acutely ill and did not remember the conversation. She stated she did instruct CNA #1 to write a Statement, but she had not read the employee statements from CNA #1, LPN #1 and the DNS because they were given directly to Corporate who had come in on 02/21/17 to investigate employee relations issues involving CNA #1, CNA #2, LPN #1 and LPN #2. Continued interview with the Administrator, revealed when the Corporate Regional Vice President and Division President arrived at the facility and conducted their investigation regarding employee relations issues, this resulted in suspension of CNA #1 and CNA #2, as the investigation determined they had used foul language, and were insubordinate to the DNS. She stated she had stepped away from the situation because one staff involved was a family member. She stated she turned it over to Corporate and was not directly involved with the investigations. Per interview, after Corporate reviewed the Statements, they should have identified the abuse allegations and notified State Agencies of the allegations related to Resident #1. She further stated Corporate should have suspended LPN #1 during the investigation and should have done a thorough investigation, to include interviewing interviewable residents and interviewing additional staff for further information related to the incidents. The Administrator revealed the system failed as the facility/Corporate did not identify the allegations as abuse and the facility only addressed the allegations as a smoking privilege problem and a staff relations problem. Interview with the Regional Vice President (RVP), on 02/27/17 at 10:45 AM, revealed the call CNA #1 made to the hotline came in on 02/18/17 at 8:34 PM and went to her Supervisor, the Division President. She further stated there was never an allegation of abuse on the hot-line; it was a compliance hot-line. She revealed the synopsis, (synopsis is a brief summary), was that CNA #1 and CNA #2 said they were bullied by night nurse LPN #2 and day shift nurse LPN #1; profanity was used; and at shift change there was insubordination by the CNAs not wanting to do what their charge nurse told them to do. She also stated the Administrator felt there was a conflict due to the family ties, so she asked Corporate to handle it. Further interview with the RVP, on 03/02/17 at 2:50 PM, revealed she and the Division President both reviewed the occurrences related to Resident #1. She stated they ascertained LPN #1 was the nurse in charge; and the CNAs were insubordinate to the nurse. She stated the DNS determined the nurse was speaking loudly, but there wasn't verbal abuse. Continued interview regarding the second incident, revealed CNA#2 was told by LPN #1 it was not appropriate for Resident #1 to eat at the nurses' station because the nurse had charts out which needed to be protected, and it was not appropriate for the resident to eat dinner at the desk. She stated the DNS did not file an abuse allegation related to the incidents on 02/18/17 regarding Resident #1 because there was never an allegation of abuse, and it was all retaliation, insubordination, and Aides not wanting to do their jobs. Per the RVP, LPN #1 told CNA #1 not to take the resident out to smoke, and she took the resident out anyway and LPN #1 informed the DNS of insubordination. Continued interview revealed LPN #1 told CNA #2 it was not appropriate for the resident to eat dinner at the nurses' station and she argued with the nurse. Per the RVP, you have a he said she said, and there was no reportable allegation of abuse. However, further interview revealed the RVP did not further investigate the allegations related to Resident #1 as she had not interviewed CNA #1, CNA #2, LPN #1 or other staff who may have been witnesses to the allegations after reading the DNS Statement. Interview with the Division President (DP), on 03/02/17 at 6:00 PM, revealed CNA #1 called the Corporate Care Line and reported a nurse was loud and argumentative with a resident which did not automatically equate abuse to her. She stated there was a lot of other concerns reported which involved two (2) CNAs and two (2) LPNs at shift change which Corporate considered Human Resources issues. She further stated the majority of the call consisted of issues between staff who had used colorful language towards each other in the facility. She stated she responded to the Care Line call and just looked at how it involved Human Resources and did not look at it as an abuse investigation. She acknowledged she had not conducted many abuse investigations in the past. She stated she normally just investigated Human Resource issues and her purpose at the facility was to investigate only Human Resource employee issues. Per interview, she had not interviewed any employees related to the allegations of abuse towards Resident #1, nor had she attempted interview with Resident #1. There was no documented evidence the Corporate representatives had identified the two (2) allegations related to Resident #1 as abuse allegations. In addition, there was no documented evidence the Corporate representatives implemented the facility's Abuse policy related to reporting the verbal abuse allegations to the State Agencies, completing a thorough investigation to interview other witnesses to the incidents in order to gain additional information, and protecting the residents as they allowed LPN #1 to continue working in resident care areas after the allegations were reported. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 that alleged removal of the Immediate Jeopardy (IJ) on 03/06/17. Review of the AOC revealed the facility implemented the following. 1) Resident #1 (BIMS of 3) was interviewed on 03/03/17, using the Resident Interview Tool, by the Regional Director of Nursing Management Services. A physical assessment of Resident #1 was completed on 03/03/17, by the Regional Director of Nursing Management Services, using the Resident Body Audit Tool. The responsible party and attending physician were notified by the administrator of the allegation on 03/03/17. 2) All alert and oriented residents (BIMS greater than 8) were interviewed utilizing the Resident Interview Tool, by the Regional Director of Nursing Management Services or the Regional Vice President by 03/04/17. Physical assessments of non-interviewable residents (BIMS less than 8) were conducted by the DNS, ADNS, or House Supervisor by 03/05/17, using the Resident Body Audit Tool. 3) The facility submitted an Initial Allegation of Abuse Report to OIG, dated 03/03/17. Per the report, APS (adult protective service), the local Ombudsman and the Police were notified on 03/03/17. The involved LPN was placed on administrative leave on 03/03/17. A thorough investigation was completed by the Divisional Senior Director of Clinical Operations to ensure evidence of completion including reporting to proper authorities in acceptance with State law. This review was completed by 03/05/17. 4) The Director of Clinical Operations and/or the Regional Vice President will be notified by the Administrator and/or DNS any time there is a report of any incident that could possibly be construed as an allegation of abuse in order to assist in determining appropriate investigation and reporting. 5) Education was provided to the Division President and the Region Vice President. This education was presented by the Senior Director of Clinical Operation and completed on 03/03/17. The education included a review of the facility's Abuse Policy to include a Staff Abuse Questionnaire to demonstrate learning. 6) Education was provided to the Administrator, Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) by the Director of Clinical Operations. This education was completed on 03/03/17 and also emphasized that yelling and/or arguing with a resident should be considered an allegation of abuse. A Staff Abuse Questionnaire was completed by each on 03/03/17, to demonstrate learning. 7) Education was provided to all licensed nursing team members which included Registered Nurses (RN) and Licensed Practical Nurses (LPN) to include a review of the facility's Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was developed by the Director of Clinical Operations and presented by the DNA, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 8) Education was provided to all non-licensed team members including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry to include a review of the Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was provided by the DNS, ADNS, Regional Director of Clinical Operations or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 9) Educational material regarding Abuse was included in the facility's orientation materials to be completed with future new hires and will be presented by the Director of Nursing Services or a designated Registered Nurse prior to providing direct care to residents. All team members will receive additional education related to abuse reporting at least twice a year. 10) All learning with current full time facility team members was completed by 03/05/17. Any team member not completing the education by 03/05/17 will not be allowed to work until the education has been completed and competency determined. The facility does not employ any agency staff. 11) Resident #1's care plan was reviewed for communication needs by the MDS coordinator on 03/02/17. The special communication needs were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station. This was completed by 03/5/17. 12) All resident care plans were reviewed for special communication needs by 03/05/17. Any identified special communication needs of the resident were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station and completed on 03/05/17. 13) The Individualized Communication Preference Guide Book, containing each resident within the center's communication needs, was placed at each nursing station on 03/05/17. Education presented to all staff was completed by 03/05/17 by the Administrator, DNS, ADNS, Director of Clinical Operations, Regional Director of Nursing Management Services and the Regional Director of Rehabilitation. 14) The Administrator, Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Regional Director of Clinical Operations, Senior Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Vice President will complete fifteen (15) Communication Preference Questionnaire forms weekly for eight (8) weeks. These will be conducted on all shifts and all department staff. 15) The Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations, or Divisional Senior Director of Clinical Operations will conduct fifteen (15) staff interviews per week for eight (8) weeks utilizing the Staff Abuse Questionnaire, regarding the facility's abuse policy and aspects of resident abuse to ensure continued and thorough understanding of the policy. These interviews will continue until determined by the facility's QA team that compliance is sustained. 16) The Administrator, DNS and/or ADNS will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe in the center and to allow a platform where the residents are encouraged to express and report any concerns regarding behaviors or actions displayed by team members, resident, family members or visitors. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. Minutes from these meetings will also be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) The Director of Clinical Operations and/or Regional Vice President will review all Resident Concerns (Grievance) Forms weekly for four (4) weeks and monthly thereafter to ensure any possible allegations have been investigated and reported per the facility policy. Resident Council Meeting minutes will be reviewed weekly for four (4) weeks to ensure that any possible allegations have been investigated and reported per the facility policy. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. 18) The facility's Governing Body, consisting of the Regional Vice President, the Regional Director of Clinical Operations, the Regional Clinical Reimbursement Specialist, and the Regional Director of Nursing Management Services will be present at the facility five (5) times each week for the next forty-five (45) days and visit weekly thereafter to ensure the facility maintains compliance with state and federal rules and regulations by reviewing the facility's staffing pattern, concern log, Resident Council Meeting minutes and the QAPI meeting minutes. The facility's Vice President of Clinical Operations and Chief Operating Officer will oversee the Governing Body to ensure the facility, administrator, and DNS receive the support needed to sustain compliance with state and federal rules and regulations, by review of quality indices and feedback reports from the Governing Body. 19) Oversight will be completed by the Administrator using the information from daily floor rounds, chart reviews, staff and resident interviews. As the QAPI leader, the Administrator will utilize the information to identify and correct non-compliance with state and federal regulations. The Administrator will review any allegations of abuse to ensure a thorough investigation and reporting per state law. The Regional Vice President and/or Regional Director of Clinical Operations will ensure the Administrator is investigating allegation of abuse according to policy and in accordance with state law. 20) On 03/05/17, a QAPI meeting was held with the Administrator, DNS and Medical Director. This meeting reviewed the actions and audits taken by the center effective 03/05/17. Findings of the audits and actions taken after 03/05/17 will be reviewed at the monthly QAPI meeting, by the QAPI team. The QAPI team includes the Medical Director, Administrator, DNS and at least three (3) other departmental leaders. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the Resident Interview Tool, dated 03/03/17, completed by the Regional Director of Nursing Management Services, revealed she had conducted an interview with Resident #1. Review of a Nurses Note, dated 03/03/17 at 9:02 PM, revealed she had conducted an interview with the resident. Review of a Resident Body Audit Tool for assessing the resident, revealed an assessment was completed by the Regional Director of Nursing Management Services on 03/03/17. Interview with the Regional Director of Nursing Management Services on, 03/09/17 at 5:40 PM, confirmed she had completed the interview, performed the assessment and had notified Resident #1's responsible party as well as the Physician. 2) Review of the Resident Interview Tool, revealed the Regional Director of Nursing Management Services or the Regional Vice President completed the interviews by 03/04/17. Review of the Resident Interview Tool, revealed there were forty (40) Resident Interview Tools completed by 03/04/17. Interviews with the Regional Director of Nursing Management Services, on 03/09/17 at 5:40 PM, and the Regional Vice President, on 03/09/17 at 5:30 PM, revealed they had performed the interviews and completed them by 03/04/17. Review of the Resident Body Audit Tool, revealed the assessments were completed by 03/05/17 by the Director of Nursing Services, Assistant Director of Nursing Services or the House Supervisor. Review of the Resident Body Audit Tool, revealed there were twenty-one (21) Resident Body Audits completed by 03/05/17. Interviews with the Director of Nursing Services, on 03/09/17 at 6:14 PM, the Assistant Director of Nursing Services, on 03/09/17 at 7:08 PM, revealed they had performed the Body Audits and completed them on 03/05/17. 3) Review of the Resident Abuse Investigation Report Form, dated 03/03/17 and electronically signed by the Administrator, revealed the investigation into alleged verbal abuse of Resident #1 on 02/18/17, was initiated on 03/03/17, as per the AOC. Review of the form revealed LPN #1 was placed on administrative leave on 03/03/17. Per the facility's Final Report, dated 03/07/17, the facility's investigation revealed the nurse was not witnessed to be using an argumentative tone with the resident. Interview with the Administrator and Senior Director of Clinical Operations, on 03/08/17 at 4:30 PM, revealed an initial report was submitted by the facility on 03/03/17 and a final report was submitted by the facility on 03/07/17. Both confirm notifications were made to the Ombudsman and police as well as LPN #1 being placed on ongoing administrative leave. 4) Interview with the Director of Clinical Operations, on 03/09/17 at 5:55 PM, revealed the facility has an Event Escalation process. Further interview revealed, the process was for the Administrator or DNS to call all potential allegations to the Director of Clinical Operations or the Director of Nursing Services Management. The notification is to be made at the time of the potential allegation of abuse. Further interview revealed, they would listen to the concerns and advise staff of further needed actions. 5) Review of the education provided to the Division President and the Regional Vice President revealed the education was provided by the Senior Director of Clinical Operations and completed on 03/03/17 to include a post-test. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, revealed she did present the education. Interview with the Division President, on 03/09/17 at 5:47 PM and the Regional Vice President, on 03/09/18 at 5:30 PM, revealed they did receive the education and post-test. 6) Review of the education provided to the Administrator, Director of Nursing Service (DNS) and the Assistant Director of Nursing Services (ADNS), revealed the education was provided by the Director of Clinical Operations and completed on 03/03/17 to include a post-test. Interview with the Administrator, on 03/09/17 at 6:32 PM, confirmed the education was provided to her, the DNS and ADNS on 03/03/17 that included a post-test. Further interview revealed the education emphasized yelling and/or arguing with a resident should be considered an allegation of abuse. Interview with the DNS, on 03/09/17 at 6:14 PM, confirmed the education was provided to her, the Administrator and ADNS on 03/03/17, that did include a post-test for learning comprehension. Further interview with the DNS revealed, the education emphasized yelling and/or arguing with a resident should be considered an allegation of abuse. 7) Review of the education provided to all licensed nursing team members, which included Registered Nurses (RN) and Licensed Practical Nurses (LPN), revealed the education was completed on 03/05/17. Those unable to attend by 03/05/17 were educated prior to working their next shift. Further review revealed, the education was presented by the DNS, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. Interview on 03/09/17 with RN #2 at 7:00 AM, LPN #7 at 9:50 AM, LPN #8 at 3:30 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, revealed they had received education on abuse. Further interview revealed, they had received the education by 03/05/17 and prior to their working the shift. Continue interview revealed they were required to complete a post-test for learning comprehension prior to working. 8) Review of the education provided to all non-licensed staff including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry, revealed the education was completed on 03/05/17. Staff unable to attend by 03/05/17 were educated prior to working their next shift. Further review revealed, the education was presented by the DNS, ADNS, Regional Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Director of Rehabilitation. Interview on 03/09/17 with CNA #14 at 7:46 AM, CNA#15 at 8:00 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, CNA #16 at 3:30 PM, CNA #6, CNA #5 at 3:34 PM, Physical Therapy Staff #3 at 2:16 PM, Housekeeping staff #18 at 3:20 PM, Laundry staff #15 at 3:25 PM, and Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, and Medical Records staff #16 at 3:40 PM, confirmed they had received education on abuse. Further interviews revealed, they had received the education by 03/05/17 and prior to working their shift. Continued interview revealed, they were required to complete a post-test for learning comprehension prior to working. 9) The facility's new hire orientation information and education was reviewed and revealed it included the abuse education and post-test. Interview with the Senior Director of Clinical Services, on 03/09/17 at 2:53 PM, revealed the facility's new hire orientation included the abuse education and post-test and would go into effect, as per the AOC. 10) The facility's abuse in-service material and post-tests were reviewed and checked against the master list of current employees. Review of the facility's master list of current employees revealed all staff disciplines were educated regarding the facility's abuse policy. The facility does not employ any agency staff. Interview on 03/09/17 with RN #2 at 7:00 AM, CNA #14 at 7:46 PM, CNA #15 at 8:00 AM, LPN #7 at 9:50 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, Housekeeping Staff #18 at 3:20 PM, Laundry Staff #15 at 3:25 PM, Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, LPN #8 at 3:30 PM, CNA #16 at 3:30 PM, CNA#6 at 3:30 PM, CNA #5 at 3:40 PM, Medical Record Staff #17 at 3:40 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #

Based on interview, record review, review of the Director of Nursing and Administrator's Job Descriptions, review of the facility's policy and procedures, it was determined the facility's administrator failed to have an effective system in place to ensure that it was administered in a manner that protected residents from abuse. The facility failed to identify two (2) separate abuse allegations on 02/18/17 between 4:25 PM and 5:00 PM, by two (2) different Certified Nursing Assistants (CNAs), which involved Resident #1 and Licensed Practical Nurse (LPN) #1. CNA #1 reported to the Director of Nursing Services (DNS) on 02/18/17 that LPN #1 had yelled at Resident #1 over a scheduled smoke break. Later, the same day CNA #2 reported to the DNS Resident #1 wanted to sit at the nurse's station desk, which was routine for the resident. However, LPN #1 stated in front of the resident he/she could not sit there, it wasn't going to happen, and she didn't want to see the resident's face. LPN #1 the relocated the resident to the hallway with bedside table. The DNS did not immediately report the allegations to the Administrator, and the Administrator was made aware of the incidents via phone per CNA #1 on 02/18/17 at approximately 8:00 PM. Neither the DNS or the Administrator reported the allegations to other officials (including the State Survey Agency) in accordance with State Law through established procedures. Although the DNS immediately interviewed CNA #1, CNA #2, and LPN #1 after the allegations, the facility's Administration failed to conduct a comprehensive investigation by only interviewing LPN #1, CNA #1, and CNA #2 and failing to interview staff who had worked at the time of the incidents. In addition, although the facility's Administration was notified on 02/18/17 of the alleged abuse which occurred on 02/18/17, LPN #1 was allowed to work and care for the residents the rest of the shift on 02/18/17 and worked as scheduled on 02/19/17, 02/20/17, 02/21/17, 02/26/17 and 02/27/17. Therefore, the facility's Administration failed to ensure residents were protected from potential abuse during the investigation. (Refer to F-223, F-225, F-226) The facility's failure to have an effective Administration to ensure the facility's policies were implemented and failure to ensure its resources were utilized effectively and efficiently has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 03/03/17 and determined to exist on 02/18/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 alleging removal of the Immediate Jeopardy on 03/06/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/06/17, prior to exit on 03/09/17, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Administrator, undated, revealed the Administrator reports to the Regional Vice President. The Administrator directs, oversees and manages the 24/7 day to day operations of the Diversicare post-acute care center. Further review revealed the Administrator's Key Responsibilities included: ensures the patient and resident is at the center of every decision made; ensures compliance with State and Federal Regulations; ensures adoption of Diversicare policies, guidelines and standards; ensures quality care and services are provided to all patients, residents and that it meets the satisfaction of the patient, resident, family, physicians and other partners. Review of the facility's Job Description for Director of Nursing (DON), undated, revealed the DON reports to the Administrator. The DON manages the Department of Nursing in accordance with policy and procedure, and state and federal regulations to promote high quality care and service to the facility and community. Further review revealed the DON's Key Responsibilities included: assumes responsibility of facility in absence of Administrator; ensures positive outcomes are accomplished for residents; responsible to develop systems and work schedules that respect resident's lifestyle and ensure the resident reaches the highest attainable level of functioning; makes rounds at least daily; follows up daily on each shift to ensure changes in status are reported and recorded; deals with families and residents when issues arise and handles complaints; and provides education regarding care as needed. Review of the DON's training record revealed Acknowledgment of Receipt of the Facility's Review of the facility's Abuse Policy (Policy # N-A-045) dated 11/20/16, revealed all allegations of abuse are reported immediately to the Administrator to State Agencies and law enforcement in accordance with existing state law. The Administrator will direct a thorough investigation of each alleged violation and was responsible for reporting the results of all investigations to the State Agencies. Results of the investigation are reported to the appropriate State Agencies in accordance with existing State Law through established procedures immediately, which means as soon as possible, but ought not to exceed twenty-four (24) hours after discovery of the incident. The results of all investigations must be reported within five (5) working days of the alleged violation. Continued review of the facility's Policy revealed employees who were alleged to have committed abuse were suspended pending outcome of an investigation. Further review of the Policy revealed the definition of verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Anytime there is an allegation of abuse, the center must not only report the alleged violation to the Administrator, the Chief Compliance Officer and other officials, but also initiate an immediate investigation and prevent further abuse. All investigations shall be conducted by the Administrator, Director of Nursing or subject matter expert. The investigation shall include interviews of team members, visitors, patients/residents, volunteers and vendors who may have knowledge of the alleged incident. Written statements from involved parties should not be requested, as all information will be documented on the investigation form or state required form. Federal law requires evidence of investigations of alleged violations. The investigation form or state required form, shall be completed after the investigation is complete and provided to survey agencies when requested or required by state and federal law. All alleged violations shall be recorded. Review of the facility's Abuse Investigations and Reports on 02/27/17, revealed no documented evidence of an investigation related to allegations of verbal abuse by LPN #1 towards Resident #1, which were reported by CNA #1 and CNA #2, on 02/18/17. On 02/28/17, the State Survey Representative did receive from the facility written statements from LPN #1 dated 02/18/17, CNA #1 dated 02/19/17, DNS Statement transcribed by the Corporate Division President dated 02/21/17, and the DNS written Statement dated 03/01/17 related to the allegations of verbal abuse for Resident #1. However, the facility provided no further evidence of an investigation related to the verbal abuse allegations. Interview with the DNS on 03/02/17 at 3:25 PM, revealed in hind-site she failed to implement the Abuse Policy when she did not immediately report either incidents as allegations of abuse to the Administrator or to State Agencies, did not protect the residents by allowing LPN #1 to continue working and did not do a thorough investigation which would have included interviewing additional witnesses. The DNS acknowledged she independently made the determination there was no abuse, as she was not authorized to do, and she took making this decision away from the Administrator. Continued interview with the DNS, revealed she had received the same abuse training all the employees receive upon orientation. She further revealed she attended a week long corporate training for her new role as DNS; however, she did not receive any additional training on abuse investigations or reporting. Interview with the Administrator, on 02/27/17 at 4:00 PM, and 03/02/17 at 4:30 PM, revealed the allegations should have been reported per the facility's Abuse Policy to herself, and to State Agencies as well as thoroughly investigated in order to protect the residents. Per interview, the DNS failed to follow the facility Abuse Policy process when she solely made the decision that no abuse had occurred Related to Resident #1. She stated she was not at the Center due to illness on 02/18/17, 02/19/17, or 02/20/17, and the DNS was acting in her stead. She further stated CNA #1 did call her the evening of 02/18/17; however, she was acutely ill in the Urgent Treatment Center and did not remember the conversation. She stated she just told CNA #1 to write a Statement. However, continued interview revealed the Administrator had not read the employee statements from CNA #1, LPN #1 and the DNS because they were given directly to Corporate who had come in on 02/21/17 to investigate employee relations issues which involved CNA #1, CNA #2, LPN #1 and LPN #2. The Administrator revealed the system failed because the facility did not identify the allegations as abuse; but addressed the allegations as a smoking privilege problem and a staff relations problem. Follow-up interview with the Administrator on 03/09/17 at 10:00 AM, revealed she, as the Administrator, was ultimately responsible for abuse investigations. She stated abuse allegations were to be dealt with quickly with a full investigation to include interviews to find root causes. She further stated she had training recently related to the company's forms, logs and how they wanted things documented; however, part of the problem with the Abuse Policy not being followed related to the allegations for Resident #1, was because she was new in the Administrator's position with this company and facility. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 that alleged removal of the Immediate Jeopardy (IJ) on 03/06/17. Review of the AOC revealed the facility implemented the following. 1) Resident #1 (BIMS of 3) was interviewed on 03/03/17, using the Resident Interview Tool, by the Regional Director of Nursing Management Services. A physical assessment of Resident #1 was completed on 03/03/17, by the Regional Director of Nursing Management Services, using the Resident Body Audit Tool. The responsible party and attending physician were notified by the administrator of the allegation on 03/03/17. 2) All alert and oriented residents (BIMS greater than 8) were interviewed utilizing the Resident Interview Tool, by the Regional Director of Nursing Management Services or the Regional Vice President by 03/04/17. Physical assessments of non-interviewable residents (BIMS less than 8) were conducted by the DNS, ADNS, or House Supervisor by 03/05/17, using the Resident Body Audit Tool. 3) The facility submitted an Initial Allegation of Abuse Report to OIG, dated 03/03/17. Per the report, APS (adult protective service), the local Ombudsman and the Police were notified on 03/03/17. The involved LPN was placed on administrative leave on 03/03/17. A thorough investigation was completed by the Divisional Senior Director of Clinical Operations to ensure evidence of completion including reporting to proper authorities in acceptance with State law. This review was completed by 03/05/17. 4) The Director of Clinical Operations and/or the Regional Vice President will be notified by the Administrator and/or DNS any time there is a report of any incident that could possibly be construed as an allegation of abuse in order to assist in determining appropriate investigation and reporting. 5) Education was provided to the Division President and the Region Vice President. This education was presented by the Senior Director of Clinical Operation and completed on 03/03/17. The education included a review of the facility's Abuse Policy to include a Staff Abuse Questionnaire to demonstrate learning. 6) Education was provided to the Administrator, Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) by the Director of Clinical Operations. This education was completed on 03/03/17 and also emphasized that yelling and/or arguing with a resident should be considered an allegation of abuse. A Staff Abuse Questionnaire was completed by each on 03/03/17, to demonstrate learning. 7) Education was provided to all licensed nursing team members which included Registered Nurses (RN) and Licensed Practical Nurses (LPN) to include a review of the facility's Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was developed by the Director of Clinical Operations and presented by the DNA, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 8) Education was provided to all non-licensed team members including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry to include a review of the Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was provided by the DNS, ADNS, Regional Director of Clinical Operations or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 9) Educational material regarding Abuse was included in the facility's orientation materials to be completed with future new hires and will be presented by the Director of Nursing Services or a designated Registered Nurse prior to providing direct care to residents. All team members will receive additional education related to abuse reporting at least twice a year. 10) All learning with current full time facility team members was completed by 03/05/17. Any team member not completing the education by 03/05/17 will not be allowed to work until the education has been completed and competency determined. The facility does not employ any agency staff. 11) Resident #1's care plan was reviewed for communication needs by the MDS coordinator on 03/02/17. The special communication needs were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station. This was completed by 03/5/17. 12) All resident care plans were reviewed for special communication needs by 03/05/17. Any identified special communication needs of the resident were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station and completed on 03/05/17. 13) The Individualized Communication Preference Guide Book, containing each resident within the center's communication needs, was placed at each nursing station on 03/05/17. Education presented to all staff was completed by 03/05/17 by the Administrator, DNS, ADNS, Director of Clinical Operations, Regional Director of Nursing Management Services and the Regional Director of Rehabilitation. 14) The Administrator, Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Regional Director of Clinical Operations, Senior Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Vice President will complete fifteen (15) Communication Preference Questionnaire forms weekly for eight (8) weeks. These will be conducted on all shifts and all department staff. 15) The Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations, or Divisional Senior Director of Clinical Operations will conduct fifteen (15) staff interviews per week for eight (8) weeks utilizing the Staff Abuse Questionnaire, regarding the facility's abuse policy and aspects of resident abuse to ensure continued and thorough understanding of the policy. These interviews will continue until determined by the facility's QA team that compliance is sustained. 16) The Administrator, DNS and/or ADNS will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe in the center and to allow a platform where the residents are encouraged to express and report any concerns regarding behaviors or actions displayed by team members, resident, family members or visitors. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. Minutes from these meetings will also be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) The Director of Clinical Operations and/or Regional Vice President will review all Resident Concerns (Grievance) Forms weekly for four (4) weeks and monthly thereafter to ensure any possible allegations have been investigated and reported per the facility policy. Resident Council Meeting minutes will be reviewed weekly for four (4) weeks to ensure that any possible allegations have been investigated and reported per the facility policy. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. 18) The facility's Governing Body, consisting of the Regional Vice President, the Regional Director of Clinical Operations, the Regional Clinical Reimbursement Specialist, and the Regional Director of Nursing Management Services will be present at the facility five (5) times each week for the next forty-five (45) days and visit weekly thereafter to ensure the facility maintains compliance with state and federal rules and regulations by reviewing the facility's staffing pattern, concern log, Resident Council Meeting minutes and the QAPI meeting minutes. The facility's Vice President of Clinical Operations and Chief Operating Officer will oversee the Governing Body to ensure the facility, administrator, and DNS receive the support needed to sustain compliance with state and federal rules and regulations, by review of quality indices and feedback reports from the Governing Body. 19) Oversight will be completed by the Administrator using the information from daily floor rounds, chart reviews, staff and resident interviews. As the QAPI leader, the Administrator will utilize the information to identify and correct non-compliance with state and federal regulations. The Administrator will review any allegations of abuse to ensure a thorough investigation and reporting per state law. The Regional Vice President and/or Regional Director of Clinical Operations will ensure the Administrator is investigating allegation of abuse according to policy and in accordance with state law. 20) On 03/05/17, a QAPI meeting was held with the Administrator, DNS and Medical Director. This meeting reviewed the actions and audits taken by the center effective 03/05/17. Findings of the audits and actions taken after 03/05/17 will be reviewed at the monthly QAPI meeting, by the QAPI team. The QAPI team includes the Medical Director, Administrator, DNS and at least three (3) other departmental leaders. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the Resident Interview Tool, dated 03/03/17, completed by the Regional Director of Nursing Management Services, revealed she had conducted an interview with Resident #1. Review of a Nurses Note, dated 03/03/17 at 9:02 PM, revealed she had conducted an interview with the resident. Review of a Resident Body Audit Tool for assessing the resident, revealed an assessment was completed by the Regional Director of Nursing Management Services on 03/03/17. Interview with the Regional Director of Nursing Management Services on, 03/09/17 at 5:40 PM, confirmed she had completed the interview, performed the assessment and had notified Resident #1's responsible party as well as the Physician. 2) Review of the Resident Interview Tool, revealed the Regional Director of Nursing Management Services or the Regional Vice President completed the interviews by 03/04/17. Review of the Resident Interview Tool, revealed there were forty (40) Resident Interview Tools completed by 03/04/17. Interviews with the Regional Director of Nursing Management Services, on 03/09/17 at 5:40 PM, and the Regional Vice President, on 03/09/17 at 5:30 PM, revealed they had performed the interviews and completed them by 03/04/17. Review of the Resident Body Audit Tool, revealed the assessments were completed by 03/05/17 by the Director of Nursing Services, Assistant Director of Nursing Services or the House Supervisor. Review of the Resident Body Audit Tool, revealed there were twenty-one (21) Resident Body Audits completed by 03/05/17. Interviews with the Director of Nursing Services, on 03/09/17 at 6:14 PM, the Assistant Director of Nursing Services, on 03/09/17 at 7:08 PM, revealed they had performed the Body Audits and completed them on 03/05/17. 3) Review of the Resident Abuse Investigation Report Form, dated 03/03/17 and electronically signed by the Administrator, revealed the investigation into alleged verbal abuse of Resident #1 on 02/18/17, was initiated on 03/03/17, as per the AOC. Review of the form revealed LPN #1 was placed on administrative leave on 03/03/17. Per the facility's Final Report, dated 03/07/17, the facility's investigation revealed the nurse was not witnessed to be using an argumentative tone with the resident. Interview with the Administrator and Senior Director of Clinical Operations, on 03/08/17 at 4:30 PM, revealed an initial report was submitted by the facility on 03/03/17 and a final report was submitted by the facility on 03/07/17. Both confirm notifications were made to the Ombudsman and police as well as LPN #1 being placed on ongoing administrative leave. 4) Interview with the Director of Clinical Operations, on 03/09/17 at 5:55 PM, revealed the facility has an Event Escalation process. Further interview revealed, the process was for the Administrator or DNS to call all potential allegations to the Director of Clinical Operations or the Director of Nursing Services Management. The notification is to be made at the time of the potential allegation of abuse. Further interview revealed, they would listen to the concerns and advise staff of further needed actions. 5) Review of the education provided to the Division President and the Regional Vice President revealed the education was provided by the Senior Director of Clinical Operations and completed on 03/03/17 to include a post-test. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, revealed she did present the education. Interview with the Division President, on 03/09/17 at 5:47 PM and the Regional Vice President, on 03/09/18 at 5:30 PM, revealed they did receive the education and post-test. 6) Review of the education provided to the Administrator, Director of Nursing Service (DNS) and the Assistant Director of Nursing Services (ADNS), revealed the education was provided by the Director of Clinical Operations and completed on 03/03/17 to include a post-test. Interview with the Administrator, on 03/09/17 at 6:32 PM, confirmed the education was provided to her, the DNS and ADNS on 03/03/17 that included a post-test. Further interview revealed the education emphasized yelling and/or arguing with a resident should be considered an allegation of abuse. Interview with the DNS, on 03/09/17 at 6:14 PM, confirmed the education was provided to her, the Administrator and ADNS on 03/03/17, that did include a post-test for learning comprehension. Further interview with the DNS revealed, the education emphasized yelling and/or arguing with a resident should be considered an allegation of abuse. 7) Review of the education provided to all licensed nursing team members, which included Registered Nurses (RN) and Licensed Practical Nurses (LPN), revealed the education was completed on 03/05/17. Those unable to attend by 03/05/17 were educated prior to working their next shift. Further review revealed, the education was presented by the DNS, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. Interview on 03/09/17 with RN #2 at 7:00 AM, LPN #7 at 9:50 AM, LPN #8 at 3:30 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, revealed they had received education on abuse. Further interview revealed, they had received the education by 03/05/17 and prior to their working the shift. Continue interview revealed they were required to complete a post-test for learning comprehension prior to working. 8) Review of the education provided to all non-licensed staff including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry, revealed the education was completed on 03/05/17. Staff unable to attend by 03/05/17 were educated prior to working their next shift. Further review revealed, the education was presented by the DNS, ADNS, Regional Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Director of Rehabilitation. Interview on 03/09/17 with CNA #14 at 7:46 AM, CNA#15 at 8:00 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, CNA #16 at 3:30 PM, CNA #6, CNA #5 at 3:34 PM, Physical Therapy Staff #3 at 2:16 PM, Housekeeping staff #18 at 3:20 PM, Laundry staff #15 at 3:25 PM, and Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, and Medical Records staff #16 at 3:40 PM, confirmed they had received education on abuse. Further interviews revealed, they had received the education by 03/05/17 and prior to working their shift. Continued interview revealed, they were required to complete a post-test for learning comprehension prior to working. 9) The facility's new hire orientation information and education was reviewed and revealed it included the abuse education and post-test. Interview with the Senior Director of Clinical Services, on 03/09/17 at 2:53 PM, revealed the facility's new hire orientation included the abuse education and post-test and would go into effect, as per the AOC. 10) The facility's abuse in-service material and post-tests were reviewed and checked against the master list of current employees. Review of the facility's master list of current employees revealed all staff disciplines were educated regarding the facility's abuse policy. The facility does not employ any agency staff. Interview on 03/09/17 with RN #2 at 7:00 AM, CNA #14 at 7:46 PM, CNA #15 at 8:00 AM, LPN #7 at 9:50 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, Housekeeping Staff #18 at 3:20 PM, Laundry Staff #15 at 3:25 PM, Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, LPN #8 at 3:30 PM, CNA #16 at 3:30 PM, CNA#6 at 3:30 PM, CNA #5 at 3:40 PM, Medical Record Staff #17 at 3:40 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, revealed they had all been educated on the facility's abuse policy and procedure and had taken a post-test. 11) Review of Resident #1's care plan for communication needs was completed on 03/02/17. Further review of the care plan, revealed goals were in place with a target date of 05/01/17. Continued review revealed, there were several approaches staff could utilize for communicating with Resident #1. Review of the Individualized Communication Preferences Guide Book, revealed Resident #1's care plan was in this book. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, confirmed the MDS nurse evaluated Resident #1's care plan for communication. Further interview revealed the care plan for Resident #1 was placed in the facility's Individualized Communication Preferences Guide Book, located at each nurse's station. 12) Review of the Individual Communication Preferences Guide Book revealed the residents had been assessed for communication needs the care plans placed in this book. Interview with the Senior Director of Clinical Operations, on 03/09/17 at 2:53 PM, confirmed the MDS nurse evaluated each of the facility's residents for their individual communication needs. Further interview revealed the care plans were placed in the facility's Individualized Communication Preferences Guide Book, located at each nurse's station. 13) Reviewed the Individualized Communication Preference Guide Book containing each resident within the center's communication needs. Interview on 03/09/17 with RN #2 at 7:00 AM, CNA #14 at 7:46 PM, CNA #15 at 8:00 AM, LPN #7 at 9:50 AM, CNA #9 at 3:05 PM, CNA #4 at 3:15 PM, Housekeeping Staff #18 at 3:20 PM, Laundry Staff #15 at 3:25 PM, Laundry Staff #16 at 3:25 PM, Housekeeping Staff #2 at 3:27 PM, LPN #8 at 3:30 PM, CNA #16 at 3:30 PM, CNA #6 at 3:30 PM, CNA #5 at 3:40 PM, Medical Record Staff #17 at 3:40 PM, LPN #6 at 3:42 PM, LPN #3 at 3:44 PM and RN #1 at 3:46 PM, confirmed they had received education on the facility's Communication Preference Guide Book. 14) Review of completed Communication Preferences Questionnaire, revealed the questionnaires had been completed by appropriate staff. Further review revealed, as of 03/09/17, there were nine (9) completed for the week of 03/05/17 to 03/12/17. Interview with the Senior Director of Clinical Operations on 03/09/17 at 2:53 PM, the Regional Director of Clinical Operations, on 03/09/17 at 5:55 PM and the Administrator, on 03/09/17 at 6:32 PM, confirmed the facility had been completing the questionnaires per the AOC. 15) Review of the facility's Staff Abuse Questionnaire revealed the Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations or the Senior Director of Clinical Operations have conducted at least fifteen (15) Staff Abuse Questionnaire forms per week, per the AOC. Interview on 03/09/17 with Regional Director of Nursing Management Services at 5:40 PM and the Regional Director of Clinical Operations at 5:55 PM, confirmed they had conducted the Staff Abuse Questionnaire forms. Further interview revealed they perform at least fifteen (15) per week per the AOC. 16) Review of the Resident Council Meeting minutes, conducted on 03/07/16, revealed the meeting was conducted with the Administrator present and concerns were followed up on by the Administrator and the Regional Director of Nursing Management Services on 03/07/17. Interview with the Administrator on 03/09/17 at 6:32 PM, revealed she had conducted the Resident Council Meeting on 03/07/17 and had a meeting scheduled for 03/14/17, 03/21/17 and 03/28/17. Interview with the Regional Director of Nursing Management Services on 03/09/17 at 5:40 PM, revealed she had reviewed the Resident Council Meeting minutes and followed up with the resident concerns on 03/07/17. Interview with both staff report the minutes of the meeting will be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) Review of the Governing Body Review Form revealed concerns were reviewed by the Regional Director of Clinical Operations. Interview with the Regional Director of Clinical Operations, on 03/09/17 at 5:55 PM, confirmed she had reviewed the resident concerns and the Resident Council Meeting minutes of 03/07/17. Further interview revealed this will be done on a weekly basis for four (4) weeks and then monthly to ensure any possible allegations have been investigated and reported per the facility policy. 18) Review of the Governing Body Calendar for March, revealed each day to have a member of the governing body present at the facility. Interview on 03/09/17 with the Senior Director of Clinical Operations at

Based on interview, record review, review of the facility's policies and procedures, and review of the Kentucky Revised Statues (KRS), it was determined failed to have an effective system to ensure all alleged allegations of abuse were reported immediately to the Administrator and to State Agencies per State Law, residents were protected after an allegation of abuse, and all alleged violations were thoroughly investigated for one (1) of eight (8) sampled residents (Resident #1). On 02/18/17 at approximately 4:25 PM, per staff interview, Certified Nursing Assistant (CNA) #1 witnessed Licensed Practical Nurse (LPN) #1 in Resident #1's face yelling it's not happening today. I'm not doing it. LPN #1 then told the resident he/she was lying about smoking after the resident requested a smoke break. CNA #1 immediately reported the incident to the Director of Nursing Services (DNS). The DNS interviewed LPN #1 related to the incident, but failed to identify this as an allegation of potential abuse and did not investigate further. Per staff interview, a second abuse allegation occurred related to Resident #1 and LPN #1, on 02/18/17 at 5:00 PM, when Resident #1 requested to sit at the nurse's station. LPN #1 refused to let the resident sit at the nurse's station, yelling in front of the resident that he/she could not sit there and stating I don't want to see (his/her) face. CNA #2 immediately reported the incident to the DNS and the DNS again interviewed LPN #1 and determined independently there was no willful action to cause harm. The DNS did not report the allegation immediately to the Administrator; did not conduct a thorough investigation; and, did not protect the residents from further potential abuse, as LPN #1 continued to work as scheduled. On 02/21/17, the Corporate representatives arrived at the facility after CNA #1 reported the two (2) allegations to the facility's Administrator and to the Corporate Care Line (Hotline) via phone conversation on 02/18/17 at approximately 8:00 PM. The Corporate representatives reviewed CNA #1's Statement related to LPN #1's behavior towards Resident #1 and also transcribed a statement from the DNS related to the allegations; however, failed to recognize the allegations as potential abuse. LPN #1 continued to work the remainder of the shift on 02/18/17, and also worked as scheduled on 02/19/17, 02/20/17, 02/21/17, 02/26/17 and 02/27/17. (Refer to F-223, F-226 and F-493) The facility's failure to ensure all alleged allegations of abuse were reported immediately to the Administrator and to State Agencies per State Law, residents were protected after an allegation of abuse, and all alleged violations were thoroughly investigated has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/03/17, and was determined to exist on 02/18/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 alleging removal of the Immediate Jeopardy on 03/06/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/06/17, prior to exit on 03/09/17, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse Policy (Policy # N-A-045) dated 11/20/16, revealed all allegations of abuse would be reported immediately to the Administrator to State Agencies and law enforcement in accordance with existing state law. The Administrator would direct a thorough investigation of each alleged violation and was responsible for reporting the results of all investigations to the State Agencies. Results of the investigation would be reported to the appropriate State Agencies in accordance with existing State Law through established procedures immediately, which meant as soon as possible, but ought not to exceed twenty-four (24) hours after discovery of the incident. The results of all investigations must be reported within five (5) working days of the alleged violation. Continued review of the facility's Policy revealed employees who were alleged to have committed abuse were suspended pending outcome of an investigation. Anytime there was an allegation of abuse, the center must not only report the alleged violation to the Administrator, the Chief Compliance Officer and other officials, but also initiate an immediate investigation and prevent further abuse. All investigations shall be conducted by the Administrator, Director of Nursing or subject matter expert. The investigation shall include interviews of team members, visitors, patients/residents, volunteers and vendors who may have knowledge of the alleged incident. Written statements from involved parties should not be requested, as all information shall be documented on the investigation form or state required form. Federal law requires evidence of investigations of alleged violations. The investigation form or state required form, shall be completed after the investigation was complete and provided to survey agencies when requested or required by state and federal law. All alleged violations shall be recorded. Review of the KRS Chapter 209.030 revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of the facility's Abuse Investigations and Reports on 02/27/17, revealed no documented evidence of an investigation related to allegations of verbal abuse by LPN #1 towards Resident #1, which were reported by CNA #1 and CNA #2, on 02/18/17. On 02/28/17 the facility provided written statements from LPN #1 dated 02/18/17, CNA #1 dated 02/19/17, DNS Statement transcribed by the Corporate Division President dated 02/21/17, and the DNS written Statement dated 03/01/17 related to the allegations. However, the facility provided no further documented evidence of an investigation completed related to the verbal abuse allegations prior to the Survey. Review of CNA #1's written Statement dated 02/19/17, revealed on 02/18/17, LPN #1 bent down in Resident #1's face and was yelling and arguing with the resident about a smoke break. Per the Statement, CNA #1 asked LPN #1 what was going on and LPN #1 told the CNA, the wanted to go smoke, but activities had just taken them out a little before 3:00 PM. Further review revealed CNA #1 explained to LPN #1 the 4:00 PM smoke was still allowed, to which LPN #1 responded it's not happening today. CNA #1 then took the resident out to smoke. Per the Statement, CNA #2 supervised the resident while CNA #1 reported the incident to the DNS. Further review revealed while CNA #1 was in the DNS's office, CNA #2 came in and reported to the DNS, LPN #1 had got nose to nose with her, yelling about Resident #1 wanting to sit at the nurse's station. Phone interview on 02/27/17 at 2:30 PM, with CNA #1, revealed she went to the DNS's office and reported the incident the first incident. CNA #1 revealed she didn't say the words the resident was verbally abused, but she thought the actions spoke for themselves. CNA #1 stated the DNS verified Resident #1 was supposed to have at smoke break at 4:00 PM, and stated she would take care of it. Phone interview with CNA #2, on 02/27/17 at 6:41 PM, revealed after the second incident she went immediately to the DNS's office and told her LPN #1 was about two (2) inches away from her nose telling her an Aide wasn't going to tell her what to do. CNA #2 revealed she told the DNS this was the second time today, she (DNS) had received a report on LPN # 1's treatment of [REDACTED]. CNA #2 stated the DNS told her to calm down and she would talk to LPN #1. Per interview, CNA #2 felt the incident she reported to the DNS was obviously verbal abuse. Phone interview with Dietary Aide (DA) #1, on 02/27/17 at 3:00 PM, revealed on 02/18/17 at 4:20 PM, the DA witnessed LPN #1 coming down the hall and she gave DA#1 a dirty look and said, (he/she) is off the chain! in reference to Resident #1. DA #1 revealed LPN #1 seemed aggravated, talked loudly and was rude to Resident #1 and said, it's not time! You just went out! Further interview revealed the DA considered LPN #1's actions and words verbal abuse according to their abuse training. DA #1 further stated CNA #1 had reported the LPN yelling and arguing with the resident to the DNS in the same timeframe; otherwise the DA would have reported it. Additional interview revealed no one, including the DNS, had asked if the DA had seen or heard anything. Phone interview with CNA #9, on 03/01/17 at 1:15 PM, revealed on 02/18/17, she observed CNA #2 pushed Resident #1 in his/her wheelchair to the nurses' station desk, and witnessed LPN #1 say, No, no, no! We're not doing this. (He/she) is not going to sit here. It's not happening. (He/she) can't be here. She revealed when LPN #1 said that in front of the resident it broke (his/her) heart. CNA #9 further revealed no one, including the DNS, asked if she had seen or heard anything related to either of the incidents. Interview with LPN #1, on 02/27/17 at 4:00 PM, and 03/03/17 at 3:30 PM, revealed on 02/18/17 at 3:30 PM, she saw Resident #1 sitting at the back exit door yelling, time to smoke, take me out to smoke. She further stated the resident was agitated and shouting and the resident's pocket radio was on very loud and the resident had ear phones in his/her ears. Per interview, she got down on eye level and had to talk loud and the resident didn't hear her. LPN #1 revealed she kept saying, you can't go out right now, it will be a few minutes, you just went out to smoke. Further interview with LPN #1, revealed right after the smoke break, Resident #1 was pushed to the nurse's desk by CNA #2, and CNA #2. LPN #1 further revealed she told CNA #2 Resident #1 could not eat there. LPN #1 revealed she obtained a bedside table and put it beside the nurses' station, set the resident's food on it, and the resident ate his/her dinner. LPN #1 stated CNA #2 then went to the DNS's office. Additional interview with LPN #1, revealed she did recall the DNS coming to the unit on 02/18/17 around dinner time. She stated she recalled speaking to the DNS at that time, but could not remember what they talked about. Interview with the DNS on 03/02/17 at 3:25 PM, revealed after CNA #1 reported on 02/18/17 around 4:30 PM, LPN #1 was yelling and arguing with Resident #1, she immediately checked on the resident by looking at the resident through the glass door and the resident was happy and smiling. However, the DNS stated she did not interview the resident because the resident was not interviewable and she did not check to see if the resident had earbuds in place or a radio on in order to verify LPN #1 had a reason to talk loudly to the resident. Per interview, she did not perceive CNA #1's report of LPN #1 yelling and arguing with the resident to be an allegation of abuse because CNA #1 did not say LPN #1 cursed and did not say what she witnessed was an allegation of abuse. She further stated she did not consider LPN #1's actions as verbal abuse because it was not an act purposefully done that resulted in harm. She further stated she made the determination it was not abuse because LPN #1 wasn't talking down to the resident. Further interview with the DNS, revealed later CNA #2 came into her office and reported she had pushed the resident to the nurse's station via wheelchair and LPN #1 said, oh no, not today. The DNS stated she had no knowledge of LPN #1 stating in front of Resident #1, I don't want to see (his/her) face, because this was not conveyed by CNA #2. She stated if LPN #1 had said this, it would have been considered abuse. Per interview, the DNS did not immediately assess Resident #1 after receiving this report; however, she did go to the unit later and observe the resident eating dinner, with no problems, at the bedside table. Per interview, after both reported incidents all employees involved returned to their work stations. The DNS stated she asked everybody involved including CNA #1, CNA #2 and LPN #1 to write statements and turn them in by 02/20/17. The DNS stated in hind-site she failed to follow the Abuse Policy when she did not immediately assess the resident after CNA #2 reported a problem; did not report either incidents as allegations of abuse to the Administrator or to State Agencies, did not protect the residents by allowing LPN #1 to continue working and did not do a thorough investigation which would have included interviewing additional witnesses. The DNS acknowledged she independently made the determination there was no abuse, as she was not authorized to do, and she took making the decision away from the Administrator. Phone interview with the Social Service Director (SSD), on 02/28/17 at 11:00 AM, revealed the Administrator had not made her aware of any allegations, investigations or reports related to Resident #1. The SSD stated communication stinks here; we don't have a system, and it didn't get reported to me about (Resident #1). She further stated it was Resident #1's right to sit at the nurse's station desk and she had observed Resident #1, and other residents, several times eating there. She further revealed the medical charts were kept in the back nurse's station, where most nurses did their charting, and the front nurses' desk was usually clear so this was not a HIPAA concern. Continued interview, revealed all allegations of abuse were to be reported immediately to the Administrator; then to State Agencies and were to be investigated thoroughly to protect the residents. Review of the LPN #1's personnel file, revealed LPN #1 had not been suspended after the alleged verbal abuse was reported to the DNS on 02/18/17. Review of the schedule and interviews with the DNS on 03/02/17 at 3:25 PM and Administrator on 02/27/17 at 4:00 PM, revealed LPN #1 continued to work the remainder of the shift on 02/18/17, and worked on 02/19/17, 02/20/17, 02/21/17, 02/26/17 and 02/27/17. Additional interviews with CNA #1 on 02/27/17 at 2:30 PM, LPN #1 on 02/27/17 at 4:00 PM, CNA #2 on 02/27/17 at 6:41 PM and LPN #2 on 02/28/16 at 6:30 AM revealed on the evening of 02/18/17 the four (4) staff had a heated verbal altercation related to staff assignments. Per interview LPN #1 asked CNA #1 and #2 to leave the building and she and LPN #2 called the Administrator and reported CNA #1 and CNA #2 being insubordinate and left a voicemail for the DNS. CNA #1 and CNA #2 stated they left the building and called the DNS from the car and reported everything that happened related to the staff argument. Further interview with CNA #1, on 02/27/17 at 2:30 PM, revealed on 02/18/17 at approximately 8:00 PM, she called the Administrator and then the Corporate Hotline and gave a report to the Division President. Per interview, she informed both the Administrator and the Corporate Division President of all the events which took place including the allegations of abuse related to how Resident #1 was treated after requesting a smoke break and how the resident was treated after smoking when wanting to sit at the nurses' desk. Per interview, she was told by both the Administrator and the DNS to write a Statement, and she gave the Statement to the DNS on 02/20/17. CNA #1 revealed, on 02/21/17 after 7:00 PM, the DNS called and told her she had been put on administrative leave by Corporate, and that they had taken disciplinary action. CNA #1 revealed she was not told why she was on administrative leave, but CNA #2 had also been put on administrative leave and she assumed this was because she and CNA #2 had reported how LPN #1 had treated Resident #1. Interview with the Administrator, on 02/27/17 at 4:00 PM, and 03/02/17 at 4:30 PM, revealed when CNA #1 and CNA #2 went to the DNS office and reported what they considered verbal abuse of Resident #1 on 02/18/17, it warranted further investigation and should have been reported to herself, and to State Agencies as well as thoroughly investigated in order to protect the residents. She further stated she was not at the Center due to illness on 02/18/17, 02/19/17, or 02/20/17, and the DNS was acting in her stead. Per interview, on 02/21/17 she was told the Regional Vice President and Division President, were going to do the investigations due to the employee relations issues for CNA #1, CNA #2, LPN #1, and LPN #2. Further interview revealed the Administrator had not read the Statements from CNA #1, LPN #1 and the DNS related to Resident #1 because they were given directly to Corporate. Further interview with the Administrator, revealed Corporate should have notified State Agencies of the allegations related to Resident #1, should have suspended LPN #1 during the investigation and should have done a more thorough investigation, which would have included interviewing interviewable residents and interviewing additional staff to gain information. The Administrator revealed the system failed because they did not identify the allegations as abuse; but addressed the allegations as a smoking privilege problem and a staff relations problem. Further interview with the Administrator, regarding the staff verbal altercation on the evening of 02/18/17, between CNA #1, CNA #2, and LPN #2, revealed she stepped away from the investigation because LPN #2 was a family member and she wasn't aware of what all was involved in the Human Resources investigation. Interview with the Regional Vice President, on 02/27/17 at 10:45 AM, on 02/27/17 at 1:00 PM, and 03/02/17 at 5:30 PM, revealed it was reported to her by CNA #1, LPN #2 cursed during an argument and LPN #2 called CNA #1 ignorant ass. She further revealed CNA #1, CNA #2, LPN #1 and LPN #2 were further interviewed as part of the Corporate Human Resources investigation. However, she stated the DNS never filed an abuse allegation related to the incidents on 02/18/17 regarding Resident #1 because the DNS interviewed LPN #1 and was informed the nurse talked loud to the resident because the resident had ear buds in and music was loud. She stated, the DNS determined the nurse was speaking loudly, but there was no verbal abuse. Further interview revealed regarding the second incident related to Resident #1, CNA#2 was told by LPN #1 it was not appropriate for Resident #1 to eat at the nurses' station because of HIPAA. Per interview, there was never an allegation of abuse, it was all about retaliation, insubordination, and Aides not wanting to do their jobs. She further stated LPN #1 told CNA #1 not to take the resident out to smoke, and she took the resident out anyway and LPN #1 informed the DNS of insubordination. Additional interview revealed LPN #1 told CNA #2 it was not appropriate for the resident to eat dinner at the nurses' station and she argued with the nurse. The Regional Vice President stated you have a he said she said, and there was no reportable allegation of abuse. However, further interview revealed she had not interviewed any staff including CNA #1, CNA #2, or LPN #1 related to the allegations regarding Resident #1 and did not investigate the allegations after reading the DNS's Statement. Interview with the Division President (DP), on 03/02/17 at 6:00 PM, revealed all allegations of abuse were to be reported to the Administrator and to other State Agencies, a thorough investigation was to be completed, and residents were to be protected during the investigation. The DP acknowledged she had transcribed the DNS's verbal statement on 02/21/17 related to the incidents regarding Resident #1 and also read Statements written by CNA #1, LPN #1, and the DNS. However, she stated the incidents on 02/18/17 of staff yelling and arguing with Resident #1 were not found credible by the DNS who was in the facility and spoke to the individuals and determined no abuse occurred. Continued interview revealed a report of yelling and arguing with a resident could be an allegation of abuse or potential abuse, but in Resident #1's situation, yelling was not yelling when the resident was wearing ear phones. Per interview, it didn't jump out at the DNS that it was abuse; therefore she didn't report it and did not look for witnesses to interview. Further interview revealed she didn't know if the DNS should have interviewed Resident #1, because it was a non-event to the DNS. She further stated she was not sure if the DNS did a thorough investigation because she wasn't there. Per interview, if the DNS thought it was an allegation, she should have reported it to the Administrator. Further interview with the Division President, revealed CNA #1 called the Corporate Care Line and reported a nurse was loud and argumentative with a resident, but there was a lot of other concerns reported which Corporate considered as Human Resources issues. She further stated since a staff member being loud and argumentative with a resident did not automatically equate abuse to her. She responded to the Care Line call and just looked at how it involved Human Resources and did not look at the concerns as an abuse investigation. She further revealed her purpose at the facility was to investigate only Human Resource employee issues. She stated she had not interviewed any employees related to allegations of abuse towards Resident #1, nor had she interviewed Resident #1. There was no documented evidence the Corporate representatives identified the allegations towards Resident #1 as abuse allegations and followed through with reporting the verbal abuse allegations to the State Agency, completing a thorough investigation to interview other witnesses to the incidents in order to gain additional information, and protecting the residents as they allowed LPN #1 to continue working in resident care areas after the allegations were reported. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/08/17 that alleged removal of the Immediate Jeopardy (IJ) on 03/06/17. Review of the AOC revealed the facility implemented the following. 1) Resident #1 (BIMS of 3) was interviewed on 03/03/17, using the Resident Interview Tool, by the Regional Director of Nursing Management Services. A physical assessment of Resident #1 was completed on 03/03/17, by the Regional Director of Nursing Management Services, using the Resident Body Audit Tool. The responsible party and attending physician were notified by the administrator of the allegation on 03/03/17. 2) All alert and oriented residents (BIMS greater than 8) were interviewed utilizing the Resident Interview Tool, by the Regional Director of Nursing Management Services or the Regional Vice President by 03/04/17. Physical assessments of non-interviewable residents (BIMS less than 8) were conducted by the DNS, ADNS, or House Supervisor by 03/05/17, using the Resident Body Audit Tool. 3) The facility submitted an Initial Allegation of Abuse Report to OIG, dated 03/03/17. Per the report, APS (adult protective service), the local Ombudsman and the Police were notified on 03/03/17. The involved LPN was placed on administrative leave on 03/03/17. A thorough investigation was completed by the Divisional Senior Director of Clinical Operations to ensure evidence of completion including reporting to proper authorities in acceptance with State law. This review was completed by 03/05/17. 4) The Director of Clinical Operations and/or the Regional Vice President will be notified by the Administrator and/or DNS any time there is a report of any incident that could possibly be construed as an allegation of abuse in order to assist in determining appropriate investigation and reporting. 5) Education was provided to the Division President and the Region Vice President. This education was presented by the Senior Director of Clinical Operation and completed on 03/03/17. The education included a review of the facility's Abuse Policy to include a Staff Abuse Questionnaire to demonstrate learning. 6) Education was provided to the Administrator, Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) by the Director of Clinical Operations. This education was completed on 03/03/17 and also emphasized that yelling and/or arguing with a resident should be considered an allegation of abuse. A Staff Abuse Questionnaire was completed by each on 03/03/17, to demonstrate learning. 7) Education was provided to all licensed nursing team members which included Registered Nurses (RN) and Licensed Practical Nurses (LPN) to include a review of the facility's Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was developed by the Director of Clinical Operations and presented by the DNA, ADNS, Director of Clinical Services or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 8) Education was provided to all non-licensed team members including department managers, Certified Nursing Assistants (CNA), therapists, dietary, housekeeping and laundry to include a review of the Abuse Policy and a Staff Abuse Questionnaire to demonstrate learning. This education was provided by the DNS, ADNS, Regional Director of Clinical Operations or the Regional Director of Nursing Management Services. The education commenced on 03/03/17 and was completed on 03/05/17. 9) Educational material regarding Abuse was included in the facility's orientation materials to be completed with future new hires and will be presented by the Director of Nursing Services or a designated Registered Nurse prior to providing direct care to residents. All team members will receive additional education related to abuse reporting at least twice a year. 10) All learning with current full time facility team members was completed by 03/05/17. Any team member not completing the education by 03/05/17 will not be allowed to work until the education has been completed and competency determined. The facility does not employ any agency staff. 11) Resident #1's care plan was reviewed for communication needs by the MDS coordinator on 03/02/17. The special communication needs were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station. This was completed by 03/5/17. 12) All resident care plans were reviewed for special communication needs by 03/05/17. Any identified special communication needs of the resident were added to the Individualized Communication Preferences Guide Book, placed at each nurse's station and completed on 03/05/17. 13) The Individualized Communication Preference Guide Book, containing each resident within the center's communication needs, was placed at each nursing station on 03/05/17. Education presented to all staff was completed by 03/05/17 by the Administrator, DNS, ADNS, Director of Clinical Operations, Regional Director of Nursing Management Services and the Regional Director of Rehabilitation. 14) The Administrator, Director of Nursing (DNS), Assistant Director of Nursing Services (ADNS), Regional Director of Clinical Operations, Senior Director of Clinical Operations, Regional Director of Nursing Management Services or the Regional Vice President will complete fifteen (15) Communication Preference Questionnaire forms weekly for eight (8) weeks. These will be conducted on all shifts and all department staff. 15) The Administrator, DNS, ADNS, Regional Director of Nursing Management Services, Regional Director of Clinical Operations, or Divisional Senior Director of Clinical Operations will conduct fifteen (15) staff interviews per week for eight (8) weeks utilizing the Staff Abuse Questionnaire, regarding the facility's abuse policy and aspects of resident abuse to ensure continued and thorough understanding of the policy. These interviews will continue until determined by the facility's QA team that compliance is sustained. 16) The Administrator, DNS and/or ADNS will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe in the center and to allow a platform where the residents are encouraged to express and report any concerns regarding behaviors or actions displayed by team members, resident, family members or visitors. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. Minutes from these meetings will also be reviewed in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. 17) The Director of Clinical Operations and/or Regional Vice President will review all Resident Concerns (Grievance) Forms weekly for four (4) weeks and monthly thereafter to ensure any possible allegations have been investigated and reported per the facility policy. Resident Council Meeting minutes will be reviewed weekly for four (4) weeks to ensure that any possible allegations have been investigated and reported per the facility policy. Any concerns will be forwarded to the Administrator and/or Regional Vice President for immediate investigation. 18) The facility's Governing Body, consisting of the Regional Vice President, the Regional Director of Clinical Operations, the Regional Clinical Reimbursement Specialist, and the Regional Director of Nursing Management Services will be present at the facility five (5) times each week for the next forty-five (45) days and visit weekly thereafter to ensure the facility maintains compliance with state and federal rules and regulations by reviewing the facility's staffing pattern, concern log, Resident Council Meeting minutes and the QAPI meeting minutes. The facility's Vice President of Clinical Operations and Chief Operating Officer will oversee the Governing Body to ensure the facility, administrator, and DNS receive the support needed to sustain compliance with state and federal rules and regulations, by review of quality indices and feedback reports from the Governing Body. 19) Oversight will be completed by the Administrator using the information from daily floor rounds, chart reviews, staff and resident interviews. As the QAPI leader, the Administrator will utilize the information to identify and correct non-compliance with state and federal regulations. The Administrator will review any allegations of abuse to ensure a thorough investigation and reporting per state law. The Regional Vice President and/or Regional Director of Clinical Operations will ensure the Administrator is investigating allegation of abuse according to policy and in accordance with state law. 20) On 03/05/17, a QAPI meeting was held with the Administrator, DNS and Medical Director. This meeting reviewed the actions and audits taken by the center effective 03/05/17. Findings of the audits and actions taken after 03/05/17 will be reviewed at the monthly QAPI meeting, by the QAPI team. The QAPI team includes the Medical Director, Administrator, DNS and at least three (3) other departmental leaders. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the Resident Interview Tool, dated 03/03/17, completed by the Regional Director of Nursing Management Services, revealed she had conducted an interview with Resident #1. Review of a Nurses Note, dated 03/03/17 at 9:02 PM, revealed she had conducted an interview with the resident. Review of a Resident Body Audit Tool for assessing the resident, revealed an assessment was completed by the Regional Director of Nursing Management Services on 03/03/17. Interview with the Regional Director of Nursing Management Services on, 03/09/17 at 5:40 PM, confirmed she had completed the interview, performed the assessment and had notified Resident #1's responsible party as well as the Physician. 2) Review of the Resident Interview Tool, revealed the Regional Director of Nursing Management Services or the Regional Vice President completed the interviews by 03/04/17. Review of the Resident Interview Tool, revealed there were forty (40) Resid

Based on interview, record review, review of the Department of Health and Human Services National Institute on [DIAGNOSES REDACTED] and other Communication Disorders- Dysphasia, revised 03/09/16, review of the Dysphasia Resources for Professionals and Patients- Aspiration Precautions Policy undated, review of the facility's Therapeutic Diet Policy, effective 08/01/12, and review of the facility's investigation, it was determined the facility failed to provide a therapeutic diet in proper form as assessed by the Speech Therapist and prescribed by the Physician for one (1) of four (4) sampled residents (Resident #1). On 05/07/16, at approximately 11:30 AM, the Administrator brought a fish sandwich to Resident #1, removed the bread, mashed up half of the fish, and added thickened water. The fish was not prepared in the Dietary department and was not properly pureed (cooked food that has been blended to the consistency of a soft creamy paste or thick liquid), and the resident was not supervised to ensure he/she did not aspirate or choke. At approximately 11:45 to 11:55 AM, the resident was found to be unresponsive and cyanotic (the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation), and the [MEDICATION NAME] Maneuver was attempted without success. Resident #1 expired in the facility at 11:57 AM. The facility's failure to provide a therapeutic diet in proper form as assessed by the Speech Therapist and prescribed by the Physician has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/27/16, and determined to exist on 05/07/16. The facility was notified of the Immediate Jeopardy on 05/27/16. The facility provided an acceptable credible Allegation of Compliance (AOC) on 05/31/16, with the facility alleging removal of the Immediate Jeopardy on 05/20/16. Based on the validation of the AOC, on 05/31/16, the State Agency verified the deficient practice was corrected on 05/20/16, prior to the initiation of the investigation on 05/26/16; therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the Department of Health and Human Services National Institutes of Health-National Institute on [DIAGNOSES REDACTED] and other Communication Disorders- Dysphasia, revised 03/09/16, revealed Dysphasia occurred when there was a problem with the neural control or the structures involved in any part of the swallowing process. Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing. Food pieces that are too large for swallowing may enter the throat and block the passage of air. In addition, when foods, air, and liquids entered the airway of someone who had dysphasia, coughing or throat clearing sometimes could not remove it. Swallowing disorders may also include the development of a pocket outside the esophagus caused by weakness in the [MEDICAL CONDITION] wall. Further review, revealed the esophagus may also be too narrow, causing food to stick. Review of the Dysphasia Resources for Professional and Patients- Aspiration Precautions Policy, undated, revealed all licensed and unlicensed personnel caring for inpatients must be informed of a patient at risk for aspiration and its complications. Personnel will be instructed in, and take appropriate precautions. Further review, revealed aspiration was a misdirection of foreign materials (oropharyngeal bacteria, food, liquids or regurgitated gastric contents) into the larynx and lower respiration tract. Review of the facility policy titled Therapeutic Diets dated 08/01/12, revealed, it was the policy of the facility to provide therapeutic diets when prescribed by the attending physician and to serve diets as ordered. Review of Resident #1's medical record, revealed the facility admitted the resident on 12/23/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was severely cognitive impaired. Continued review of the MDS, revealed the facility assessed Resident #1 as requiring supervision with meals (oversight, encouragement, or cueing) with the support of one (1) person physical assist, and as receiving a mechanically altered diet. Review of the Comprehensive Care Plan, dated 12/23/14, revealed Resident #1 was at risk for altered nutritional status related to receiving a mechanically altered diet-pureed for a [DIAGNOSES REDACTED]. The Care Plan goal revealed the resident's weight would remain stable with no signs and symptoms of dehydration. There were several Care Plan approaches including: observe for acute changes with difficulty swallowing; provide tray set up and supervise as needed; nosey cup (cups with a cut out on the non-drinking side so they may be tilted without interference by the nose) as ordered; report signs and symptoms of Pneumonia/Aspiration; observe for any acute signs and symptoms or difficulty swallowing and report promptly if noted; and, provide diet and snacks as ordered. The care plan was reviewed on a quarterly review dated 06/25/15. Review of the Hospital Report of Consultation, dated 10/26/15 revealed the patient presented with moderate Oropharyngeal Dysphasia. Further review, revealed the recommendations included: 1) Puree diet with nectar liquids 2) medication crushed in puree, and 3) ninety (90) degrees for all PO (by mouth) foods. Review of the Speech Therapist Progress and Discharge Summary, dated 01/06/16, revealed the resident was discharged back to the skilled nursing facility (SNF) with recommendations to continue current dietary orders and recommendations for Puree Texture and Honey thick Liquids. Further review revealed the resident was to be out of bed positioned at ninety (90) degrees for all meals and to remain upright for at least ninety (90) minutes to decrease risk of aspiration, and the resident should remain under standard aspiration precautions. Review of the Physician's orders dated May 2016, revealed orders for a pureed diet, honey thickened liquids, no straws, nosey cup for all meals, and to keep upright in the chair at least ninety (90) minutes following all meals. Review of the facility's Quality Assurance Document-Investigation Template dated 05/17/16, revealed under Description of the Allegation: a paragraph from a Topix Posting (forum website) by Concerned. Review of the Topix Posting, revealed the Administrator of the facility gave a resident a fish sandwich who was supposed to be on a pureed diet, and apparently the patient choked to death. Continued review revealed it was heard the Director of Nursing (DON) and nurses tried to cover it up by documenting the resident choked on ice cream, and something needed to be done. Further review of the facility's Quality Assurance Document-Investigation Template revealed under the heading titled Investigation Summary, revealed upon resident request, the Administrator brought a fish sandwich to the resident, on 05/07/16 at 11:30 AM. The Administrator removed the bread and mashed up half of the fish, also adding thickened (honey) water to the fish patty making it the consistency of oatmeal. The resident had a food tray from lunch still in the room at this time, and the resident always fed self. After consuming the fish the resident was noted to be sitting up in his/her chair in his/her room watching Television (TV) and his/her lunch tray was picked up, and no one at this time noted the resident to be in distress. Further review of the Investigation Summary, revealed at 11:55 AM the Administrator went back down the hallway and looked in the room and saw the resident slumped over and noticed all food items were removed from the resident's room. The Administrator called for assistance and the CMA came and was unable to assist so she sent the CNA (Certified Nursing Assistant ) to get the Licensed Practical Nurse (LPN) who was assisting with lunch. During this time the CMA and CNA assisted the Administrator with performing the [MEDICATION NAME] maneuver (abdominal thrusts used to treat upper airway obstruction or choking by a foreign object), while the LPN went to get the Registered Nurse (RN). Further review revealed the Administrator was Cardiopulmonary Resuscitation (CPR) certified, and the [MEDICATION NAME] Maneuver produced no food or other object of obstruction. Continued review of the Investigation Summary, revealed when the RN entered the room, she requested the resident to be placed on the bed for a better exam. A finger sweep (technique of clearing a mechanical obstruction from the upper airway of an unconscious patient) was performed by the RN with no discovery of food, food particles, only clear saliva. The RN requested the LPN to go verify CODE status. Once the resident was in the bed, the RN noted three (3) agonal breaths (sporadic gasping breaths) and then complete respiration and cardiac cessation which was noted to occur at 11:57 AM. Further review, revealed code status was confirmed by the LPN as a Do Not Resuscitate (DNR), and the RN pronounced the resident deceased at 11:57 AM. Review of the Departmental Note, dated 05/07/16, at 1:27 PM, signed by LPN #1, revealed Resident #1 was found unresponsive in his/her chair with head down at approximately 11:45 AM. Staff alerted nurses and other staff members of the resident's condition. Further review of the same Note revealed prior to being found in this condition staff stated that he/she was sitting in his/her chair watching television. The Note further revealed there was ice cream that was opened on his/her table that appeared to have some missing. Continued review revealed the nurses and a RN from the other hall performed the [MEDICATION NAME] maneuver in case of possible choking. Per the Note, the resident was still seated in his/her wheelchair at the time with no success for several thrusts. Continued review of the Note, revealed the RN instructed staff to transfer the resident to the bed, and once the resident was on the bed a mouth sweep done by RN with no results. Continued review of the Note, revealed the resident took approximately three (3) agonal respirations once he/she was transferred to the bed, and the resident's pulse check was performed by the RN with no pulse felt. Per the Note, the resident had a Do Not Resuscitate (DNR) Advanced Directive, so Cardiopulmonary Resuscitation (CPR) was not initiated. Continued review, revealed the Nurses then immediately auscultated heart rate (HR) and respirations for approximately two (2) minutes with no heart beat or respirations heard, and the RN called time of death (TOD) at 11:57 AM. Telephone Interview on 05/26/16 at 12:14 PM with Resident #1's Former Case Manager (FCM), revealed he was Resident #1's case Manager through Pre-admission Screening and Resident Review (PASRR); however, in 2012 he changed companies and was no longer over his/her case. The FCM revealed Resident#1 had been in the hospital for problems with swallowing and dysphasia, and that was the main reason for the referral to the nursing home in 2014. Continued interview with the FCM revealed he continued to be very active in Resident #1's care and attended his/her care plan meetings, even though he was no longer the resident's FCM. The FCM revealed he was informed of Resident #1's death and was shocked to hear how he/she expired. Further interview with the FCM, revealed he was informed by a staff member that was not present on 05/07/16, that the Administrator gave the resident a fish sandwich and the staff member was afraid to state his/her name for fear of retaliation from the facility. Interview on 05/26/16 at 3:32 PM, with Certified Medication Technician (CMT) /Certified Nursing Aide (CNA) #6, revealed she was working on 05/07/16 and went to the kitchen to ask the cook for Ice cream for Resident #1. She stated the cook informed her Resident #1 was on thickened liquids and could not have ice cream, but could have a Magic Cup (Frozen Desert appropriate for individuals on a Pureed diet). She stated she placed the Magic Cup on the resident's table, opened it for the resident, and left the room, leaving the unit to get food for herself. Further interview, revealed upon her return she heard the Administrator call her name and state help me, help me, which was about 11:55 AM. CMT/CNA #6 revealed when she looked at Resident #1 he/she was already blue (cyanotic). Continued interview with CMT/CNA #6 revealed the Administrator told her, it was all my fault, I did it. CMT/CNA #6 revealed she asked the Administrator what she did, and the Administrator pointed to the table. Further interview with CMT/CNA #6, revealed she saw a one half (1/2) of a McDonald's fish sandwich in a box, which was described in regular food form, not pureed, and she would not have noticed except it was pointed out by the Administrator. She stated she told LPN #1 and CNA #7 and they went to the room, and LPN #1 attempted to do the [MEDICATION NAME] Maneuver with the resident being lifted by two (2) staff. Additional interview with CMT/CNA#6, revealed she went for help when RN #1 came and called the time of death. Further interview with CMT/CNA #6 revealed when she stepped back into the room the half (½) fish sandwich was gone. CMT/CNA #6 revealed I can't tell you what actually caused his/her death; however, I know it was not ice cream, and I saw the half fish sandwich on the table. Interview on 05/26/16 at 3:32 PM, with CNA #7, revealed she was working on 05/07/16 and was the CNA assigned to Resident #1. CNA #7 revealed before her break, she witnessed the Administrator come in the facility with a McDonalds's bag in her hand and when she returned from her break, CNA #8 called to her, and told her to check on Resident #1. Continued interview with CNA #7, revealed when she entered Resident #1's room, the resident was slumped over in the wheelchair and was blue (cyanotic). She stated RN #1 instructed her to get on the other side of Resident #1 and hold him/her with LPN #1, while RN #1 performed the abdominal thrust. CNA#7 revealed they had a problem holding the resident up in performing the [MEDICATION NAME] Maneuver and they moved Resident #1 from the wheelchair to the bed. Additional interview with CNA #7, revealed when they moved Resident #1 from the wheelchair to the bed, she noticed the wheelchair was full of fish crumbs. Per interview, due to being upset about the resident, she didn't know if staff performed further finger sweeps or thrusts after the resident was in bed. She stated I never heard any sounds coming from Resident #1. Further interview with CNA #7, revealed she heard the Administrator say, do something, do something, it's all my fault. Interview on 05/27/16 at 2:23 PM, with LPN #1, revealed she was in the dining room with other residents when she was informed that something was happening on her floor. She revealed when she entered Resident #1's room, the Administrator, CMT/CNA #6, and CNA #7 were attempting the [MEDICATION NAME] Maneuver. LPN #1 stated RN #1 entered the room right behind her, and she and RN #1 attempted an abdominal thrust and could not get anything out. She stated the resident's lips were blue and he/she was not breathing. Continued interview with LPN #1, revealed Resident #1 was placed on his/her bed, and she was sent by RN #1 to get the Pulse Oximeter (a device that measures the oxygen saturation of arterial blood by utilizing a sensor attached typically to a finger). LPN #1 revealed when she returned, RN #1 stated she did a sweep of Resident #1's mouth; however, she did not witness the sweep nor did she witness breath sounds. Additional interview with LPN #1, revealed the Administrator was very upset and kept repeating, it's my fault I gave him/her a fish sandwich. Interview on 05/26/16 at 3:22 PM, with CNA #4, revealed she was present when Resident #1 died , but she was not assigned to the resident on that date. CNA #4 revealed she entered Resident #1's room as RN #1 and CNA #7 was assisting the resident to bed. She revealed RN #1 did a sweep of Resident #1's mouth; however, she did not witness an abdominal thrust being done. She stated after the finger sweep of the mouth, the RN pronounced the resident dead around 11:57 AM. Additional interview with CNA #4 revealed, there was fish still on his/her wheelchair; however, she did not see any ice cream. appropriate for individuals on a pureed diet Frozen Dessert Frozen DessertInterview on 05/26/16 at 2:51 PM, with CNA #3, revealed she was not assigned to Resident #1; however, did work on 05/07/16. She revealed she was told to get an oxygen (02) tank for the resident by RN #1. CNA #3 stated by the time she retrieved the tank and entered Resident #1's room, RN #1 was calling the time of death at 11:57 PM. Additional interview with CNA #3, revealed she did not see the Administrator bring in the fish sandwich; however, she observed fish crumbs in Resident #1's wheel chair and the resident was already gone (deceased ) by the time she got to the room. Additional Phone interview with CNA #5, on 05/30/16 at 1:24 PM, revealed on 05/30/16 at approximately 1:15 PM, she was informed by RN #1 to say she did hear breaths coming from Resident #1 and to say she had witnessed the time of death. However, she stated she did not witness any breath sounds and she did not know who pronounced the resident's death or did not know the time of death, because Resident #1 was already deceased when she came into the room. Interview on 05/28/16 at 11:40 AM, with RN #1, revealed she was the charge nurse the weekend of 05/07/16, and was on the B wing when she received a call over the walkie-talkie related to Resident #1 being found unresponsive. She stated she grabbed her stethoscope and ran to the A Hall. RN #1 revealed when she entered Resident #1's room, LPN #1 and CMT/CNA #6 were holding the resident up out of the wheelchair while attempting the abdominal thrust without success, and she then attempted the abdominal thrust while the other staff held the resident up, without success. RN #1 revealed she then instructed staff to transfer Resident #1 to the bed and at that time she heard three (3) agonal breaths from the resident and she did a finger sweep with no foreign objects noted in the resident's throat. Further interview with RN #1, revealed CNA #5 was beside her, heard the breaths and was present when she called the time of death at 11:57 AM. Interview on 05/26/16 at 3:04 PM, with the Speech Therapist (ST), revealed Resident #1 was referred to her and the start of care date was 12/08/15 and end of care date was 01/06/16. She revealed the discharge instructions were made available for staff in her Progress and Discharge Summary. The ST stated her recommendations were to keep Resident #1 on a pureed diet and honey thick fluids as per her Discharge Summary. Further interview with the ST, revealed mashing up fish and putting honey thick liquids on the fish was definitely not pureed food and pre-made thickened water should never be mixed with any type of food. She stated pureed food must be completed in dietary with a special limit process, and under no circumstances would cutting up the food and adding honey thick liquids be the same as pureed food. Further interview revealed Pureed food was a blended diet very smooth, like pudding and apple sauce, and Resident #1 should not have received any type of food unless it came from dietary. She stated aspiration was always a concern when there was variance in the mechanically altered diet. Post Survey interview with the ST on 06/07/16 at 10:48 AM, revealed standard precautions were used for every resident in the building which meant if a resident was seen having difficulty with coughing on liquids or foods, to alert the nurse and physician as needed. She stated Resident #1 was on standard precautions; however, was safe to be left alone to eat only with the diet and thickened liquids she had recommended for the resident, which was pureed diet and honey thickened liquids. Interview on 05/26/16 at 4:21 PM, with the Dietary Manager (DM), revealed Resident #1's food had to be blended to a creamy like texture as per the prescribed Pureed diet. Continued interview with the DM, revealed Resident #1 should not have received food outside the kitchen, and mixing honey thickened water to fish was not the same as pureed food. She revealed the fish would still have lumpy like constancy and that was not pureed consistency. Additional interview with the DM, revealed the recommendation of ST and Physician's orders should be followed for all special diets to ensure the correct consistency to prevent choking or any other concerns. Interview on 05/27/16 at 3:06 PM, with the Consultant Registered Dietitian (RD), revealed Resident #1's diet recommendations came from the ST and she followed the ST's recommendations. The RD revealed when a resident was on a pureed diet it was a blended textured food and needed to be prepared only in the kitchen. She stated fish mashed up with honey thickened liquids added was not the same consistency as pureed food and should not be given to a resident on a pureed diet. The RD revealed doing this would possibly cause choking or aspiration. Interview on 05/27/16 at 12:50 PM with the DON, revealed she was not in the building when Resident #1 expired; however, when the resident was found, the Resident's code status was checked and it was noted the resident was a Do not Resuscitate (DNR) code status. The DON revealed the facility did not report the death because they did not feel it was a reportable incident. However, after receiving training from the Service Director of Clinical Operations (SDCO)/Advance Practice Register Nurse (APRN) along with the Administrator, she realized Resident #1 should not have received the fish. Further interview, revealed although the Administrator gave the resident the fish out of the goodness of her heart, it was an error in judgment. The DON revealed Resident #1 was placed at risk by the facility not following his/her prescribed diet. Interview on 05/26/16 at 12:45 PM, with the Administrator revealed on 05/06/16 she had asked Resident #1 if he/she wanted a fish sandwich, and the resident said yes. She further stated she was the Manager on Duty for 5/07/16, and on 05/07/16 at 11:15 AM she left the facility to get the fish sandwich, and gave the resident the fish at 11:30 AM. The Administrator revealed she did not check with dietary or nursing; however, was aware of Resident's #1's orders for a pureed diet. Continued interview with the Administrator revealed she took the bread off the fish and mashed the fish to what she thought was oatmeal consistency and felt Resident #1 would be able to consume the fish. She revealed Resident #1 was in his/her room when she left the resident alone with the fish. Further interview with the Administrator, revealed she came back to Resident #1's room to check on him/her at 11:45 AM, and found him/her slumped over in his/her wheelchair. She revealed she called for help and CMT/CNA #6 and LPN #1 lifted the resident up from the wheelchair and she did the [MEDICATION NAME] Maneuver without any results. Further interview with the Administrator revealed she could not recall telling staff anything regarding it being her fault, and she spoke with RN #1 and was informed she was not at fault because when RN #1 performed a sweep of Resident #1's mouth, nothing was there. Continued interview with the Administrator, revealed the Topix Posting was found on 05/16/16, and she called her Regional Vice President (RVP) to inform her of the posting. Continued interview with the Administrator revealed she did not report to the RVP she gave Resident #1 the fish because she thought it was a sudden death as the RN had indicated. The Administrator revealed it was not until the Assistant Director of Nursing (ADON) from a sister facility was sent by the RVP to enquire about the posting, did corporate realize she gave the resident the fish. She stated on 05/17/16 the SDCO/APRN entered the building once the RVP realized the fish was not mechanically altered in the dietary department. Further interview with the Administrator revealed Resident #1 did not get the right type of food for his/her diet, and received food that was not mechanical altered in the kitchen. Interview on 05/26/16 at 5:08 PM, with the ADON from a sister facility, revealed the Administrator discovered the Topix Posting and she arrived at the facility 05/17/16 per request of the RVP. The ADON revealed she interviewed the staff regarding the Topix Posting and her role was to assist the DON with in-services. Interview on 05/29/16 at 12:13 PM with the RVP, revealed she was notified on 05/16/16 by the Administrator in regards to the Topic Posting and was not aware prior to that call of the incident. The RVP revealed she did not find out until 05/17/16 the food which was given to Resident #1 was not mechanically altered in the dietary department. She stated, We sent one of our nurses from another facility to come down and to see what physically was going on in the facility. Continued interview with the RVP revealed the Administrator gave the resident the fish out of the goodness of her heart, and immediately received re-education from the SDCO/APRN. The RVP revealed the incident was not reported because she did not fill it met any reportable requirements. She stated, they did not see any evidence of signs of her choking when they looked in his/her mouth, they did not see any food . Interview on 05/27/16 at 12:13 PM, SDCO/APRN, revealed she entered the building on 05/16/16 at 5:18 PM when the RVP notified her the fish Resident #1 consumed was not mechanically altered in the kitchen. Per the SDCO/APRN, the facility did not follow the resident's prescribed diet and did not contact the regional office of the incident until the Topix Posting. Additional interview with the SDCO/APRN revealed her main focus was to re-educate the Administrator and ensure she understood she placed the resident at risk by not following his/her ordered diet and plan of care. Interview on 05/29/16 at 8:10 PM, with Resident #1's Guardian, revealed she requested a test to see if Resident #1 could have other foods, and was informed by the Medical Director his/her diet needed to continue as a pureed diet and it was not in the resident's best interest to give him/her food alternate to the diet. The Guardian revealed she left the decision up to the Medical Director. Interview on 06/02/16 at 3:30 PM, with the Medical Director (MD), of the facility revealed he did not find out about the true nature of the concern until 05/19/16 by the DON, after they heard about the Topix Posting. He stated, prior to that I assumed his/her death was other medical issues, he/she was a DNR, so I didn't expect a report other than he/she expired in the facility. Continued interview revealed he was not immediately informed of the Administrator providing fish, and he would not have approved of Resident #1 receiving food alternate to his/her approved diet. Additional interview with the MD revealed there was a medical reason for Resident #1 to be on a pureed diet and the diet should have been followed related to physician's orders and ST recommendations. He stated, the Administrator should not have given him/her the fish; she was not the Power of Attorney (POA) or the dietary department. The MD revealed the facility did not follow proper protocol regarding this resident and they went against his orders. The facility provided an acceptable credible allegation of compliance (AOC) on 06/20/16 that alleged removal of Immediate Jeopardy (IJ) effective 05/31/16. Review of the AOC revealed the facility implemented the following: 1. Resident #1 expired on 05/07/16. 2. On 05/18/16, the RVP notified the ADON of the sister facility to initiate an action plan to identify all residents on a modified texture diet ensuring the Physician's orders, care plan and meal card correlated. This was completed by the ADON of the sister facility using the Diet Audit Tool. 3. On 05/18/6 the SDCO/APRN implemented an immediate education tool , the Nicholasville Quality Focused Team Member in-service, for the Administrator and the DON regarding modified textures diets. 4. On 05/19/16 all departments in the facility received in-services on modified textured diets, thickened liquids and care plan compliance by the DON and Speech Therapist. 5. On 05/19/16, the Educational Tool Nicholasville Quality Focused Team Member in-service was added to the new hire orientation packet. 6. On 05/19/16, the facility continued Quality Assurance (QA) audits to ensure system compliance initiated on 05/17/16 and continued through 05/31/16, by the management team of the facility. 7. The Quality Assurance Performance Improvement (QAPI) committee met on 05/09/16 with the attendance of the Administrator, Director of Nursing (DON), Dietary Manager (DM) and Medical Director (MD) via phone. 8. On 05/19/16, random team members across all departments were questioned about their knowledge of provision of correct consistency of food and liquids using the QAPI questionnaire document. 9. Questionnaires have been and will continue to be completed by members of the QAPI team which includes the Administrator, DON, Assistant Director of Nursing (ADON), regional support team members and the DM. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Resident #1 received food that was not of part of the pureed diet in which the resident was prescribed, on 05/07/16 at 11:30 AM, and was found unresponsive at 11:55 AM, with time of death called at 11:57 AM. 2. Review of the Physician order List, revealed fifty eight (58) residents were identified on 05/18/16 by the ADON of the sister facility, as having a modified textured diet and five (5) residents were identified as having thickened liquids. Review of the Diet Audit, validated the Care Plan, SRNA Care Guide, and Meal Tray Ticket were accurate compared to the Physician's order list. 3. Review of the re-education tool, Nicholasville Quality Forced Team Member in-service attendance record sheet, dated 05/18/16 validated signatures of the SDCO/APRN, DON and the Administrator. Review of the Nicholasville Quality Focused Team Member in-service, revealed the in-service titled modified textured diets, contained information defining each modified diet. The two (2) modified diets listed were Mechanical soft and Pureed Diet. The in-serviced also included education on thicken liquids; Honey, Nectar, and Pudding. Continued review of the in-service revealed all modified textured diets were prepared in the kitchen as they had the equipment necessary to grind, blend and mash foods to the recommendation textures. Additional review of the in-service revealed there were three (3) types of thickened liquids served in the facility, Nectar-like thicken, Honey-like and Pudding-thick liquid. Interview on 05/27/16 at 12:30, with the Administrator and 05/27/16 at 12:50 PM, with the DON, confirmed they received the in-services presented by the SDCO/ARNP and were able to voice the two (2) types of mechanical altered diets as well as the three (3) types of thickened liquids. 4. Review of the in-service Attendance Record dated 05/19/19, validated each department's signatures for the in-service given by the DON and the Speech Therapist on Modified texture diets, Thickened liquids, and Care Plan compliance. Further review revealed the departments listed on the in-service sign in list included: Therapy department, Activity department, Housekeeping department, Dietary department, and Nursing department. Inte

Based on interview, record review, and review of the Centers for the Medicare and Medicaid Resident Assessment Instrument (RAI) Version 3.0 Manual, dated [DATE], it was determined the facility failed to ensure services were provided in accordance with each resident's written Plan of Care for one (1) of four (4) sampled residents (Resident #1). Resident #1's Comprehensive Plan of Care, reviewed [DATE], revealed the resident was at risk for altered nutritional status related to receiving a mechanically altered pureed diet for a [DIAGNOSES REDACTED]. However, on [DATE] at approximately 11:30 AM, Resident #1 received fish that was not properly pureed and the resident was left alone in his/her room unsupervised. At approximately 11:45 AM to 11:55 AM, Resident #1 was found to be unresponsive and cyanotic and staff performed the [MEDICATION NAME] Maneuver without success. Resident #1 expired on [DATE] at 11:57 AM. The facility's failure to ensure each resident's written care plan interventions were implemented has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. Based on the validation of the AOC, on [DATE], the State Agency verified the deficient practice was corrected on [DATE], prior to the initiation of the investigation on [DATE]; therefore, it was determined to be Past Immediate Jeopardy. The findings include: Interview with the Director of Nursing (DON) on [DATE] at 12:50 PM, revealed the facility had no policy related to following the care plan, and utilized the RAI Manual. Review of the Centers for the Medicare and Medicaid Resident Assessment Instrument (RAI) Version 3.0 Manual, dated [DATE], chapter four (4.7), revealed, the Comprehensive Care Plan was an interdisciplinary communication tool, and must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review, revealed the services provided or arranged must be consistent with each resident's written plan of care. Review of Resident #1's clinical record, revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was severely cognitive impaired. Further review of the MDS, revealed the facility assessed Resident #1 as requiring supervision with meals (oversight, encouragement, or cueing) with the support of one (1) person physical assist, and as receiving a mechanically altered diet. Review of the Comprehensive Plan of Care, dated [DATE], revealed Resident #1 was at risk for altered nutritional status related to receiving a mechanically altered diet-pureed (cooked food that has been blended to the consistency of a soft creamy paste or thick liquid), for a [DIAGNOSES REDACTED]. The goal revealed the resident's weight would remain stable with no signs and symptoms of dehydration. There were several Care Plan interventions including: observe for acute changes with difficulty swallowing; provide tray set up and supervise as needed; nosey cup (cups with a cut out on the non-drinking side so they may be tilted without interference by the nose) as ordered; report signs and symptoms of Pneumonia/Aspiration; observe for any acute signs and symptoms or difficulty swallowing and report promptly if noted; and provide diet, and snacks as ordered. The care plan was reviewed on [DATE]. Review of the Speech Therapist Progress and Discharge Summary, dated [DATE], revealed Resident #1's diet recommendations were for Puree Texture and Honey thick Liquids. Further review revealed the resident was to be out of bed positioned at ninety (90) degrees for all meals and to remain upright for at least ninety (90) minutes to decrease risk of aspiration, and should remain under standard aspiration precautions. Review of Resident #1's physician's orders [REDACTED]. Review of the Departmental Note, dated [DATE], at 1:27 PM, signed by LPN #1, revealed Resident #1 was found unresponsive in his/her chair with head down at approximately 11:45 AM, and staff alerted nurses and other staff members of the resident's condition. Further review of the same Note revealed prior to being found in this condition, staff stated that the resident was sitting in his/her chair watching television. The Note revealed there was ice cream that was opened on his/her table that appeared to have some missing. Per the Note, the nurses and Registered Nurse (RN) from the other hall performed the [MEDICATION NAME] Maneuver in case of possible choking, and the the resident was still seated in his/her wheelchair at the time with no success for several thrusts. Continued review of the Note, revealed the RN instructed staff to transfer the resident to bed, and once in the bed a mouth sweep done by RN with no results. Per the Note, Resident #1 expired on [DATE] at 11:57 AM. Interview on [DATE] at 3:32 PM, with Certified Medication Technician (CMT) /Certified Nursing Aide (CNA) #6, revealed on [DATE] the Administrator called her name and stated help me, help me, which was about 11:55 AM. CMT/CNA #6 revealed when she looked at Resident #1 he/she was already blue (cyanotic-the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation). CMT/CNA #6 revealed the Administrator told her, it was all my fault, I did it. CMT/CNA #6 further revealed she asked the Administrator what she did, and the Administrator pointed to the table. Continued interview with CMT/CNA #6, revealed she saw a one half (,[DATE]) of a McDonald's fish sandwich in a box, which was described in regular food form, not pureed, which was pointed out by the Administrator. Interview on [DATE] at 3:32 PM, with CNA #7, revealed she witnessed the Administrator come in the facility with a McDonalds's bag in her hand. CNA #7, further revealed when they transferred Resident #1 from the wheelchair to the bed, she noticed the wheelchair was full of fish crumbs. Per interview, she heard the Administrator say, do something, do something, it's all my fault. Interview on [DATE] at 2:23 PM, with LPN #1, revealed the Administrator was very upset and kept repeating, it's my fault I gave him/her a fish sandwich. Further interview on [DATE] at 4:19 PM with LPN #1, revealed Resident #1's care plan was not followed on [DATE] because Resident #1 received food that was not prescribed. Interview on [DATE] at 3:22 PM, with CNA #4, revealed on [DATE] she entered Resident #1's room as RN #1 and CNA #7 were transferring the resident to bed. CNA #4 revealed, there was fish still on his/her wheelchair. appropriate for individuals on a pureed diet Frozen Dessert Frozen DessertInterview on [DATE] at 2:51 PM, with CNA #3, revealed on [DATE]. she did not see the Administrator bring in the fish sandwich; however, she observed fish crumbs in Resident #1's wheel chair and the resident was already gone (deceased ) by the time she got to the room. Interview on [DATE] at 11:40 AM, with RN #1, revealed when she entered the resident's room she did not see any remains of a fish sandwich when she entered the room on [DATE]. Interview on [DATE] at 3:04 PM, with the Speech Therapist (ST), revealed Resident #1 was on a pureed diet and honey thick fluids. Per interview, mashing up fish and putting honey thick liquids on the fish was definitely not pureed food and pre-made thickened water should never be mixed with any type of food. She further stated under no circumstances would cutting up the food and adding honey thick liquids be the same as pureed food. Per interview, pureed food was a blended diet very smooth, like pudding and apple sauce, and Resident #1 should not have received any type of food unless it came from dietary. The ST stated, aspiration was always a concern when there was variance in the mechanically altered diet. Interview on [DATE] at 4:21 PM, with the Dietary Manager (DM), revealed the dietary department did not serve fish on [DATE]. The DM revealed Resident #1's food had to be blended to a creamy like texture as per the prescribed Pureed diet. Continued interview, revealed Resident #1 should not have received food outside the kitchen, and mixing honey thickened water to fish was not the same as pureed food. Per the DM, the fish would still have lumpy like constancy and that was not pureed consistency. The DM revealed the physician's orders [REDACTED]. Interview on [DATE] at 3:06 PM, with the Consultant Registered Dietitian (RD), revealed Resident #1's diet recommendations came from the ST and she followed the ST's recommendations. Per the RD, when a resident was on a pureed diet it was a blended textured food and needed to be prepared only in the kitchen. She further stated fish mashed up with honey thickened liquids added was not the same consistency as pureed food and should not be given to a resident on a pureed diet. The RD stated, doing this would possibly cause choking or aspiration. The RD revealed the DM was responsible for updating the care plan and there was not an intervention on the care plan related to receiving food outside of the dietary department. Additional interview revealed if Resident #1 received food that was not pureed the care plan was not followed. Interview on [DATE] at 1:26 PM with the MDS Coordinator, revealed the Care Plan was a guide for the staff to follow in caring for the residents and the Administrator did not follow the care plan or the physician's orders [REDACTED].#1 food which was not prescribed. Interview on [DATE] at 12:50 PM with the DON, revealed the Administrator gave the resident the fish out of the goodness of her heart, it was an error in judgment, and Resident #1 was placed at risk by the facility not following his/her prescribed diet. Additional interview on [DATE] at 4:52 PM, with the DON, revealed she expected everyone to follow the physician's orders [REDACTED]. Interview on [DATE] at 12:45 PM, with the Administrator, revealed , she was the Manager on Duty for [DATE], and on [DATE] at 11:15 AM, she left the facility to get the fish sandwich, and gave Resident #1 the fish at 11:30 AM. She stated she was aware of Resident's #1's orders for a pureed diet, and took the bread off the fish and mashed the fish to what she thought was oatmeal consistency, thinking Resident #1 would be able to consume the fish. She revealed Resident #1 was in his/her room when she left the resident unsupervised with the fish. Per interview with the Administrator, when she came back to Resident #1's room to check on him/her at 11:45 AM, she found him/her slumped over in his/her wheelchair. Additional interview on [DATE] at 5:02 PM with the Administrator, revealed she did not follow the care plan as she did not provide the resident the diet prescribed when she gave the resident the fish, and it was important to review the care plans before providing care for a resident. The facility provided an acceptable credible allegation of compliance (AOC) on [DATE] that alleged removal of Immediate Jeopardy (IJ) effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. Resident #1 expired on [DATE]. 2. On [DATE], the RVP notified the ADON of the sister facility to initiate an action plan to identify all residents on a modified texture diet ensuring the physician's orders [REDACTED]. This was completed by the ADON of the sister facility using the Diet Audit Tool. 3. On [DATE] the SDCO/APRN implemented an immediate education tool , the Nicholasville Quality Focused Team Member in-service, for the Administrator and the DON regarding modified textures diets. 4. On [DATE] all departments in the facility received in-services on modified textured diets, thickened liquids and care plan compliance by the DON and Speech Therapist. 5. On [DATE], the Educational Tool Nicholasville Quality Focused Team Member in-service was added to the new hire orientation packet. 6. On [DATE], the facility continued Quality Assurance (QA) audits to ensure system compliance initiated on [DATE] and continued through [DATE], by the management team of the facility. 7. The Quality Assurance Performance Improvement (QAPI) committee met on [DATE] with the attendance of the Administrator, Director of Nursing (DON), Dietary Manager (DM) and Medical Director (MD) via phone. 8. On [DATE], random team members across all departments were questioned about their knowledge of provision of correct consistency of food and liquids using the QAPI questionnaire document. 9. Questionnaires have been and will continue to be completed by members of the QAPI team which includes the Administrator, DON, Assistant Director of Nursing (ADON), regional support team members and the DM. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Resident #1 received food that was not of part of the pureed diet in which the resident was prescribed, on [DATE] at 11:30 AM, and was found unresponsive at 11:55 AM, with time of death called at 11:57 AM. 2. Review of the Physician order [REDACTED]. Review of the Diet Audit, validated the Care Plan, SRNA Care Guide, and Meal Tray Ticket were accurate compared to the physician's orders [REDACTED]. 3. Review of the re-education tool, Nicholasville Quality Forced Team Member in-service attendance record sheet, dated [DATE] validated signatures of the SDCO/APRN, DON and the Administrator. Review of the Nicholasville Quality Focused Team Member in-service, revealed the in-service titled modified textured diets, contained information defining each modified diet. The two (2) modified diets listed were Mechanical soft and Pureed Diet. The in-serviced also included education on thicken liquids; Honey, Nectar, and Pudding. Continued review of the in-service revealed all modified textured diets were prepared in the kitchen as they had the equipment necessary to grind, blend and mash foods to the recommendation textures. Additional review of the in-service revealed there were three (3) types of thickened liquids served in the facility, Nectar-like thicken, Honey-like and Pudding-thick liquid. Interview on [DATE] at 12:30, with the Administrator and [DATE] at 12:50 PM, with the DON, confirmed they received the in-services presented by the SDCO/ARNP and were able to voice the two (2) types of mechanical altered diets as well as the three (3) types of thickened liquids. 4. Review of the in-service Attendance Record dated [DATE], validated each department's signatures for the in-service given by the DON and the Speech Therapist on Modified texture diets, Thickened liquids, and Care Plan compliance. Further review revealed the departments listed on the in-service sign in list included: Therapy department, Activity department, Housekeeping department, Dietary department, and Nursing department. Interview on [DATE] at 2:30 PM with CNA #1, [DATE] at 2:40 PM with CNA #2, [DATE] at 2:51 PM with CNA #3, [DATE] at 3:22 PM with CNA #4, [DATE] at 3:32 PM with CNA #5, [DATE] at 3:43 PM with CNA #6, [DATE] at 2:58 PM with CNA #7, [DATE] at 2:23 PM with LPN #1, [DATE] at 12:30 PM LPN #2, [DATE] at 12:58 PM with CNA #9, [DATE] at 2:52 PM with the Activity Supervisor, [DATE] at 3:58 PM with Housekeeping #1, [DATE] at 4:02 PM with Housekeeping #2, [DATE] at 4:07 PM with Dietary Aide #1, [DATE] at 4:11 PM with Dietary aide #2, [DATE] at 4:14 PM with the Physical Therapist (PT), and [DATE] at 4:28 PM with Occupational Therapist (OT), revealed they had received an in-service on mechanical soft and pureed diet textures and different types of thickened liquids; and they were able to explain the difference between the two (2) textured foods and name the thickened liquids. 5. Review of the New Hire Orientation Packet, validated the addition of the Nicholasville Quality Focused Team Member in-service. Interview on [DATE] at 12:13 PM with the SDCO/APRN, revealed the teaching tool was added; however, at the time the four (4) point plan was developed, no new employees had started at the facility. 6. Review of the diet and meal delivery audits tool first initiated by the ADON on [DATE], validated the audits continued to include date of audit, meal served, name of auditor, area monitored, if all meals were served accurately based on Physician orders, and if orders were followed for thickened liquids. Review of each area was documented by the auditors and if there was recorded variances, it was documented what the variances were. Observation of the lunch meal service on [DATE] at 11:20 AM, of Resident #3 revealed he/she was on a mechanical soft diet and his/her meal card matched the Physician orders [REDACTED]. Continued observation of the lunch meal service, revealed Resident #4's meal card revealed he/she was on a regular texture diet and was validated as correct on the Physician orders [REDACTED]. 7. Review the QAPI Improvement Meeting sign-in sheet dated [DATE], validated the signature of the Administrator, the DON, the DM and Medical Director (MD) via phone. A review of the meeting agenda validated the subject covered was Modified Textured diets. 8. Review of the QAPI calendar titled, Ten Team Member Questionnaires per Week, validated two (2) questionnaires were completed on [DATE], nine (9) questionnaires were completed [DATE], fourteen (14) questionnaires were completed [DATE], seventeen (17) questionnaires were completed on [DATE]. one (1) questionnaire was completed on [DATE], ten (10) questionnaires were completed on [DATE] and two (2) questionnaires were completed on [DATE]. Additional review revealed the questionnaires completed correlated with the QAPI calendar number of employees that received the QAPI questionnaires quiz with answers attached. Interview on [DATE] at 2:52 with the Activity Supervisor, [DATE] at 3:03 with CNA #5, [DATE] at 3:09 with CNA #2, [DATE] at 3:10 with CNA #1, [DATE] at 3:27 PM with RN #2, [DATE] at 3:37 with CNA #4, [DATE] at 3:58 PM with Housekeeping #1, [DATE] at 4:02 PM with Housekeeping #2, [DATE] at 4:07 PM with Dietary Aide #1, [DATE] at 4:11 PM with Dietary Aide #2, [DATE] at 4:14 PM with the Physical Therapist (PT), [DATE] at 4:19 PM with LPN #1, and [DATE] at 4:28 PM with the Occupational Therapist (OT), revealed they received the QAPI questionnaire and were able to identify their names for the surveyor on the sign in sheet and on their test. 9. Interview on [DATE] with the DON, revealed the Administrator, the DM, the ADON from the sister facility, the regional support team, and herself, would continue to present the staff with the QAPI questionnaires. Further interview revealed the facility posted signs at each nurse's station and the front entrance alerting staff that no was to bring food into the facility, and if a family member brought in food, it was to be reported immediately. Observation [DATE] at 1:15 PM of the A and B wing nurses station, and the font door entrance validated the signs were posted. Interview on [DATE] at 5:02 PM, with the Administrator verified she planned to ensure the audits continued well after the Plan of Correction (POC) was completed and accepted. Further interview revealed she would ensure everyone including herself would follow the four point plan and comply with the resident's ordered diets. Additional interview with the Administrator, revealed, the agenda for the next meeting had not been completed; however, the audits would be at the top of the list.

Based on interview, record review and review of the facility's policy and procedure, the facility failed to have an effective system to ensure care plans were reviewed and revised to reflect the resident's current condition for fourteen (14) of sixteen (16) sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, and #16). Interview and record review revealed a treatment for [REDACTED].#5, #6, #7 and #9). On 07/27/14, Residents #1, #2, #3, #4, #8, #10, #11, #12 and #14 as well as eight (8) unsampled residents (Unsampled Residents A, B, C, D, E, F G and H) were also treated for [REDACTED]. and guidelines. On 08/20/14, Resident #7 required re-treatment with scabies topical medications, and on 08/21/14 and 01/02/15, Resident #6 required re-treatment with scabies topical medications. The facility's failure to have an effective system in place to ensure the care plans were reviewed and revised to reflect each resident's current condition has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/30/15 and found to exist on 07/27/14, and the facility was notified on 01/30/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 02/05/15, with the facility alleging removal of the Immediate Jeopardy on 02/05/15. The State Survey Agency verified removal of the Immediate Jeopardy on 02/05/15 as alleged, prior to exit on 02/06/15, with remaining non-compliance at Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled "Comprehensive Plan of Care", effective 08/01/12, revealed the purpose was to provide an individualized Plan of Care for each resident. Continued review revealed the Comprehensive Care Plan should describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, with measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the Comprehensive Assessment. Per the facility's policy, the Comprehensive Care Plan was to be updated to reflect the resident's current condition at least every ninety (90) days, or whenever significant changes occurred. Further review revealed progress or the lack of progress toward the goal was to be documented each time the Care Plan was reviewed, noting the probable reason for success or failure. Review of the facility's policy titled "Care System Guidelines - Skin Care", undated, revealed the Director of Nursing Services (DON) or designee was responsible for implementing and monitoring the skin integrity program. Further review revealed a key element was for any skin risk identified to have corresponding interventions in the plan of care. Per the policy, the plan of care would address problems, goals, and interventions directed towards identified skin integrity concerns. Review of the facility's policy titled "Isolation - Categories of Transmission-Based Precautions", revised August 2012, revealed the facility would ensure each resident's care plan and care specialist communications system indicated the type of precautions implemented for the resident. Interview with Registered Nurse (RN) #1, on 01/30/15 at 4:00 PM, revealed the Minimum Data Set nurse was responsible for updating the care plans. Further interview revealed the care plan should consist of the problem area to be addressed, the goal and date of the goal, with the interventions listed. RN #1 stated the care plan for a resident receiving treatment for [REDACTED]. Further interview revealed she did not know if the residents' care plans related to scabies included any of these interventions. 1. Record review revealed Resident #1 was admitted by the facility on 09/12/13, and re-admitted [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 12/01/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of the Comprehensive Care Plan for Resident #1 revealed the facility had care planned the resident to be at risk for an impairment in skin integrity related to chronic bilateral lower extremity [MEDICAL CONDITION]. Further review of the Care Plan revealed the facility identified Resident #1 to have a rash between his/her toes on 04/11/14, at which time treatments were implemented. Continued review revealed the Care Plan was revised to include [MEDICATION NAME] Cream (treatment for [REDACTED]. and guidelines. 2. Record review revealed Resident #2 was admitted by the facility on 05/25/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/16/14, revealed the facility assessed Resident #2 to have a BIMS score of eleven (11) out of fifteen (15), which indicated the resident exhibited moderate cognitive impairment. Review of the Comprehensive Care Plan revealed the facility care planned Resident #2 for a potential impairment in skin integrity related to a self-care deficit. Further review of the Care Plan revealed the facility identified Resident #2 to have a rash and itching on 06/08/14 with an order for [REDACTED]. and guidelines. 3. Record review revealed Resident #3 was admitted by the facility on 03/22/13 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS Assessment, dated 01/19/15, revealed the facility assessed Resident #3 to have a BIMS score of twelve (12), indicating the resident was moderately cognitively impaired. Review of the Comprehensive Care Plan revealed the facility had care planned Resident #3 for the risk of impaired skin integrity related to recurrent bilateral lower left extremity [MEDICAL CONDITION]. Further review of the Care Plan revealed the facility identified Resident #3 to have a rash or itching on 06/30/14, with [MEDICATION NAME] cream and [MEDICATION NAME] ordered for the symptoms. Continued review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions was added as a care plan intervention, and no evidence the Care Plan was revised to include the implementation of monitoring for the effectiveness of the treatment, or monitoring of the appearance of the rash to ensure eradication of the infestation, per the facility's policies and guidelines. 4. Record review revealed Resident #4 was admitted by the facility on 09/13/12 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/14/15, revealed the facility assessed Resident #4 to have a BIMS score of seven (7), which indicated the resident was severely cognitively impaired. Review of the Comprehensive Care Plan revealed the facility assessed Resident #4 to be at risk for skin integrity impairment related to a history of chronic Stage Two (2) diabetic ulcers, and related to the resident "picking" at self. Further review revealed the care plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence the Care Plan was revised to include Contact Isolation Precautions, or monitoring of the rash for treatment effectiveness and alleviation of symptoms, to ensure eradication of the scabies infestation per the facility's policies and guidelines. 5. Record review revealed, Resident #5 was admitted by the facility on 04/16/12 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 12/02/14, revealed the facility assessed Resident #5 to have a BIMS score of eight (8), indicating moderate cognitive impairment. Review of the Comprehensive Care Plan revealed the facility assessed Resident #5 to be at risk for impaired skin integrity, related to frailty and weakness, and the need for assistance with all care. Further review of the Care Plan revealed the facility identified Resident #5 to have a rash on 06/11/14, when an oral steroid was initiated related to the rash. Further review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as an intervention, and no evidence the Care Plan was revised to include implementation of monitoring for the effectiveness of the treatment, or monitoring of the appearance of the rash to ensure eradication of the infestation, per the facility's policies and guidelines. 6. Record review revealed Resident #6 was admitted by the facility on 12/17/13 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 01/11/15, revealed the facility assessed Resident #6 to have a BIMS score of six (6), which indicated severe cognitive impairment. Review of the Comprehensive Care Plan revealed the facility assessed Resident #6 to be at risk for impaired skin integrity related to low body weight and end-stage [MEDICAL CONDITION]. Further review of the Care Plan revealed on 06/09/14 the facility identified Resident #6 to have a rash on his/her chest and axillary area, with [MEDICATION NAME] Cream ordered. Further review revealed the care plan was revised to include [MEDICATION NAME] Cream to be applied on 07/21/14, 08/21/14, 09/10/14 and 12/15/14; however, there was no documented evidence the Care Plan was revised at any time to include Contact Isolation Precautions interventions, and no evidence the Care Plan was ever revised to include the implementation of monitoring for the effectiveness of the treatment, or monitoring the appearance of the rash to ensure eradication of the infestation, per the facility's policies and guidelines. 7. Record review revealed Resident #7 was admitted by the facility on 05/17/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 12/15/14, revealed the facility assessed Resident #7 to have a BIMS of eight (8), indicating moderate cognitive impairment. Review of the Comprehensive Care Plan revealed the facility assessed Resident #7 to be at risk for skin integrity impairment related to a self-care deficit and the need for extensive staff assist. Further review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as an intervention, and no evidence the Care Plan was revised to include monitoring for the effectiveness of the treatment or monitoring of the rash to ensure the scabies were eradicated, per the facility's policies and guidelines. 8. Record review revealed Resident #8 was admitted by the facility on 01/28/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 01/14/15, revealed the facility assessed Resident #8 to have a BIMS of six (6), indicating the resident was severely cognitively impaired. Review of the Comprehensive Care plan revealed the facility care planned Resident #8 for a potential of impaired skin integrity related to frequent bowel and bladder incontinence, and a self-care deficit. Further review of the Care Plan revealed the facility identified Resident #8 to have a rash or itching on 06/30/14, with [MEDICATION NAME] cream and oral [MEDICATION NAME] ordered. Continued review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as an intervention, and no evidence the Care Plan was revised to include the implementation of monitoring for the effectiveness of the treatment or monitoring of the appearance of the rash to ensure eradication of the infestation, per the facility's policies and guidelines. 9. Record review revealed Resident #9 was admitted by the facility on 01/02/14 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 12/30/14, revealed the facility assessed Resident #9 to have a BIMS score of three (3), indicating severe cognitive impairment. Review of the Comprehensive Care plan revealed the facility care planned Resident #9 for potential skin integrity impairment related to frequent bladder incontinence. Further review of the Care Plan revealed, on 06/09/14, the facility identified Resident #9 to have a rash on his/her back with [MEDICATION NAME] cream ordered. Continued review revealed the care plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as an intervention, and no evidence the Care Plan was revised to include implementation of monitoring for the effectiveness of the treatment or monitoring of the appearance of the rash to ensure the scabies were eradicated, per the facility's policies and guidelines. Additional review revealed Resident #9 was admitted to an acute care hospital on [DATE], where he/she was identified to have scabies and the resident was administered treatment at the hospital. 10. Record review revealed Resident #10 was admitted by the facility on 08/05/10 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/13/14, revealed the facility assessed Resident #10 to have a BIMS score of three (3), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan revealed the resident was assessed by the facility to be at risk for skin integrity impairment related to a self-care deficit, bowel incontinence and the presence of pressure ulcers. Further review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as a care plan intervention, and no evidence the care plan was revised to include monitoring for the effectiveness of the treatment or monitoring of the appearance of the rash to ensure eradication of the infestation, per the facility's policies and guidelines. 11. Record review revealed Resident #11 was admitted by the facility on 09/03/85 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 01/16/15, revealed the facility assessed Resident #10 to have a BIMS score of twelve (12), which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan revealed the facility assessed Resident #11 to be at risk for impaired skin integrity related to impaired mobility, non-ambulatory status and decreased range of motion. Further review of the care plan revealed on 06/28/14, the facility identified Resident #11 to have redness on his/her sacrum with "Magic Butt" cream ordered. Continued review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as a care plan intervention, and no evidence the Care Plan was revised to include the implementation of monitoring the appearance of the rash and the effectiveness treatment to ensure the scabies were eradicated, per the facility's policies and procedures. 12. Record review revealed Resident #12 was admitted by the facility on 03/12/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/20/14, revealed the facility assessed Resident #12 to have a BIMS of three (3). which indicated severe cognitive impairment. Review of the Comprehensive Care Plan revealed the facility assessed Resident #12 to be at risk for skin integrity impairment related to a requirement for staff assistance for activities of daily living. Further review revealed the facility identified Resident #12 to have a rash to his/her axilla and perineal area on 06/12/14, and an oral steroid was ordered. Continued review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence the Care Plan was revised to include Contact Isolation Precautions or interventions related to monitoring the resident's rash and effectiveness of the treatment, to ensure the scabies were eradicated, per the facility's policies and procedures. 13. Record review revealed Resident #14 was admitted by the facility on 06/05/14, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/22/14, revealed the facility assessed Resident #14 to have a BIMS score of six (6), indicating severe cognitive impairment. Review of Resident #14's Comprehensive Care Plan revealed the facility assessed Resident #14 to be at risk for impaired skin integrity related to a self-care deficit and incontinence of bowel and bladder. Continued review revealed the Care Plan was revised to include [MEDICATION NAME] Cream to be applied on 07/27/14; however, there was no documented evidence Contact Isolation Precautions were added as an intervention, and no evidence the Care Plan was revised to include monitoring for the effectiveness of the treatment or the appearance of the rash to ensure eradication of the infestation, per the facility's policies and guidelines. 14. During the Partial Extended Survey, Resident #16 was identified by the State Survey Agency to have a rash and itching. Interview with Resident #16, on 02/04/15 at 8:05 AM, revealed the resident reported itching on his/her back for about two (2) weeks. Continued interview revealed the resident did report the itching to staff, but was not aware of any new treatment orders. The resident stated the nurse put some lotion on the itch but it only helped for a short time. Observation of a skin assessment conducted by LPN #2, on 02/04/15 at 9:58 AM, revealed Resident #16 had red linear abrasions on the left lower back. In addition, the resident exhibited a raised red rash in clusters on the upper back, neck and both shoulders. Continued observation revealed a scabbed area behind the right ear. At the time of the skin assessment, Resident #16 stated he/she had scabies many years ago, and this felt exactly the same. Clinical record review revealed Resident #16 was admitted by the facility on 01/16/15 for rehabilitation after a fall at home, and was receiving occupational therapy, speech therapy and physical therapy five (5) times per week. Review of the Brief Interview for Mental Status (BIMS), dated 01/23/15, revealed the facility assessed Resident #16 to have a score of fifteen (15) which indicated the resident was cognitively intact and interviewable. Review of the Comprehensive Care Plan for Resident #16, dated 01/16/15, revealed the resident was assessed by the facility to be at risk for impaired skin integrity. However, the Care Plan was not revised to address the specific problem of the resident's itching and scratching, and it did not include a treatment goal or interventions for managing the symptoms. Interview with the MDS Coordinator, on 01/30/15 at 4:20 PM, revealed she was responsible for updating the Comprehensive Care Plan. Further interview revealed the care plans should list the problem area, goals to be achieved with a date to achieve the goal and interventions that would be used to address the problem and achieve the goal. Continued interview revealed the facility's process was to update the care plan daily based on new physician orders, and at least quarterly in conjunction with the MDS assessments. She stated for residents with confirmed or suspected scabies and ordered treatment, the care plans should include contact isolation, decontamination of resident rooms and community areas, and monitoring for effectiveness of treatment as interventions. Interview with the Director of Nursing (DON), on 01/30/15 at 5:07 PM, revealed the MDS Coordinator was responsible for updating the care plans. She stated care plan updates were completed daily based on physician orders. Continued interview revealed if a rash were identified, interventions should include monitoring of the rash for effectiveness of treatments ordered. In addition, if a resident were treated for [REDACTED]. She further stated the Care Plan should include the stated problem and treatment goals, as well as interventions to be implemented. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 02/05/15 which alleged removal of the IJ effective 02/05/15. Review of the AOC revealed the facility implemented the following: 1. On 01/26/15, the Medical Director and the Director of Nursing (DON) assessed ten (10) residents identified to have current treatment orders for a change in skin condition. 2. On 01/26/15, body audits were completed on all in-house residents by an RN and a LPN. Based on the skin assessments, the Medical Director gave verbal orders for STAT (immediate) dermatology appointments for three (3) of the residents. Appointments were made for the same day. Two (2) of the three (3) residents (Residents #1 and #10) were confirmed to have scabies. 3. On 01/26/15, the Medical Director was notified of the positive for results and orders were given to treat all thirty-one (31) residents on the B-wing for scabies. The orders included the following for all of the residents: contact precautions; [MEDICATION NAME] cream to be applied beginning 01/27/15 and repeated in seven (7) days; and Stromectal tablets to be administered on day 1, 2, 8, 9, and 15 of the treatment process. The Responsible Party for all residents on the B wing was notified of the treatment orders by the Assistant DON (ADON) or the Activities Director. 4. On 01/26/15, all B wing residents were placed on contact isolation per the facility's guidelines. The DON, Director of Clinical Operations (DCO), Administrator and the Housekeeping/Laundry supervisor placed signs on all resident doors and on entrance doors. Personal Protective Equipment (PPE) was distributed and each department was notified of the precautions in place. 5. On 01/26/15, the DCO educated the DON and the Administrator related to scabies in long term care facilities, including prevention and control. The training included a review of the "Scabies Fact Sheet". The DON and the Administrator were educated by the DCO prior to proceeding to train all facility staff. 6. On 01/26/15, the Administrator and the DON initiated education for all staff related to contact isolation procedures, including the appropriate application and removal of PPE. Staff was required to complete the education prior to returning to work, with validation of effective learning through observation of staff adherence to isolation procedures and proper use of PPE. 7. On 01/26/15, an emergency Quality Assurance (QA) meeting was held and attended by the Administrator, DON, DCO, Housekeeping/Laundry Supervisor, Staff Development Coordinator (SDC) and the Medical director. The purpose of the meeting was to review the actions taken by the facility beginning 01/26/15. 8. On 01/27/15, all B wing residents were treated with [MEDICATION NAME] cream, with application of the treatment by licensed nursing staff. The cream was left on for eight (8) to fourteen (14) hours before residents were bathed and dressed in clean clothes. The baths/showers were provided by the State Registered Nursing Assistants (SRNAs) and the LPN on duty, and the entire process was overseen by two (2) RNs. 9. On 01/27/15, all B wing residents received their first dose of Stromectal dose, as ordered by the Physician, administered by the LPN. 10. On 01/27/15, the Housekeeping/Laundry Supervisor provided training for all laundry and housekeeping staff related to cleaning of contaminated isolation rooms, per facility guidelines. 11. On 01/27/15, all linen items, including personal clothing, bed linens and privacy curtains were removed from each resident room on the B wing by laundry staff. The linens were washed separately from other residents in the facility using hot water and hot dryer cycles. The laundry machines were disinfected with bleach germicidal cleaner. All non-washable personal belongings were placed in sealed bags or wrapped in plastic wrap and quarantined outside the center, where they are to remain for fourteen (14) days per facility guidelines. The entire process was overseen by the Housekeeping/Laundry Supervisor. 12. On 01/27/15, furniture and equipment throughout the facility, including the common areas on both wings and the dining room, was disinfected with the bleach germicidal cleaner by housekeeping staff and monitored by the Housekeeping/Laundry Supervisor. 13. On 01/27/15, the Administrator contacted the local health Department by telephone and via e-mail to report the diagnosed scabies, rashes and treatment. 14. On 01/27/15, the Minimum Data Set (MDS) Coordinator revised the Care Plan for each resident receiving treatment. The revisions included the current problem related to scabies treatment, isolation precautions, treatment of [REDACTED]. 15. On 01/27/15, the option for treatment was provided to each employee of the facility. The DON began distributing [MEDICATION NAME] cream on 01/27/15 along with verbal instructions. The DON is maintaining a log of staff who accepted treatment. On 02/03/15, the DON distributed a questionnaire to staff to determine if the treatment was effective and if staff continued to have symptoms and required additional treatment. 16. On 01/28/15, two (2) residents on the A wing began treatment for [REDACTED]. Treatment included contact isolation, application of [MEDICATION NAME] cream with repeat application in one (1) week, and Stromectal tablets to be administered on day 1, 2, 8, 9 and 15. Resident rooms, clothing, personal items and equipment were cleaned per facility protocol. 17. On 01/28/15, the DON educated all licensed staff on accurately completing a skin assessment. The DON will oversee five (5) skin inspections weekly for six (6) weeks to ensure accuracy of assessment and competency of licensed staff. Any discrepancy will be immediately addressed and the nurse will be re-educated. 18. On 01/30/15, the Administrator and the DON initiated training on the "Scabies Fact Sheet" and the "Guidelines for Scabies" through handouts and discussion. The education for all staff to be completed by 02/04/15. Beginning 02/04/15, written post-tests were initiated for all departments to ensure staff retention of knowledge related to the training. Thirty (30) post-tests will be administered weekly for six (6) weeks and then monthly for six (6) months to ensure continued compliance. Any staff unable to complete the post-test with 100% accuracy will receive immediate re-education by the DON, Administrator or RN supervisor. Also beginning, 02/04/15, the "Scabies Fact Sheet" will be included in new employee orientation and annual infection control in-services. Any staff on leave and any agency staff will receive the education and complete the post-test prior to a return to work. 19. On 01/30/15, the DCO in-serviced the DON on infection control surveillance logs, tracking and trending for scabies or other rashes, and the need for ongoing monitoring. The proper use of the "Scabies/Rash Tracking Log" and the "Skin Inspection Log" was included in the training. 20. On 01/30/15, the DCO educated the MDS Coordinator related to ensuring the Care Plans related to scabies/rashes included the specific problem, goal, and interventions for ongoing monitoring. 21. Evaluation and monitoring of each resident receiving treatment will included skin inspections for resolution of rashes, and observation for new skin eruptions in two (2) to six (6) weeks per Centers for Disease Control (CDC) guidelines. Skin inspections will be completed by licensed staff on all residents in the facility twice weekly beginning 01/31/15 for seven (7) weeks and weekly thereafter. The Physician will be notified of any findings and treatment will be initiated per Physician orders. Residents treated will be monitored for response to treatment and the presence of any treatment side effects. 22. On 01/31/15, a QA meeting was held with the Administrator, DON, Regional Vice President (RVP), DCO and the Medical Director to re-evaluate all measures implemented since 01/26/15, and to outline action items moving forward. 23. As of 01/31/15, daily corporate oversight will occur until removal of abatement of the Immediate Jeopardy, then weekly for at least seven (7) weeks to ensure continued compliance of Administration. 24. On 01/31/15, the facility established a "Scabies Prevention and Control Plan" which included the following: implementation of the "Scabies Guidelines" based on CDC guidelines; promotion of a high index of suspicion for scabies as a possible cause of undiagnosed skin rash; and referral to a Dermatologist after a failed initial course of treatment. 25. On 02/03/15, the Responsible Party for each A wing resident was notified by phone by the ADON or the Activities Director of a scabies outbreak, with messages left for those parties who did not answer. 26. On 02/04/15, the Medical Director gave orders to initiate treatment on all remaining residents on the A wing. Treatment orders were the same as for all other residen

Based on observation, record review, interview and review of the facility's policy/procedure, the facility failed to have an effective system to ensure the necessary care and services related to the assessment, care, monitoring, evaluation and treatment of [REDACTED].#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #16). Interview and record review revealed [MEDICATION NAME] cream, a treatment for [REDACTED].#5, #6, #7 and #9. On 07/27/14, seventeen (17) additional resident (Residents #1, #2, #3, #4, #8, #10, #11, #12 and #14, and Unsampled Residents A, B, C, D, E, F, G and H) were also treated with [MEDICATION NAME] for Scabies. However, there was no documented evidence on 07/27/14, the facility ensured the "Scabies" Policy was followed, to include placing the seventeen (17) residents in contact isolation and performing decontamination of resident areas. In August 2014, Residents #6 and #7 were again treated for [REDACTED]. On 09/10/14, Resident #6 was also treated with [MEDICATION NAME] (an oral medication for treatment of [REDACTED]. Additionally, Resident #9 was treated again while hospitalized between 01/03/15 and 01/06/15 for Scabies, and again at the facility on 01/11/15. Five (5) of the sixteen (16) sampled residents, Resident #1, #2, #6, #7 and #11, developed skin related bacterial infections and required the administration of topical and/or oral antibiotic medication. Topical antibiotic ointment was ordered for Resident #2 on 07/27/14, Resident #11 on 08/01/14 and Resident #1 on 01/26/15. Oral antibiotics were ordered for Resident #6 on 09/10/14 and Resident #7 on 12/01/14. Observation revealed numerous residents scratching areas on their bodies, with some of the residents observed to have dark reddish spots, which appeared to be blood, on their clothing and bedding. Further observation revealed none of these residents were in contact isolation. Review of the facility's Census and Condition form revealed five (5) residents were identified to have rashes on 01/22/15. However, after the facility conducted a skin assessment sweep of residents, a total of fourteen (14) residents were identified to have rashes, with thirteen (13) of the fourteen (14) residents identified residing on the B wing of the facility, and one (1), Resident #13 residing on the A wing. Review of the Comprehensive Care Plans for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #14 revealed no documented evidence their care plans were revised for monitoring the effectiveness of the scabies treatment to ensure eradication of the contagious Scabies infestation. Additionally, during the Partial/Extended Survey, Resident #16, who resided on A wing and was not identified to have a rash during the facility's skin assessment sweep, was observed by the State Survey Agency to have itching and a rash. Per interview, Resident #16 had experienced the rash for approximately two (2) weeks. The facility's failure to have an effective system in place to ensure residents received the necessary care and services regarding Scabies treatment was likely to cause serious injury, harm impairment or death to a resident. Immediate Jeopardy was identified on 01/30/15, and found to exist on 07/27/14. The facility was notified of the Immediate Jeopardy on 01/30/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 02/05/15, with the facility alleging removal of the Immediate Jeopardy on 02/05/15. The State Survey Agency verified removal of the Immediate Jeopardy on 02/05/15 as alleged, prior to exit on 02/06/15, with remaining non-compliance at Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, "Scabies", effective 08/01/12, revealed Scabies was an itching skin irritation caused by the microscopic human itch mite which burrows into the skin's upper layers. The Policy revealed secondary bacterial infections might result from untreated Scabies. Review revealed Scabies was spread through skin-to-skin contact, or through contact with bedding, clothing, privacy curtains and some furniture. Per the Policy, the [DIAGNOSES REDACTED]. However, the Policy noted the failure to identify scrapings for microscopic examination as positive did not necessarily indicate a negative [DIAGNOSES REDACTED]. According to the Policy, often [DIAGNOSES REDACTED]. The Policy stated procedures for individual cases were to: establish contact isolation immediately, including use of a gown with gloves "tightly" covering the cuff of the gown; contact the Physician, and if he/she ordered scrapings to contact the laboratory; however, negative scrapings were not significant and treatment should be done if symptoms were present; and obtain an order for [REDACTED]. Further review revealed it was recommended that residents sharing a room with a suspected Scabies case should be examined carefully, and it was recommended to [MEDICATION NAME] treat the roommate "due to the high level of contagiousness". Review of the facility's, "Care System Guideline, Skin Care", undated, revealed the purpose of the Guideline was to provide a system for evaluation of residents' skin at risk, identify individual interventions to address the risk and process for care of changes/disruption in their skin integrity. Per the Guideline a "weekly review" was to be performed of each resident's skin by the nurse and documented in the electronic medical record (EMR). The Guideline revealed the Director of Nursing (DON) or designee would be responsible for implementing and monitoring the facility's "skin integrity program". Interview with the Administrator, on 01/28/15 at 4:01 PM, revealed the facility had implemented an electronic medical record (EMR) system in August 2014. He stated the facility's process for skin integrity documentation was weekly skin assessments performed by the nurses, and if skin was intact, no further documentation was performed. Per interview, as the facility utilized an EMR, if residents were noted to have skin intact, the only report available from the EMR was the "Skin Inspection Report". The Administrator revealed if a resident's skin was not intact a "Wound Assessment" would be generated in addition to the "Skin Inspection Report". Review of the three (3) Dermatology consults obtained by the facility, on 01/26/15, revealed two (2) of the three (3) residents, Resident #1 and #10, were microscopically confirmed positive for Scabies. Continued review revealed the third resident, Resident #14, was microscopically negative for Scabies; however, per the Dermatologist's report the resident was being treated empirically (based on the Physician's experience and observation rather than on systematic logic) for Scabies because of his/her exposure to Scabies at the facility, as well as his/her clinical presentation being consistent for Scabies. 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/01/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #1's Comprehensive Care Plan revealed the facility had care planned the resident to be at risk for impaired skin integrity with an intervention for weekly skin assessments. Review of Resident #1's Physician Orders, revealed an order for [REDACTED].#1 was placed on contact isolation precautions, as per the facility's policy. Continued review of the physician's orders [REDACTED]. Review of the Physician's and PA's Notes revealed on 08/24/14, the PA noted Resident #1 "still" had pruritis (itching) of the right shoulder area, neck and chest with some maculopapular which she had asked the Physician "to assess". Continued review of the physician's orders [REDACTED]. Review of the 09/18/14, PA's Note revealed Resident #1 had a "rash" and "[MEDICAL CONDITION]". The PA noted Resident #1 "still" had some reddened maculopapular (flat, red area on the skin that is covered with small bumps) [MEDICAL CONDITION] on his/her shoulder and some scattered on his/her chest wall with a one (1) treatment of [REDACTED]. Continued review of the physician's order [REDACTED]. Review of Resident #1's "Skin Inspection Report", revealed on 08/26/14 and 09/23/14, documentation which noted "skin not intact-existing". Review of the 08/26/14 "Wound Assessment Report", also generated through the facility's EMR if skin issues were noted, revealed Resident #1 was noted to have "dried scabs to upper torso and both upper extremities also noted with self-inflicted scratches to left clavicle" with no treatment required. Review of the 09/23/14 "Wound Assessment Report" revealed Resident #1 had "chronic [MEDICAL CONDITION]" to his/her left and right lower extremities with no treatment required noted. Review of the PA's Note dated 09/25/14, revealed the PA noted Resident #1's rash was "no better", and the resident had a Dermatology appointment on 10/06/14, with orders for [MEDICATION NAME] laundry detergent, body wash and lotion. However, record review revealed no documented evidence Resident #1 had a Dermatology consult on 10/06/14 as noted. Review of the 10/07/14 Physician's Note revealed the Physician had seen Resident #1, with no orders noted regarding the rash noted by the PA on 09/25/14. Review of the 10/22/14 PA note, revealed the PA noted Resident #1 had "evidence of Stasis [MEDICAL CONDITION]", with no new orders noted in regards to this. Review of the 11/14/14 Note revealed the PA noted Resident #1 had a "rash, "chronic Stasis [MEDICAL CONDITION]", increased redness, warmth and "scaling", and had a 3 centimeter (cm) superficial excoriation with eschar (a dry, dark scab or falling away of dead skin) on his/her left thigh, with orders for Keflex (an oral antibiotic). Review of the PA's Note dated 12/17/14, revealed Resident #1 for follow up related to the "Stasis [MEDICAL CONDITION]". Review of the 01/05/15 Note revealed the Physician noted Resident #1 had a "rash" to his/her "upper trunk" which was "persistent", with no new orders noted for treatment to the area. However, continued review of Resident #1's "Skin Inspection Report" revealed on 09/09/14, 10/13/14, 10/17/14, 10/24/14, 11/01/14, 11/08/14, 11/14/14, 11/21/14, 11/28/14, 12/06/14, 12/12/14, 12/19/14, 12/27/14, 01/02/15, 01/03/15, 01/09/15, 01/10/15 and 01/16/15, the nurses noted the resident's "skin intact". Even though there was documented evidence, in the Physician's/PA's Notes and Physician Orders, Resident #1 had a rash and was receiving treatment. Further review of Resident #1's "Wound Assessment Report", dated 01/17/15, revealed a "skin tear" was identified behind the resident's right ear with the "cause" documented as "self-inflicted scratching/picking". Review of the "Wound Assessment Report" dated 01/22/15, revealed the nurse documented Resident #1 had a "rash" which covered his/her "entire" left and right arms, and noted it to be a "reddened rash", with some areas "raised and some with scabs", and this was a "chronic condition for resident". Continued review of the 01/22/15 Report revealed Resident #1's "entire" abdomen and "entire" left thigh were also covered with a "reddened rash", with some areas "raised and some with scabs", and this was a "chronic condition for resident". Further review of the Report revealed the nurse noted the "cause" as "unknown" for all the areas. In addition, the nurse documented all the areas were being treated with [MEDICATION NAME] lotion and body wash. Observation of Resident #1, on 01/22/15 at 11:30 AM, revealed the resident was sitting up in a wheel chair in his/her room. Observation revealed Resident #1 was actively scratching his/her arms, and his/her clothing and bed linens were spotted with a reddish brown blood like substance. Interview with Resident #1, on 01/22/14 at 11:30 AM, revealed he/she was "itching all over" especially on his/her back and neck. Resident #1 reported the itching had been going on "a long time" and he/she was "miserable". Continued interview, on 01/29/14 at 1:12 PM, revealed the itching made Resident #1 want to rub his/her skin and it was "aggravating". Observation, on 01/22/15 at 3:13 PM, of a skin assessment completed by Registered Nurse (RN) #1 for Resident #1 revealed the resident had a rash with scabbing to both arms, both upper legs, shoulders and front and back of his/her torso. Further observation revealed RN #1 did not remove Resident #1's Unna Boots (a compression gauze dressing filled with zinc paste used to treat venous issues) on his/her lower legs as they were not due to be changed. Interview with RN #1, on 01/22/15 at 3:13 PM, at the time of the skin assessment, revealed Resident #1 had a history of [REDACTED].#1 revealed Resident #1 had reported a rash and itching for at least a month or longer. Additional interview, on 01/26/15 at 9:15 AM, with RN #1 revealed she did not know what the itching or rash was, and reported staff was not utilizing any type of contact isolation precautions in regards to the rash. Review of a Dermatology Consult dated 01/26/15, revealed Resident #1 was diagnosed with [REDACTED]. Further review of the physician's orders [REDACTED]. On 01/27/15, [MEDICATION NAME] tablets (oral Scabies Treatment medication) were ordered; and, on 01/29/15 [MEDICATION NAME] was ordered for itching. Interview with the Director of Nursing (DON), on 01/26/15 at 1:00 PM, revealed a physician's orders [REDACTED]. The DON revealed Resident #1's primary nurse called the Dermatology office indicated on the order, and was advised this Dermatologist did not accept Resident #1's insurance, which was Medicaid. Continued interview revealed the Physician was aware of this information. According to the DON, she was not aware if more than one (1) Dermatologist was contacted by the nurse. She stated Resident #1's family was contacted; however, the family declined to pay for the Dermatology consult. Per interview, therefore, Resident #1 did not receive the Dermatology consult to properly diagnose and treat the on-going rash and itching. 2. Record review revealed Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/13/14, revealed the facility assessed Resident #10 to have a BIMS score of three (3) of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #10's Comprehensive Care Plan revealed the facility had care planned the resident to be at risk for impaired skin integrity with an intervention for weekly skin assessments. Review of Resident #10's Physician order [REDACTED].#10 was placed on contact isolation precautions, as per the facility's policy. Continued review of the physician's orders [REDACTED].#10's extremities and trunk two (2) times a week on shower days. Review of the EMR "Skin Inspection Report" revealed on: 08/26/14, 09/02/14, 09/09/14, 09/15/14, 09/22/14, 09/29/14, 10/06/14, 10/13/14, 10/20/14, 10/27/14, 10/31/14, 11/03/14, 11/10/14 and 11/18/14 the nurses documented Resident #10's "skin intact". Continued review of the "Skin Inspection Report" revealed on 11/24/14, 12/01/14, 12/08/14, 12/13/14, 12/15/14, 12/22/14, 12/29/14, 01/05/14 and 01/12/15 the nurses documented Resident #10's skin as "skin not intact-existing". Review of the "Wound Assessment Report" dated 11/25/14, 12/01/14, 10/08/14, 12/15/14, 12/22/14, 12/29/14, 01/05/15, 01/06/15, 01/12/15, 01/19/15 revealed the nurses documented Resident #10 had an area of irritation/excoriation on his/her left center of the coccyx. Review of the "Wound Assessment Report" dated 01/23/15, revealed the nurse documented Resident #10 had a "rash" on his/her "entire chest" area, with the "cause" noted as "yeast/fungus", which measured 20 cm by 20 cm, and on the "right lower quadrant" which measured 15 cm by 15 cm. Further review of the 01/23/15 "Wound Assessment Report" and the physician's orders [REDACTED].#10's chest and abdomen. Review of the "Nursing" Notes revealed a Dermatology Consult was obtained on 01/26/15, with a positive microscopic confirmation of Scabies. Review of the Physician's Note and Orders dated 01/26/15, revealed orders for [MEDICATION NAME] Cream and [MEDICATION NAME] tablets and Contact Isolation Precautions. Observation, on 01/28/15 at 5:03 PM, of a skin assessment, performed by RN #1, revealed a red raised rash area to Resident #10's back, abdomen, both upper thighs, right lower leg, and left arm. Although, the "Wound Assessment Report" dated 01/23/15, revealed Resident #10 only had a "rash" on his/her "entire chest" area on that date. Interview with RN #1, on 01/26/15 at 9:15 AM, revealed she did not know what the cause of the itching or rash was and reported staff was not utilizing any type of contact isolation precautions. 3. Record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 01/19/15, revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #3's Comprehensive Care Plan revealed the facility had care planned the resident on 06/24/13, to be at risk for impaired skin integrity related to recurrent bilateral [MEDICAL CONDITION]. Review of Resident #3's Physician order [REDACTED]. However, further review of the 07/27/14 order revealed no documented evidence Resident #3 was placed on contact isolation precautions, as per the facility's policy. Review of Resident #3's EMR "Skin Inspection Report", revealed on 08/07/14 documentation of "skin not intact-new". However, review of Resident #3's "Weekly Skin Assessment" forms, which were in place prior to the facility going to an EMR, revealed no documented evidence of a skin assessment performed on 08/07/14. Review of the physician's orders [REDACTED]. Review of Resident #3's Comprehensive Care Plan for risk of impaired skin integrity, revealed documentation dated 08/07/14, stating to schedule a Dermatology follow-up; however, it was noted the resident was not an established patient, and the Dermatologist was not accepting new patients. Continued record review revealed no documented evidence the facility attempted to contact other Dermatologists who might be accepting new patients to ensure treatment was obtained for Resident #3 as per the physician's orders [REDACTED]. Review of the "Weekly Skin Assessment" form dated 08/11/14 revealed Resident #3 had a "blister to knee" with a new order written; however, there was no documented evidence of a rash on the resident's body. Review of the Physician's Assistant's (PA's) Notes for Resident #3 revealed on 08/12/14, the PA asked the Physician "to see" Resident #3, related to the rash on his/her chest which did not look improved, and he/she was status [REDACTED]. However, there was no documented evidence the Physician examined Resident #3 until 10/08/14. Review of the "Weekly Skin Assessment" form dated 08/13/14, revealed the resident had a skin tear to his/her right arm with treatment "in progress" and no "other skin issues noted", even though the PA noted Resident #3 to have a "rash" on his/her chest on 08/12/14 which she had asked the Physician "to see". Continued review of the physician's orders [REDACTED]. axilla and bilateral upper extremities. Review of the EMR "Skin Inspection Report" revealed on 09/09/14 and 09/22/14, the nurses noted Resident #3's "skin intact". However, review of the Orthopedic Consultant Physician's Note dated 09/25/14, revealed Resident #3 was noted to have complaints of pain in the left rib area/mid-axillary line, with "itching at site". Additionally, review of the 09/29/14 "Skin Inspection Report" revealed Resident #3's "skin not intact-existing". A "Wound Assessment Report" was requested by the State Survey Agency for 09/29/14, to determine why Resident 3's skin was noted not to be intact, but no documented evidence was provided, even though per interview with the Administrator this was the facility's process since implementation of the EMR. Continued review of the "Skin Inspection Report" revealed on 10/06/14, Resident #3's skin was noted to be intact. However, review of the Physician's Note dated 10/08/14, revealed Resident #3 had a "rash". Review of the PA's Note dated 10/09/14, revealed the PA had examined Resident #3 related to "bilateral [MEDICAL CONDITION] of lower extremities", with no documentation related to the "rash". Review of the physician's orders [REDACTED]. Review of the "Skin Inspection Report" dated 10/13/14, revealed the nurse noted "skin not intact-new". Review of the "Wound Assessment Report" dated 10/13/14, generated as a result of Resident #3's skin not being intact, revealed the resident had a "rash" on his/her "entire back" with the "cause" noted to be "allergic reaction/adverse drug reaction". Continued review of the 10/13/14 "Wound Assessment Report" and physician's orders [REDACTED]. Review of the "Skin Inspection Report" dated 10/20/14, revealed Resident #3's skin was noted to be intact. However, review of the "Wound Assessment Report" dated 10/20/14, revealed Resident #3 had a "rash" on his/her "entire back", with the "cause" noted to be "accident/other trauma", and the nurse documented the "rash" had improved, continue to use "[MEDICATION NAME] wash and lotion". Additionally, review of the physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the "Skin Inspection Report" dated 10/27/14, revealed the nurse documented Resident #3's "skin not intact-existing". Review of the "Wound Assessment Report" dated 10/27/14, revealed Resident #3 had a "rash" to his/her "entire chest" which had "improved" with the "cause" noted to be "unknown". Continued review of the "Wound Assessment Report" dated 10/27/14, revealed [MEDICATION NAME] lotion to body twice daily on bath days had been ordered on [DATE]. Continued review of the "Skin Inspection Report" revealed on 11/03/14, Resident #3's skin was noted to be intact. However, review of the "Wound Assessment Report" dated 11/03/14, revealed Resident #3 had a "rash" on his/her "entire back", with the "cause" noted to be "moisture", and the nurse documented "pending treatment orders". However, there was no documented evidence of further treatment orders for the "rash" until 11/07/14, four (4) days later. Review of the PA's Note dated 11/07/14, revealed Resident #3 still had a maculopapular "rash" on his/her chest wall, with [MEDICATION NAME] cream ordered. Review of the physician's orders [REDACTED]. Review of the "Wound Assessment Report" for the date of 11/10/14, revealed Resident #3 had a "rash" on his/her "entire chest", with the "cause" noted to be "bacterial/[MEDICAL CONDITION] infection", and the nurse noted orders had been received on 11/07/14, for [MEDICATION NAME] cream to be mixed with [MEDICATION NAME] lotion and applied to the rash area twice a day for ten (10) days. However, there was no documented evidence of additional orders to treat the "rash" even though the nurse documented the PA was notified on the "Wound Assessment Report". Review of the "Skin Inspection Report" revealed on 11/17/14, Resident #3's skin was noted to be intact. However, review of the "Wound Assessment Report" dated 11/17/14, revealed Resident #3 had a "rash" on his/her "entire back", with the "cause" noted to be "yeast/fungus", and the nurse documented [MEDICATION NAME] cream mixed with [MEDICATION NAME] lotion to be applied to the rash twice a day for ten (10) days was ordered on [DATE], [MEDICATION NAME] lotion and body wash had been ordered on [DATE] twice a day on bath days. However, there was no documented evidence of further orders received to treat the "rash", even though the nurse documented the Physician was notified. Further review of the "Skin Assessment Report" for the dates of 11/24/14 through 01/19/15 revealed the nurses documented Resident #3's "skin not intact-existing". Review of the "Wound Assessment Report" for the date of 11/24/14, revealed Resident #3 had a "rash" to his/her "entire chest", with the "cause" noted to be "yeast/fungus", and [MEDICATION NAME] lotion and body wash had been ordered on [DATE] twice a day on bath days. However, there was no documented evidence of additional orders for treatment of [REDACTED]. Review of the "Wound Assessment Report" for the dates of 12/01/14 through 01/19/15, revealed Resident #3 had a "rash" on his/her "entire back" and "entire chest", with the "cause" noted to be "yeast/fungus", with no documented evidence of a change in treatment for [REDACTED]. Review of the PA's Note dated 12/17/14, revealed Resident #3 continued to have an anterior chest wall "rash", and reported his/her clothes made him/her "itch". Continued review of the PA's 12/17/14 Note and physician's orders [REDACTED]. Review of the PA's Note dated 01/15/15, revealed Resident #3 continued to have the chest rash, and the Physician had "recently seen" the resident and diagnosed him/her with Xerosis (abnormally dry skin), with no new orders received for treatment to the rash area. Review of the Physician's Note dated 01/16/15, revealed Resident #3 had a "rash". Continued review of the EMR "Wound Healing Progress Report" revealed documentation of measurements of the "rash" on Resident #3's chest and back for the dates of 10/13/14, 10/20/14, 10/27/14, 11/03/14, 11/10/14, 11/17/14, 11/24/14, 12/01/14, 12/12/14, 12/15/14, 12/22/14, 12/29/14, 01/05/15, 01/12/15 and 01/19/15. Further review of the "Wound Healing Progress Report" revealed the rash on Resident #3's chest measured 20 centimeters (cm) by (x) 20 cm on all those dates; and the rash on the resident's back measured 20 cm x 20 cm on all dates, except 01/12/15 and 01/19/15, when it was noted to measure 15 cm x 15 cm. Further review of the Physician's Notes and physician's orders [REDACTED].#3 had a "rash" to his/her chest, and ordered Contact Isolation Precautions and [MEDICATION NAME] cream and [MEDICATION NAME] tablets "per orders for Scabies [MEDICATION NAME]" (course of action used to prevent disease). Observation and interview, on 01/22/14 at 1:14 PM, revealed Resident #3 was sitting up on the edge of his/her bed actively scratching his/her left shoulder and arm. Resident #3 stated he/she was "itching all over" and was "very embarrassed" even in his/her own room because if the privacy curtain was not pulled, "you can see me scratching everything". Continued observation revealed the resident to have reddish brown blood like spotting on his/her clothing and bed linens. Observation, on 01/22/15 at 3:45 PM, of Resident #3's skin assessment performed by Registered Nurse (RN) #1, revealed a rash covering the front and back of the resident's torso and both arms. Interview with RN #1, on 01/26/15 at 9:15 AM, revealed she did not know what the cause of Resident #3's itching or rash was. RN #1 stated staff was not utilizing any type of contact isolation precautions. 4. Record review revealed Resident #14 was admitted to the facility, on 06/05/14, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/22/14, revealed the facility assessed Resident #14 to have a BIMS score of six (6) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #14's Comprehensive Care Plan revealed the facility had care planned the resident to be at risk for impaired skin integrity with an intervention for weekly skin assessments. Review of Resident #14's Physician order [REDACTED]. However, further review of the 07/27/14 order revealed no documented evidence Resident #14 was plac

Based on observation, interview, record review and review of the facility's policies, and the Center for Disease Control (CDC) and Prevention guidelines it was determined the facility failed to maintain an effective Infection Control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility failed to implement their Infection Control Policy including the Contact Isolation Policy to prevent, detect, investigate and control infections and to properly store, handle, process and transport linens to minimize contamination for the facility's residents to ensure decontamination of the facility and the eradication of scabies. Additionally, the facility failed to implement and adhere to the facility's "Scabies" policy regarding treatment and precautionary measures to be taken to ensure eradication of Scabies which resulted in cross contamination to uninfested residents, continued rashes, itching and discomfort for the facility's residents. The facility's failure affected fifteen (15) of sixteen (16) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #16) and nine (9) of nine (9) unsampled residents (Unsampled Residents A, B, C, D, E, F, G, H and I). From 07/21/14 through 07/23/14, four (4) residents were treated with [MEDICATION NAME] Cream (a cream prescribed for the treatment of [REDACTED]. However, the facility failed to initiate contact isolation for the seventeen (17) residents, failed to adequately decontaminate residents' rooms and common areas, and failed to ensure ongoing monitoring of residents to ensure the treatment was effective. There was no documented evidence the facility tracked and trended the residents with rashes, nor maintained a record of incidents and corrective actions to ensure there were no reinfestations. The facility failed to re-educate staff on the facility's Scabies Policy to ensure decontamination of residents' personal belongings, rooms, and common areas. As a result, the facility re-treated two (2) residents with the [MEDICATION NAME] cream in August 2014, three (3) residents in September 2014 and one (1) resident, for a third time, again in January 2015. Interviews and record reviews revealed multiple residents had unresolved rashes throughout the entire time. There was no evidence the facility performed surveillance and investigation to control the outbreak and cross-contamination using transmission-based precautions. (Refer to F-309) The facility's failure to have an established Infection Control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection to ensure decontamination of the facility and the eradication of scabies has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/30/15 and was determined to exist on 07/27/14. The facility was notified of the Immediate Jeopardy on 01/30/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 02/05/15, with the facility alleging removal of the Immediate Jeopardy on 02/05/15. The State Survey Agency verified removal of the Immediate Jeopardy on 02/05/15 as alleged, prior to exit on 02/06/15, with remaining non-compliance at Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program monitors to ensure compliance with systemic changes. Additionally, observation of the laundry area, on 02/05/15 during the validation of abatement of the Immediate Jeopardy revealed a bio-hazardous bag of contaminated linen sitting on the floor and directly touching clean and decontaminated residents' clothing and a bio-hazardous bag of trash, with a contact isolation gown partially out of the bag, on the floor next to and touching a cart containing clean and decontaminated items. Non-compliance continued to exist at a Scope and Severity of an "E", while the facility develops and implements a plan of correction and the facility's Quality Assurance monitors to ensure ongoing compliance. The findings include: 1. Review of the facility's policy, titled "Policies and Practices - Infection Control" revised August 2007, revealed the facility's infection control policies and practices were to prevent, detect, investigate, control infections, establish guidelines for implementing Isolation Precautions, provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment and to maintain records of incidents and corrective actions related to infections. Continued review revealed all staff would be trained on the infection control policies and practices upon hire and periodically thereafter with the depth of training appropriate to the degree of direct resident contact and job responsibilities. Further review revealed inquires concerning the facilities infection control policies and practices should be referred to the Infection Control Coordinator or the Director of Nursing Services. Review of the facility's policy, titled "Isolation - Categories of Transmission - Based Precautions", revised August 2012, revealed Standard Precautions would be utilized to provide care for residents at all times regardless of their suspected or confirmed infection status. Further review revealed Transmission Based Precautions would be used whenever measures more stringent than Standard Precautions were needed to prevent or control the spread of infection. Per the policy, three (3) types of Transmission Based Precautions had been established based on the Center for Disease Control and Prevention (CDC) which included Contact Precautions. Further review revealed Contact Precautions should be implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Per CDC guidelines, Contact Precautions should be used for Scabies. Staff should utilize gloves and contact isolation gowns for resident care. Further review revealed if use of common resident care equipment was unavoidable, staff should adequately clean and disinfect the equipment between resident use. Review of the CDC guidelines, updated 11/02/10, related to a Scabies diagnosis, revealed scabies outbreaks in long-term care facilities were frequently the result of a delayed [DIAGNOSES REDACTED]. Further review revealed appropriate isolation and infection control practices should be used when providing hands-on care to residents who might have scabies. All persons (staff, relatives, residents, etc) having prolonged direct skin-to-skin contact with an infested person before he/she was treated should be identified and treated, and treatment should be offered to household members of staff who were receiving treatment. Continued review revealed epidemiologic and clinical information about confirmed and suspected scabies residents should be collected and used for systematic review in order to facilitate early identification of and response to potential outbreaks. Per the CDC guidelines, long-term surveillance for scabies was imperative to eradicate scabies from an institution. Review of the facility's policy, titled "Scabies" effective 08/01/12, revealed after a [DIAGNOSES REDACTED]. Continued review revealed the procedures included to establish contact isolation immediately, contact the physician, and obtain an order for [REDACTED]. Further review revealed one gown and one set of street clothes should be washed for each resident with the remainder of resident clothing in the clean storage area and not returned to the resident's room until the twenty-four (24) hour decontamination process had been completed. Per the facility's policy, two full sets of bed linens should be washed and set aside on a clean cart with a disinfected cover and kept in a separate area. Continued review revealed common areas should be cleaned before resident bathing/decontamination so the "treated" resident did not use the contaminated areas to prevent cross contamination. Interview with the Director of Nursing (DON), on 01/29/15 at 10:06 AM, revealed the facility utilized the Standards of Best Practice and the Center for Disease Control and Prevention (CDC) guidelines. Review of the clinical records revealed medical treatment for [REDACTED].#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14 and Unsampled Residents A, B, C, D, E, F, G and H in July, 2014. Record review revealed Resident #2 required a topical antibiotic ointment for his/her rash on 07/27/14 and Resident #11 on 08/01/14. Continued review revealed Residents #6 and #7 were treated for [REDACTED].#6 required treatment with an oral antibiotic on 09/10/14 and Resident #7 required oral antibiotic treatment on 12/01/14 from complications related to the rashes. Further review revealed Unsampled Resident B, C and I were treated for [REDACTED]. Further review revealed Resident #9 was treated again during the hospitalization between 01/03/15 and 01/06/15, and again on 01/11/15 at the facility. Continued review revealed there was no documented evidence the residents were placed in contact isolation precautions, per the facility's policies and there was no documented evidence the residents were monitored for the effectiveness of the Scabies treatments to ensure eradication of the infestation per the facility's Infection Control Policy and CDC guidelines. Interview and record review revealed no documented evidence the facility decontaminated common areas, educated staff, provided treatment to staff, or implemented an infection control surveillance program for monitoring, tracking and trending and identification of suspicious rashes per the facility's policy and procedures. Review of the facility's Census and Condition, obtained upon entrance to the facility on [DATE], revealed the facility had assessed and identified five (5) residents to have a rash. However, observation, on 01/22/15, revealed multiple residents (including Residents #1, #2, #3, #10 and #12) aggressively scratching their bodies, with several residents observed to have dark reddish blood-like spots on their clothing and bed linens. Continued observation revealed no residents were in contact isolation. Interview with the DON, who was the Interim Infection Control Nurse, on 01/23/15 at 11:25 AM, revealed residents in the facility did have rashes; however, the Physician and PA were providing treatment. She stated she documented on the Census and Condition there were five (5) residents with rashes. Review of the revised Census and Condition, completed, on 01/26/15, after a resident skin assessment sweep for signs and symptoms of rashes after State Surveyor intervention, revealed the facility had assessed an additional nine (9) residents to also have rashes. Further interview with the DON revealed after walking the B Wing hall, with the Physician, on 01/26/15, she had identified eight (8) residents to have rashes. Per interview, the facility completed a sweep of all facility residents, assessing the residents for signs and symptoms of scabies such as a rash, and had identified fourteen (14) residents. Continued interview revealed upon the State Survey Agency entrance to the facility, she did not know the exact number of residents with a rash due to the facility's infection control program did not monitor for rashes or itching without a rash. Further observation during skin assessments for fifteen (15) of the sixteen (16) sampled residents on 01/22/15 through 02/04/15 revealed all residents had rashes and/or scabbing of varying degrees on their bodies. Interview with State Registered Nursing Assistant (SRNA) #13, on 01/26/15 at 7:30 AM, revealed residents had been itching, scratching and digging at their skin for at least one month; however, the rash had been in the facility for at least six (6) months to one (1) year. She stated it was indirectly communicated to her to keep quiet and just do the job and not discuss the rashes. Further interview revealed contact isolation precautions were not consistently implemented or adhered to, per the facility's policy. Per interview, the facility had provided treatment for [REDACTED].#13, sought treatment for [REDACTED]. Further interview revealed she was very hesitant to talk with the State Surveyors for fear of losing her job because it was rumored threats had been made to terminate the employee that reported the issue. Interview with SRNA #5, on 01/26/15 at 12:10 PM, revealed residents in the facility have had rashes on and off for approximately two (2) years and approximately one (1) year ago, she was aware of several residents treated for [REDACTED]. However, the facility never inquired to ensure the rash was resolved. Further interview revealed she did not remember contact isolation precaution being utilized consistently in the past when a resident received treatment for [REDACTED]. Interview with SRNA #6, on 01/26/15 at 1:14 PM, revealed the residents had been complaining of a rash and/or itching for at least one (1) year. Continued interview revealed he had suffered from the same type of rash and itching as the residents; however, could not afford to seek medical treatment and reported the facility denied the residents had scabies and did not provide him treatment. Interview with the Wound Care Nurse (WC), on 01/26/15 at 12:00 PM, revealed several of the residents were receiving treatment for [REDACTED]. Continued interview, on 02/05/15 at 3:20 PM, revealed when residents had been treated for [REDACTED]. Further interview revealed the furniture was not cleaned or removed from the rooms and some of the residents that received treatment were placed in contact isolation precautions; however, it was not strict and the whole wing was not in isolation and not decontaminated. Interview with Registered Nurse (RN) #1, on 01/26/15 at 9:15 AM, revealed several of the residents currently had rashes and had previously been treated for [REDACTED]. Interview with the DON, who was the Interim Infection Control Nurse, on 01/29/15 at 10:06 AM, revealed the facility employed an Infection Control Nurse in July of 2014 when the Physician's Assistant ordered Scabies treatment for [REDACTED]. Further interview revealed the facility's complete infection control program, policies, procedures and guidelines were not followed with each incident. Per interview, had the facility monitored for rashes or tracked and trended the residents' rashes and itching, the facility may have identified this to be an ongoing and unresolved issue. Continued interview revealed Contact Isolation was implemented with each incident; however, interview and record review revealed no evidence contact isolation was implemented, per the facility policy. Further interview revealed the facility's common areas were not decontaminated, all staff was not educated, staff was not offered and/or provided treatment, residents' roommates were not treated with each incident, and monitoring for effectiveness of the treatment with surveillance of suspicious rashes was not performed. Interview with the Medical Director, on 01/26/15 at 10:19 AM, revealed he was aware several residents had rashes; however, he was not aware of how many. He stated he was not aware that on 01/26/15, there was a total of thirteen (13) residents on the B Wing that had current rashes, but that he would check with nursing. He continued by stating he was not following all the residents with rashes and he would not have expected to be notified of each and every rash as he had a Physician's Assistant that the facility would notify about residents' rashes. Further interview revealed with the number of rashes, an investigation should have been implemented to determine if the etiology (cause) was of a contagious nature for infection control purposes. Interview with the Administrator, on 01/29/15 at 2:07 PM, revealed he was aware some residents had rashes; however, was not aware there were that many. Further interview revealed he did review the CDC guidelines for scabies in August 2014 after two (2) residents were treated for [REDACTED]. He stated he was not aware the CDC guidelines recommended decontaminating residents' belongings and rooms as well as treating the common areas. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 02/05/15 which alleged removal of the IJ effective 02/05/15. Review of the AOC revealed the facility implemented the following: 1. On 01/26/15, the Medical Director and the Director of Nursing (DON) assessed ten (10) residents identified to have current treatment orders for a change in skin condition. 2. On 01/26/15, body audits were completed on all in-house residents by an RN and a LPN. Based on the skin assessments, the Medical Director gave verbal orders for STAT (immediate) dermatology appointments for three (3) of the residents. Appointments were made for the same day. Two (2) of the three (3) residents (Residents #1 and #10) were confirmed to have scabies. 3. On 01/26/15, the Medical Director was notified of the positive for results and orders were given to treat all thirty-one (31) residents on the B-wing for scabies. The orders included the following for all of the residents: contact precautions; [MEDICATION NAME] cream to be applied beginning 01/27/15 and repeated in seven (7) days; and [MEDICATION NAME] tablets to be administered on day 1, 2, 8, 9, and 15 of the treatment process. The Responsible Party for all residents on the B wing was notified of the treatment orders by the Assistant DON (ADON) or the Activities Director. 4. On 01/26/15, all B wing residents were placed on contact isolation per the facility's guidelines. The DON, Director of Clinical Operations (DCO), Administrator and the Housekeeping/Laundry supervisor placed signs on all resident doors and on entrance doors. Personal Protective Equipment (PPE) was distributed and each department was notified of the precautions in place. 5. On 01/26/15, the DCO educated the DON and the Administrator related to scabies in long term care facilities, including prevention and control. The training included a review of the "Scabies Fact Sheet". The DON and the Administrator were educated by the DCO prior to proceeding to train all facility staff. 6. On 01/26/15, the Administrator and the DON initiated education for all staff related to contact isolation procedures, including the appropriate application and removal of PPE. Staff was required to complete the education prior to returning to work, with validation of effective learning through observation of staff adherence to isolation procedures and proper use of PPE. 7. On 01/26/15, an emergency Quality Assurance (QA) meeting was held and attended by the Administrator, DON, DCO, Housekeeping/Laundry Supervisor, Staff Development Coordinator (SDC) and the Medical director. The purpose of the meeting was to review the actions taken by the facility beginning 01/26/15. 8. On 01/27/15, all B wing residents were treated with [MEDICATION NAME] cream, with application of the treatment by licensed nursing staff. The cream was left on for eight (8) to fourteen (14) hours before residents were bathed and dressed in clean clothes. The baths/showers were provided by the State Registered Nursing Assistants (SRNAs) and the LPN on duty, and the entire process was overseen by two (2) RNs. 9. On 01/27/15, all B wing residents received their first dose of [MEDICATION NAME] dose, as ordered by the Physician, administered by the LPN. 10. On 01/27/15, the Housekeeping/Laundry Supervisor provided training for all laundry and housekeeping staff related to cleaning of contaminated isolation rooms, per facility guidelines. 11. On 01/27/15, all linen items, including personal clothing, bed linens and privacy curtains were removed from each resident room on the B wing by laundry staff. The linens were washed separately from other residents in the facility using hot water and hot dryer cycles. The laundry machines were disinfected with bleach germicidal cleaner. All non-washable personal belongings were placed in sealed bags or wrapped in plastic wrap and quarantined outside the center, where they are to remain for fourteen (14) days per facility guidelines. The entire process was overseen by the Housekeeping/Laundry Supervisor. 12. On 01/27/15, furniture and equipment throughout the facility, including the common areas on both wings and the dining room, was disinfected with the bleach germicidal cleaner by housekeeping staff and monitored by the Housekeeping/Laundry Supervisor. 13. On 01/27/15, the Administrator contacted the local health Department by telephone and via e-mail to report the diagnosed scabies, rashes and treatment. 14. On 01/27/15, the Minimum Data Set (MDS) Coordinator revised the Care Plan for each resident receiving treatment. The revisions included the current problem related to scabies treatment, isolation precautions, treatment of [REDACTED]. 15. On 01/27/15, the option for treatment was provided to each employee of the facility. The DON began distributing [MEDICATION NAME] cream on 01/27/15 along with verbal instructions. The DON is maintaining a log of staff who accepted treatment. On 02/03/15, the DON distributed a questionnaire to staff to determine if the treatment was effective and if staff continued to have symptoms and required additional treatment. 16. On 01/28/15, two (2) residents on the A wing began treatment for [REDACTED]. Treatment included contact isolation, application of [MEDICATION NAME] cream with repeat application in one (1) week, and [MEDICATION NAME] tablets to be administered on day 1, 2, 8, 9 and 15. Resident rooms, clothing, personal items and equipment were cleaned per facility protocol. 17. On 01/28/15, the DON educated all licensed staff on accurately completing a skin assessment. The DON will oversee five (5) skin inspections weekly for six (6) weeks to ensure accuracy of assessment and competency of licensed staff. Any discrepancy will be immediately addressed and the nurse will be re-educated. 18. On 01/30/15, the Administrator and the DON initiated training on the "Scabies Fact Sheet" and the "Guidelines for Scabies" through handouts and discussion. The education for all staff to be completed by 02/04/15. Beginning 02/04/15, written post-tests were initiated for all departments to ensure staff retention of knowledge related to the training. Thirty (30) post-tests will be administered weekly for six (6) weeks and then monthly for six (6) months to ensure continued compliance. Any staff unable to complete the post-test with 100% accuracy will receive immediate re-education by the DON, Administrator or RN supervisor. Also beginning, 02/04/15, the "Scabies Fact Sheet" will be included in new employee orientation and annual infection control in-services. Any staff on leave and any agency staff will receive the education and complete the post-test prior to a return to work. 19. On 01/30/15, the DCO in-serviced the DON on infection control surveillance logs, tracking and trending for scabies or other rashes, and the need for ongoing monitoring. The proper use of the "Scabies/Rash Tracking Log" and the "Skin Inspection Log" was included in the training. 20. On 01/30/15, the DCO educated the MDS Coordinator related to ensuring the Care Plans related to scabies/rashes included the specific problem, goal, and interventions for ongoing monitoring. 21. Evaluation and monitoring of each resident receiving treatment will included skin inspections for resolution of rashes, and observation for new skin eruptions in two (2) to six (6) weeks per Centers for Disease Control (CDC) guidelines. Skin inspections will be completed by licensed staff on all residents in the facility twice weekly beginning 01/31/15 for seven (7) weeks and weekly thereafter. The Physician will be notified of any findings and treatment will be initiated per Physician orders. Residents treated will be monitored for response to treatment and the presence of any treatment side effects. 22. On 01/31/15, a QA meeting was held with the Administrator, DON, Regional Vice President (RVP), DCO and the Medical Director to re-evaluate all measures implemented since 01/26/15, and to outline action items moving forward. 23. As of 01/31/15, daily corporate oversight will occur until removal of abatement of the Immediate Jeopardy, then weekly for at least seven (7) weeks to ensure continued compliance of Administration. 24. On 01/31/15, the facility established a "Scabies Prevention and Control Plan" which included the following: implementation of the "Scabies Guidelines" based on CDC guidelines; promotion of a high index of suspicion for scabies as a possible cause of undiagnosed skin rash; and referral to a Dermatologist after a failed initial course of treatment. 25. On 02/03/15, the Responsible Party for each A wing resident was notified by phone by the ADON or the Activities Director of a scabies outbreak, with messages left for those parties who did not answer. 26. On 02/04/15, the Medical Director gave orders to initiate treatment on all remaining residents on the A wing. Treatment orders were the same as for all other residents in the building, and included disinfection of resident rooms, clothing, personal items and equipment. In addition, common areas were cleaned according to facility guidelines. 27. Residents #1 and #10, with confirmed scabies diagnoses, will have a follow-up appointment with the Dermatologist on 02/06/15. The DON or the RN will accompany the residents to the physician's office. 28. The facility's QA process will monitor implemented interventions as follows: The Administrator, DON or RN Supervisor will review the "Scabies/Rash Tracking Log" daily for six (6) weeks, then weekly for four (4) weeks, then monthly in the Quality Assurance/Process Improvement (QAPI) meeting. The Administrator, DON or RN Supervisor will review the "Skin Inspection Log" daily for six (6) weeks, then weekly for four (4) weeks, then monthly in the QAPI meeting. The Administrator, DON or RN Supervisor will review the Care Plans of residents being treated for [REDACTED]. The Administrator and/or the DON will ensure all staff has successfully completed the training and post-test related to the facility's "Scabies Prevention and Control Plan". The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the Physician Extended Care Notes, dated 01/26/15 and signed by the Medical Director, revealed the ten (10) residents with treatment orders for a change in skin condition on that date were seen by the Physician for a complete physical examination and evaluation of their skin concerns. Continued review revealed each examination was comprehensive and included documentation by the Physician of each resident's skin and recommended treatment. 2. Review of the "Body Audit" forms, dated 01/26/15 and signed by the RN or the LPN, revealed sixty-five (65) residents in the facility received a head-to-toe skin assessment on that date. Continued review revealed each resident was assessed for eleven (11) specific skin conditions as follows: redness/discoloration/bruises; open areas; edema; rash; dry/flakey; excoriation; ecchymosis; skin tears; abrasions; surgical wounds or incisions; and psoriasis. Findings were documented by type and location. Review of the Dermatologist's "Visit Notes", dated 01/26/15, revealed three (3) residents were seen in the office on that day. Continued review revealed two (2) of the three (3) residents (Residents #1 and #10), based on microscopic examination, were found to be positive for scabies and treatment orders were given. Additionally, the resident who did not have a confirmed [DIAGNOSES REDACTED]. 3. Review of the Physician Orders, dated 01/26/15, revealed the Medical Director gave orders for scabies treatment to be initiated on 01/27/15 for all residents on the B wing. Continued review revealed the orders were consistent with those given by the Dermatologist for the confirmed cases, with treatment to be administered as follows: apply [MEDICATION NAME] ([MEDICATION NAME]) 5% cream to body from neck down, leave on 8-14 hours then wash off; repeat in one (1) week; after cream applied, administer [MEDICATION NAME], 3 milligram (mg) tablets on day 1,2,8,9, and 15. In addition, Physician order [REDACTED]. Review of Departmental Notes, dated 01/27/15, revealed the Responsible Party for each resident on the B wing was notified of the new orders by the Activities Director or the ADON. Interview with the ADON, on 02/04/15 at 2:02 PM, revealed she had made calls to the families of the B wing residents, informing them of new treatment orders and contact isolation procedures. She stated some families had questions and she answered as they arose. Interview with the POA for Unsampled Resident J, on 02/04/15 at 6:58 PM, revealed she was notified by the facility of treatment orders and isolation procedures for all residents on the B wing, including Resident J. 4. Observation upon entering the facility, on 01/28/15 at 4:01 PM, revealed signs directing visitors to see the nurse prior to visiting with residents were posted on the front entrance doors and on the door of each resident room on the B wing. In addition, the signs on resident room doors indicated Contact Isolation was in effect. Continued observation revealed PPE, including gowns, masks, gloves and shoe covers, was stocked in bins in the hall outside resident rooms on the B wing. During survey activities throughout the day on 01/26/15, staff from all departments was observed to utilize the PPE prior to entering resident rooms. Also, staff was observed to dispose of PPE appropriately, in biohazard containers inside resident rooms, upon exit from the room. 5. Review of training record signatures revealed the DCO provided training to the Administrator and the DON on 01/26/15. The in-service was titled "Scabies in Long Term Care" and utilized the "Scabies Fact Sheet", for education related to the prevention and control of scabies in the long term care setting. Interview with the DCO, on 02/05/15 at 2:45 PM, revealed she

Based on observation, interview, record review and review of the facility's policy and procedures it was determined the facility's Administration failed to have an effective system to ensure the facility was administered to promote the highest practicable physical, mental, and psychosocial well-being for fifteen (15) of sixteen (16) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #16) and nine (9) of (9) nine unsampled residents (Unsampled Residents A, B, C, D, E, F, G, H and I) with rashes and/or [DIAGNOSES REDACTED]. (Refer to F-309 and F-441) Interview and record review revealed a treatment for [REDACTED]. On 07/27/14, seventeen (17) additional residents were treated for [REDACTED]. Continued review revealed two (2) residents were retreated for [REDACTED]. Additionally, one resident was retreated for [REDACTED]. Staff interview revealed numerous residents were identified with rashes during this time period. However, there was no documented evidence the facility identified the multiple rashes and repeated Scabies treatments as a concern, when it failed to follow its "Scabies Guidelines" to eradicate the condition and prevent re-infestation. The facility's failure to have an effective system in place to ensure it was administered effectively to promote the highest practicable well-being of all residents was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 01/30/15, and found to exist on 07/27/14. The facility was notified of the Immediate jeopardy on 01/30/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 02/05/15, with the facility alleging removal of the Immediate Jeopardy on 02/05/15. The State Survey Agency verified removal of the Immediate Jeopardy on 02/05/15 as alleged, prior to exit on 02/06/15, with remaining non-compliance at Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program monitors to ensure compliance with systemic changes. The findings include: Review of the "Scabies Guidelines", revised August 2012, revealed the purpose was to treat residents infected with the Scabies mite, and prevent the spread of Scabies to other residents and staff. Continued review revealed the facility's Infection Control Committee should coordinate interdepartmental planning to promote a rapid and effective treatment program. Review of the policy titled "Infection Control", revised August 2007, revealed its purpose was to facilitate the maintenance of a "safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections". Continued review revealed infection control objectives included maintaining records of incidents and corrective actions related to infections. Further review revealed the Administrator had adopted the infection control policies and practices, to reflect the need for preventing the transmission of infection, according to current professional guidelines and recommendations. On 01/22/15, the facility submitted its Census and Condition form which indicated five (5) residents in the building had a rash. However, after the State Survey Agency observed multiple residents itching and scratching during the initial tour on 01/22/15, the facility conducted a skin assessment of every resident and identified a total of fourteen (14) residents to have a rash (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). In addition, on 02/04/15 the State Survey Agency observed a skin assessment for Resident #16 and identified another rash. Record review and interview revealed a total of twenty-one (21) residents were treated for [REDACTED]. There was no documented evidence the facility utilized isolation procedures to prevent the spread of infection or performed adequate cleaning and disinfection of resident rooms and common areas. In addition, staff interviews revealed no education was provided related to the rashes and/or Scabies. In addition, record review revealed no documented evidence residents affected were monitored to ensure the effectiveness of treatment; therefore potentially exposing other residents who could have been in contact with the Scabies mites. Interview with the DON, on 02/05/15 at 12:50 PM, revealed in July 2014, twenty-on (21) residents were treated for [REDACTED]. The DON stated the residents treated in July, August and September were placed on contact isolation. However, staff interviews revealed isolation was not consistently implemented. Further interview and their rooms were cleaned; however, she acknowledged there was no facility-wide cleaning of common areas, staff was not offered treatment, no special laundering was conducted, and personal belongings and furniture which could not be disinfected were not removed according to facility practice guidelines. Additionally, she could provide no documented evidence any education for staff, residents or families was provided. In addition, the DON could not say why no one, including herself, felt the ongoing problem of rashes and repeated Scabies treatments required further action. Interview with the corporate Director of Clinical Operations (DCO), on 02/06/15 at 2:48 PM, revealed she had been assigned to the facility since August 2014. She stated she was not aware of the twenty-one (21)residents treated for [REDACTED]. She further stated the facility did not follow its protocol related to Scabies, including the failure to ensure disinfection of common areas used by the residents and failure to provide education to staff. Interview with the Administrator, on 01/29/15 at 2:07 PM, on 01/30/15 at 2:46 PM, and on 02/06/15 at 2:48 PM, revealed he assumed his role at the facility in August 2014. He stated he was responsible for ensuring the facility's policies and procedures were followed. He stated he had no knowledge of the twenty-one (21) residents treated for [REDACTED]. The Administrator stated although he knew that residents were treated in August and September 2014 for Scabies, there had been no infection control tracking to determine if the treatment was effective. Further interview revealed, he did review the CDC guidelines for Scabies in August 2014 after two (2) residents were treated for [REDACTED]. Continued interview revealed there was no discussion of a Scabies concern at the monthly meetings from August 2014 to January 2015, until after the State Agency Survey was initiated. The Administrator stated the facility did not follow its guidelines for handling Scabies cases when no education was provided to staff. Further interview revealed, to the Administrator's knowledge, there had been no confirmed cases of Scabies until the present time. However, he acknowledged that even with a negative biopsy, an individual could still have Scabies, with the potential for spreading the infestation to other residents. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 02/05/15 which alleged removal of the IJ effective 02/05/15. Review of the AOC revealed the facility implemented the following: 1. On 01/26/15, the Medical Director and the Director of Nursing (DON) assessed ten (10) residents identified to have current treatment orders for a change in skin condition. 2. On 01/26/15, body audits were completed on all in-house residents by an RN and a LPN. Based on the skin assessments, the Medical Director gave verbal orders for STAT (immediate) dermatology appointments for three (3) of the residents. Appointments were made for the same day. Two (2) of the three (3) residents (Residents #1 and #10) were confirmed to have scabies. 3. On 01/26/15, the Medical Director was notified of the positive for results and orders were given to treat all thirty-one (31) residents on the B-wing for scabies. The orders included the following for all of the residents: contact precautions; [MEDICATION NAME] cream to be applied beginning 01/27/15 and repeated in seven (7) days; and Stromectal tablets to be administered on day 1, 2, 8, 9, and 15 of the treatment process. The Responsible Party for all residents on the B wing was notified of the treatment orders by the Assistant DON (ADON) or the Activities Director. 4. On 01/26/15, all B wing residents were placed on contact isolation per the facility's guidelines. The DON, Director of Clinical Operations (DCO), Administrator and the Housekeeping/Laundry supervisor placed signs on all resident doors and on entrance doors. Personal Protective Equipment (PPE) was distributed and each department was notified of the precautions in place. 5. On 01/26/15, the DCO educated the DON and the Administrator related to scabies in long term care facilities, including prevention and control. The training included a review of the "Scabies Fact Sheet". The DON and the Administrator were educated by the DCO prior to proceeding to train all facility staff. 6. On 01/26/15, the Administrator and the DON initiated education for all staff related to contact isolation procedures, including the appropriate application and removal of PPE. Staff was required to complete the education prior to returning to work, with validation of effective learning through observation of staff adherence to isolation procedures and proper use of PPE. 7. On 01/26/15, an emergency Quality Assurance (QA) meeting was held and attended by the Administrator, DON, DCO, Housekeeping/Laundry Supervisor, Staff Development Coordinator (SDC) and the Medical director. The purpose of the meeting was to review the actions taken by the facility beginning 01/26/15. 8. On 01/27/15, all B wing residents were treated with [MEDICATION NAME] cream, with application of the treatment by licensed nursing staff. The cream was left on for eight (8) to fourteen (14) hours before residents were bathed and dressed in clean clothes. The baths/showers were provided by the State Registered Nursing Assistants (SRNAs) and the LPN on duty, and the entire process was overseen by two (2) RNs. 9. On 01/27/15, all B wing residents received their first dose of Stromectal dose, as ordered by the Physician, administered by the LPN. 10. On 01/27/15, the Housekeeping/Laundry Supervisor provided training for all laundry and housekeeping staff related to cleaning of contaminated isolation rooms, per facility guidelines. 11. On 01/27/15, all linen items, including personal clothing, bed linens and privacy curtains were removed from each resident room on the B wing by laundry staff. The linens were washed separately from other residents in the facility using hot water and hot dryer cycles. The laundry machines were disinfected with bleach germicidal cleaner. All non-washable personal belongings were placed in sealed bags or wrapped in plastic wrap and quarantined outside the center, where they are to remain for fourteen (14) days per facility guidelines. The entire process was overseen by the Housekeeping/Laundry Supervisor. 12. On 01/27/15, furniture and equipment throughout the facility, including the common areas on both wings and the dining room, was disinfected with the bleach germicidal cleaner by housekeeping staff and monitored by the Housekeeping/Laundry Supervisor. 13. On 01/27/15, the Administrator contacted the local health Department by telephone and via e-mail to report the diagnosed scabies, rashes and treatment. 14. On 01/27/15, the Minimum Data Set (MDS) Coordinator revised the Care Plan for each resident receiving treatment. The revisions included the current problem related to scabies treatment, isolation precautions, treatment of [REDACTED]. 15. On 01/27/15, the option for treatment was provided to each employee of the facility. The DON began distributing [MEDICATION NAME] cream on 01/27/15 along with verbal instructions. The DON is maintaining a log of staff who accepted treatment. On 02/03/15, the DON distributed a questionnaire to staff to determine if the treatment was effective and if staff continued to have symptoms and required additional treatment. 16. On 01/28/15, two (2) residents on the A wing began treatment for [REDACTED]. Treatment included contact isolation, application of [MEDICATION NAME] cream with repeat application in one (1) week, and Stromectal tablets to be administered on day 1, 2, 8, 9 and 15. Resident rooms, clothing, personal items and equipment were cleaned per facility protocol. 17. On 01/28/15, the DON educated all licensed staff on accurately completing a skin assessment. The DON will oversee five (5) skin inspections weekly for six (6) weeks to ensure accuracy of assessment and competency of licensed staff. Any discrepancy will be immediately addressed and the nurse will be re-educated. 18. On 01/30/15, the Administrator and the DON initiated training on the "Scabies Fact Sheet" and the "Guidelines for Scabies" through handouts and discussion. The education for all staff to be completed by 02/04/15. Beginning 02/04/15, written post-tests were initiated for all departments to ensure staff retention of knowledge related to the training. Thirty (30) post-tests will be administered weekly for six (6) weeks and then monthly for six (6) months to ensure continued compliance. Any staff unable to complete the post-test with 100% accuracy will receive immediate re-education by the DON, Administrator or RN supervisor. Also beginning, 02/04/15, the "Scabies Fact Sheet" will be included in new employee orientation and annual infection control in-services. Any staff on leave and any agency staff will receive the education and complete the post-test prior to a return to work. 19. On 01/30/15, the DCO in-serviced the DON on infection control surveillance logs, tracking and trending for scabies or other rashes, and the need for ongoing monitoring. The proper use of the "Scabies/Rash Tracking Log" and the "Skin Inspection Log" was included in the training. 20. On 01/30/15, the DCO educated the MDS Coordinator related to ensuring the Care Plans related to scabies/rashes included the specific problem, goal, and interventions for ongoing monitoring. 21. Evaluation and monitoring of each resident receiving treatment will included skin inspections for resolution of rashes, and observation for new skin eruptions in two (2) to six (6) weeks per Centers for Disease Control (CDC) guidelines. Skin inspections will be completed by licensed staff on all residents in the facility twice weekly beginning 01/31/15 for seven (7) weeks and weekly thereafter. The Physician will be notified of any findings and treatment will be initiated per Physician orders. Residents treated will be monitored for response to treatment and the presence of any treatment side effects. 22. On 01/31/15, a QA meeting was held with the Administrator, DON, Regional Vice President (RVP), DCO and the Medical Director to re-evaluate all measures implemented since 01/26/15, and to outline action items moving forward. 23. As of 01/31/15, daily corporate oversight will occur until removal of abatement of the Immediate Jeopardy, then weekly for at least seven (7) weeks to ensure continued compliance of Administration. 24. On 01/31/15, the facility established a "Scabies Prevention and Control Plan" which included the following: implementation of the "Scabies Guidelines" based on CDC guidelines; promotion of a high index of suspicion for scabies as a possible cause of undiagnosed skin rash; and referral to a Dermatologist after a failed initial course of treatment. 25. On 02/03/15, the Responsible Party for each A wing resident was notified by phone by the ADON or the Activities Director of a scabies outbreak, with messages left for those parties who did not answer. 26. On 02/04/15, the Medical Director gave orders to initiate treatment on all remaining residents on the A wing. Treatment orders were the same as for all other residents in the building, and included disinfection of resident rooms, clothing, personal items and equipment. In addition, common areas were cleaned according to facility guidelines. 27. Residents #1 and #10, with confirmed scabies diagnoses, will have a follow-up appointment with the Dermatologist on 02/06/15. The DON or the RN will accompany the residents to the physician's office. 28. The facility's QA process will monitor implemented interventions as follows: The Administrator, DON or RN Supervisor will review the "Scabies/Rash Tracking Log" daily for six (6) weeks, then weekly for four (4) weeks, then monthly in the Quality Assurance/Process Improvement (QAPI) meeting. The Administrator, DON or RN Supervisor will review the "Skin Inspection Log" daily for six (6) weeks, then weekly for four (4) weeks, then monthly in the QAPI meeting. The Administrator, DON or RN Supervisor will review the Care Plans of residents being treated for [REDACTED]. The Administrator and/or the DON will ensure all staff has successfully completed the training and post-test related to the facility's "Scabies Prevention and Control Plan". The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the Physician Extended Care Notes, dated 01/26/15 and signed by the Medical Director, revealed the ten (10) residents with treatment orders for a change in skin condition on that date were seen by the Physician for a complete physical examination and evaluation of their skin concerns. Continued review revealed each examination was comprehensive and included documentation by the Physician of each resident's skin and recommended treatment. 2. Review of the "Body Audit" forms, dated 01/26/15 and signed by the RN or the LPN, revealed sixty-five (65) residents in the facility received a head-to-toe skin assessment on that date. Continued review revealed each resident was assessed for eleven (11) specific skin conditions as follows: redness/discoloration/bruises; open areas; [MEDICAL CONDITION]; rash; dry/flakey; excoriation; ecchymosis; skin tears; abrasions; surgical wounds or incisions; and psoriasis. Findings were documented by type and location. Review of the Dermatologist's "Visit Notes", dated 01/26/15, revealed three (3) residents were seen in the office on that day. Continued review revealed two (2) of the three (3) residents (Residents #1 and #10), based on microscopic examination, were found to be positive for scabies and treatment orders were given. Additionally, the resident who did not have a confirmed [DIAGNOSES REDACTED]. 3. Review of the Physician Orders, dated 01/26/15, revealed the Medical Director gave orders for scabies treatment to be initiated on 01/27/15 for all residents on the B wing. Continued review revealed the orders were consistent with those given by the Dermatologist for the confirmed cases, with treatment to be administered as follows: apply [MEDICATION NAME] ([MEDICATION NAME]) 5% cream to body from neck down, leave on 8-14 hours then wash off; repeat in one (1) week; after cream applied, administer Stromectal, 3 milligram (mg) tablets on day 1,2,8,9, and 15. In addition, Physician order [REDACTED]. Review of Departmental Notes, dated 01/27/15, revealed the Responsible Party for each resident on the B wing was notified of the new orders by the Activities Director or the ADON. Interview with the ADON, on 02/04/15 at 2:02 PM, revealed she had made calls to the families of the B wing residents, informing them of new treatment orders and contact isolation procedures. She stated some families had questions and she answered as they arose. Interview with the POA for Unsampled Resident J, on 02/04/15 at 6:58 PM, revealed she was notified by the facility of treatment orders and isolation procedures for all residents on the B wing, including Resident J. 4. Observation upon entering the facility, on 01/28/15 at 4:01 PM, revealed signs directing visitors to see the nurse prior to visiting with residents were posted on the front entrance doors and on the door of each resident room on the B wing. In addition, the signs on resident room doors indicated Contact Isolation was in effect. Continued observation revealed PPE, including gowns, masks, gloves and shoe covers, was stocked in bins in the hall outside resident rooms on the B wing. During survey activities throughout the day on 01/26/15, staff from all departments was observed to utilize the PPE prior to entering resident rooms. Also, staff was observed to dispose of PPE appropriately, in biohazard containers inside resident rooms, upon exit from the room. 5. Review of training record signatures revealed the DCO provided training to the Administrator and the DON on 01/26/15. The in-service was titled "Scabies in Long Term Care" and utilized the "Scabies Fact Sheet", for education related to the prevention and control of scabies in the long term care setting. Interview with the DCO, on 02/05/15 at 2:45 PM, revealed she educated the Administrator and DON to ensure they were knowledgeable about managing a scabies outbreak, prior to their training of the rest of the staff, in order for all education to be consistent and according to facility guidelines. Interview with the DON on 02/05/15 at 12:50 PM, and the Administrator on 02/06/15 at 2:45 PM, revealed both received training from the corporate DCO related to scabies infestation. Continued interview revealed the training by the DCO occurred prior to the Administrator and the DON educating the staff. 6. Review of training records revealed, on 01/26/15, the Administrator and the DON initiated education for all staff related to Isolation Precautions, with emphasis on contact precautions. Review of training materials revealed the education included the proper use of PPE. Further review of in-service sign-in sheets revealed eighty (80) of eighty (80) staff had received the mandatory training on or before 01/30/15. Interviews with Housekeeping Staff #13 on 01/29/15 at 1:34 PM, Housekeeping Staff #14 on 01/29/15 at 1:56 PM, SRNA #23 on 01/29/15 at 2:04 PM, Laundry Staff #12 on 01/29/15 at 2:07 PM, Housekeeping Staff #11 on 01/29/15 at 2:19 PM, SRNA #1 on 01/29/15 at 3:50 PM, SRNA #7 on 01/29/15 at 4:25 PM, SRNA #8 on 01/29/15 at 4:37 PM, RN #2 on 01/29/15 at 4:38 PM, Housekeeping Supervisor on 01/29/15 at 4:47 PM, SRNA #12 on 01/30/15 at 3:25 PM, SRNA #11 on 01/30/15 at 3:35 PM, SRNA #24 on 01/30/15 at 3:55 PM, LPN #2 on 01/30/15 at 3:43 PM, SRNA #9 on 01/31/15 at 4:00 PM, Wound Care Nurse on 02/04/15 at 3:20 PM, RN #1 on 02/05/15 at 4:30 PM, LPN #6 on 02/05/15 at 4:55 PM, Rehabilitation Staff #18 on 02/06/15 at 1:45 PM, Dietary Worker #26 on 02/06/15 at 2:00 PM, Rehabilitation Staff #17 on 02/06/15 at 3:05 PM, and Laundry Worker #25 on 02/06/15 at 6:20 PM, revealed all had received training related to isolation precautions. During the interviews, all were able to express the appropriate PPE required for contact isolation. Interview with the DON on 02/05/15 at 12:50 PM, and the DCO on 02/05/15 at 2:45 PM, revealed in addition to the eighty (80) "active" staff, three (3) staff members were currently on leave. Continued interview revealed the DON was responsible for scheduling and was tracking those staff members to ensure they were in-serviced prior to returning to work. Further interview revealed the facility had used Agency staff on occasion and notification was sent to the Agency of the required in-servicing prior to any further scheduling of Agency staff. In addition, the DON was tracking to ensure no Agency staff worked without receiving the education. She stated no Agency staff had worked at the facility since the in-services were initiated. Observations, on 01/28/15 at 11:30 AM and on 02/05/15 at 4:00 PM, revealed the Administrator, the DON and the Housekeeping Supervisor were on the resident units, observing staff and monitoring availability and proper use of PPE. 7. Review of QA records revealed an "Emergency" meeting was held on 01/26/15 at 7:30 PM, and was attended by the Medical Director, the DCO, the Administrator, the DON, the Assistant DON and the Housekeeping Supervisor, as evidenced by their signatures. Meeting attendees reviewed the confirmed cases of scabies, and recommendations from the Medical Director to treat all residents on the B wing, and to offer and encourage treatment to staff. Other items discussed included the initiation of Contact Precautions, body audits of all residents, cleaning and disinfection of resident rooms and common areas, and the prescribed treatment for [REDACTED]. Interview with the Administrator, on 02/06/15 at 2:45 PM, revealed the Medical Director had been present and very involved in developing and implementing the facility's action plan to remove the Immediate Jeopardy. He stated although it was not in the QA minutes, he had a conversation with the Medical Director whose stated intent was to complete a re-assessment of every resident in the facility once the treatment was completed. 8. Review of the Medication Administration Records for the B wing residents revealed all were treated with [MEDICATION NAME] cream on 01/27/15. Continued review revealed the cream was applied by licensed nursing staff. Review of the facility's schedule for applying the cream and subsequent showering of each resident revealed a minimum of eight (8) hours elapsed between application and removal of the cream. Interviews with RN #2 on 01/29/15 at 4:35 PM, SRNA #18 on 01/31/15 at 2:47 PM, RN #1 on 02/05/15 at 4:30 PM, SRNA #4 on 02/05/15 at 4:38 PM, and SRNA #15 on 02/05/15 at 6:04 PM, revealed they had been involved in application of the [MEDICATION NAME] cream and removal by bath or shower eight (8) to fourteen (14) hours later. The interviewees described the process whereby the cream was applied on one shift, and washed off on the next shift, following the same order of residents, according to the schedule. RN #1 and RN #2 reported they were responsible for applying the cream, and ensuring it was bathed off by the SRNAs, providing assistance if needed. The SRNAs stated they assisted the nurse with positioning during application of the cream, but their primary job was to bathe or shower the residents after at least eight (8) hours had passed. Interview with the DON, on 02/06/15 at 1:50 PM, revealed the RN or LPN on duty on the shift the cream was applied, and on the shift when removed, was responsible for overseeing the process. Continued interview revealed the DON took ultimate responsibility for ensuring each resident was treated appropriately, according to the physician's orders [REDACTED]. 9. Review of the MARs for the B wing residents revealed all were administered Stromectal tablets, according to the Physician orders, on 01/27/15. Interview with the DON, on 02/06/15 at 1:50 PM, revealed her oversight of the treatment process included a review for timely administration of the Stromectal. 10. Review of training records revealed the Housekeeping Supervisor provided education to eight (8) of eight (8) housekeeping and laundry staff on 01/27/15. Continued review revealed the education included the proper handling of trash and linens, cleaning and disinfecting of horizontal surfaces, walls, furniture and bathrooms, dust mopping and damp mopping, and proper disposal of trash and transport of linens to be laundered. Interviews with Housekeeping Staff #13 on 01/29/15 at 1:34 PM, Housekeeping Staff #14 on 02/19/15 at 1:56 PM, Housekeeping Staff #12 on 01/29/15 at 2:07 PM, and Housekeeping Staff #11 on 01/29/15 at 2:19 PM, revealed all received training related to "deep cleaning" of contaminated isolation rooms. All interviewees were able to answer specific questions related to topics covered in the in-service, including the types of disinfectants to be used, as well as the process to be followed. Interview with the Housekeeping Supervisor, on 01/29/15 at 4:47 PM, revealed he had in-serviced his staff on 01/27/14 related to the procedure for cleaning and disinfecting the isolation rooms after an outbreak of scabies. He stated the process required a team effort and his role was to ensure his staff was educated, and to oversee the cleaning to ensure all steps were followed properly. 11. Observation, on 01/28/15 at 11:30 PM revealed staff was in the process of decontaminating all resident linens, including personal clothing, bed linens and privacy curtains on the B wing. Linens had been transported to the laundry area on 01/27/15 for laundering using hot washer and dryer settings. Continued observation revealed resident room were cleaned and disinfected while the residents were out of the rooms for their baths or showers. All washable surfaces were disinfected with a bleach product, according to the facilities "Scabies Guidelines". No non-washable items, including cloth furniture, were observed anywhere in the facility, including resident rooms and common areas. The Housekeeping Supervisor was observed to be actively participating and overseeing the process. In addition, housekeeping staff were observed to be utilizing PPE during the cleaning. Interview with Laundry Worker #25, on 02/05/15 at 5:30 PM, revealed she was responsible for laundering contaminated linens during her shift. She stated the linens arrived in the laundry area in red biohazard bags. She further stated the linens were removed from the bags and placed directly in the washer for laundering in hot water, followed by drying on the hot cycle for at least twelve (12) minutes. Continued interview revealed the process was followed for residents' personal clothing, bed linens, privacy curtains, "anything washable". Further interview revealed the washers and dryers were disinfected with a bleach disinfectant between uses. 12. Interview with the Housekeeping Supervisor, on 01/28/15 at 11:30 AM, revealed all furniture and equipment in common areas throughout the building was disinfected on 01/27/15. He stated the resident rooms, including washable furniture were being cleaned on 01/28/15 while residents were out of their rooms for bathing. He further explained all personal clothing, linens and privacy curtains had been removed prior to bathing to ensure the room was decontaminated prior to the residents returning. Continued interview revealed all cloth furniture and any items which could not be disinfected had been wrapped in plastic, removed from the building, and were stored in an outbuilding for the next fourteen (14) days, per the facili

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to identify a Quality Assurance (QA) concern, and develop and implement appropriate plans of action. The facility's QA system's failure to develop and implement appropriate plans of action prevented the facility from ensuring effective measures were in place for appropriate identification, treatment, monitoring and prevention of contagious scabies outbreaks. Record review revealed [MEDICATION NAME] cream, a treatment for [REDACTED].#5, #6, #7 and #9. On 07/27/14, seventeen (17) additional resident (Residents #1, #2, #3, #4, #8, #10, #11, #12 and #14, and Unsampled Residents A, B, C, D, E, F, G and H) were also treated with [MEDICATION NAME] for Scabies. However, there was no documented evidence on 07/27/14, the facility ensured implementation of the "Scabies" Policy, to include placing the seventeen (17) residents in contact isolation and performing decontamination of resident areas. The facility's Quality Assurance failed to identify this as a problem. Therefore, Residents #6 and #7 were again treated for [REDACTED]. Additionally, on 09/10/14, Resident #6 was also treated with [MEDICATION NAME] (an oral medication for treatment of [REDACTED]. Also, Resident #9 was treated again while hospitalized between 01/03/15 and 01/06/15 for Scabies, and again at the facility on 01/11/15. Observation during initial tour, revealed multiple residents actively scratching their bodies, with several residents observed to have dark reddish blood-like spots on their clothing and bed linens. Continued observation revealed no residents were in contact isolation. Observations during skin assessments for fifteen (15) of the sixteen (16) sampled residents revealed all had rashes of varying degrees on their bodies. The facility's QA system failed to identify, develop and implement plans of action to address: infection control surveillance for scabies or suspicious rashes; the early identification of signs and symptoms for scabies; appropriate procedures for infection control, treatment of [REDACTED]. (Refer to F-309, F-441 and F-490) The facility's failure to develop and implement an action plan for the facility's infection control and surveillance of suspicious rashes and or scabies, the early identification of signs and symptoms of scabies, appropriate procedures for infection control of potentially contagious disease and infestations, treatment of [REDACTED]. Immediate Jeopardy was identified on 01/30/15 and determined to exist on 07/27/14. The facility was notified of the Immediate Jeopardy on 01/30/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 02/05/15, with the facility alleging removal of the Immediate Jeopardy on 02/05/15. The State Survey Agency verified removal of the Immediate Jeopardy on 02/05/15 as alleged, prior to exit on 02/06/15, with remaining non-compliance at Scope and Severity of an "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program monitors to ensure compliance with systemic changes. The findings include: Review of the facility's, Quality Assurance and Process Improvement Meeting" guidelines, Template 2014, revealed the mission of the Quality Assessment and Process Improvement (QAPI) was to improve every life touched by providing exceptional healthcare and exceeding expectations. Further review revealed, the purpose was to monitor core processes to identify trends and variations through appropriate analysis of data from multiple data sources. Further review revealed, a Performance Improvement Project (PIP) was a concentrated effort on a particular problem in one area of the facility or facility wide; it involved gathering information systematically to clarify issues or problems, and intervening for improvements. Further review revealed the facility would conduct PIPs to examine and improve care or services in areas that the facility identified as needing attention. Continued review revealed, the guidelines addressed utilizing Infection Control Surveillance Documents for Patterns and Trends. Review of the facility's policy, titled "Policies and Practices - Infection Control", dated August 2007, revealed the Quality Assessment and Assurance Committee, through the Infection Control Committee, should oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. Continued review revealed, inquiries concerning the infection control policies and facility practices should be referred to the Director of Nursing Services. Review of the "Scabies Guidelines", revised August 2012, revealed the purpose was to treat residents infected with the scabies mite, and prevent the spread of scabies to other residents and staff. Continued review revealed the facility's Infection Control Committee should coordinate interdepartmental planning to promote a rapid and effective treatment program. Review of the facility's policy, titled "Scabies" effective 08/01/12, revealed procedures which included to establish contact isolation procedures immediately, contact the physician and obtain an order for [REDACTED]. The common areas should be cleaned before the resident's bathing/decontamination so the "treated" resident did not use the contaminated areas to prevent cross contamination. Review of the Quality Assurance Meeting Agenda, for 09/25/14, 10/30/14, 11/24/14, and 01/08/15, provided by the facility, revealed there was no documented evidence the facility initiated an action plan for suspicious rashes, implemented a surveillance process for suspicious rashes or monitored the treatments to ensure eradication of the infestation of scabies. On 01/22/15, the facility submitted its Census and Condition form which indicated five (5) residents in the building had a rash. However, after the State Survey Agency observed multiple residents itching and scratching during the initial tour on 01/22/15, the facility conducted a skin assessment of every resident and identified a total of fourteen (14) residents to have a rash (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). In addition, on 02/04/15 the State Survey Agency observed a skin assessment for Resident #16 and identified another rash. Observation, on 01/22/15, revealed multiple residents scratching their bodies, with several residents observed to have dark reddish blood-like spots on their clothing and bed linens. Continued observations revealed no residents were in contact isolation, as per policy. Also, observations during skin assessments for fifteen (15) of the sixteen (16) sampled residents revealed all of the residents had rashes of varying degrees on their bodies. Interview and record review revealed residents in the facility were treated for [REDACTED]. There was no documented evidence the facility utilized isolation procedures to prevent the spread of infection or performed adequate cleaning and disinfection of resident rooms and common areas. In addition, staff interviews revealed no education was provided related to the rashes and/or Scabies. Record review revealed no documented evidence that residents affected were monitored to ensure the effectiveness of treatment; therefore potentially exposing other residents who could have been in contact with the scabies mites. Interview with the Wound Care Nurse (WC), on 01/26/15 at 12:00 PM, revealed several of the residents were receiving treatment for [REDACTED]. Further interview revealed, treatment was being provided; however, it was not resolving the rashes. Continued interview, on 01/29/15 at 11:25 PM, revealed the WC thought the rashes had been going on for eight (8) months or longer. On 02/05/15 at 3:20 PM, the WC stated the residents had been treated for [REDACTED]. However, the rooms had not been cleaned thoroughly, as the furniture was not cleaned or removed from the rooms. Some of the residents, who had received treatment were placed in contact isolation precautions; but, the whole wing had not been in isolation or decontaminated. During an interview with the Director of Nursing, on 01/29/15 at 10:06 AM, she stated she co-chaired the QA Committee with the Administrator. The DON stated she was aware several residents had rashes; however, she was not aware of how many rashes were in the facility. Continued interview revealed, the Infection Control Nurse was terminated in November and she (the DON) had been the interim Infection Control Nurse. Continued interview revealed, the Infection Control Committee/Quality Assurance Committee did not address or discuss the treatment of [REDACTED]. Further interview revealed, infection control issues were discussed however, since there was not a confirmed case of scabies, she did not list it to be discussed during the Committee meeting and she did not track and trend for patterns or monitor for the effectiveness of the medications. Further interview revealed, the facility should have monitored the treatments and appearance of the rashes after the facility treated the residents in July 2014. She further stated the facility should have tracked and trended the rashes to ensure the eradication of the scabies. Further interview with the DON, on 02/05/15 at 12:50 PM, revealed in July 2014, eighteen (18) residents were treated for [REDACTED]. She stated the issue of scabies was not forwarded for any Quality Assurance (QA) action and no audits or ongoing monitoring to rule out treatment failure, re-infestation, or spread to other residents was performed. The DON further stated the former Staff Development Coordinator was in charge of QA activities at that time, and she did not bring the concern to QA meetings. In addition, the DON could not say why no one, including herself, felt the ongoing problem of rashes and repeated scabies treatments required further action. Interview with the Administrator, on 01/29/15 at 4:01 PM, revealed he was hired by the facility on August 1, 2014 and he co-chaired the QA Committee with the DON. Further interview revealed he was aware two (2) residents were treated in August 2014; three (3) in September 2014 and one (1) in January 2015. He stated he did not have a clinical background and did not question if contact isolation should have been implemented, or if the facility should be decontaminated, the effectiveness of the treatment and the appearance of the rash should have been monitored, or the physician's orders [REDACTED]. Additional interview with the Administrator, on 01/30/15 at 2:46 PM, revealed he was responsible for ensuring the facility's policies and procedures were followed, and the QA and Infection Control programs were effective. He further stated the former Staff Development Coordinator (SDC) was in charge of QA until November 2014. Continued interview revealed there was no discussion of a scabies concern at the monthly meetings from August 2014 to January 2015, until after the State Agency Survey was initiated. Further interview with the Administrator, on 02/06/15 at 2:48 PM, revealed he assumed control over the QA process in January 2015 after the former SDC left employment and no longer headed that committee. He stated he had reviewed the QA minutes from July 2014 to the present and found no evidence of any discussion of scabies, rashes or skin concerns. He acknowledged, in view of the number of residents with itching and rashes, and the multiple scabies treatments administered over the course of a few months, a QA concern should have been identified for further review. The Administrator stated although several residents were treated in August and September for scabies, there had been no infection control tracking to determine if the treatment was effective. Continued interview revealed the Administrator acknowledged the facility did not follow its guidelines for handling scabies cases when no education was provided to staff. Further interview revealed, to the Administrator's knowledge, there had been no confirmed cases of scabies until the present time; however, he acknowledged that even with a negative biopsy, an individual could still have scabies, with the potential for spreading the infestation to other residents. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 02/05/15 which alleged removal of the IJ effective 02/05/15. Review of the AOC revealed the facility implemented the following: 1. On 01/26/15, the Medical Director and the Director of Nursing (DON) assessed ten (10) residents identified to have current treatment orders for a change in skin condition. 2. On 01/26/15, body audits were completed on all in-house residents by an RN and a LPN. Based on the skin assessments, the Medical Director gave verbal orders for STAT (immediate) dermatology appointments for three (3) of the residents. Appointments were made for the same day. Two (2) of the three (3) residents (Residents #1 and #10) were confirmed to have scabies. 3. On 01/26/15, the Medical Director was notified of the positive for results and orders were given to treat all thirty-one (31) residents on the B-wing for scabies. The orders included the following for all of the residents: contact precautions; [MEDICATION NAME] cream to be applied beginning 01/27/15 and repeated in seven (7) days; and Stromectal tablets to be administered on day 1, 2, 8, 9, and 15 of the treatment process. The Responsible Party for all residents on the B wing was notified of the treatment orders by the Assistant DON (ADON) or the Activities Director. 4. On 01/26/15, all B wing residents were placed on contact isolation per the facility's guidelines. The DON, Director of Clinical Operations (DCO), Administrator and the Housekeeping/Laundry supervisor placed signs on all resident doors and on entrance doors. Personal Protective Equipment (PPE) was distributed and each department was notified of the precautions in place. 5. On 01/26/15, the DCO educated the DON and the Administrator related to scabies in long term care facilities, including prevention and control. The training included a review of the "Scabies Fact Sheet". The DON and the Administrator were educated by the DCO prior to proceeding to train all facility staff. 6. On 01/26/15, the Administrator and the DON initiated education for all staff related to contact isolation procedures, including the appropriate application and removal of PPE. Staff was required to complete the education prior to returning to work, with validation of effective learning through observation of staff adherence to isolation procedures and proper use of PPE. 7. On 01/26/15, an emergency Quality Assurance (QA) meeting was held and attended by the Administrator, DON, DCO, Housekeeping/Laundry Supervisor, Staff Development Coordinator (SDC) and the Medical director. The purpose of the meeting was to review the actions taken by the facility beginning 01/26/15. 8. On 01/27/15, all B wing residents were treated with [MEDICATION NAME] cream, with application of the treatment by licensed nursing staff. The cream was left on for eight (8) to fourteen (14) hours before residents were bathed and dressed in clean clothes. The baths/showers were provided by the State Registered Nursing Assistants (SRNAs) and the LPN on duty, and the entire process was overseen by two (2) RNs. 9. On 01/27/15, all B wing residents received their first dose of Stromectal dose, as ordered by the Physician, administered by the LPN. 10. On 01/27/15, the Housekeeping/Laundry Supervisor provided training for all laundry and housekeeping staff related to cleaning of contaminated isolation rooms, per facility guidelines. 11. On 01/27/15, all linen items, including personal clothing, bed linens and privacy curtains were removed from each resident room on the B wing by laundry staff. The linens were washed separately from other residents in the facility using hot water and hot dryer cycles. The laundry machines were disinfected with bleach germicidal cleaner. All non-washable personal belongings were placed in sealed bags or wrapped in plastic wrap and quarantined outside the center, where they are to remain for fourteen (14) days per facility guidelines. The entire process was overseen by the Housekeeping/Laundry Supervisor. 12. On 01/27/15, furniture and equipment throughout the facility, including the common areas on both wings and the dining room, was disinfected with the bleach germicidal cleaner by housekeeping staff and monitored by the Housekeeping/Laundry Supervisor. 13. On 01/27/15, the Administrator contacted the local health Department by telephone and via e-mail to report the diagnosed scabies, rashes and treatment. 14. On 01/27/15, the Minimum Data Set (MDS) Coordinator revised the Care Plan for each resident receiving treatment. The revisions included the current problem related to scabies treatment, isolation precautions, treatment of [REDACTED]. 15. On 01/27/15, the option for treatment was provided to each employee of the facility. The DON began distributing [MEDICATION NAME] cream on 01/27/15 along with verbal instructions. The DON is maintaining a log of staff who accepted treatment. On 02/03/15, the DON distributed a questionnaire to staff to determine if the treatment was effective and if staff continued to have symptoms and required additional treatment. 16. On 01/28/15, two (2) residents on the A wing began treatment for [REDACTED]. Treatment included contact isolation, application of [MEDICATION NAME] cream with repeat application in one (1) week, and Stromectal tablets to be administered on day 1, 2, 8, 9 and 15. Resident rooms, clothing, personal items and equipment were cleaned per facility protocol. 17. On 01/28/15, the DON educated all licensed staff on accurately completing a skin assessment. The DON will oversee five (5) skin inspections weekly for six (6) weeks to ensure accuracy of assessment and competency of licensed staff. Any discrepancy will be immediately addressed and the nurse will be re-educated. 18. On 01/30/15, the Administrator and the DON initiated training on the "Scabies Fact Sheet" and the "Guidelines for Scabies" through handouts and discussion. The education for all staff to be completed by 02/04/15. Beginning 02/04/15, written post-tests were initiated for all departments to ensure staff retention of knowledge related to the training. Thirty (30) post-tests will be administered weekly for six (6) weeks and then monthly for six (6) months to ensure continued compliance. Any staff unable to complete the post-test with 100% accuracy will receive immediate re-education by the DON, Administrator or RN supervisor. Also beginning, 02/04/15, the "Scabies Fact Sheet" will be included in new employee orientation and annual infection control in-services. Any staff on leave and any agency staff will receive the education and complete the post-test prior to a return to work. 19. On 01/30/15, the DCO in-serviced the DON on infection control surveillance logs, tracking and trending for scabies or other rashes, and the need for ongoing monitoring. The proper use of the "Scabies/Rash Tracking Log" and the "Skin Inspection Log" was included in the training. 20. On 01/30/15, the DCO educated the MDS Coordinator related to ensuring the Care Plans related to scabies/rashes included the specific problem, goal, and interventions for ongoing monitoring. 21. Evaluation and monitoring of each resident receiving treatment will included skin inspections for resolution of rashes, and observation for new skin eruptions in two (2) to six (6) weeks per Centers for Disease Control (CDC) guidelines. Skin inspections will be completed by licensed staff on all residents in the facility twice weekly beginning 01/31/15 for seven (7) weeks and weekly thereafter. The Physician will be notified of any findings and treatment will be initiated per Physician orders. Residents treated will be monitored for response to treatment and the presence of any treatment side effects. 22. On 01/31/15, a QA meeting was held with the Administrator, DON, Regional Vice President (RVP), DCO and the Medical Director to re-evaluate all measures implemented since 01/26/15, and to outline action items moving forward. 23. As of 01/31/15, daily corporate oversight will occur until removal of abatement of the Immediate Jeopardy, then weekly for at least seven (7) weeks to ensure continued compliance of Administration. 24. On 01/31/15, the facility established a "Scabies Prevention and Control Plan" which included the following: implementation of the "Scabies Guidelines" based on CDC guidelines; promotion of a high index of suspicion for scabies as a possible cause of undiagnosed skin rash; and referral to a Dermatologist after a failed initial course of treatment. 25. On 02/03/15, the Responsible Party for each A wing resident was notified by phone by the ADON or the Activities Director of a scabies outbreak, with messages left for those parties who did not answer. 26. On 02/04/15, the Medical Director gave orders to initiate treatment on all remaining residents on the A wing. Treatment orders were the same as for all other residents in the building, and included disinfection of resident rooms, clothing, personal items and equipment. In addition, common areas were cleaned according to facility guidelines. 27. Residents #1 and #10, with confirmed scabies diagnoses, will have a follow-up appointment with the Dermatologist on 02/06/15. The DON or the RN will accompany the residents to the physician's office. 28. The facility's QA process will monitor implemented interventions as follows: The Administrator, DON or RN Supervisor will review the "Scabies/Rash Tracking Log" daily for six (6) weeks, then weekly for four (4) weeks, then monthly in the Quality Assurance/Process Improvement (QAPI) meeting. The Administrator, DON or RN Supervisor will review the "Skin Inspection Log" daily for six (6) weeks, then weekly for four (4) weeks, then monthly in the QAPI meeting. The Administrator, DON or RN Supervisor will review the Care Plans of residents being treated for [REDACTED]. The Administrator and/or the DON will ensure all staff has successfully completed the training and post-test related to the facility's "Scabies Prevention and Control Plan". The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the Physician Extended Care Notes, dated 01/26/15 and signed by the Medical Director, revealed the ten (10) residents with treatment orders for a change in skin condition on that date were seen by the Physician for a complete physical examination and evaluation of their skin concerns. Continued review revealed each examination was comprehensive and included documentation by the Physician of each resident's skin and recommended treatment. 2. Review of the "Body Audit" forms, dated 01/26/15 and signed by the RN or the LPN, revealed sixty-five (65) residents in the facility received a head-to-toe skin assessment on that date. Continued review revealed each resident was assessed for eleven (11) specific skin conditions as follows: redness/discoloration/bruises; open areas; [MEDICAL CONDITION]; rash; dry/flakey; excoriation; ecchymosis; skin tears; abrasions; surgical wounds or incisions; and psoriasis. Findings were documented by type and location. Review of the Dermatologist's "Visit Notes", dated 01/26/15, revealed three (3) residents were seen in the office on that day. Continued review revealed two (2) of the three (3) residents (Residents #1 and #10), based on microscopic examination, were found to be positive for scabies and treatment orders were given. Additionally, the resident who did not have a confirmed [DIAGNOSES REDACTED]. 3. Review of the Physician Orders, dated 01/26/15, revealed the Medical Director gave orders for scabies treatment to be initiated on 01/27/15 for all residents on the B wing. Continued review revealed the orders were consistent with those given by the Dermatologist for the confirmed cases, with treatment to be administered as follows: apply [MEDICATION NAME] ([MEDICATION NAME]) 5% cream to body from neck down, leave on 8-14 hours then wash off; repeat in one (1) week; after cream applied, administer Stromectal, 3 milligram (mg) tablets on day 1,2,8,9, and 15. In addition, Physician order [REDACTED]. Review of Departmental Notes, dated 01/27/15, revealed the Responsible Party for each resident on the B wing was notified of the new orders by the Activities Director or the ADON. Interview with the ADON, on 02/04/15 at 2:02 PM, revealed she had made calls to the families of the B wing residents, informing them of new treatment orders and contact isolation procedures. She stated some families had questions and she answered as they arose. Interview with the POA for Unsampled Resident J, on 02/04/15 at 6:58 PM, revealed she was notified by the facility of treatment orders and isolation procedures for all residents on the B wing, including Resident J. 4. Observation upon entering the facility, on 01/28/15 at 4:01 PM, revealed signs directing visitors to see the nurse prior to visiting with residents were posted on the front entrance doors and on the door of each resident room on the B wing. In addition, the signs on resident room doors indicated Contact Isolation was in effect. Continued observation revealed PPE, including gowns, masks, gloves and shoe covers, was stocked in bins in the hall outside resident rooms on the B wing. During survey activities throughout the day on 01/26/15, staff from all departments was observed to utilize the PPE prior to entering resident rooms. Also, staff was observed to dispose of PPE appropriately, in biohazard containers inside resident rooms, upon exit from the room. 5. Review of training record signatures revealed the DCO provided training to the Administrator and the DON on 01/26/15. The in-service was titled "Scabies in Long Term Care" and utilized the "Scabies Fact Sheet", for education related to the prevention and control of scabies in the long term care setting. Interview with the DCO, on 02/05/15 at 2:45 PM, revealed she educated the Administrator and DON to ensure they were knowledgeable about managing a scabies outbreak, prior to their training of the rest of the staff, in order for all education to be consistent and according to facility guidelines. Interview with the DON on 02/05/15 at 12:50 PM, and the Administrator on 02/06/15 at 2:45 PM, revealed both received training from the corporate DCO related to scabies infestation. Continued interview revealed the training by the DCO occurred prior to the Administrator and the DON educating the staff. 6. Review of training records revealed, on 01/26/15, the Administrator and the DON initiated education for all staff related to Isolation Precautions, with emphasis on contact precautions. Review of training materials revealed the education included the proper use of PPE. Further review of in-service sign-in sheets revealed eighty (80) of eighty (80) staff had received the mandatory training on or before 01/30/15. Interviews with Housekeeping Staff #13 on 01/29/15 at 1:34 PM, Housekeeping Staff #14 on 01/29/15 at 1:56 PM, SRNA #23 on 01/29/15 at 2:04 PM, Laundry Staff #12 on 01/29/15 at 2:07 PM, Housekeeping Staff #11 on 01/29/15 at 2:19 PM, SRNA #1 on 01/29/15 at 3:50 PM, SRNA #7 on 01/29/15 at 4:25 PM, SRNA #8 on 01/29/15 at 4:37 PM, RN #2 on 01/29/15 at 4:38 PM, Housekeeping Supervisor on 01/29/15 at 4:47 PM, SRNA #12 on 01/30/15 at 3:25 PM, SRNA #11 on 01/30/15 at 3:35 PM, SRNA #24 on 01/30/15 at 3:55 PM, LPN #2 on 01/30/15 at 3:43 PM, SRNA #9 on 01/31/15 at 4:00 PM, Wound Care Nurse on 02/04/15 at 3:20 PM, RN #1 on 02/05/15 at 4:30 PM, LPN #6 on 02/05/15 at 4:55 PM, Rehabilitation Staff #18 on 02/06/15 at 1:45 PM, Dietary Worker #26 on 02/06/15 at 2:00 PM, Rehabilitation Staff #17 on 02/06/15 at 3:05 PM, and Laundry Worker #25 on 02/06/15 at 6:20 PM, revealed all had received training related to isolation precautions. During the interviews, all were able to express the appropriate PPE required for contact isolation. Interview with the DON on 02/05/15 at 12:50 PM, and the DCO on 02/05/15 at 2:45 PM, revealed in addition to the eighty (80) "active" staff, three (3) staff members were currently on leave. Continued interview revealed the DON was responsible for scheduling and was tracking those staff members to ensure they were in-serviced prior to returning to work. Further interview revealed the facility had used Agency staff on occasion and notification was sent to the Agency of the required in-servicing prior to any further scheduling of Agency staff. In addition, the DON was tracking to ensure no Agency staff worked without receiving the education. She stated no Agency staff had worked at the facility since the in-services were initiated. Observations, on 01/28/15 at 11:30 AM and on 02/05/15 at 4:00 PM, revealed the Administrator, the DON and the Housekeeping Supervisor were on the resident units, observing staff and monitoring availability and proper use of PPE. 7. Review of QA records revealed an "Emergency" meeting was held on 01/26/15 at 7:30 PM, and was attended by the Medical Director, the DCO, the Administrator, the DON, the Assistant DON and the Housekeeping Supervisor, as evidenced by their signatures. Meeting attendees reviewed the confirmed cases of scabies, and recommendations from the Medical Director to treat all residents on the B wing, and to offer and encourage treatment to staff. Other items discussed included the initiation of Contact Precautions, body audits of all residents, cleaning and disinfection of resident rooms and common areas, and the prescribed treatment for [REDACTED]. Interview with the Administrator, on 02/06/15 at 2:45 PM, revealed the Medical Director had been present and very involved in developing and implementing the facility's action plan to remove the Immediate Jeopardy. He stated although it was not in the QA minutes, he had a conversation with the Medical Director whose stated intent was to complete a re-assessment of every resident in the facility once the treatment was completed. 8. Review of the Medication Administration Records for the B wing residents revealed all were treated with [MEDICATION NAME] cream on 01/27/15. Continued review revealed the cream was applied by licensed nursing staff. Review of the facility's schedule for applying the cream and subsequent showering of each resident revealed a minimum of eight (8) hours elapsed between application and removal of the cream. Interviews with RN #2 on 01/29/15 at 4:35 PM, SRNA #18 on 01/31/15 at 2:47 PM, RN #1 on 02/05/15 at 4:30 PM, SRNA #4 on 02/05/15 at 4:38 PM, and SRNA #15 on 02/05/15 at 6:04 PM, revealed