Every finding on record at Owsley County Health Care Center, Inc.

Based on interview, record review, and facility policy review, it was determined the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for two (2) of three (3) sampled residents. (Resident #43 and Resident #15). Resident #43 was diagnosed with Major Depressive Disorder on 09/06/2021 and Resident #43 was diagnosed with Moderate Major Depressive Disorder on 08/06/2020; however, the facility failed to ensure a Level II PASARR assessment was completed. The findings include: Review of the facility policy titled Preadmission Screening and Resident Review, dated 01/2021 revealed the designated facility personnel will be responsible for: Accurately completing and submitting the PASARR Level I screening for all individuals prior to admission; providing (with the Level I screening) a complete history and physical that reflects the individual's current functioning, lists all current medications, and is signed by a physician; providing the completed provisional admission forms (with the Level I screening) as applicable; ensure final determinations for PASARR are complete prior to admission (except for provisional admissions); appropriately reporting Significant Changes for PASARR/potentially PASARR individuals; and ensuring PASARR recommendations are part of the Nursing Facility (NF) Care Plan and are followed. Further view revealed, individuals who are found to have a potential serious mental illness, intellectual disability, or related condition through the Level I screen must participate in the Level II process in order to be admitted to, or remain in the facility, regardless of payment source. 1. Review of Resident #43's medical record revealed the facility admitted the resident on 05/30/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of six (6), indicating the resident was significantly cognitively impaired. Further record review revealed Resident #43 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that Resident #43 had a Level II PASARR assessment when the resident was newly diagnosed with Major Depressive Disorder on 09/06/2021. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 10/02/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of fourteen (14), indicating the resident was cognitively intact. Further review revealed Resident #15 was diagnosed with Moderate Major Depressive Disorder on 08/06/2020. There was no documented evidence that Resident #15 had a Level II PASARR assessment when the resident was newly diagnosed with Moderate Major Depressive Disorder on 08/06/2021. Interview with the Admissions Coordinator, on 01/05/2021 at 12:00 PM, revealed he/she was responsible for completing PASARR screening assessments for residents and was unaware that she was supposed to ensure a Level II PASARR assessment was completed on Resident #43 and Resident #15 following new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #15. Interview with Director of Nursing (DON), on 01/07/2022 at 1:35 PM, revealed she was not aware PASARR Level II was to be completed for new psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated a PASARR Level ll should have been completed for Resident #43 following his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 01/07/202 at 2:10 PM, revealed she was not aware the Level II PASARR's were not being completed when residents received a new psychiatric diagnosis. She further stated Level II PASARR's should have been completed for Resident #43 and Resident #15 when the residents both received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, record review, and facility policy review, it was determined the facility failed to provide written notice to the resident and resident's representative at the time of transfer for hospitalization s that specified the duration of the bed-hold policy for two (2) of five (5) sampled residents (Resident #46 and #37). The findings include: Review of the facility policy titled, Resident Bed Hold, dated 06/08/2021, revealed the facility would follow regulatory guidance for bed hold procedure. 1. Record review revealed the facility admitted Resident #37 on 09/30/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of this resident's Nursing Home to Hospital Transfer documentation, dated 12/23/21, revealed Resident #37 was transferred to an acute care hospital on 12/23/2021; however, there was no documented evidence in the medical record of a Bed Hold offered to this resident or resident's representative until 12/29/2021 approximately six (6) days after transfer. 2. Record review revealed the facility admitted Resident #46 on 03/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility transfer to hospital documentation dated 10/25/2021, revealed Resident #46 was transferred to an acute care hospital on 10/25/2021; however, the facility had no documented evidence of a Bed Hold offered to the resident until 11/01/2021, when the resident was readmitted to the facility approximately six (6) day after the transfer. Interview with Bookkeeper, on 01/05/2022 at 6:00 PM and 6:20 PM, revealed she was responsible for providing residents with bed hold notification. She stated that she was unaware that the regulatory guidance indicated a specified time frame. Interview with the Director of Nursing (DON), on 01/07/2022 at 1:35 PM, revealed she was unaware that the facility was not providing bed hold upon transfer per regulatory guidelines. Interview with the Administrator, on 01/07/2022 at 1:45 PM, revealed she was unaware the facility was not providing bed hold upon transfer per regulatory guidelines. She stated after the Bookkeeper and/or Minimum Data Set (MDS) Nurse was responsible for notification of bed hold. She stated that Resident #46 and #37 should have had been offered bed hold upon transfer/discharge from the facility.

Based on record review, staff interview and review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) the facility failed to issue a NOMNC form to a resident, or his/her responsible party, two (2) days before the last day of coverage as indicated on the completed NOMNC forms; for one (1) of three (3) residents sampled for Beneficiary Protection Notification (Resident #65). The findings include: Review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- revealed A Medicare health provider must give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled nursing, no later than two days before the termination of services. Review of Resident #65 record revealed the facility admitted the resident to Medicare Part A Services on 10/27/2021 and discharged the resident home on 12/13/2021. Further record review revealed the facility did not provide the resident or his/her representative a NOMNC notice two (2) days before the last day of coverage for a planned discharged on [DATE]. Interview with Minimum Data Set (MDS) Nurse, on 01/05/2022 at 3:53 PM, revealed she did not provide Resident #65 with a NOMNC prior to discharge. She stated she was unaware the resident was required to have a NOMNC form due to being discharged home. She stated that Resident #65 was a planned discharged from the facility.

Based on observation, interview, record review, and a review of the facility policy, it was determined the facility failed to ensue one (1) of three (3) sampled residents (Resident #1) received adequate supervision to prevent accidents. On 09/05/2021, Resident #1, who was cognitively impaired and at risk for falls, was left unsupervised by staff when the resident was sitting on the facility front porch. The findings include: A review of the facility policy for supervision of residents titled Accidents and Supervision dated 12/09/2020 revealed it was facility policy to provide adequate supervision based on the individual need of each resident. A review of the medical record for Resident #1 revealed the facility admitted the resident on 07/02/2015 with diagnoses, which included [CONDITION(S)], Repeated Falls, Difficulty in Walking, and [CONDITION(S)]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed to be severely impaired for cognition with a Brief Interview for Mental Status (BIMS) score of five (5). Additional review of the MDS revealed Resident #1 was assessed to require the assistance of one staff for ambulation and transfers, and was assessed to be at risk for falls. A review of the wander elopement risk assessment completed for Resident #1 on 07/14/2021 revealed the resident was assessed to not be a wander or elopement risk. Interview with Housekeeper #1, on 09/21/2021 at 2:55 PM, revealed the Housekeeper pushed Resident #1 outside in his/her wheelchair to sit on the front porch of the facility on 09/05/2021 at 11:00 AM. According to Housekeeper #1, she went to her car for a few minutes in the facility parking lot to get some cigarettes and left the resident unsupervised on the front porch of the facility. Housekeeper #1 stated she was unaware she needed to stay right with the resident because the resident was sitting on the front porch and the Housekeeper could see the porch from her car. Interview with LPN #1, on 09/21/2021 at 1:15 PM, revealed on 09/05/2021 at approximately 11:00 AM, she was returning from lunch and she observed Resident #1 sitting on the front porch with a housekeeping staff. The LPN stated she instructed State Registered Nurse Aide (SRNA) #1 and SRNA #2 to bring the resident back into the facility for lunch. Interview with SRNA #1, on 09/21/2021 at 1:50 PM, revealed she and SRNA #2 went to the front porch to bring Resident #1 back inside the facility on 09/05/2021, and the resident was unattended on the front porch. According to SRNA #1, no staff was with the resident on the porch and she did not see a staff member outside when she went to the front porch to bring the resident back into the facility. Interview with SRNA #2, on 09/21/2021 at 2:10 PM, revealed he and SRNA #1 was instructed by LPN #1 to go outside and bring Resident #1 in from the porch at lunchtime. According to SRNA #2, Resident #1 was sitting in a rocking chair on the front porch and no staff members were with the resident on the porch or outside. The SRNA stated LPN was notified the resident was unsupervised on the porch and the LPN notified the Director of Nursing. Observation of the facility front porch and parking lot conducted on 09/21/22 at 3:00 PM, revealed the facility parking lot was adjacent to busy state highway. Further observation revealed housekeeper #1 traveled approximately 90 feet from the front porch of the facility to get to the area where her car was located. The porch was level with the pavement which lead to the parking lot and the parking lot was easily accessed from the porch. An interview with the Director on Nursing (DON), on 09/22/2021 at 2:20 PM, revealed the resident would require staff supervision if outside the facility. The DON stated she would expect staff to remain on the porch with the resident if they took the resident outside to ensure the resident was safe. Interview with the Administrator, on 09/22/2021 at 2:34 PM, revealed she would expect staff to remain on the porch with the resident or close enough to supervise the resident if the resident was outside on the porch because the resident was cognitively impaired. The Administrator stated the resident being left unsupervised could be a safety issue due to the facility parking lot being a high traffic area and a major highway being adjacent to the facility parking lot. The Administrator stated a cognitively impaired resident could be hit by a car or fall and get hurt if not supervised by staff.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident received adequate supervision and devices to prevent accidents for one (1) of three (3) sampled residents (Resident #3). On 06/30/2020, State Registered Nurse Aide (SRNA) #3 was transporting Resident #3 via wheelchair in the resident's room when the resident slid from the wheelchair. The resident sustained [REDACTED]. The fall investigation revealed Dycem (nonslip material) should have been in Resident #3's wheelchair. However, the Dycem (nonslip material) was not in place at the time of Resident #3's fall. The findings include: Review of the facility's policy titled, Falls Management, dated 01/13/2020, revealed all residents who had been determined to be at increased risk for falls would have an individual falls risk care plan developed with appropriate interventions to minimize falls and injuries. Review of the medical record for Resident #3 revealed the facility admitted the resident on 07/24/2015, with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment completed for Resident #3 dated 04/15/2020, revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident had severely impaired cognition and was therefore not interviewable. The MDS also revealed the facility had assessed the resident to require the extensive assistance of one (1) person for locomotion, and required a wheelchair. The MDS indicated the resident had not sustained any falls during the assessment period. Review of the care plan for Resident #3 dated 04/21/2020, revealed an intervention for the resident to have Dycem (nonslip material) placed in his/her chair to help keep the resident fall free. Review of a Fall Risk Assessment completed by the facility for Resident #3 dated 05/11/2020, revealed the facility had assessed the resident to be at moderate risk for falls. Review of the nurse's notes for Resident #3 dated 06/30/2020 at 5:28 PM, revealed SRNA #3 reported Resident #3 slid out of his/her wheelchair as the SRNA turned the resident's wheelchair to face the sink in order to provide routine care. The nurse's notes revealed an assessment was completed and the only injury was documented to be a scrape to the resident's right posterior side adjoining the rib cage area. The nurse's notes revealed Resident #3 had denied any pain or discomfort. Review of a fall investigation for Resident #3 revealed on 06/30/2020 at 3:15 PM, SRNA #3 was transporting the resident to the sink in the resident's room and the resident slid out of the wheelchair. The resident sustained [REDACTED]. The investigation revealed Dycem (nonslip material) was supposed to have been in place in Resident #3's wheelchair. However, the Dycem (nonslip material) was not in place at the time of Resident #3's fall. Interview conducted with SRNA #3 on 08/11/2020 at 3:30 PM, revealed Resident #3 had slid out of the wheelchair while she was attempting to turn the wheelchair toward the sink. The SRNA stated Dycem (nonslip material) was not in the resident's wheelchair. The SRNA stated it should have been. The SRNA stated she did not know why the Dycem had not been in the wheelchair. Interview conducted with the Director of Nursing (DON) on 08/12/2020 at 10:15 AM, revealed she was aware the Dycem had not been in Resident #3's wheelchair when the resident experienced the fall. The DON stated SRNA #3 no longer worked at the facility. The DON stated she made rounds daily to ensure residents were safe from accident hazards. The DON stated the Dycem should have been in Resident #3's wheelchair.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the comprehensive care plan for one (1) of three (3) sampled residents (Resident #3). Review of Resident #3's care plan dated 04/21/2020, revealed the resident was to have Dycem (nonslip material) placed on his/her chair to prevent falls. Review of a fall investigation dated 06/30/2020 revealed Resident #3 had slid out of his/her wheelchair while State Registered Nurse Aide (SRNA) #3 was turning the wheelchair in the resident's room. The fall investigation revealed Dycem (nonslip material) had not been in place in the resident's wheelchair. The findings include: Review of the facility's policy titled, Comprehensive Person Centered Care Planning, dated November 2017, revealed interventions would be developed with specific care area needs and approaches that were necessary for the SRNA to provide care to individual residents. A review of the medical record for Resident #3 revealed the facility admitted the resident on 07/24/15, with [DIAGNOSES REDACTED]. A review of an annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident had severely impaired cognition and was therefore not interviewable. The MDS also revealed the facility had assessed the resident to require the extensive assistance of one (1) person for locomotion, and required a wheelchair. The MDS indicated the resident had not sustained any falls during the assessment period. A review of Resident #3's care plan dated 04/21/2020 revealed an intervention for the resident to have Dycem (nonslip material) placed in his/her chair to help keep the resident fall free. A review of a fall investigation for Resident #3 revealed on 06/30/2020 at 3:15 PM, SRNA #3 was transporting the resident by wheelchair to the sink in the resident's room and the resident slid out of the wheelchair. The resident sustained [REDACTED]. The investigation revealed Dycem (nonslip material) was supposed to have been in place in Resident #3's wheelchair. However, the Dycem (nonslip material) was not in place at the time of Resident #3's fall. Interview conducted with SRNA #3 on 08/11/2020 at 3:30 PM, revealed she was required to check the care plan at the beginning of every shift. The SRNA stated she was aware Resident #3 was required to have Dycem (nonslip material) in his/her wheelchair to prevent falls. The SRNA stated she should have checked and did not know why she had not. Interview conducted with the Director of Nursing (DON) on 08/12/2020 at 10:15 AM, revealed staff were required to check care plans at the beginning of every shift. The DON stated she made rounds several times daily to ensure residents received care as directed by their care plans. The DON stated she had been aware the Dycem (nonslip material) had not been in Resident #3's wheelchair when the resident slipped out of the wheelchair on 06/30/2020 and stated it should have been.

Based on interview and record review, the facility failed to ensure the care plan for one (1) of four (4) sampled residents (Resident #3) was reviewed and revised related to aggressive behaviors. Resident #3 had a history of [REDACTED]. On 03/04/2020, Resident #3 hit Resident #6 on the back of the head and dashed cold coffee on Resident #6 after Resident #6 accidently bumped into Resident #3. On 07/16/2020, Resident #4 wandered into Resident #3's room and Resident #3 hit Resident #4 in the face with his/her fist. However, the facility failed to revise Resident #3's care plan to address the resident's aggression toward other residents. On 07/25/2020, Resident #2 was wandering in the hallway near Resident #3's room when Resident #3 pushed Resident #2 causing Resident #2 to fall to the floor. Resident #2 sustained a non-displaced [MEDICAL CONDITION] as a result of the fall. The findings include: Review of the facility policy titled, Behavior Management Policy, dated 11/01/2019, revealed residents will be monitored at least quarterly and PRN (as needed) for care plan effectiveness and revisions as indicated. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the Minimum Data Set (MDS) assessment completed 05/27/2020 was an annual assessment and documented that the resident did not exhibit behaviors. The MDS further noted that the resident's Brief Interview for Mental Status (BIMS) score was six (6) which indicates severe cognitive impairment. Review of the progress notes for Resident #3 revealed the resident displayed aggressive/combative behavior toward staff on 01/21/2020. The progress note revealed that Resident #3 hit a State Registered Nursing Assistant (SRNA) in the face during care. Review of the comprehensive care plan revealed Resident #3 had a potential for alteration in mood/behavior that was initiated on 04/25/2017 and revised on 06/08/2020. The interventions included to assist the resident in getting snacks and coffee as requested, educate the resident to allow others plenty of time to move out of the way, and to get older staff members to do care when the resident will not allow others to help. Further review of the care plan revealed that Resident #3 did not like change, had a history of [REDACTED]. The care plan did not include person-centered interventions related to Resident #3's aggressive behaviors toward other residents. Review of facility investigations revealed that Resident #3 was involved in resident-to-resident altercations on 07/24/2019, 03/04/2020, 07/16/2020, and 07/25/2020. Review of the facility investigation dated 07/26/2019 revealed on 07/24/2019 at approximately 4:45 PM, Resident #3 was in the dining room sitting at a table with Resident #5, and Resident #3 dashed Resident #5 with cold coffee. The investigation further noted that there were no injuries and the resident's care plans were updated. Review of the comprehensive care plan for Resident #3 revealed an intervention initiated on 07/24/2019 related to the resident-to-resident altercation to encourage the resident to ask for assistance with coffee and not to dash it on others. Other interventions were to observe for mood changes and report to the physician and do a pharmacy review as needed. Review of the facility investigation dated 03/06/2020 revealed that on 03/04/2020 at approximately 12:40 PM, Resident #6 was propelling his/herself in a wheelchair in the hallway and accidentally bumped into Resident #3. Resident #3 hit Resident #6 on the back of the head and dashed cold coffee on Resident #6. The investigation noted that Resident #6 did not sustain any injury related to the incident and Resident #6 was moved to a different room (the residents were roommates at the time). Further review of the investigation revealed that the actions taken to protect residents included an update of the care plan. However, review of Resident #3's care plan revealed no new interventions after the 03/04/2020 incident. Review of the facility investigation dated 07/20/2020 revealed on 07/16/2020 at approximately 3:40 PM, Resident #4 walked/wandered into Resident #3's room. The investigation stated that Resident #3 asked Resident #4 to leave the room, but Resident #4 did not understand so Resident #3 became aggressive and hit Resident #4 on the left side of the face with his/her fist. The investigation further stated that the actions taken to protect residents were that the care plans were updated. Review of the care plan revealed that the interventions that were put into place after the incident on 07/16/2020 were to follow up with psychiatric services at the next visit and to do a medication review to see if the resident's medication needs adjusting for behaviors. Further review of the care plan revealed no other interventions to address the resident's aggression toward other residents. Review of the facility investigation dated 07/29/2020 revealed on 07/25/2020 at approximately 6:00 PM, Resident #2 wandered down the hallway where Resident #3 resided. Resident #3 came out of his/her room and Resident #2 was in his/her pathway and Resident #3 pushed/shoved Resident #2 and Resident #2 fell /sat down on the floor. The investigation further revealed that Resident #2 sustained a [MEDICAL CONDITION] ramus (pelvis) as a result of the incident. Interview with State Registered Nursing Assistant (SRNA) #2 on 07/30/2020 at 4:34 PM revealed that Resident #3 was independent with most of his/her activities of daily living and did not like it when others get in (his/her) way. Interview with SRNA #3 on 07/31/2020 at 10:31 AM revealed Resident #3 could get aggressive at times, but it was usually with staff. She stated the resident was protective of his/her belongings and did not like others to bother his/her belongings. Interview with Licensed Practical Nurse (LPN) #2 on 07/30/2020 at 4:11 PM revealed she was the MDS (Minimum Data Set) Nurse for the East Wing of the facility. She further stated that she did not do the section of the MDS related to behaviors. Per the LPN, the Social Services Director (SSD) did that section of the MDS and the behavior care plan as well, and then the Interdisciplinary Team (IDT) reviewed the care plan. Interview with the SSD on 08/04/2020 at 1:40 PM revealed she does the behavior section on the MDS and develops the care plan with the IDT. She stated that the facility has a behavior meeting monthly and reviews incidents of behaviors in the morning meetings. The SSD further stated the monthly behavior meeting focused on review of the [MEDICAL CONDITION] medications and the morning clinical meeting focused more on behaviors. She stated that she does not necessarily have the documents of the behaviors to review and that the staff just know the residents and their behaviors. The SSD stated she can make revisions to the behavior care plan when necessary and that the team tried to put interventions in place for Resident #3 to prevent the aggressive behavior.

Based on interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Residents #2 and #4) were free from abuse. On 07/16/2020 at 3:40 PM, Resident #4 wandered into Resident #3's room. Resident #3 struck Resident #4 on the face because Resident #4 did not leave the room immediately. Then on 07/25/2020, Resident #2 was wandering in the hallway outside of Resident #3's room. Resident #3 shoved Resident #2, causing Resident #2 to fall to the floor. Resident #2 sustained a non-displaced [MEDICAL CONDITION] as a result of the fall. The findings include: Review of the facility policy titled, Policy on Abuse, (undated) revealed the facility will actively promote the absence of abuse and the resident has the right to be free from abuse. The policy further defined abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish. The facility defined willful as the individual must have acted deliberately, not that the individual intended to inflict harm. Review of the medical record for Resident #3 revealed the facility admitted the resident on 07/01/2009 and the resident's [DIAGNOSES REDACTED]. Further review of the record revealed the Minimum Data Set (MDS) assessment completed on 05/27/2020 was an annual assessment and documented that the resident did not exhibit behaviors. The MDS further noted that the resident's Brief Interview for Mental Status (BIMS) score was six (6) which indicated severe cognitive impairment. Review of the progress notes for the resident revealed the resident displayed aggressive/combative behavior toward staff on 01/21/2020, and on 03/04/2020 Resident #3 threw coffee on another resident in the hallway and hit the resident on the back of the head when the resident was in Resident #3's way. Review of the facility investigation dated 03/06/2020 revealed the facility investigated the incident and determined that there were no injuries related to the incident. Review of the comprehensive care plan revealed Resident #3 had a potential for alteration in mood/behavior that was initiated on 04/25/2017 and revised on 06/08/2020. The interventions included to assist the resident in getting snacks and coffee as requested, educate the resident to allow others plenty of time to move out of the way, and to get older staff members to do care when the resident will not allow others to help. Further review of the care plan revealed the resident did not like change and the resident had a history of [REDACTED].#3 was reluctant to interact with others. Interviews with staff that worked with Resident #3 including the Social Services Director on 07/29/2020 at 2:55 PM, State Registered Nursing Assistant (SRNA) #1 on 07/30/2020 at 4:26 PM, and SRNA #2 on 07/30/2020 at 4:34 PM, revealed Resident #3 was territorial and did not like to be bothered, would get agitated easily, and did not like for people to be in his/her way. 1. Review of the medical record for Resident #4 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment completed on 05/06/2020 revealed the resident displayed wandering behavior one (1) to three (3) days during the lookback period. Further review of the MDS revealed Resident #4's BIMS score was one (1) indicating severe cognitive impairment and that the resident was not interviewable. Review of the care plan revealed interventions for the wandering behavior initiated on 03/03/2020 which included redirecting the resident from wandering by offering diversional activities such as food or a doll. Review of a facility investigation dated 07/16/2020 revealed at 3:40 PM, Resident #4 wandered into Resident #3's room. The investigation stated that Resident #3 asked Resident #4 to leave the room; however, Resident #4 did not understand the request. Resident #3 then became aggressive toward Resident #4 and hit Resident #4 on the left side of the face with his/her fist. The investigation further revealed a State Registered Nursing Assistant (SRNA) heard screaming and went to the room to separate the residents, but it was over. Resident #3's roommate reported that he/she saw the event as it was reported. Resident #4 was removed from the room and was noted to have redness to the left side of the face/cheek and the left hand, and Resident #4 complained of pain to the left hand. The investigation further revealed that x-rays were ordered and completed of Resident #4's face and hand with no fractures or dislocations noted. Interview with Licensed Practical Nurse (LPN) #1 on 7/31/2020 at 10:22 AM revealed she worked on the East Wing where Resident #4 and Resident #3 resided. LPN #1 stated she was not working when the incident occurred between the residents, but had been told about the incident. LPN #1 stated that she was not aware of any changes made to Resident #3's care plan or Resident #4's care plan after the incident. The LPN further stated that they just tried to keep Resident #4 out of that area after the incident and no further interventions were put into place to prevent wandering residents from entering Resident #3's room. Interviews with SRNA #3 on 07/31/2020 at 10:31 AM and with SRNA #4 on 08/01/2020 at 9:03 AM revealed that they worked on the East Wing where Resident #3 and Resident #4 resided. Both of the SRNAs stated they were not working when the incident occurred between Resident #3 and Resident #4 and were not aware of the incident. In addition, both stated they were not aware of any changes that had been made to the care plans for the residents. Interview with Resident #9 on 07/30/2020 at 12:20 PM revealed he/she was Resident #3's roommate before the resident was moved on 07/25/2020. Resident #9 stated that when the incident occurred between Resident #3 and Resident #4, he/she was coming out of the bathroom and saw Resident #3 hit Resident #4 in the face. Resident #9 stated he called for help and staff came and took Resident #4 out of the room. Resident #9 did not know if Resident #4 sustained injuries from the incident. Review of the record for Resident #9 revealed the resident's BIMS score was fifteen (15) indicating that the resident was cognitively intact. Review of the Care Plan for Resident #3 revealed it was revised on 07/16/2020 with an intervention for the resident to be seen by telehealth psychiatric services. Further review of the record revealed Resident #3 had routine telehealth psychiatric visits every four (4) weeks and had previously been seen on 06/25/2020. Resident #3 was seen on 07/23/2020 by telehealth for the routine visit. The psychiatric nurse practitioner recommended an increase in the resident's [MEDICATION NAME] (anti-psychotic medication) which was approved and initiated on 07/25/2020. There was no evidence of any other interventions initiated for Resident #3 related to the incident. Interview with the Social Services Director on 08/04/2020 at 1:40 PM revealed she investigated the incident between Resident #3 and Resident #4. She stated that Resident #4 did wander in the facility, but did not usually go down the hallway where Resident #3 resided. She stated the only interventions they put into place after the incident was the psychiatric consultation for Resident #3, and to redirect Resident #4 when wandering. 2. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment with a reference date of 05/20/2020 revealed the resident had wandering behavior one (1) to three (3) days during the reference period. Further review of the MDS revealed the resident's BIMS score was two (2) indicating severe cognitive impairment and that the resident was not interviewable. Review of the Comprehensive Care Plan with an initiation date of 02/25/2020 and revision date of 05/21/2020 revealed Resident #2 was at risk for elopement due to wandering behavior and the interventions for the wandering behavior included to redirect the resident to the lounge when he/she was wandering toward the exits or to other residents' rooms. Review of the facility's final investigation dated 07/29/2020 revealed on 07/25/2020 at approximately 6:00 PM, Resident #2 wandered down the hallway where Resident #3 resided. The investigation further stated that Resident #3 came out of his/her room and Resident #2 was in Resident #3's pathway and Resident #3 then pushed/shoved Resident #2 out of his/her way. Resident #2 fell /sat down on the floor as a result of the push and Resident #2 complained of pain to the lower back and buttocks. The investigation further stated that x-rays were performed and a CT (computerized tomography) scan was completed and Resident #2 had a non-displaced [MEDICAL CONDITION] inferior pubic ramus (pelvis). Interview with Resident #9 on 07/30/2020 at 12:20 PM revealed he/she was in the bathroom when the incident occurred between Resident #2 and Resident #3. Resident #9 stated when he/she came out of the bathroom, Resident #2 was on the floor and he heard yelling. Resident #9 stated that staff responded quickly to the incident. Interview with Resident #10 on 07/30/2020 at 12:15 PM revealed he/she witnessed the incident with Resident #2 and Resident #3 on 07/25/2020. Resident #10 stated he/she was in his/her room and the incident happened in the hallway just outside of his/her room, which was directly across the hallway from Resident #3's room. Resident #10 stated that Resident #2 was walking in the hallway and Resident #3 pushed Resident #2 causing Resident #2 to fall. Resident #10 stated that Resident #2 wasn't doing anything when Resident #3 pushed him/her. Resident #10 stated that he/she called out for help and staff responded right away to take care of Resident #2. Review of the list of residents with their BIMS scores provided by the facility revealed the BIMS score for Resident #10 was fifteen (15) indicating Resident #10 was cognitively intact. Interview with SRNA #3 on 07/31/2020 at 10:31 AM revealed she was working on 07/25/2020 when the incident occurred between Resident #2 and Resident #3. She stated she was in the dining room when the incident occurred. SRNA #3 further stated that Resident #2 wanders all over East Wing and the resident is easily redirected. SRNA #3 stated she was unaware of Resident #3 being aggressive toward other residents prior to this incident. Interview with SRNA #5 on 07/29/2020 at 2:10 PM revealed she was working on 07/25/2020 when the incident occurred between Resident #2 and Resident #3. She stated she heard another resident yell that Resident #3 pushed Resident #2. She stated that Resident #2 was on the floor and the nurses came and assessed the resident and assisted the resident to his/her room. SRNA #5 stated that Resident #3 can be aggressive and has been aggressive toward staff and other residents in the past. Interview with Registered Nurse (RN) #1 on 07/29/2020 at 2:30 PM revealed she was working on 07/25/2020 when the incident occurred between Resident #2 and Resident #3. She stated that another resident called out and when they arrived Resident #2 was on the floor and complained that his/her back and bottom were hurting. RN #1 stated the other nurse that was working assessed Resident #2 and she assessed Resident #3. She stated Resident #3 had no injuries and that when Resident #3 was asked about the incident, he/she stated, (he/she) was in my way. Interview with RN #2 on 07/29/2020 at 2:03 PM revealed she was working on 07/25/2020 when the incident occurred. She stated she is the Quality Assurance (QA) Nurse for the facility and was in the building assisting the nurses. RN #2 stated that she saw Resident #2 sitting on the floor and complaining of pain in his/her back. RN #2 stated she assessed Resident #2 for injuries and called the doctor and got an order for [REDACTED].#2 stated that Resident #2 was known to wander on East Wing hall and often went into other residents' rooms. She stated that they would try to redirect the resident and some of the residents would notify staff when Resident #2 was going into other residents' rooms. RN #2 stated staff had a difficult time keeping up with Resident #2. Further interview with RN #2 revealed that she talked to Resident #3 after the incident with Resident #2 and Resident #3 admitted to pushing Resident #2. Interview with the Social Services Director on 07/29/2020 at 2:55 PM and on 08/04/2020 at 1:40 PM revealed she does the abuse investigations for the facility and investigated the incidents with Resident #2, Resident #3, and Resident #4. She stated that Residents #2 and #4 were known to wander on the East Wing of the facility and Resident #3 was known to be territorial and did not like to be bothered. She stated that the facility decided to move Resident #3 to a different wing of the facility after the incident with Resident #2 because there were fewer residents who wander on the West Wing. The Social Services Director stated that they did not implement any further interventions after the incident on 07/16/2020 with Resident #4 because Resident #4 did not usually wander on the hallway where Resident #3 resided, and they did not consider concerns with other residents who wandered. Interview with the Administrator on 08/04/2020 at 3:12 PM revealed that any time there is an allegation of abuse, she is notified. She stated that the investigation did reveal that Resident #3 pushed Resident #2 and the decision was made to move Resident #3 to a different wing. The Administrator stated she was unaware of interventions that were put into place after the incident on 07/16/2020 with Resident #3 and Resident #4 and that the former Director of Nursing (DON) would know more about the incident; however, the former DON was unavailable to be interviewed at that time.

Based on interviews, record review, and the facility's visitation policy, it was determined that the facility failed to ensure end of life visitation rights were honored one (1) of three (3) sampled residents (Resident #1). Review of the record for Resident #1 revealed the resident's health status had declined over a three (3) month period, with a significant mental/physical change assessment performed on [DATE]. Further review of the record revealed a significant decline in Resident #1's health status was noted on [DATE] during which the family was notified. The family requested visitation; however, the family was not given the opportunity to visit at that time and Resident #1 expired on [DATE] at approximately 6:15 AM without receiving visitors. The findings include: The facility provided a copy of the Centers for Medicare and Medicaid Services (CMS) recommended guidelines that suggest limiting visitation in long-term care (LTC) facilities during the COVID-19 outbreak, which made allowances for residents with end of life concerns to receive visitation. Interview with the facility Administrator on [DATE] at 2:00 PM revealed the facility was using the CMS guidance as well as recommendations from the Centers for Disease Control and Prevention (CDC) when considering visitors in the facility at this time. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated [DATE] and performed due to a significant change in Resident #1's health status, revealed Resident #1's cognition had moderate impairment with a brief interview for mental status (BIMS) score of 10. Further review of Resident #1's MDS assessment revealed that he/she listed the question, How important is it to you to have your family or a close friend involved in discussions about your care? as 1- Very Important. Further review of Resident #1's records revealed that a care plan meeting was held on [DATE] at 2:07 PM to discuss Resident #1's mental and physical declines and change in health status, including that Resident #1 has not rebounded from acute illnesses as it was thought they might. Further review of the record for Resident #1 revealed a nursing progress note dated [DATE] at 11:55 AM that stated the physician was notified due to a decline in the resident's status. The resident was unable to sit up and was holding food in his/her mouth and not wanting to swallow it. The note further revealed that the physician offered no new orders. Another nursing progress note dated [DATE] at 9:19 PM revealed the resident did not meet his/her fluid need for the day because the resident was declining. Nursing Progress notes for [DATE] at 8:00 AM and 6:07 PM revealed Resident #1 was refusing to eat, breathing hard, not talking or responding when spoken to, and was weak. Review of a nursing progress note dated [DATE] revealed that at 4:00 AM staff checked on the resident; the resident was resting and vital signs were obtained. Further review of the nursing progress notes for [DATE] revealed at 5:51 AM, Resident #1 had labored breathing and the resident's skin was mottling (a condition where the heart is no longer able to pump blood effectively and the skin becomes discolored). The note also stated that the family was notified of the changes and was on their way to the facility. The progress notes for [DATE] further revealed that at 6:15 AM, Resident #1 did not have a pulse or respirations and that the family arrived at approximately 6:30 AM. An interview conducted with Resident #1's family member on [DATE] at 11:26 AM revealed she received a call on Sunday, [DATE], from a nurse at the facility (did not remember who) and was told that Resident #1 was declining. She stated someone from the facility called again on [DATE] and stated that the resident's condition was continuing to decline. She stated she asked the nurse if her family member was dying and was told that she was probably getting close to death. The family member stated that she reached out to the Director of Nursing (DON) on [DATE] and requested a visit because it appeared that her family member was dying. She stated the DON told her that the Administrator would be calling regarding the visitation; however, she did not receive a phone call from the Administrator. She stated she received a call early in the morning on [DATE] and was told she should come to the facility because Resident #1 was dying. The family member stated that she had not visited Resident #1 since the restrictions were put into place due to the pandemic and did not request to visit until she was told by nursing staff at the facility that they felt Resident #1 was getting close to death. The family member stated that Resident #1 died before the family arrived at the facility. Interview with Registered Nurse (RN) #4 on [DATE] at 10:49 AM revealed she remembered calling the family on a Sunday (she did not recall the exact date) and discussing with the family that the resident was not eating well and was declining. RN #4 stated the family did not request a visit at that time and she was not aware if they ever requested a visit. RN #4 stated the Administrator would make the decision during this time as to whether family could visit or not due to the restrictions related to the pandemic. The DON resigned on [DATE] and was unavailable for interview. Interview with the Administrator on [DATE] at 3:12 PM revealed that she and the previous Infection Preventionist had a meeting about Resident #1 on [DATE] because the family had requested to visit with the resident and the facility was only allowing visits for end of life situations. The Administrator stated that the resident's health had fluctuated, but they told the family they would have a meeting to discuss whether they could visit and get back with them. The Administrator further stated that she could not remember all of the details but she thought the DON at the time had talked with the family as well. The Administrator stated the resident passed before they had a chance to decide if the family could visit.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to establish an Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program to include antibiotic use protocols and a system to monitor antibiotic use. The facility was unable to submit documented evidence of an Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use in order to optimize the treatment of [REDACTED]. The findings include: Review of facility policy titled, Antibiotic Stewardship Policy, dated 01/04/18, revealed the Antibiotic Stewardship Committee would support and promote antibiotic use protocols. Interview with the Infection Control Preventionist, on 04/04/19 at 3:52 PM, revealed the facility did not have antibiotic use protocols in place. She further stated the Antibiotic Stewardship Program was not yet off the ground. The Infection Control Preventionist stated the pharmacist was unable to attend meetings for the last four (4) months to review antibiotic prescribing. Continued interview revealed the Committee was working on the implementation of Antibiotic Stewardship Requirements. Interview with the Director of Nursing (DON), on 04/04/19 at 3:52 PM and 4:48 PM, revealed she had oversight for the Infection Control Preventionist and the Antibiotic Stewardship Program. She stated antibiotic prescribing protocols were important to reduce unnecessary antibiotic usage. Continued interview revealed the protocols for the Antibiotic Stewardship Program were not yet developed and utilized. Upon further interview, the DON stated the regulations for antibiotic usage prescribing protocols would help the Antibiotic Stewardship Program engage the providers. The DON stated the use of antibiotic prescribing protocols would help prevent resistant organisms and the unnecessary use of antibiotics which, in turn, helped residents achieve better outcomes. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed her expectation for the Director of Nursing and the Infection Control Preventionist to manage the infection control activities for the facility. She stated adherence to the Antibiotic Stewardship processes was important for ensuring optimal outcomes for residents.

Based on interview, record review and review of facility's Policies, it was determined the facility failed to establish an Infection Prevention and Control Program (IPCP) that included an annual review of its IPCP in order to update their program as necessary. The facility was unable to submit documented evidence its IPCP and infection control policies were reviewed annually. The findings include: Review of facility's Policy titled, Antibiotic Stewardship Policy, dated 01/04/18, revealed there was no documented evidence an annual review was performed in (MONTH) 2019. Review of facility's Policy titled, Procedural Guideline for Isolation Precautions, undated, revealed there was no documented evidence an annual review was performed. Review of facility's Policy titled, Policy for Influenza/Pneumococcal Vaccination of Residents, undated, revealed there was no documented evidence an annual review was performed. Review of facility's procedure titled, Procedure for Isolation: Initiation of Isolation, undated, revealed there was no documented evidence an annual review was performed. Interview with the Infection Control Preventionist, on 04/04/19 at 3:52 PM, revealed infection control policies had not undergone annual review. She stated she was unaware of the review requirement and had not facilitated an annual infection control policy review. The Infection Control Preventionist stated she was new to the role and was learning infection control requirements. Interview with the Director of Nursing (DON), on 04/04/19 at 4:48 PM, revealed the facility had reviewed the Infection Prevention and Control policy on 09/17/18; however, other infection control policies had not received an annual review. She stated the Infection Control Preventionist was new and learning the position and all infection control policies had not received annual review. The DON stated the purpose of annual infection control policy review was to ensure policies reflected current best practice and residents received optimal care. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed the Infection Control Preventionist (ICP) had responsibility for coordinating infection control policy reviews. The Director of Nursing (DON) had oversight responsibility for Infection Control. The Administrator stated it was important for infection control policies to undergo annual review to ensure the policies were consistent with current practice.

Based on observation, interview, record review, and review of facility's Policies, it was determined the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support the residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (2) of twenty-two (22) sampled residents (Resident #37 and Resident #46). 1. Resident #37's Care Plan and Activity Log revealed the resident watched television, the resident did not have a television and no staff had observed the resident watching television. In addition, at the time of survey, Resident #37 was confined to his/ her room based on his/her roommate's medical condition requiring isolation precautions. Resident #37 enjoyed being in the hallway and was deprived of this activity with no individual activities offered in the room. 2. Resident #46's Activity logs were not complete, and did not provide activities per Resident #46's preferences, nor did the facility provide any 1:1 activities while the resident was confined to his/ her room for tube feeding. The findings include: Review of facility's Policy titled, Activity Program Policy and Procedure, revised 11/01/18, revealed individual activities were developed in accordance with the comprehensive assessment. The policy further stated periodic evaluation of the appropriateness of activities would be conducted with changes in programming as needed. The Activities Coordinator was responsible for the direction of the ongoing plan for resident activities. Review of the facility job description titled, Activity Coordinator revealed the Activity Coordinator was responsible for developing, initiating, implementing, and maintaining a comprehensive resident centered activity program for each resident. The job responsibilities included assessing each resident's activity needs, assessment and completion of assigned sections of the Minimum Data Set (MDS), development of the resident's activity care plan with review, and updating to the Care Plan as needed. Review of Activity Calendars for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 revealed group activities were offered each day. Further review revealed in (MONTH) two (2) Sunday activities were TV Time, in (MONTH) one (1) Sunday activity was TV Time, and in (MONTH) two (2) Sundays offered TV Time as the only scheduled activity. All Saturdays offered Bingo as the only activity. Review of the facility activity log titled, One on One List, undated, revealed Resident #37 and Resident #46 were not on the list for individualized activities. 1. Record review revealed Resident #37 was initially admitted by the facility on 09/12/14 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's Quarterly Minimum Data Set (MDS) Assessment, dated 01/301/9, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), indicating the resident to have severe cognitive impairment. Continued review of the MDS revealed the resident had disorganized thinking and illogical flow of ideas (Section C). The MDS further revealed the resident had difficulty concentrating on television nearly every day (Section D, #G). Review of Resident #37's Comprehensive Care Plan, with admitted [DATE], revealed a Focus Area for Resident #37's socialization with others when the resident sat in the hall before meals. The focus area also included the resident's attendance at special events including parties and music. The goal was for the resident to be out of the room daily and in attendance at activities as desired. Interventions included encouraging the resident to be more social during the day, reminding the resident of daily activities, times and places in the facility, monitoring for signs and symptoms of [MEDICAL CONDITION] (C. Diff) and reminders for Resident #37 to have his/her fingernails polished weekly. The Care Plan further revealed Resident #37 had Alzheimer's Dementia with mood/behavioral disturbances and anxiety The Focus Area revealed the resident was disoriented, gave his/her first name at times, had a short attention span, and rambling conversation. The goal was for the resident to be able to state his/her name through the quarter and be cooperative with staff during care needs as much as possible. Interventions included an Activities Calendar in the room, calling the resident by name, reassuring the resident when the resident was worrisome or had unrealistic fears, medications as ordered, and keeping a clock and calendar in the room. Review of facility document titled, Documentation Survey Report v2(activity log) for Resident #37, dated (MONTH) 2019, revealed his/her activities included six (6) days with no activities, eight (8) days of activities of watching television and observing. No group activities were documented nor were any manicures or fingernail painting documented. Review of Resident #37's activity log, dated (MONTH) 2019, revealed Resident #37 did not attend any group activities. Four (4) days during the month had no activities documented. Continued review revealed there were nineteen (19) days activities documented included observing or passive socialization with others. Review of Resident #37's activity log, dated (MONTH) 2019, revealed eight (8) days with no activities recorded. Resident #37 did not attend any group activities. Passive television watching was recorded on two (2) days. Four (4) days were listed as NA which was an unknown code. Passive socialization was recorded on ten (10) days and active socialization was recorded on six (6) days. Observation of Resident #37, on 04/02/19 at 12:38 PM, 2:39 PM, and 5:32 PM, on 04/03/19 at 10:23 AM and 2:43 PM, and on 04/04/19 at 8:30 AM and 11:00 AM revealed the resident did not have a television. Although the roommate had a television, it was on the wall farthest from Resident #37 and was often out of sight when the curtain was pulled. The resident was not permitted out of the room on the three (3) days of observation because the roommate was on isolation precautions. No individualized activities with the resident were observed. Interview with State Registered Nursing Assistant (SRNA) #3, on 04/04/19 at 2:21 PM, revealed he was assigned to Resident #37. SRNA #3 stated the resident did not pay attention to the television. The SRNA further stated he never turned on the television for Resident #37 because the resident never requested to watch television and because Resident #37 did not have a television in the room. The television in the room belonged to the roommate and was across the room from Resident #37. SRNA #3 further stated the Activity Staff did all activities with Resident #37. Interview with SRNA #2, on 04/04/19 at 2:28 PM, revealed he cared for the resident on occasion. SRNA #2 stated Resident #37 never asked to watch television. The SRNA further stated the resident talked to the roommate on occasion but he was unaware of any other activities for the resident. SRNA #2 stated the Activities Staff had responsibility for resident activities. Interview with SRNA #1, on 04/04/19 at 2:35 PM, revealed she cared for Resident #37 at various times. The SRNA stated the resident did not have a television and never asked to watch TV (television). SRNA #1 further stated it was doubtful that Resident #37 could understand what was on TV. The SRNA stated she fed the resident and talked to the resident during meal times. She also stated Resident #37 talked to his/her roommate at times, although the resident was confused. Interview with Licensed Practical Nurse (LPN) #1, on 04/04/19 at 2:38 PM, revealed she was assigned to Resident #37. She stated the resident generally roamed the facility in his/her wheelchair when not on isolation precautions. LPN #1 stated staff were told during report the resident could not leave the room because the roommate was on isolation precautions for shingles. She stated staff talked to the resident but did not do activities with the resident. Upon continued interview, she had never observed Resident #37 watching television nor did she ever turn on a TV for the resident. Interview with LPN #2, on 04/04/19 at 2:46 PM, revealed she generally did not work the hall where Resident #37 lived. She stated she did know the resident and had never observed the resident watching TV. She further stated the resident socialized with other residents; however, she had never observed Resident #37 attending planned activities. Interview the Unit Manager, on 04/04/19 at 2:53 PM, revealed she was very familiar with Resident #37. She stated the resident came out of his/her room on normal days but currently was not permitted out of the room because the roommate was on isolation precautions. She stated the television in Resident #37's room did not belong to the resident. She further stated Resident #37 had never asked her to turn the television on. Per interview, she had not observed any one to one (1:1) activities with Resident #37. She stated the activity staff had responsibility for planning and delivering activities for all residents. Interview with the Infection Control Preventionist, on 04/04/19 at 3:52 PM, revealed it was acceptable for Resident #37 to be out of the room despite the roommate's condition. She stated she was not aware the resident was on isolation precautions due to the roommate. She stated there must have been a lack of communication causing the unnecessary isolation of Resident #37. Interview with the Activity Coordinator, on 04/04/19 at 1:47 PM, revealed she was unaware Resident #37 was on isolation precautions due to a roommate with shingles. She then verbalized she had not received any information Resident #37 was confined to the room based on the roommate's condition. She stated one to one (1:1) activities has been planned for the resident; however, she could not locate any documentation of planned 1:1 activities. The Activity Coordinator stated usually Resident #37 sat in the hallway. She stated the resident did not have a television for watching TV activities but the roommate did. Upon further interview, the Activity Coordinator stated she was not sure Resident #37 could see the roommate's television nor could she see the TV when the privacy curtain was pulled. 2. Review of Resident #46's medical record revealed the resident was originally admitted by the facility on 11/15/16 with [DIAGNOSES REDACTED]. Review of Resident #46's Annual MDS Assessment, dated 02/06/19, revealed the facility assessed the resident to have a BIMS score of two (2) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed Section B assessed the resident to usually understand others and usually makes self-understood. Section D revealed Resident #46 indicated he/she was having trouble concentrating on things such as newspapers or watching television. Further review revealed Resident #46 was the primary respondent for the Daily and Activities Preferences. Resident #46's highest ranked activity preferences were listening to music and participating in religious services/ practices. Resident #46 ranked as secondary preferences being around animals/ pets, keeping up with the news, doing things with a group of people, engaging in his/her favorite activities and going outside to get fresh air when the weather was good. Having books, newspapers, and magazines were coded as his/ her least favorite activity. Review of Resident #46's feeding tube orders as of (MONTH) 3, 2019 revealed Resident #46's Physician ordered the resident to be administered tube feeding to be turned on each day at 6:00 PM, continue through the night and to be turned off at 12:00 PM, for a total of six (6) hours without the tube feed infusing. Review of Resident #46's Comprehensive Care Plan, dated 09/05/18 and revised 02/19/18, revealed a focus area for alteration in thought process with a goal that he/she will make decisions in care daily and will remain oriented to person and facility with the interventions to include staff to encourage the resident to be out of bed when the tube feeding is off to receive social stimulation, talk to the resident about current events, weather, upcoming holidays to help with time orientation, and talk with the resident daily during care. Continued review revealed a focus area initiated 06/21/15 and revised 02/19/19 was the potential for alteration in mood and behavior with a goal that the resident will not exhibit depressed mood or behaviors. Interventions in place included 1:1 activities two (2) times each week and to encourage the resident to attend activities and group events. Further review revealed a focus area, initiated 02/13/19, with the goal for the resident to continue socializing and moving self around the facility. Interventions in place included to encourage the resident to be out of his/her room daily or as he/she can tolerate, re-direct the resident to activities, locations with others when he/she is out in the hallway, continue to attend activities as can tolerate and staff to transport the resident to and from activities as he/she can tolerate attending. Review of Resident #46's Activity log, dated (MONTH) 2019, revealed no activities were documented on any Sunday, and one Monday was lacking documentation of activities. The remainder of (MONTH) revealed seven (7) days with passive television and observing the socialization of others was the documented activities most prevalent. Review of Resident #46's Activity log, dated (MONTH) 2019, revealed no activities were documented on any Sunday, and one Friday. Continued review revealed passive TV watching was recorded twelve (12) times as the day's activity. Eight (8) other days involved passive observations. One group activity was documented as attended by Resident #46. Review of Resident # 46's Activity log, dated (MONTH) 2019, reveal no activities were documented on any Sunday and two (2) Saturdays. Four (4) days were documented as NA as the activity with no key code to corresponded to NA to identify the activity. Ten (10) days documented only passive TV as the activity. Four (4) days had documented actively socialization with others. Observation of Resident #46, on 04/02/19 at 12:45 PM, revealed the resident was noted to be up in a wheel chair sitting near the nurse's station by the wall with no interaction with other residents or staff. Continued observation revealed the resident had no activities occurring at this time. Observation of Resident #46, on 04/02/19 at 6:30 PM, revealed the resident was noted to be lying in bed on his/her right side facing the wall, which had a television mounted approximately twenty-four (24) inches above the resident's head. The resident's bed was up against the wall. The resident's television was on, with cartoons playing. Tube feeding was in progress per physician orders. Observation of Resident #46, on 04/03/19 at 8:00 AM, revealed Resident #46 was noted to be lying in bed, facing the wall, with the television on cartoons. No activities or conversation was noted at this time. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 9:00 AM, revealed the resident was lying in bed on his/ her right side, facing the wall. The television was on, with cartoons playing. No activities were being provided. Tube feeding in progress per physician orders. Observation of Resident #46, on 04/03/19 at 10:00 AM, revealed he/she was lying in bed, facing the wall, with cartoons playing on the television. Tube feeding in progress per physician orders. Continued observation revealed a church service with music was occurring in the dining room; however, Resident #46 was not in attendance. Observation of Resident #46, on 04/03/19 at 11:30 AM, revealed the resident remained lying in bed on the right side facing the wall with cartoons on television. Continued observation revealed SRNA #7 was preparing to perform daily care in order to get the resident up for the day. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 2:15 PM to 4:30 PM, revealed the resident was sitting up in a wheel chair by the wall near the nurse's station, very near the same spot occupied the afternoon of 04/02/19. There was one other resident noted to be briefly in that area, but was taken to their room by staff. No activities, other than the staff occasionally speaking to the resident, were occurring. Continued observation revealed various activities were being held in the Florida Dining Room during the afternoon; however, Resident #46 was not involved in the activities and was sitting in a wheel chair by the nurse's station. Observation of Resident #46, on 04/04/19 at 11:00 AM, revealed the resident again noted to be lying in bed, on his/her right side, facing the wall, with the television on and cartoons playing. Observation of Resident #46 on 04/04/19 at 12:05 PM, revealed the resident was again up in wheel chair sitting by the wall near the nurse's station, on the opposite wall from 04/03/19. Observation of Resident #46, on 04/04/19 at 3:00 PM, revealed the resident to be in a wheel chair still at the nurse's station. Continued observation revealed the facility passed out fruit and dip as the activity of the afternoon; however, per physician orders, Resident #46 is allowed only honey-thickened water upon his request and therefore not involved in this activity. No alternate activity was provided to Resident #46. Observation of Resident #46, on 04/04/19 at 5:00 PM, revealed the resident in a wheel chair by the wall facing the nurse's station. Continued observation revealed other residents were beginning to be directed to the dining room for dinner. No activities of any type were being held for this resident. The resident was not in conversation with other residents or staff at this time. Further observation revealed around 6:00 PM, the resident was wheeled back into his/her room, and placed in bed. Tube feeding was resumed per orders. The television remained on and tuned to cartoons. No 1:1 activities were taking place. Interview with SRNA #7, on 04/03/19 at 9:24 AM, revealed he/she cared for the resident regularly. SRNA #7 stated Resident #46's typical day consisted of getting out of bed around lunch, and then the resident lays back down around supper due to the tube feeding. SRNA #7 stated Resident #46 is able to let the staff know when he/ she need to use the toilet. Interview with SRNA #6, on 04/03/19 at 1:15 PM, revealed he/she cares for the resident regularly. SRNA #6 stated Resident #46 does not really watch television; he does glance at it once in a while. SRNA #6 was unable to relay how the television came to be on only cartoons during this survey, did not know how long the TV had been on that channel, and was unaware of who was responsible for ensuring someone spends time with resident. SRNA #6 stated she talks to the resident during care each day she is here. SRNA #6 stated the resident's family visit once or twice per month, but not that much. Per interview Resident #46 doesn't do anything while sitting in the wheel chair by the nurse's station, just sits. SRNA #6 further stated Resident #46 does not go to activities, does not go to church, or participate in food activities. SRNA #6 is aware that the resident is not to have any solid food or thin liquids by mouth. SRNA #6 further revealed the resident never goes on field trips; she was unaware if the resident was asked to go on the trips. SRNA stated the resident just sits during the winter. SRNA #6 also stated that resident really does not talk to anyone. Interview with LPN #2, on 04/04/19 at 9:45 AM, revealed she was on a float schedule' and had very limited knowledge of Resident #46. Interview with Unit Manager for East Hall, on 04/04/19 at 10:00 AM, revealed the activities department holds activities with the residents, spends time with the other residents, and provides socialization. The Unit Manager stated the activities help calm down the residents. The Unit Manager stated she is very familiar with Resident #46, who likes to watch Westerns in the evenings, but was unsure if the resident likes cartoons. Per interview, the SRNAs will change the channel on the television. Continued interview revealed Resident #46 sits at the nurse's station, but he/she is able to self-propel in the wheel chair around the building, even occasionally setting off alarms. The Unit manager clarified the self-propelling is not a consistent event; it depended on Resident #46's personal preference. Further interview revealed Resident #46 knows his/her family, is able to converse with spouse, who visits at least weekly and is able to make needs known, especially when needing to be toileted. The Unit Manager did not recall the resident attending activities and does not recall the activities staff conducting any 1:1 activities with Resident #46. Further, the Unit Manager stated Resident #46 does not go to group activities, as many are food based. The Unit Manager stated the nursing staff would talk to the resident, as they are caring for him / her. Interview with the Wellness Coach (who also worked as a part time activity assistant), on 04/04/19 at 3:10 PM, revealed she was new to the position. She stated she worked part time, usually in the evenings or weekends to provide resident activities. The Wellness Coach stated she did not provide any group or 1:1 activity for Resident #37 or Resident #46. She further stated she did not have a form to document individual activities but was in the process of creating a 1:1 documentation form. The Wellness Coach stated she had not received any activity assessments from the Activity Coordinator; however, she was just initiating visits to residents to determine likes and dislikes. The Wellness Coach stated she focuses on sensory activities such as fleece tying of lap blankets and pillows. The Wellness Coach stated she comes in on Sunday to hold make up sessions for resident who may have missed activities earlier in the week. She stated she utilized the [NAME] Arnold technique for 1:1 activities, usually once per week. Per interview, she had never been given any 1:1 activities by the AD. Additional interview with Activity Coordinator/ Director (AD), on 04/04/19 at 1:47 PM revealed she was responsible for creating and updating Care Plans for activities for the residents. Continued interview revealed she completes an assessment on each of the facility's residents. Per interview, all 1:1 activities go in to the resident's care plan just as the other activities for the other residents and it was the activities department that was responsible to conduct the activities. The Activity Coordinator stated Resident #37 and Resident #46 liked to attend music activities; however, the activity log for the residents did not reflect attendance at the music events offered on 01/02/19, 01/08/19, 01/09/19, 01/16/19, 01/23/19, 01/30/19 and 01/31/19. Fifteen (15) music activities were offered in (MONTH) and March; however, there was no documented evidence either of the residents attended any music events. She stated she had completed an activity assessment for Resident #37 and Resident #46 but she had given those to a volunteer and kept no copies. Additional interview with the Activity Coordinator, on 04/04/19 at 5:01 PM, revealed she had no activity assessment for Resident #37 or Resident #46 as stated in the facility policy. She further stated there was no documentation located for any 1:1 individualized activities for Resident #37 or Resident #46. Interview with the Director of Nursing (DON), on 04/04/19 at 4:48 PM, revealed the Activity Coordinator created the activity portion of the Care Plan and arranged for resident activities. Nursing staff did not deliver activity services. She stated Resident #37 liked to be out in the hallway rather than in his/her room. She further stated Resident #37 was deprived of that activity while on isolation precautions. The DON stated there was a communication gap between Nursing, Infection Control, and the Activities staff and acknowledged Resident #37 should not have been isolated for any infection control issue. The DON stated she had never observed Resident #37 watching television nor did the resident ever ask for someone to turn the TV on. She further stated one to one (1:1) individualized activities were planned and should be delivered to residents who could not or would not attend group activities. The Care Plan should reflect the current needs of each resident consistent with the resident's abilities. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed her expectation for the Activity Coordinator was to gather the likes and dislikes of residents and create the Activity Care Plan consistent with the capabilities of each resident. As residents experienced changes, the activity section of the Care Plan should be revised by the Activities Coordinator. She further stated Resident #37 did not watch television. Other one to one activities appropriate to the resident should have been planned and delivered. The Administrator stated there should have been better communication between Infection Control, Nursing, and the Activity staff to avoid unnecessary isolation of Resident #37. Upon continued interview, she stated it was important for each resident to have meaningful activities for the residents' well-being.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to store and label medications in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on 04/03/19 revealed an opened and undated Humalog Insulin multi-dose pen in the East Unit refrigerator and expired Lantaprost eye drops in the East Hall Medication Cart. Observation of the East Medication Cart, on 04/04/19, revealed ten (10) medications were left in a drawer, not in their pharmacy dispensed packaging, and were loose in a cup labeled with a resident's name. The findings include: Review of the facility's Policy, titled Medication Storage in the Facility undated, revealed medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier. Per review, outdated, contaminated medications are to be immediately removed from stock and disposed of and reordered from pharmacy. Continued review revealed each medication label should include an accessory label including storage requirements. Interview with the Director of Nursing (DON), on 04/04/19 at 5:00 PM, revealed the facility utilized Lippincott Manual of Nursing Practice, Ninth edition for their Standard of Practice. Review of the Lippincott Manual of Nursing Practice, Ninth edition, under section Specific Medication Administration Proceduresrevealed the policy was to ensure medications were administered in a safe and effective manner. Continued review revealed the medication cart is locked at all times unless in use and under the direct observation of the medication nurse or aide. Further review revealed staff should check the expiration date on the package or container prior to administration. Per the policy, once a medication was removed from the package or container, unused doses should be disposed of in accordance with the medication destruction policy. 1. Observation of the East Medication Room, on 04/03/19 at 11:00 AM, revealed a Humalog Insulin multi-dose pen opened and undated. Observation of the East Medication Cart, on 04/03/19 at 4:30 PM, revealed one (1) bottle of Lantaprost eye drops opened and labeled with an open date of 01/24/19. Interview with Licensed Practical Nurse (LPN) #1, on 04/04/19 at 3:00 PM, revealed the medication was in the medication cart for resident use. Continued interview revealed once a medication was open, it expired in approximately 30 days and the eye drops were expired. Per interview, expired medications should not be used because it could be less effective or cause adverse effects for the resident. Continued interview revealed the facility has a policy not to use expired medications. 2. Observation of East Hall Medication Cart, on 04/04/19 at 8:45 AM, revealed the top drawer of the locked cart contained medications not in their pharmacy dispensed packaging, and were loose in a cup labeled with a resident's name. Interview with LPN #2, on 04/04/19 at 8:50 AM, revealed she had removed the medications from the original pharmacy packaging and placed them in the cup found in the cart. Per LPN #2 the medications were: [MEDICATION NAME], Donepezil, Escitlapram, Folic Acid, Jardiance, Multivitamin, Calcium [MEDICATION NAME], Magnesium Oxide, [MEDICATION NAME] and [MEDICATION NAME]. Continued interview revealed her intent was to administer the medications to a resident, per the physician orders; however, did not find the resident in his/her assigned room. LPN #2 stated she then placed the cup of pills in the top drawer. LPN #2 further stated she knew she should not have put the medications in the drawer opened and without their pharmacy packaging. She stated she should have stopped, located the resident and administered the medications as ordered. Interview with the Unit Manager, on 04/03/19 at 11:05 AM, revealed medications should be dated when opened and expiration date put on the label. Continued interview revealed open medications should be then put in the medications cart and not left in the refrigerator. Per interview, the medication is only effective for so many days after the date it is opened so the medication needs to be labeled with the date opened to know when it expires. Additional interview, on 04/04/19 at 9:45 AM, revealed medications should never be pulled and stored without the pharmacy packaging, even in a locked medication cart drawer. Per interview, after realizing the resident was not in his/her room, the LPN should have gone immediately to find the resident to administer the medications. Further interview revealed the consequences of storing medications not in their pharmacy packaging would include a wandering resident may pick them up and consume them or the nurse could become distracted and administer them to the wrong resident. Interview with the Director of Nursing (DON), on 04/04/19 at 4:00 PM, revealed the facility does have a policy related to the storage of medications. Per interview, the facility's policy was to date and label the medication after it was opened. Continued interview revealed staff need to know when the medication was opened to know when it expires. Further interview revealed it was important to date the medication so expired medications were not administered to a resident. Per interview, expired medications could be stronger or weaker in strength. Additional interview on 04/04/19 at 5:00 PM, revealed staff should never leave a cup of medications in the top drawer of the cart. Per interview, she stated this was an infection control issue and someone else could take them resulting in drug diversion. The DON further stated the nurse should have either wasted the medications or located the resident to have the correct resident consume the medications. The DON stated the facility should have followed the facility's policy. Interview with the Administrator, on 04/04/19 at 3:59 PM, revealed medications should be dated when opened to be able to determine when the medication has expired. Continued interview revealed expired medications should be pulled from stock and not available for resident use. Further interview revealed medication is to be discarded per the manufacturer's recommendations. It was her expectation that staff follow the facility's policy. Per interview, expired medications should not be administered to residents for the safety of the resident. Additional interview, on 04/04/19 at 5:15 PM, revealed opened medications not in the pharmacy packaging should not be put back into the medication cart. Per interview, the nurse should find the resident to administer the medications or dispose of them. Further interview revealed it was not acceptable to leave the medications in the top of the cart due to the possibility of error because the nurse could not know whose pills were in the cup nor how long they had been in there. The Administrator further stated there was increased room for error when not following the facility's medication pass policy.

Based on observation, interview, record review, and review of facility's policies, it was determined the facility failed to ensure the Comprehensive Care Plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for two (2) of twenty-two (22) sampled residents (Resident #37 and Resident #46). The facility failed to revise the activity program to meet the needs of Resident #37 and Resident #46. 1. Resident #37's Care Plan and Activity Log revealed the resident watched television, the resident did not have a television and no staff had observed the resident watching television. In addition, at the time of survey, Resident #37 was confined to his/ her room based on his/her roommate's medical condition requiring isolation precautions. Resident #37 enjoyed being in the hallway and was deprived of this activity with no individual activities offered in the room. 2. Resident #46's Activity logs were not complete, and did not provide activities per Resident #46's preferences, nor did the facility provide any 1:1 activities while the resident was confined to his/ her room for tube feeding. The findings include: Review of facility's Policy titled, Individual and Interdisciplinary Plan of Care, undated, revealed the facility maintains a patient focused approach to all functions and responsibilities within its organization; therefore, it shall be the policy of the facility to maintain an up-to-date plan of care on each resident. Per the policy, the primary reason for Interdisciplinary Team (IDT) is to meet the changing needs of the patient by using an interdisciplinary system. The care plan will be comprehensive and reasonable and it would be reflective of the needs of the patient. Continued review revealed, the comprehensive care plan would contain approaches to care that will benefit the needs of the resident and the care planning and updates would be made in a reasonable and timely manner. Further review revealed team members involved in the development of the Care Plan included activities. Review of facility's Policy titled, Activity Program Policy and Procedure, revised 11/01/18, revealed individual activities were developed in accordance with the comprehensive assessment. The policy further stated periodic evaluation of the appropriateness of activities would be conducted with changes in programming as needed. The Activities Coordinator was responsible for the direction of the ongoing plan for resident activities. Review of the facility job description titled, Activity Coordinator revealed the Activity Coordinator was responsible for developing, initiating, implementing, and maintaining a comprehensive resident centered activity program for each resident. The job responsibilities included assessing each resident's activity needs, assessment and completion of assigned sections of the Minimum Data Set (MDS), development of the resident's activity care plan with review, and updating to the Care Plan as needed. Review of the Activity Calendars for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019, revealed group activities were offered each day. Further review revealed in (MONTH) two (2) Sunday activities were TV Time, in (MONTH) one (1) Sunday activity was TV Time, and in (MONTH) two (2) Sundays offered TV Time as the only scheduled activity. All Saturdays offered Bingo as the only activity. Review of the facility activity log titled, One on One List, undated, revealed Resident #37 and Resident #46 were not on the list for individualized activities. 1. Record review revealed Resident #37 was initially admitted by the facility on 09/12/14 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), indicating the resident had severe cognitive impairment. Continued review of the MDS revealed the facility assessed the resident as having disorganized thinking and illogical flow of ideas (Section C). The MDS further revealed the resident had difficulty concentrating on television nearly every day (Section D, #G). Review of Resident #37's Comprehensive Care Plan, with admitted [DATE], revealed a Focus Area for Resident #37's socialization with others when the resident sat in the hall before meals. The focus area also included the resident's attendance at special events including parties and music. The goal was for the resident to be out of the room daily and in attendance at activities as desired. Interventions included encouraging the resident to be more social during the day, reminding the resident of daily activities, times and places in the facility, monitoring for signs and symptoms of [MEDICAL CONDITION] (C. Diff) and reminders for Resident #37 to have his/her fingernails polished weekly. Continued review of the care plan revealed Resident #37 had Alzheimer's Dementia with mood/behavioral disturbances and anxiety. Review of the Focus Area revealed the resident was disoriented, gave his/her first name at times, had a short attention span, and rambling conversation. The goal was for the resident to be able to state his/her name through the quarter and be cooperative with staff during care needs as much as possible. Interventions included an Activities Calendar in the room, calling the resident by name, reassuring the resident when the resident was worrisome or had unrealistic fears, medications as ordered, and keeping a clock and calendar in the room. Review of facility document titled, Documentation Survey Report v2(activity log) for Resident #37, dated (MONTH) 2019, revealed his/her activities included six (6) days with no activities, eight (8) days of activities of watching television and observing. Continued review revealed no group activities were documented nor were any manicures or fingernail painting documented. Review of Resident #37's activity log, dated (MONTH) 2019, revealed Resident #37 did not attend any group activities. Continued review revealed four (4) days during the month had no activities documented. Further review revealed nineteen (19) days documented activities included observing or passive socialization with others. Review of Resident #37's activity log, dated (MONTH) 2019, revealed eight (8) days with no activities recorded. Continued review revealed Resident #37 did not attend any group activities for the month. Passive television watching was recorded on two (2) days and four (4) days were listed as NA which was an unknown code. Passive socialization was recorded on ten (10) days and active socialization was recorded on six (6) days. Observation of Resident #37, on 04/02/19 at 12:38 PM, 2:39 PM, and 5:32 PM, on 04/03/19 at 10:23 AM and 2:43 PM, and on 04/04/19 at 8:30 AM and 11:00 AM revealed the resident did not have a television. Although the roommate had a television, it was on the wall farthest from Resident #37 and was often out of sight when the curtain was pulled. The resident was not permitted out of the room on the three (3) days of observation because the roommate was on isolation precautions. No individualized activities with the resident were observed. Interview with State Registered Nursing Assistant (SRNA) #3, on 04/04/19 at 2:21 PM, revealed he was assigned to Resident #37. SRNA #3 stated the Resident #64 did not pay attention to the television. The SRNA further stated he never turned on the television for Resident #37 because the resident never requested to watch television and because Resident #37 did not have a television in the room. The television in the room belonged to the roommate and was across the room from Resident #37. SRNA #3 further stated the Activity Staff did all activities with Resident #37. Interview with SRNA #2, on 04/04/19 at 2:28 PM, revealed he cared for the resident on occasion. SRNA #2 stated Resident #37 never asked to watch television. The SRNA further stated the resident talked to his/her roommate on occasion but was unaware of any other activities for the resident. SRNA #2 stated the Activities Staff had responsibility for resident activities. Interview with SRNA #1, on 04/04/19 at 2:35 PM, revealed she cared for Resident #37 at various times. The SRNA stated the resident did not have a television in his/her room and never asked to watch TV (television). SRNA #1 further stated it was doubtful that Resident #37 could understand what was on TV. The SRNA stated she fed the resident and talked to the resident during meal times. She also stated Resident #37 talked to his/her roommate at times, although the resident was confused. Interview with Licensed Practical Nurse (LPN) #1, on 04/04/19 at 2:38 PM, revealed she was assigned to Resident #37. She stated the resident generally roamed the facility in his/her wheelchair when not on isolation precautions. LPN #1 stated staff were told during report the resident could not leave the room because his/her roommate was on isolation precautions for shingles. She stated staff talked to the resident but did not do activities with the resident. Upon continued interview, she had never observed Resident #37 watching television nor did she ever turn on a TV for the resident. Interview with LPN #2, on 04/04/19 at 2:46 PM, revealed she generally did not work the hall where Resident #37 lived. She stated she did know the resident and had never observed the resident watching TV. She further stated the resident usually socialized with other residents; however, she had never observed Resident #37 attending planned activities. Interview the Unit Manager, on 04/04/19 at 2:53 PM, revealed she was very familiar with Resident #37. She stated the resident came out of his/her room on normal days but currently was not permitted out of the room because his/her roommate was on isolation precautions. She stated the television in Resident #37's room did not belong to the resident. She further stated Resident #37 had never asked her to turn the television on. Per interview, she had not observed any one to one (1:1) activities with Resident #37. She stated the activity staff had responsibility for planning and delivering activities for all residents. Interview with the Activity Coordinator, on 04/04/19 at 1:47 PM, revealed she was unaware Resident #37 was on isolation precautions due to a roommate with shingles. She then verbalized she had not received any information Resident #37 was confined to the room based on the roommate's condition. She stated one to one (1:1) activities has been planned for the resident; however, she could not locate any documentation of planned 1:1 activities. The Activity Coordinator stated usually Resident #37 sat in the hallway. She stated the resident did not have a television for watching TV activities but the roommate did. Upon further interview, the Activity Coordinator stated she was not sure Resident #37 could see the roommate's television nor could she see the TV when the privacy curtain was pulled. 2. Review of Resident #46's medical record revealed the resident was originally admitted by the facility on 11/15/16 with [DIAGNOSES REDACTED]. Review of Resident #46's Annual MDS Assessment, dated 02/06/19, revealed the facility assessed the resident to have a BIMS score of two (2) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed Section B assessed the resident to usually understand others and usually makes self-understood. Section D revealed Resident #46 indicated he/she was having trouble concentrating on things such as newspapers or watching television. Further review revealed Resident #46 was the primary respondent for the Daily and Activities Preferences. Resident #46's highest ranked activity preferences were listening to music and participating in religious services/ practices. Resident #46 ranked as secondary preferences being around animals/ pets, keeping up with the news, doing things with a group of people, engaging in his/her favorite activities and going outside to get fresh air when the weather was good. Having books, newspapers, and magazines were coded as his/ her least favorite activity. Review of Resident #46's feeding tube orders as of (MONTH) 3, 2019 revealed Resident #46's Physician ordered the resident to be administered tube feeding to be turned on each day at 6:00 PM, continue through the night and to be turned off at 12:00 PM, for a total of six (6) hours without the tube feed infusing. Review of Resident #46's Comprehensive Care Plan, dated 09/05/18 and revised 02/19/18, revealed a focus area for alteration in thought process with a goal that he/she will make decisions in care daily and will remain oriented to person and facility with the interventions to include staff to encourage the resident to be out of bed when the tube feeding is off to receive social stimulation, talk to the resident about current events, weather, upcoming holidays to help with time orientation, and talk with the resident daily during care. Continued review revealed a focus area initiated 06/21/15 and revised 02/19/19 was the potential for alteration in mood and behavior with a goal that the resident will not exhibit depressed mood or behaviors. Interventions in place included 1:1 activities two (2) times each week and to encourage the resident to attend activities and group events. Further review revealed a focus area, initiated 02/13/19, with the goal for the resident to continue socializing and moving self around the facility. Interventions in place included to encourage the resident to be out of his/her room daily or as he/she can tolerate, re-direct the resident to activities, locations with others when he/she is out in the hallway, continue to attend activities as can tolerate and staff to transport the resident to and from activities as he/she can tolerate attending. Review of Resident #46's Activity log, dated (MONTH) 2019, revealed no activities were documented on any Sunday, and one Monday was lacking documentation of activities. The remainder of (MONTH) revealed seven (7) days with passive television and observing the socialization of others was the documented activities most prevalent. Review of Resident #46's Activity log, dated (MONTH) 2019, revealed no activities were documented on any Sunday, and one Friday. Continued review revealed passive TV watching was recorded twelve (12) times as the day's activity. Eight (8) other days involved passive observations. One group activity was documented as attended by Resident #46. Review of Resident # 46's Activity log, dated (MONTH) 2019, reveal no activities were documented on any Sunday and two (2) Saturdays. Four (4) days were documented as NA as the activity with no key code to corresponded to NA to identify the activity. Ten (10) days documented only passive TV as the activity. Four (4) days had documented actively socialization with others. Observation of Resident #46, on 04/02/19 at 12:45 PM, revealed the resident was noted to be up in a wheel chair sitting near the nurse's station by the wall with no interaction with other residents or staff. Continued observation revealed the resident had no activities occurring at this time. Observation of Resident #46, on 04/02/19 at 6:30 PM, revealed the resident was noted to be lying in bed on his/her right side facing the wall, which had a television mounted approximately twenty-four (24) inches above the resident's head. The resident's bed was up against the wall. The resident's television was on, with cartoons playing. Tube feeding was in progress per physician orders. Observation of Resident #46, on 04/03/19 at 8:00 AM, revealed Resident #46 was noted to be lying in bed, facing the wall, with the television on cartoons. No activities or conversation was noted at this time. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 9:00 AM, revealed the resident was lying in bed on his/ her right side, facing the wall. The television was on, with cartoons playing. No activities were being provided. Tube feeding in progress per physician orders. Observation of Resident #46, on 04/03/19 at 10:00 AM, revealed he/she was lying in bed, facing the wall, with cartoons playing on the television. Tube feeding in progress per physician orders. Continued observation revealed a church service with music was occurring in the dining room; however, Resident #46 was not in attendance. Observation of Resident #46, on 04/03/19 at 11:30 AM, revealed the resident remained lying in bed on the right side facing the wall with cartoons on television. Continued observation revealed SRNA #7 was preparing to perform daily care in order to get the resident up for the day. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 2:15 PM to 4:30 PM, revealed the resident was sitting up in a wheel chair by the wall near the nurse's station, very near the same spot occupied the afternoon of 04/02/19. There was one other resident noted to be briefly in that area, but was taken to their room by staff. No activities, other than the staff occasionally speaking to the resident, were occurring. Continued observation revealed various activities were being held in the Florida Dining Room during the afternoon; however, Resident #46 was not involved in the activities and was sitting in a wheel chair by the nurse's station. Observation of Resident #46, on 04/04/19 at 11:00 AM, revealed the resident again noted to be lying in bed, on his/her right side, facing the wall, with the television on and cartoons playing. Observation of Resident #46 on 04/04/19 at 12:05 PM, revealed the resident was again up in wheel chair sitting by the wall near the nurse's station, on the opposite wall from 04/03/19. Observation of Resident #46, on 04/04/19 at 3:00 PM, revealed the resident to be in a wheel chair still at the nurse's station. Continued observation revealed the facility passed out fruit and dip as the activity of the afternoon; however, per physician orders, Resident #46 is allowed only honey-thickened water upon his request and therefore not involved in this activity. No alternate activity was provided to Resident #46. Observation of Resident #46, on 04/04/19 at 5:00 PM, revealed the resident in a wheel chair by the wall facing the nurse's station. Continued observation revealed other residents were beginning to be directed to the dining room for dinner. No activities of any type were being held for this resident. The resident was not in conversation with other residents or staff at this time. Further observation revealed around 6:00 PM, the resident was wheeled back into his/her room, and placed in bed. Tube feeding was resumed per orders. The television remained on and tuned to cartoons. No 1:1 activities were taking place. Interview with SRNA #7, on 04/03/19 at 9:24 AM, revealed she cared for the resident regularly. SRNA #7 stated Resident #46's typical day consisted of getting out of bed around lunch, and then the resident would lay back down around supper due to the tube feeding. SRNA #7 stated Resident #46 is able to let the staff know when he/ she need to use the toilet. Interview with SRNA #6, on 04/03/19 at 1:15 PM, revealed she cares for the resident regularly. SRNA #6 stated Resident #46 does not really watch television; he/she does glance at it once in a while. SRNA #6 was unable to relay how the television came to be on only cartoons during this survey, did not know how long the TV had been on that channel, and was unaware of who was responsible for ensuring someone spends time with resident. SRNA #6 stated she talks to the resident during care each day she is here. SRNA #6 stated the resident's family visit once or twice per month, but not that much. Per interview Resident #46 doesn't do anything while sitting in the wheel chair by the nurse's station, just sits. SRNA #6 further stated Resident #46 does not go to activities, does not go to church, or participate in food activities. SRNA #6 is aware that the resident is not to have any solid food or thin liquids by mouth. SRNA #6 further revealed the resident never goes on field trips; she was unaware if the resident was asked to go on the trips. SRNA stated the resident just sits during the winter. SRNA #6 also stated that resident really does not talk to anyone. Interview with Unit Manager for East Hall, on 04/04/19 at 10:00 AM, revealed the activities department assesses the residents for their preference on activities and holds activities with the residents, spends time with the other residents, and provides socialization. The Unit Manager stated the activities help calm down the residents. Per interview, the resident's preference are care planned. The Unit Manager stated she is very familiar with Resident #46, who likes to watch Westerns in the evenings, but was unsure if the resident likes cartoons. Per interview, the SRNAs will change the channel on the television. Continued interview revealed Resident #46 sits at the nurse's station, but he/she is able to self-propel in the wheel chair around the building, even occasionally setting off alarms. The Unit manager clarified the self-propelling is not a consistent event; it depended on Resident #46's personal preference. Further interview revealed Resident #46 knows his/her family, is able to converse with spouse, who visits at least weekly and is able to make needs known, especially when needing to be toileted. The Unit Manager did not recall the resident attending activities and does not recall the activities staff conducting any 1:1 activities with Resident #46. Further, the Unit Manager stated Resident #46 does not go to group activities, as many are food based and the resident is unable to have solid foods. The Unit Manager stated the nursing staff would talk to the resident, as they are caring for him/her. Interview with the Wellness Coach (who also worked as a part time activity assistant), on 04/04/19 at 3:10 PM, revealed she was new to the position. She stated she worked part time, usually in the evenings or weekends to provide resident activities. The Wellness Coach stated she did not provide any group or 1:1 activity for Resident #37 or Resident #46. She further stated she did not have a form to document individual activities but was in the process of creating a 1:1 documentation form. The Wellness Coach stated she had not received any activity assessments from the Activity Coordinator; however, she was just initiating visits to residents to determine likes and dislikes. The Wellness Coach stated she focuses on sensory activities such as fleece tying of lap blankets and pillows. The Wellness Coach stated she comes in on Sunday to hold make up sessions for resident who may have missed activities earlier in the week. She stated she utilized the [NAME] Arnold technique for 1:1 activities, usually once per week. Per interview, she had never been given any 1:1 activities by the AD. Additional interview with Activity Coordinator/ Director (AD), on 04/04/19 at 1:47 PM revealed she was responsible for creating and updating Care Plans for activities for the residents. Per interview, the care plan should be up-to-date based on the resident's needs. Continued interview revealed she completes an assessment on each of the facility's residents. Per interview, all 1:1 activities go in to the resident's care plan just as the other activities for the other residents and it was the activities department that was responsible to conduct the activities. The Activity Coordinator stated Resident #37 and Resident #46 liked to attend music activities; however, the activity log for the residents did not reflect attendance at the music events offered on 01/02/19, 01/08/19, 01/09/19, 01/16/19, 01/23/19, 01/30/19 and 01/31/19. Fifteen (15) music activities were offered in (MONTH) and March; however, there was no documented evidence either of the residents attended any music events. She stated she had completed an activity assessment for Resident #37 and Resident #46 but she had given those to a volunteer and kept no copies. Additional interview with the Activity Coordinator, on 04/04/19 at 5:01 PM, revealed she had no activity assessment for Resident #37 or Resident #46 as stated in the facility policy. She further stated there was no documentation located for any 1:1 individualized activities for Resident #37 or Resident #46. Per interview, Resident #37 and Resident #46 should had their care plans up dated to reflect the need to be in their room for extended periods of time and should have been offered individualized activities based on each resident's preference. Interview with the Director of Nursing (DON), on 04/04/19 at 4:48 PM, revealed the Activity Coordinator created the activity portion of the Care Plan and arranged for resident activities. Nursing staff did not deliver activity services. She stated Resident #37 liked to be out in the hallway rather than in his/her room. She further stated Resident #37 was deprived of that activity while on isolation precautions. The DON stated there was a communication gap between Nursing, Infection Control, and the Activities staff and acknowledged Resident #37 should not have been isolated for any infection control issue. The DON stated she had never observed Resident #37 watching television nor did the resident ever ask for someone to turn the TV on. She further stated one to one (1:1) individualized activities were planned and should be delivered to residents who could not or would not attend group activities. Per interview, the care plan should be updated if a resident could not or would not leave their room, or any change in the resident's status. The Care Plan should reflect the current needs of each resident consistent with the resident's abilities. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed her expectation for the Activity Coordinator was to gather the likes and dislikes of residents and create the Activity Care Plan consistent with the capabilities of each resident. As residents experienced changes, the activity section of the Care Plan should be revised by the Activities Coordinator. Upon continued interview, she stated it was important for each resident to have meaningful activities for the residents' well-being.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to assure the accuracy of Section M of the Minimum Data Set (MDS) Assessment, for one (1) of twenty-two (22) sampled residents, (Resident #50). Resident #50's MDS Assessment was coded to reflect a pressure ulcer was present on admission; however, during the resident's stay, the pressure ulcer subsequently worsened and the MDS was incorrectly coded as present upon admission. The findings include: Review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, dated (MONTH) (YEAR), Chapter 3, revealed the intent of Section M: Skin Conditions, was to document the risk, presence, appearance, and change of pressure ulcers. This section also notes other skin ulcers, wounds, or [MEDICAL CONDITION] and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. Per the RAI Manual, a complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Further review of the RAI Version 3.0 User Manual, revealed if a pressure ulcer was present on admission/entry or re-entry and subsequently worsened to a higher stage during the resident's stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered present on admission. Review of Resident #50's medical record revealed the facility originally admitted the resident on 04/15/13 and readmitted the resident on 05/31/15. The resident's [DIAGNOSES REDACTED]. Review of Resident #50's MDS Quarterly Assessment, Section M (skin conditions), dated 08/23/17, revealed the resident was assessed to have no unhealed pressure ulcers at stage 1 or higher. Review of the MDS Quarterly Assessment, Section M, dated 11/22/17, revealed Resident #50 was assessed to have one (1) stage two (2) pressure ulcer that was not present upon admission or re-entry to the facility. Review of the MDS Annual assessment, Section M, dated 02/14/18, revealed Resident #50 was assessed to have one (1) stage two ( 2) pressure ulcer that was present upon admission or re-entry to the facility. Review of the MDS Quarterly Assessment, Section M, dated 05/16/18, revealed Resident #50 was assessed to have one (1) stage three (3) pressure ulcer that was present upon admission or re-entry to the facility. Review of the MDS Quarterly Assessment, Section M, dated 08/15/18 and 11/14/18, revealed Resident #50 was assessed to have one (1) stage four (4) pressure ulcer that was present upon admission or re-entry to the facility. Interview with the MDS Coordinator, on 04/04/19 at 3:54 PM, revealed she uses the RAI manual for completing MDS assessments. She stated she is responsible for the accurate completion of section M of the MDS, for Resident #50. Continued interview revealed she is responsible for ensuring MDS accuracy before transmission. The MDS Coordinator stated that she retrieves the information used to fill out section M of the MDS from the resident's chart, weekly wound and skin assessments, and nurses notes. Further interview revealed Resident #50's pressure ulcer was not coded accurately due to the pressure ulcer being facility acquired. Interview with the Director of Nursing (DON), on 04/04/19 at 4:52 PM, revealed the MDS Coordinators use the RAI manual for completing assessments. The DON further stated the MDS coordinator is responsible for filling out section M of the MDS, and is also responsible for assuring MDS accuracy before transmission. Continued interview revealed information used to complete MDS assessments would be found in resident charts, physician orders, physician visits, diagnoses, and MDS Coordinators should be assessing the resident. Further interview revealed, the DON does not audit MDS assessments. The DON further stated, Section M of the MDS for Resident # 50 was inaccurately coded, due to the Resident's pressure ulcer being facility acquired. Interview with the Administrator, on 04/04/19 at 4:45 PM, revealed it was her expectation that all MDS assessments were coded accurately, and that the MDS coordinator would be checking for documentation to be coded correctly. She stated, MDS Coordinators should rely on good communication with floor staff, nurse aides, and nurses to ensure accuracy. Continued interview revealed the facility requires all MDS documentation to be correct because it drives the Resident's Comprehensive Care Plan and will provide staff with the most accurate information available, in order to provide appropriate resident care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective system for preventing the spread of infection for one (1) of eighteen (18)sampled residents. Resident #236 had a [DIAGNOSES REDACTED]. However, the facility failed to post signage to alert visitors and staff that precautions were required when entering the resident's room. The findings include: Review of the facility's Infection Control Program, undated, revealed compliance with the Infection Control Program would include staff evaluation and observations of practices, with appropriate follow-up by the Infection Control Nurse, Director of Nursing, Staff Development Director, Administration, and Quality Assurance Committee. Further review revealed the policy did not address the requirement to post signage outside the resident's room identifying the Centers for Disease Control (CDC) category of transmission- based precautions, instructions for Personal Protective Equipment (PPE), and/or instructions to see the nurse before entering. Review of Resident #236's medical record revealed the facility admitted the resident on 01/09/18 and readmitted the resident on 02/19/18 with a [DIAGNOSES REDACTED]. A review of Resident #236'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), which indicated the resident was cognitively intact. Review of a nursing assessment dated [DATE] upon return from the hospital revealed the resident was alert and confused. Review of Resident #236's plan of care, revised 02/19/18, revealed the facility identified that the resident had a Urinary Tract Infection with VRE and developed an intervention to place the resident in Contact Isolation. Review of the State Registered Nurse Aide (SRNA) plan of care for Resident #236, undated, also revealed the resident was on Contact Isolation. Observation of Resident #236's room on 02/20/18 at 11:15 AM, on 02/20/18 at 2:11 PM, and on 02/21/18 at 9:00 AM, revealed PPE was on a table in the hallway outside the resident's room. However, the PPE was located between Resident #236's room and the resident room next door and no signage was observed to denote which room was under transmission-based precautions. Observation of Resident #236 on 02/20/18 at 2:11 PM revealed the resident was awake and sitting up in bed. Interview with SRNAs #2 and #3 on 02/21/18 at 12:52 PM revealed they were aware contact precautions were required when entering Resident #236's room. Interview with Registered Nurse (RN) #2 on 02/21/18 at 1:00 PM revealed when a resident was placed on transmission-based precautions PPE was placed outside the resident's door. RN #2 stated a sign should also be posted on the resident's door to alert staff and visitors that the resident was on precautions. Interview with the Director of Nursing (DON) on 02/22/18 at 4:03 PM confirmed a sign should have been posted outside Resident #236's door, alerting visitors and staff that precautions were required.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure staffing data that included actual hours employees worked was posted. Review of the past eighteen (18) months of staffing data revealed the facility did not post the actual staff hours worked daily. The findings include: Review of the facility's policy, Posted Daily Staffing Data Report, dated 08/01/15, revealed the facility required the following information to be posted daily: the facility name; date; resident census; and the total number of Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides and the actual hours worked. Observation of the facility's daily staffing posting on 02/21/18 at 3:08 PM revealed the facility posted the number of staff on duty; however, there was no evidence the facility posted the actual number of hours that staff worked. Review of daily staffing postings for 08/01/16 through 02/20/18 revealed the data did not include the number of hours that staff actually worked. Interview with the Staffing Coordinator on 02/22/18 at 9:05 AM revealed it was her job to post daily staffing. The Coordinator stated she posted the current census and the number of staff from each discipline who were scheduled to work, but confirmed she did not post the number of hours that staff actually worked. Interview with the Director of Nursing (DON) on 02/22/18 at 4:00 PM revealed she instructed the Staffing Coordinator how to post the daily staffing, and was aware that hours needed to be posted. The DON stated the facility staffing form was altered and failed to include a designation for number of hours worked.

Based on interview, closed record review, and review of facility policy, it was determined the facility failed to ensure the physician documented the need for a discharge for one (1) of two (2) sampled residents (Resident #1). Resident #1 struck another resident with a cane while the resident was lying in Resident #1's bed. According to a hospital record for Resident #1, the facility consulted the hospital for a psychiatric evaluation for the resident. After a teleconference, the hospital told the facility that the resident did not meet criteria for a psychiatric admission and that the facility should not send the patient to the hospital. There was no documented evidence the resident had any further behaviors. However, on 02/01/17 the facility discharged the resident and transferred the resident to the hospital, even though the facility was aware the resident did not meet criteria for a hospital psychiatric admission. Resident #1 spent nine (9) days in the hospital before the hospital could find placement at another facility for the resident. Interview with the resident's physician revealed she was not involved in Resident #1's discharge. The findings include: A review of the facility's policy titled Transfer and Discharge, dated 11/28/16, revealed the facility would permit each resident to remain in the facility and would not discharge the resident, unless the safety of individuals in the facility was endangered. Further review of the policy revealed documentation must be made by the resident's physician when the discharge was necessary for the safety of individuals in the facility. A review of the closed medical record for Resident #1 revealed the facility admitted the resident on 11/11/16 with [DIAGNOSES REDACTED]. A review of a psychiatric mental status exam dated 11/17/16 revealed the resident had a [DIAGNOSES REDACTED]. According to the assessment, Resident #1 was cooperative. A review of the 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 seven (7), which indicated the resident's cognition was moderately impaired. According to the assessment, the resident did not have any behaviors. A review of Resident #1's care plan, revised on 12/01/16, revealed the facility developed a care plan related to [MEDICAL CONDITION] drug use. The care plan stated the resident was having no side effects from the medication and was cooperative, pleasant, smiles when spoken to. Further review of Resident #1's medical record revealed a Social Service Progress Note dated 01/06/17. The note stated Resident #1 was alert, responded in a friendly manner when approached, and gets along well with others. Review of nursing notes for Resident #1 revealed on 01/31/17 at 7:30 PM, another resident was in Resident #1's bed and staff witnessed Resident #1 strike the resident with a cane. According to the notes, the resident's physician, family, and the Administrator of the facility were notified of the altercation. There was no documented evidence the resident had further behaviors/altercations after the incident on 01/31/17 at 7:30 PM. However, further review of the nursing notes dated 02/01/17 at 12:00 PM, revealed the facility social worker was going to get a court order to send Resident #1 to the hospital for a psychiatric evaluation. Review of a nursing note dated 02/01/17 at 1:40 PM revealed an ambulance was at the facility to transfer the resident, but was waiting on the sheriff with a court order. The note stated staff read a discharge paper to the resident, the reasons the resident was being discharged were explained to the resident, and the resident stated he/she understood. Further review of the nursing notes revealed the facility transferred Resident #1 to the hospital on [DATE] at 2:05 PM (approximately 18 hours after the incident) and there was no evidence the resident returned to the facility. Review of a discharge notice dated 02/01/17 revealed the facility discharged Resident #1 because the resident was a danger to him/her self and a danger to others. However, there was no evidence the physician documented the basis for Resident #1's transfer, the specific resident needs that the facility could not meet, how the facility had attempted to meet the resident's needs, and what service the receiving facility had available to meet the resident's needs. A review of a history and physical (H&P) from Resident #1's hospital admitted d 02/02/17 revealed the facility sent Resident #1 to the hospital for a psychiatric evaluation. According to the H&P, the facility called the psychiatric admission nurse at the hospital late the prior day (02/01/17), stating they wanted to send Resident #1 for an evaluation. After doing a teleconference with the nurses at the facility, the psychiatric evaluation nurse at the hospital did not feel the resident was appropriate for a psychiatric admission and told the facility not to send the resident to the hospital. However, the facility sent the resident anyway. Upon arrival to the hospital, the resident was evaluated and once again determined it was not appropriate to place the resident in the psychiatric center. The H&P further stated the plan was to send the resident back to the facility; however, the facility refused to take the resident back. According to the H&P, the resident was admitted for observation because the facility refused to readmit Resident #1 and Social Services was consulted to assist with finding placement for the resident in another facility. The hospital discharged Resident #1 to another facility on 02/10/17, nine days later. An interview with Resident #1's Primary Care Physician on 02/15/17 at 1:55 PM revealed she was not involved in the discharge of the resident. According to the physician, she did not evaluate the basis for the discharge and document why the resident's needs could not be met by the facility. The physician stated she was unsure why the facility discharged the resident because she was not aware of any prior incidents with the resident. An interview with the Administrator on 02/15/17 at 2:30 PM revealed nursing staff contacted her on 01/31/17 regarding the incident involving Resident #1. According to the Administrator, she directed the facility social worker to start an investigation and report an allegation to the required state agencies. Further interview revealed the facility was going to discharge Resident #1 on 01/31/17, but the Administrator contacted Residents #1's family, who stated they would come and get the resident the next day, 02/01/17. The Administrator stated the family did not come and get the resident, and the facility obtained a court order to have the resident sent to the hospital for an involuntary admission. The resident was discharged from the facility and was transported by ambulance and the sheriff to the hospital. According to the Administrator, the hospital would not admit the resident because the resident did not meet the criteria for a psychiatric admission. However, the Administrator would not allow the resident to return to the facility because she was concerned that the resident had harmed another resident and other residents could be endangered. According to the Administrator, she was not aware a physician was required to document the basis for the resident's discharge and why the resident's needs could not be met at the facility, even though it was required according to the facility's policy. Interview with Resident #1's Family Member (FM #1) on 03/20/17 at 5:30 PM revealed the facility Administrator contacted FM #1 on 01/31/17 and informed her that the facility was discharging Resident #1 because the resident hit another resident. FM #1 stated the Administrator told her that she would have to come to the facility and get the resident. According to FM #1, she informed the Administrator that she could not take the resident home because she was not able to take care of the resident. Further interview with FM #1 revealed the facility transferred the resident to the hospital the next day for a psychiatric evaluation. The resident did not meet criteria for admission to the hospital, but the facility refused to take the resident back. FM #1 stated, It was like they threw (Resident #1) out and I didn't know what I was going to do. Interview with Resident #1 on 03/20/17 at 9:20 AM revealed the facility discharged the resident because he/she hit another resident. According to the resident, the facility sent him/her down the road. The resident stated he/she was sent here and there in an ambulance and ended up at the hospital.

Based on observation, interview, and record review it was determined the facility failed to provide services in accordance with each resident's written plan of care for five (5) of eighteen (18) sampled residents (Residents #2, #3, #4, #7, and #9). The facility failed to provide care in accordance with the care plan for Resident #2 related to the administration of enteral feeding and nail care, for Residents #3 and #7 related to the care of urinary catheters, for Resident #4 related to assistive devices and elevating the heels, and for Resident #9 related to the administration of oxygen. The findings include: A review of the facility care plan policy titled Individual and interdisplinary plan of care, (sic) undated, revealed it was the intent of the facility to achieve and maintain each resident's highest practicable status and the care plan process was the primary instrument used to meet the objectives for each resident. The policy stated the patient-focused approach sought favorable outcomes in consideration of each resident's characteristics, severity of condition, strengths, needs, abilities, disabilities, disease, impairment, and other significant factors. 1. Medical record review for Resident #3 revealed the facility admitted the resident on 09/02/16 with a [DIAGNOSES REDACTED]. A review of the plan of care developed for Resident #3 dated 09/30/16 revealed interventions for the resident to have urinary catheter care every shift and as needed. Observation of Resident #3 during a skin assessment on 11/30/16 at 2:00 PM revealed Residents #3's urinary catheter was not secured to the resident's leg. Observation of urinary catheter care provided by State Registered Nurse Aide (SRNA) #1 on 11/30/16 at 2:10 PM revealed the SRNA did not secure the resident's catheter to the resident's leg after completing the catheter care. Interview with SRNA #1 conducted on 11/30/16 at 2:15 PM revealed she did not know why the resident's catheter was not secured to the resident's leg or why she did not secure the resident's catheter after completing the catheter care. Interview with the Director of Nursing (DON) on 12/01/16 at 3:40 PM revealed it was facility policy to secure the urinary catheter to the resident's thigh to prevent pulling and catheters should be secured as part of routine catheter care. The DON stated the resident should have had a device placed to secure the urinary catheter to the resident's leg. Further interview with the DON revealed she conducted random audits of urinary catheter care and had not identified any concerns with urinary catheters not being secured as care planned. 2. Review of the medical record for Resident #9 revealed the facility admitted the resident on 06/01/15, with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment completed by the facility for Resident #9 dated 10/12/16, revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had been assessed by the facility to be severely cognitively impaired and was therefore not interviewable. Review of Resident #9's plan of care with a revision date of 10/27/16 revealed oxygen would be administered to the resident as ordered by the physician. Review of a physician's orders [REDACTED]. Observation of Resident #9 on 11/29/16, at 2:00 PM and 4:00 PM, revealed the resident was observed to be in bed and was not wearing oxygen. Interview conducted with RN #4 on 12/01/16, at 2:20 PM, revealed she had made rounds and had not identified Resident #9's oxygen was off, but should have. The RN stated she was required to check the care plan for residents daily. Interview conducted with the Director of Nursing (DON) on 12/01/16, at 4:40 PM revealed she made rounds daily to ensure residents were receiving care as directed by their care plans. The DON stated staff was required to review residents' care plans at the beginning of their shift. The DON stated she had not identified any concerns with residents not being provided with the care as directed by their care plans. 5. Review of the medical record for Resident #4 revealed the facility admitted the resident on 05/05/15, with [DIAGNOSES REDACTED]. Review of the MDS Comprehensive review of a significant change MDS assessment dated [DATE], revealed Resident #4 had been assessed to have a BIMS score of 8, which indicated the resident had moderately impaired cognition, and was required to have a pressure-reducing device for the chair. Review of Resident #4's care plan dated 05/19/16, and with a revision date of 11/07/16, revealed Resident #4 was to have a lumbosacral back brace and wear the brace when the resident was out of bed. The care plan also revealed Resident #4 was to have a pressure-reducing cushion in the wheelchair. In addition the care plan revealed Resident #4 was to have a wedge pillow between the resident's legs and the resident's heels were to be floated off the bed to prevent pressure. The care plan stated Resident #4 would have geri-sleeves (sleeves to prevent skin trauma) placed on the resident's lower extremities daily. Observation on 11/29/16 at 5:03 PM of Resident #4 revealed the resident was sitting in the dining room in a wheelchair. The resident was not observed to be wearing a lumbosacral back brace nor was a pressure-reducing cushion observed in the resident's wheelchair. Observation on 11/30/16 at 9:55 AM of Resident #4 revealed a wedge pillow was not observed between the resident's legs, nor were the resident's heels observed to be floating off the bed. In addition, no geri-sleeves were observed on the resident's legs. Interview with SRNA #2 on 12/01/16 at 2:55 PM, revealed she was aware the resident was to have a wedge pillow between the legs and heels floating off the bed while the resident was in bed, and Resident #4 was resistant to it and the SRNA had not been using the wedge pillow or floating the resident's heels. SRNA #2 revealed she did not know the lumbosacral back brace was for use any time the resident was out of bed and thought he/she only needed it when in pain. SRNA #2 revealed that most of the time Resident #4 used the pressure-reducing cushion in the wheelchair, but SRNA #2 was not sure why he/she did not have it at the time of the observations on 11/29/16 and 11/30/16. SRNA #2 revealed she was aware the resident was supposed to have the geri-sleeves on his/her lower extremities and was unsure why the resident did not have them on. SRNA #2 revealed she was aware the interventions were all written on the care plan and she was supposed to look at the care plan daily. Interview with RN #3 on 12/01/16 at 3:10 PM, revealed she was aware the wedge pillow between the legs, the heels floating off the bed while the resident is in bed, the lumbosacral back brace, the pressure-reducing cushion in the wheelchair, and the geri-sleeves on the lower extremities were care planned. The RN stated Resident #4 did not like to use the wedge pillow or to float his/her heels in bed. The RN stated Resident #4 also did not like to use the lumbosacral back brace, and the refusals had never been documented in the chart but should have been. RN #3 revealed she was unsure about the pressure-reducing cushion in the wheelchair not being present. RN #3 revealed all staff was responsible for following the care plan every day. Interview on 12/01/16 at 2:55 PM with RN #4 who was the Unit Manager for the East Unit revealed she knew the care plan stated Resident #4 when in bed was required to have a wedge pillow between the resident's legs and the resident's heels were required to be floating off the bed. In addition, the RN stated she was aware Resident #4's care plan indicated geri-sleeves were to be applied daily, to have a pressure-reducing cushion in the wheelchair, and required a lumbosacral back brace to be worn. RN #4 revealed the resident refused at times to have these interventions. RN #4 revealed there was no documentation in the medical record of Resident #4's refusal of the interventions. Interview with LPN #1 who was the MDS Coordinator on 12/01/16 at 3:35 PM revealed that she was aware of Resident #4's care plan for the wedge pillow, floating heels, geri-sleeves, lumbosacral back brace, and pressure-reducing cushion in the wheelchair. The MDS Coordinator stated she had not been informed of or identified any documentation supporting Resident #4's refusal of the interventions but should have been. Interview with the DON on 12/01/16 at 3:38 PM revealed she made rounds on all three shifts and staff was required to check care plans at the beginning of every shift and care plans should be followed. The DON stated she had not identified any concerns with care plans not being followed. The DON revealed when a resident refused interventions, the physician should be notified with any documentation, and the care plan should have been updated and/or revised. 3. Review of Resident #2's medical record revealed the facility admitted the resident on 11/02/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of 2 indicating severe cognitive impairment. Further review revealed the facility assessed the resident to require a feeding tube. Review of the comprehensive care plan dated 11/20/15 revealed interventions to document tube feeding/fluid totals every shift. Review of the December Physician order [REDACTED]. Review of the Physician order [REDACTED]. Observation of Resident #2 on 11/29/16 at 12:15 PM revealed the resident's tube feeding was turned off. Observation on 11/30/16 at 8:50 AM revealed the resident's tube feeding was off. Observation of a skin assessment on 11/30/16 at 10:10 AM revealed the resident had thick, long, jagged toenails. Interview with Registered Nurse (RN) #2 on 12/01/16 at 1:30 PM revealed she was the nurse that provided care for Resident #2 on 11/29/16 and 12/01/16. She stated Resident #2's tube feeding should have been infusing on 11/29/16 at 12:15 PM and 11/30/16 at 8:50 AM. She further stated she may have forgotten to turn it back on after his/her medications had been administered. Interview with the Director of Nursing (DON) on 12/01/16 at 3:38 PM revealed that Resident #2's tube feeding should have been infusing on 11/29/16 and 12/01/16 during the times the observations were made. She said the only thing she could figure out was that the nurse forgot to restart it after she administered the resident's medications. She stated the nurse was responsible for ensuring the resident's tube feeding was infusing as ordered. She further stated she had not identified any concerns with tube feedings not infusing as ordered. 4. Review of Resident #7's medical record revealed the facility admitted the resident on 02/25/14 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of 8 indicating moderate cognitive impairment. Further review revealed the resident was not assessed to require the use of an indwelling urinary catheter on the MDS; however, on 11/27/16 an indwelling urinary catheter was ordered related to [MEDICAL CONDITION]. Review of Resident #7's comprehensive care plan revealed an intervention dated 03/17/14 to treat with dignity at all times. Further review revealed an intervention dated 11/27/16 to provide catheter care every shift and as needed. Observation of Resident #7 on 11/29/16 at 12:20 PM revealed the resident was in bed with the head of his/her bed elevated with CNA #4 standing over the resident feeding him/her lunch. Observation of indwelling urinary catheter care on 11/30/16 at 10:21 AM revealed CNA #3 did not secure the indwelling urinary catheter tubing to prevent pain or injury while cleaning the catheter tubing. Further observation revealed she dried the tubing from the distal end of the tubing to the proximal end of the tubing. Interview with CNA #3 on 12/01/16 at 1:20 PM revealed she was trained to secure the catheter tubing before cleaning it to prevent pain or injury. She further stated that she thought she secured the tubing with her non-dominant hand but she was nervous. She further stated she looked at the CNA care plan daily. She further stated she should have cleaned the tubing closest to the insertion site first and then moved to the tubing that was farthest away from the resident. Interview with CNA #4 revealed she was trained to sit beside the resident when feeding them. She stated she was nervous and therefore did not follow the care plan. Interview with RN #2 on 12/01/16 at 1:30 PM revealed the CNAs were trained to secure the tubing when they clean a resident's indwelling urinary catheter. Further interview revealed the CNAs were trained to clean and dry the catheter tubing from the proximal end of the tubing to the distal end of the tubing. She stated she made rounds at least once a shift. She further stated she had not identified any concerns with catheter care. She stated the CNAs should sit next to the resident when they feed them to have eye contact with the resident. Interview with the DON on 12/01/16 at 3:38 PM revealed she made rounds on all three shifts to ensure the residents receive the care that they require. She stated that staff was expected to look at the care plan at the beginning of every shift. She further stated the staff was updated if there was a new order. Further interview revealed she had not identified any concerns with staff not following the residents' care plans. She stated the staff was expected to secure the resident's indwelling urinary catheter tubing when providing catheter care and to clean/dry the catheter tubing from the proximal end of the tubing to the distal end of the tubing.

Based on observation, interview, and facility policy review it was determined the facility failed to ensure that the resident environment was as free from accident hazards as possible for eight (8) residents (sampled Resident #9 and unsampled Residents F, G, H, I, J, K, and L) of eighty-five (85) residents of the facility to include both East and West nursing units. Observation on 11/29/16, of the Florida Dining Room revealed a metal storage container unlocked which contained intravenous angiocaths and a bottle of Normal Saline one hundred (100) milliliters with an expiration date of December 2015, that posed as accident hazards to wandering residents. Continued observation of the Main Dining Room revealed a metal storage container that was unlocked and contained several items that could have posed accident hazards to wandering residents. The findings include: Review of a facility policy titled Medication Storage in the Facility, undated, revealed medications and biologicals were to be stored safely, securely, and properly following all manufacturer's recommendations or those of the supplier. Continued review of the facility policy revealed the medication supply was to be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to have access. Review of a list of wandering residents in the facility revealed the facility had eight residents who had been assessed by the facility to be wanderers. Observation on 11/29/16, at 5:30 PM of the Florida Dining Room, revealed a metal storage container unlocked which contained three 24-gauge intravenous angiocaths, three 20-gauge intravenous angiocaths, three 22-gauge intravenous angiocaths, and a bottle of Normal Saline 100 milliliters with an expiration date of December 2015, in the top drawer. Observation of the Main Dining Room on 11/29/16, at 5:45 PM, revealed a metal storage container that was unlocked and contained one 20-gauge intravenous angiocath, one 22-gauge intravenous angiocath, and three 10-milliliter syringes with normal saline with an expiration date of November 2015, in the top drawer. Interview conducted with the Director of Nursing (DON) on 11/29/16, at 6:00 PM, revealed she had placed the storage containers in the Florida Dining Room and the Main Dining Room. The DON stated only oxygen supplies were supposed to be in the cart. The DON stated she was unaware of how the other supplies had gotten into the cart and that the other supplies should not have been there.

Based on interview, record review, and facility policy review it was determined the facility failed to have an effective system to ensure the resident's physician was notified when a significant change in physical status occurred for one of twenty-three sampled residents (Resident #14). On 06/17/11, at 8:00 PM, facility staff assessed Resident #14 to have an abnormally low blood pressure and pulse rate. Facility staff failed to report the abnormal findings to Resident #14's attending physician at the time of the assessment. Approximately eight hours later, the resident was found by direct care staff to be nonresponsive and without any signs of life. Resident #14 was pronounced dead on 06/18/11, at 4:15 AM, by the coroner. The facility's failure to promptly inform Resident #14's attending physician regarding a significant change in condition placed Resident #14 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 06/17/11. An acceptable Allegation of Compliance was received on 06/29/11, and an amended AOC was received on 07/27/11, which alleged removal of Immediate Jeopardy on 06/29/11. The State Agency determined the Immediate Jeopardy was removed on 06/29/11, which lowered the scope and severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy/procedure related to physician notification (dated December 2007) revealed facility staff was responsible to promptly notify the attending physician of changes in a resident's medical/mental condition. According to the policy, nursing supervisors/charge nurses were required to notify a resident's attending physician or on-call physician when a significant change occurred in a resident's physical/emotional/mental condition, when a change in baseline vital signs occurred, or when a need to alter a resident's medical treatment significantly had been identified. A closed record review revealed Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED].#14's blood pressure ranged from 124/68 to 110/64, and the resident's heart rate ranged from 76-84 beats per minute. A review of the progress notes dated 06/17/11, at 8:00 PM, revealed Licensed Practical Nurse (LPN) #1 attempted to administer medications to Resident #14, but was unable to administer the medications due to the resident's refusal to open his/her mouth. At that time, according to the progress notes, LPN #1 obtained the resident's vital signs and documented the resident had a blood pressure of 86/30 and a heart rate of 40. However, there was no documented evidence LPN #1 notified the resident's attending physician of the abnormal vital signs and change in the resident's condition. Further review of the progress notes revealed on 06/18/11, at 3:55 AM, LPN #1 was called to Resident #14's room after direct care staff discovered the resident to be unresponsive and not breathing. Record review revealed LPN #1 assessed and noted the resident's legs and feet were cold and discolored, the resident's hands were cool to touch, and the resident's skin color was pale. LPN #1 documented Resident #14 had no "signs of life" with no obtainable blood pressure, heart rate, or respirations. An interview conducted with LPN #1 on 06/23/11, at 4:25 PM, revealed the LPN worked part-time during the 7:00 PM to 7:00 AM shift at the facility. LPN #1 stated she had obtained Resident #14's blood pressure and heart rate at 8:00 PM on 06/17/11. The LPN stated she did not know what Resident #14's blood pressure and heart rate usually were and did not compare the resident's blood pressure and heart rate to the resident's vital sign record. LPN #1 further stated she considered a blood pressure of 86/30, and a heart rate of 40 to be abnormal for "anyone." The LPN stated she did not notify the resident's attending physician of the resident's abnormal vital signs at the time they were obtained. An interview with Resident's #14's attending physician (MD #1) on 06/23/11, at 6:30 PM, revealed she would have expected facility staff to report changes in the resident's condition and vital signs to her. MD #1 stated the resident's systolic (top number of a blood pressure reading) blood pressure usually was 100-110 and his/her heart rate of 40 would have been "alarming" to her. MD #1 further stated she would have considered sending Resident #14 to the emergency room for further evaluation/treatment, or at least considered intravenous therapy to increase the resident's blood pressure, if she had been made aware of the changes in Resident #14's condition. An interview conducted with the Director of Nursing (DON) on 06/23/11, at 8:15 PM, revealed the nurse was responsible to notify a resident's physician when a change in condition was identified. The DON stated LPN #1 should have informed Resident #14's attending physician about a change in blood pressure and heart rate on 06/17/11, at 8:00 PM. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was received on 06/29/11, and an amended AOC was received on 07/27/11, which alleged the Immediate Jeopardy was removed on 06/29/11. According to the AOC, a thorough review of all residents' medical records was conducted by the Executive Director of Nursing (EDON), Director of Nursing (DON), Quality Assurance Nurse (QAN), MDS Coordinators, Medical Records Director, Registered Nurse (RN) and all Unit Managers (UMs) on 06/25/11, 06/26/11, 06/27/11, and 06/28/11. The reviews were conducted to identify changes in residents' condition that would require notification of the resident's physician and/or responsible party. If a change in condition was identified as a result of the record review, facility staff was to further assess the resident's condition and make notifications to the physicians and/or legal representatives/interested family members as indicated. Further review of the AOC revealed on 06/28/11, the facility began a daily review of all residents' current physician's orders [REDACTED]. The daily reviews were to be completed by the EDON, DON, QAN, Medical Records Director, and/or UM to determine and ensure significant changes in a resident's condition had been immediately reported to the resident's physician and family member/legal representative. In addition, the daily reviews were to determine if continued assessment of a resident's condition was indicated and to determine if resident assessments were made in a timely manner. The AOC revealed on 06/27/11 and 06/28/11, all licensed nurses were in-serviced by the EDON, DON, QAN, and UM related to the facility's policy and procedure on notification of the resident's physician and family when changes in the resident's condition occur. The AOC also revealed all licensed nurses were in-serviced on resident assessment, follow-up assessments, and documentation of changes in resident condition. Licensed nursing staff who had not attended the in-service by 06/28/11, would be required to attend the in-service prior to being permitted to work. Continued review of the AOC revealed the above information would be included in the Orientation Process for all newly hired staff. A review of the AOC revealed on 06/28/11, the facility implemented a 72 Hour Charting Policy and charting form. Facility staff was to utilize the policy and forms to identify, report, and assess residents for a change in condition. Licensed nurses were in-serviced by the EDON, DON, QAN, and Unit Managers on 06/27/11 and 06/28/11, on the 72 Hour Charting Policy and charting form. These forms were to be reviewed daily by the EDON, DON, QAN, Unit Managers, or a designated licensed nurse to ensure appropriate notification occurred. Review of the AOC revealed the facility was to ensure continued compliance by reporting all audit findings to members of the Quality Assurance (QA) Committee on a weekly basis until compliance was achieved, and then on a monthly basis for three months to ensure continued compliance. Following the submission of the monthly reports for three months, staff was to continue to submit findings on an as needed basis for review, to ensure sustained compliance. The AOC revealed the Administrator was responsible for overall compliance through attendance of the Clinical Meetings, by directing and oversight of the QA Meeting, and reviewing all audits. **The surveyor validated the corrective action taken by the facility as follows: A review of the facility's audits on 06/29/11, verified the facility completed a thorough review of all residents' medical records. A review of sign-in sheets and interviews with staff (RNs #3, #4, #5, #6, #7, and #8 and LPNs #2, #3, #4, #5, and #6) on 06/29/11, verified the facility had in-serviced nursing staff on 06/27/11 and 06/28/11, related to the identification and assessment of changes in resident conditions, notification of changes to physicians and responsible parties, and the 24-hour reports and 72-hour charting policy and form. In addition, according to observations and interviews with staff (RNs #3, #4, and #7 and LPNs #3, #4, and #6) on 06/29/11, the 24 and 72-hour monitoring records were kept at the nurses' stations and monitored daily by the administrative staff (Administrator, EDON, DON, MDS Coordinators, UMs, and QAN) . An interview with the Director of Nursing (DON) on 06/29/11, at 6:10 PM, and record review verified the 24 and 72-hour reports, utilized to monitor residents for changes in condition, were reviewed daily in the Daily Clinical Meeting, and any concerns were addressed and acted upon at that time. An interview with the Administrator on 06/29/11, at 7:35 PM, verified administrative staff (Administrator, EDON, DON, MDS Coordinators, UMs, and QAN) reviewed the 24 and 72-hour reports daily in the Daily Clinical Meeting, to ensure concerns observed with changes in resident condition and/or physician notification would have immediate correction. Based on the above findings, it was determined the Immediate Jeopardy was removed on 06/29/11. Noncompliance continued with the scope and severity lowered to "D" based on the need for the facility to evaluate and implement systematic changes and quality assurance activities.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure necessary care and services were provided to maintain the physical well-being for one of twenty-three sampled residents (Resident #14). Resident #14 had a living will and a physician's orders [REDACTED]. Resident #14 was identified to have a change in condition with an abnormal blood pressure reading of ,[DATE] and a heart rate of 40 on [DATE], at 8:00 PM. However, there was no documented evidence facility staff monitored and assessed Resident #14 for further changes in vital signs or physical condition. On [DATE], at 3:55 AM, the resident was found unresponsive, not breathing, and with no signs of life. Resident #14 expired at the facility on [DATE]. Facility staff was not aware of Resident #14's code status of "CPR only" and failed to discuss this with the resident's physician when the physician was informed of the resident's condition. The failure of the facility to ensure care and services to maintain physical well-being was provided placed Resident #14 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE], and an amended AOC was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. The State Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's Change in Condition Monitoring Assessment policy (no date) revealed the facility nurse was required to conduct an assessment of a resident prior to notifying the resident's physician of a change in the resident's condition. The policy further stated the assessment would include vital signs, airway/breathing assessment, circulation, a review of the relevant labs, recent medication changes, and any deviation from the resident's normal findings. A review of the facility's Vital Signs policy/procedure (no date) revealed vital signs would be taken as ordered by the resident's physician. The policy further noted licensed nurses were responsible to use professional judgment to determine when vital signs would be indicated. Review of the facility's Advance Directives/Code Status policy/procedures (dated [DATE]) revealed the facility would honor the Advance Directives of each resident in accordance with state law. The policy/procedures stated a resident's code status would be designated in the resident's medical record under the advance directive tab. According to the policy, for a resident who requested "Do Not Resuscitate" (DNR) status, a red strip would be placed on the spine of the medical record and consent would be placed under the advance directive tab of the resident's medical record. The policy/procedure further directed CPR would not be initiated when the resident had orders for DNR, or when obvious signs of death were present. The policy defined the most reliable signs of death to be dependent livedo (general bluish discoloration of the skin, as in pooling of blood in dependent body parts), rigor mortis (hardening of muscles or rigidity), algor mortis (cooling of the body), and/or injuries incompatible with life. A closed record review revealed Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Living Will Declaration notarized on [DATE], revealed Resident #14 directed no life-prolonging treatment would be provided if the treatment would only serve to artificially prolong the resident's death and also directed the administration of medication or performance of any medical treatment deemed necessary be provided to alleviate pain or for nutrition/hydration. The resident's code status was identified as "CPR only." A review of the medical record revealed Resident #14's blood pressure ranged from ,[DATE] to ,[DATE] and the resident's heart rate ranged from ,[DATE] beats per minute from [DATE] to [DATE]. According to the current physician's orders [REDACTED]. A review of the medical record revealed LPN #1 documented in the progress notes on [DATE], at 8:00 PM, that Resident #14 refused to take medications as ordered by the physician. The progress notes stated the resident would not open his/her mouth and refused the medications. Further review of the progress notes revealed LPN #1 obtained the resident's blood pressure (,[DATE]) and the resident's heart rate (40). However, there was no further documentation the nurse monitored or assessed Resident #14 for further changes in blood pressure, heart rate, or overall physical condition. According to the progress notes, direct care staff reported to LPN #1 on [DATE], at 3:55 AM, that Resident #14 was nonresponsive and not breathing. LPN #1 noted in the progress notes that Resident #14's legs and feet were cold and discolored, his/her hands were cool to touch, vital signs could not be obtained, and there were no signs of life. An interview conducted with LPN #1 on [DATE], at 4:25 PM, revealed the LPN had obtained Resident #14's blood pressure and heart rate at 8:00 PM on [DATE]. The LPN stated she did not know what Resident #14's blood pressure and heart rate usually were and did not compare the blood pressure and heart rate to the resident's vital sign record. LPN #1 further stated she considered the blood pressure (,[DATE]) and the heart rate (40) to be abnormal for "anyone." The LPN stated she did see Resident #14 again at 9:00 PM on [DATE], and at approximately 12:00 AM on [DATE], and Resident #14 was responsive to touch and there were no visible signs of change in the resident's condition. However, LPN #1 stated she did not recheck the resident's blood pressure and heart rate or do a physical assessment of the resident after 8:00 PM on [DATE]. The LPN further stated she had been trained to recheck a resident's vital signs and to assess/monitor the resident for further changes in physical condition when an abnormal vital sign reading was obtained. However, LPN #1 stated she did not recheck Resident #14's vital signs because she did not see any "visible" changes in the resident. In addition, LPN #1 stated she could not recall a specific training being provided regarding facility policies for identification of a resident's code status and was not familiar with Resident #14's order for "CPR only" to be administered. LPN #1 stated she believed the resident was a DNR and did not believe CPR would have been effective for Resident #14. However, the LPN did not discuss the CPR order with the resident's physician when the physician was informed of the resident's condition at 4:10 AM on [DATE]. An interview conducted with Certified Nursing Assistant (CNA) #1 and CNA #2 on [DATE], at 5:35 PM, revealed CNA #1 and CNA #2 conducted a bed check at approximately 11:00 PM on [DATE]. CNA #1 stated he observed Resident #14 to be less responsive than the night before when the CNA provided care for the resident. CNA #1 also stated he reported this information to LPN #1 and the nurse directed the CNAs to offer the resident fluids during each bed check. CNA #2 stated she and CNA #1 provided incontinence care for Resident #14 at approximately 1:15 AM on [DATE], and observed that the resident continued to respond poorly with no visible signs of respiratory difficulty. CNA #2 stated at approximately 3:50 AM, CNAs #1 and #2 went into Resident #14's room to provide incontinence care during a routine bed check and observed the resident to be cold to touch with blue discoloration from the resident's feet to the trunk area of the resident's body. The CNAs stated they immediately reported the resident's condition to LPN #1. An interview conducted with the Director of Nursing (DON) on [DATE], at 8:15 PM, and on [DATE], at 5:20 PM, revealed the nurse was responsible to conduct a head to toe physical assessment, which included an evaluation of all body systems, and to document the assessment information in the progress notes when a change in a resident's condition occurred. The DON stated the nurse was also responsible to conduct and document ongoing assessment/monitoring of a resident's condition to evaluate for further changes in the resident's condition. The DON also stated the nurse was responsible to obtain vital signs of the resident at least weekly. In addition, the DON stated the nurse should use good nursing judgment to determine when to recheck a resident's vital signs after a change was noted. The DON further stated LPN #1 should have continued to monitor Resident #14's vital signs and to assess the resident for further changes in physical condition. The DON stated although the facility policy directed no CPR would be done if signs of death were present, the nurse should inform the physician of the resident's assessment and follow the directions of the physician. Resident #14's attending physician stated in an interview on [DATE], at 6:30 PM, she would have expected facility staff to report changes in the resident's condition and vital signs to her. MD #1 stated the resident's systolic (top number of a blood pressure reading) blood pressure usually was ,[DATE] and his/her heart rate of 40 would have been "alarming" to her. MD #1 further stated she would have considered sending Resident #14 to the emergency room for further evaluation/treatment, or at least considered intravenous therapy to increase the resident's blood pressure, if she had been made aware of the changes in Resident #14's condition. Per interview on [DATE], at 4:20 PM, the physician stated facility staff that has been trained in CPR should be able to make a judgment regarding initiating CPR when a resident has been found to be unresponsive with no signs of life. The physician stated if the resident was assessed to have rigor mortis or to be cold CPR would not be indicated and facility staff should not be required to obtain a physician's orders [REDACTED]. The Staff Development Nurse/Executive Director of Nurses (EDON) stated in an interview on [DATE], at 6:10 PM, the facility did not have procedures in place for new staff to receive the appropriate training to ensure proper code status was followed when a resident was found unresponsive and not breathing. According to the EDON and a review of staff in-service training, mandatory in-services related to Advance Directives were scheduled bi-annually and an in-service had been provided for staff on [DATE]. LPN #14 did not attend; however, no disciplinary action or retraining had been implemented for LPN #14. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was received on [DATE], and an amended AOC was received on [DATE], which alleged the Immediate Jeopardy was removed on [DATE]. A review of the AOC revealed a comprehensive review of residents' medical records was conducted by the facility's Clinical Management Staff: Executive Director of Nursing (EDON), Director of Nursing (DON), Quality Assurance Nurse (QAN), Unit Managers (UMs), Medical Records Director, MDS Coordinator RN, and MDS Coordinator LPN. The records and documents reviewed by the Clinical Management Staff were the 24-hour report, physician's orders [REDACTED]. The reviews were completed by the facility on [DATE], [DATE], [DATE], and [DATE], to identify any changes in resident condition. In addition, a chart audit was conducted on [DATE], [DATE], and [DATE] by the EDON, DON, UMs, and QAN to determine the accuracy of each resident's Advance Directives. The AOC revealed on [DATE], the facility began a daily review of residents' physician's orders [REDACTED]. The daily reviews were to be completed by the EDON, DON, QAN, UMs, and/or Medical Records Director to ensure facility staff conducted an assessment of the resident as required, if a change in a resident's condition occurred. The AOC revealed all licensed nurses had attended an in-service on [DATE] and [DATE], and had been trained on the facility's policy and procedure on assessment of a resident's change in condition, follow-up, and documentation of change in a resident's condition. All licensed staff that had not been in-serviced by [DATE], was required to attend an in-service prior to their return to work. In addition, the facility's policy on Assessment of Change in Condition was added to the orientation process for all newly hired employees. The AOC also revealed if the facility utilized staff from a contracted agency, the same above information would be included in the orientation of the contracted employee. The AOC further revealed the facility's policy on Advance Directives was updated on [DATE], and in-services for staff were provided on [DATE] and [DATE], by the EDON, DON, UMs, and QAN regarding the updated policy and procedure for Advance Directives and identification of residents' code status. The AOC noted routine education regarding Advance Directives would continue twice a year per the facility's routine in-service schedule and the Advance Directive/Code Status policy would also be included in the Orientation Process for all new hires. A review of the AOC revealed a 72-hour Charting Policy and form was implemented on [DATE]. The facility staff was to utilize the policy and form to identify, assess, and report any changes in resident condition to the resident's physician and/or family. Licensed nursing staff was in-serviced on the policy and charting form on [DATE] and [DATE]. The AOC revealed the 72-hour charting forms would be reviewed by the EDON, DON, UMs, QAN, or nurse designated by the EDON, daily in the Clinical Meeting to ensure follow-up assessments were completed if a change in a resident's condition was identified. The AOC further revealed on Saturdays and Sundays the charting forms were to be reviewed by the EDON and/or the DON, or a designated licensed nurse, to ensure changes in a resident's condition had been identified. The AOC included Advance Directive audits would be conducted on ten percent of all resident records weekly for one month and then monthly by the QAN, EDON, DON, UMs, and Medical Director to ensure the policy/procedures on Advance Directives and identification of residents' code status was followed. In addition, the AOC revealed Advance Directives of new admissions would be reviewed in the Clinical Meeting utilizing the Admission Audit tool and staff interviews would be conducted weekly by the QAN, EDON, DON, and UMs to ensure staff's comprehension of the Advance Directive in-services. Further review of the AOC revealed the facility was to ensure continued compliance by reporting all audit findings to members of the Quality Assurance (QA) Committee on a weekly basis until compliance was achieved, then monthly for three months to ensure compliance was maintained, and on an as needed basis thereafter to ensure continued compliance. The QA committee will review audits and implement changes as they are needed to sustain compliance. The Administrator will be responsible for overall compliance and would attend the Clinical Meetings and review audits. **The surveyor validated the corrective action taken by the facility as follows: The facility's documentation reviewed on [DATE] and [DATE], verified the residents' medical records had been comprehensively reviewed (monitored physician notification, change in status, 24-hour report, 72-hour log, and code status/advance directives) as stated in the facility's AOC. A review of the facility's in-service sign-in sheets and interviews with staff RNs (RNs #3, #4, #5, #6, #7, and #8) and LPNs (LPNs #2, #3, #4, #5, and #6) on [DATE], [DATE] and [DATE], verified staff had been in-serviced on [DATE] and [DATE], as stated in the AOC. Staff further revealed they had been in-serviced to document any change in a resident's condition on the 24-hour record, and to ensure reassessment of the resident would occur. Further interviews with licensed nursing staff (RNs #3, #4, #5, #6, #7, #8, and #9 and LPNs #2, #3, #4, #5, and #6) on [DATE], revealed staff had utilized the 24 and 72-hour monitoring records to ensure a change in a resident's condition was identified. In addition, interviews conducted with RNs #3, #4, #5, #7, #8, and #9, LPNs #3 #4, #6, #7, and #8, and Certified Nurse Aides #1, #2, #3, #10, #12, #13, #14, #15, and #16 confirmed staff had been in-serviced regarding Advance Directives and identification of a resident's code status. An interview with the facility's MDS staff on [DATE], at 7:00 PM and 7:15 PM, and record review verified all 24 and 72-hour reports were reviewed on a daily basis in the Clinical Meeting. MDS staff stated the reports and resident medical records were reviewed to determine if there had been any changes in a resident's status, incidents, and/or abnormal labs, and if the physician had been notified of the findings. In addition, admission audits were conducted and reviewed in the Clinical Meeting to ensure the resident's Advance Directive information was accurate and available. Interview with the EDON on [DATE], at 1:45 PM, revealed nursing staff was to report all significant changes in resident status to her. The EDON stated she would be meeting with Administration daily to report any problems identified through resident record audits and/or any areas of concern identified through the morning Clinical Meeting. The EDON stated in an interview on [DATE], at 4:40 PM, that post tests were being administered to all staff after each mandatory in-service to ensure staff understanding of material provided. Interview with the Administrator on [DATE], at 7:35 PM, revealed she would be communicating with the facility's EDON and/or DON daily to be aware of occurrences inside the facility. The Administrator further stated the facility's Nurse Consultant would conduct weekly audits to ensure systems were working properly. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the need for the facility to evaluate and implement systematic changes and quality assurance activities.

Based on interview, record review, and review of facility policies, it was determined the facility failed to be administered in a manner that promoted the highest physical well-being for one of twenty-three sampled residents (Resident #14). The facility failed to have an effective system in place to ensure policies and procedures were implemented. The facility's Administration failed to ensure staff assessed and monitored residents when a significant change in a resident's condition was identified. Facility Administration also failed to ensure staff received appropriate training/orientation regarding facility policies/procedures for Advance Directives. In addition, the Administration failed to ensure the resident's attending physician was notified timely regarding significant changes in a resident's condition. On [DATE], facility staff identified abnormal vital signs and a change in Resident #14's physical condition. However, facility staff failed to inform the resident's attending physician of the condition change and failed to assess and monitor Resident #14 for further changes. On [DATE], facility staff found Resident #14 unresponsive with no signs of life. Resident #14 expired on [DATE]. (Refer to F157 and F309.) These facility failures placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE], and an amended AOC was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. The State Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's Change in Condition Monitoring Assessment policy (no date) revealed the facility nurse was required to conduct an assessment of a resident prior to notifying the resident's physician of a change in the resident's condition. The policy further stated the assessment would include vital signs, airway/breathing assessment, circulation, a review of the relevant labs, recent medication changes, and any deviation from the resident's normal findings. A review of the facility's Vital Signs policy/procedures (no date) revealed vital signs would be taken as ordered by the resident's physician. The policy further noted licensed nurses were responsible to use professional judgment to determine when vital signs would be indicated. A review of the facility's policy/procedure related to physician notification (dated [DATE]) revealed facility staff was responsible to promptly notify the attending physician of changes in a resident's medical/mental condition. According to the policy, nursing supervisors/charge nurses were required to notify a resident's attending physician, or on-call physician, when a significant change occurred in a resident's physical/emotional/mental condition, when a change in baseline vital signs occurred, or when a need to alter a resident's medical treatment significantly had been identified. Review of the facility's Advance Directives/Code Status policy/procedures (dated [DATE]) revealed the facility would honor the Advance Directives of each resident in accordance with state law. The policy/procedure stated a resident's code status would be designated in the resident's medical record under the advance directive tab. According to the policy, for a resident who requested "Do Not Resuscitate" (DNR) status, a red strip would be placed on the spine of the medical record and consent would be placed under the advance directive tab of the resident's medical record. The policy/procedure further directed CPR would not be initiated when the resident had orders for DNR, or when obvious signs of death were present. The policy defined the most reliable signs of death to be dependent livedo (general bluish discoloration of the skin as in pooling of blood in dependent body parts), rigor mortis (hardening of muscles or rigidity), algor mortis (cooling of the body), and/or injuries incompatible with life. A review of Resident #14's closed medical record revealed progress notes dated [DATE], at 8:00 PM, documenting that Licensed Practical Nurse (LPN) #1 obtained a blood pressure of ,[DATE] and a heart rate of 40 for Resident #14. However, further review of the progress notes revealed no documented evidence Resident #14 was further assessed or monitored. On [DATE], at 3:55 AM, Resident #14 was found to have no vital signs and no signs of life. An interview conducted with LPN #1 on [DATE], at 4:25 PM, revealed LPN #1 failed to notify the resident's attending physician about the abnormal vital signs and failed to reevaluate the resident's blood pressure and heart rate. In addition, LPN #1 stated she believed Resident #14 was a DNR and was not aware of a physician's orders [REDACTED].#14. Thus, the LPN did not discuss the CPR order with the resident's physician when the physician was informed of the resident's condition at 4:10 AM on [DATE]. The LPN further stated she did not believe CPR would have been effective for Resident #14. The LPN stated she did not recall a specific training being provided regarding the facility's policy for identification of a resident's code status. An interview conducted with the Director of Nursing (DON) on [DATE], at 8:15 PM, revealed Resident #14's medical record had been reviewed during the clinical meeting on [DATE]. A problem had been identified with the nurse's failure to notify Resident #14's attending physician timely of the resident's abnormal blood pressure, heart rate, and the change in Resident #14's medical condition, and to identify the resident's code status order of "CPR only." However, the DON stated Facility Administration had not implemented a plan of correction to ensure residents were appropriately assessed when a change in condition occurred and the resident's physician notified timely when a change in a resident's condition occurred. An interview conducted with the facility's Administrator on [DATE], at 8:45 PM, revealed Resident #14's death was reported to her on [DATE]. The Administrator stated she was aware of the concerns related to Resident #14's death and planned to take disciplinary action for LPN #1. The Administrator stated no disciplinary action had been initiated at the time of the interview on [DATE]. The Administrator further stated no plan of correction had been implemented to ensure established policy/procedures were followed to ensure all residents were assessed appropriately or to ensure the resident's physician was informed timely of changes in a resident's condition. Interview conducted with the Staff Development Nurse/Executive Director of Nurses (EDON) on [DATE], at 8:05 PM, revealed mandatory in-services related to the facility's code status policy were provided for staff twice a year. However, there was no evidence the facility monitored to ensure staff attended the mandatory in-services or monitored for staff competency after the in-services were provided. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was received on [DATE], and an amended AOC was received on [DATE], which alleged the Immediate Jeopardy was removed on [DATE]. Review of the AOC revealed the facility held a Quality Assurance (QA) Committee Meeting on [DATE], and the following facility staff members were present: Facility Administrator, Executive Director of Nursing (EDON), Director of Nursing (DON), Unit Managers (UMs), Quality Assurance Nurse (QAN), Medical Records Director, and Medical Director. The AOC revealed all initial audit results of residents' records were reviewed by the committee members during the meeting. The AOC also revealed the facility's compliance would be monitored daily by the Administrator. Further review of the AOC revealed the Administrator would communicate daily with the EDON and/or DON, and discuss the results of the audits of resident physician's orders [REDACTED]. The results of these findings were to be evaluated by the QA Committee members, and the members were to make interventions as needed. The QA Committee was to meet weekly, or more often if necessary, and discuss areas of concern that had been identified until sustained compliance with the corrective actions had been demonstrated. The QA Committee members were also to track and trend the audit findings to evaluate and implement needed improvements. Review of the AOC revealed the facility would monitor their continued compliance through audits conducted by the QAN to determine that policies and procedures implemented related to Advance Directives and the notification of a resident's physician, legal representative, or family member had been followed when a change in a resident's condition occurred. The QAN would complete the above evaluations monthly for three months or until sustained compliance has been determined. The AOC revealed Process Reviews would be completed on ten percent of the in-house census weekly to ensure continued compliance. The AOC revealed an external nurse consultant would review the audit results weekly and complete an additional audit of one chart weekly for three months, or until substantial compliance had been maintained by the facility. The AOC revealed the results of all facility reviews and/or audits would be reported to the QA Committee for review and recommendation of changes as needed. **The surveyor validated the corrective action taken by the facility as follows: Interview with the Administrator on [DATE], at 7:35 PM, and record review verified she had attended the Clinical Meetings and the QA Meeting. Per interview she would be attending the Clinical Meetings daily and the QA Meetings weekly and/or as needed, to ensure the above monitoring policies and procedures were being utilized. The Administrator stated the facility's external nurse consultant would complete weekly audits and would assist facility staff in the development of additional monitoring tools as they were needed. An interview with the facility's Medical Director on [DATE], at 4:00 PM, and record review verified he attended the QA Meeting. Per interview, he would be attending the weekly QA meeting and working closely with the facility staff to develop and/or implement the policies and procedures to ensure the facility maintained their compliance. Based on the above findings, it was determined the Immediate Jeopardy was removed on [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the need for the facility to evaluate and implement systematic changes and quality assurance activities.