Every finding on record at Pine Meadows Post Acute

Based on observation, interview, record review, review of a U.S. Food and Drug Administration document, and review of the facility's policies, the facility failed to provide a safe, sanitary environment for food production and storage, which could affect 117 of the 117 current residents that received food from the kitchen.During the initial kitchen tour on 09/02/2025, observations revealed staple food bins unlabeled and undated, other commercial mixes out of the original packaging with no opened date, and personal items, including backpack and jacket, stored in the dry storage room on top of canned and packaged foods. Also, temperatures were missing on the logs for the tray line and for the walk-in refrigerator and freezer. Observation of the kitchen ceiling on 09/03/2025 and 09/04/2025 revealed dripping condensation and peeling gray paint on the ceiling. Observation of one nourishment refrigerator on 09/05/2025 revealed an expired item which had no opened date marked on it, and review of another nourishment refrigerator temperature log revealed the log had the acceptable range for the refrigerator was 36 degrees Fahrenheit (F) to 46 degrees F, instead of the facility's policy of at or below 41 degrees F. On 09/04/2025, this refrigerator's temperature was recorded at 42 degrees F. The findings include:Review of the facility's policy titled, Food Preparation and Service, revised November 2022, revealed identification of potential hazards in the food preparation process and adhering to critical control points could reduce the risk of food contamination and thereby minimize the risk of foodborne illness. Further review revealed food preparation staff must adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Per the policy, appropriate measures must be used to prevent cross contamination, including sanitizing towels and cloths used for wiping surfaces in containers filled with approved sanitizing solution. Additional review revealed proper hot and cold temperatures were maintained during food distribution and service, and foods held above 41 degrees Fahrenheit (F) and below 135 degrees F must be discarded after 4 hours. The policy also revealed the temperatures of foods held in steam tables were monitored throughout the meal service by food service staff.Review of the facility's policy titled, Food Receiving and Storage, revised November 2022, revealed foods were to be stored in a manner that complied with safe food handling practices. The review also revealed when food was delivered to the facility it was inspected for safe transport and quality before being accepted. Further review revealed dry foods that were stored in bins were removed from the original packaging, labeled and dated with the deadline of when the food must be used, and such foods were rotated using a first in, first out system. Continued review revealed food must not be stored under leaking waterlines, including under lines on which water had condensed. Additional review revealed all foods stored in the refrigerator or freezer were covered, labeled, and dated with the use-by-date. Further review revealed refrigerated foods were stored at or below 41 degrees F, and were labeled, dated, and monitored so they were used by their use-by-date, frozen, or discarded. The review also revealed frozen foods were maintained at a temperature to keep the food frozen solid, with wrappers of frozen foods remaining intact until thawing. Continued review revealed all food items to be kept at or below 41 degrees F on the nursing units, were placed in the nourishment refrigerator and labeled with a use-by-date. The policy also revealed refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, revealed the facility must ensure safe refrigerator and freezer maintenance, temperature and sanitation, and must observe food expiration guidelines. Further review revealed refrigerators must keep foods at or below 41 degrees F and freezers keep foods frozen solid. Continued review revealed monthly tracking sheets for all refrigerators and freezers were posted to record temperatures and must include time, refrigerator temperature, initials, and action taken if the measured temperatures were not acceptable. Additional review revealed all food was appropriately dated to ensure proper rotation. Further review revealed supervisors were responsible for ensuring food items in the pantry, refrigerators, and freezers were not used past their use-by or expiration dates.Review of the document, U.S. Food and Drug Administration [FDA] 2022 Food Code, 01/18/2023 Version, revealed the FDA recommended that food entities limit the cold storage of ready-to-eat foods to a maximum temperature of 41 degrees F for food safety.Observation during the initial kitchen tour on 09/02/2025 at 6:17 PM revealed a mixing bowl and frying pans turned up, and a clear bin with assorted utensils turned up and uncovered on the bottom shelf in the production area next to the pot and pan sink. The chopping boards were stored on the bottom shelf of the same wire rack with no liner or other protection from potential splash underneath. Further observation of the shelf opposite the pot and pan sink revealed cornmeal and flour packages opened and undated, and sprouting potatoes in a bowl with dusty rim, sitting on top of the ingredient bins on a shelf and undated. Continued observation revealed a clear, round container with a red top holding a brown crumb looking substance, unlabeled and undated. Also observed was a package of yellow cake mix that was opened, but undated, as well as an opened bottle of hot sauce, unrefrigerated with no opened date or use-by-date. Additional observation of the same shelf revealed a beef flavor package opened, without a seal and not dated; biscuit gravy mixes and white grits in a clear zip lock bag, undated. Observation also revealed a box of quick oats with an opened end and not dated. Observation of the reach-in refrigerator revealed an opened package of shredded cheese, undated. Observation of the kitchen dry storage room on 09/02/2025 at 6:40 PM revealed an ingredient bin of thickener opened and undated; pasta and rice in four ingredient bins not dated; two dented #10 cans of butter beans on the second shelf with the other #10 cans; and five bags of yellow cake mix on the shelf with no date. Further observation in the dry storage room revealed staff personal items on the shelf, including a purse, a mobile phone, and a grocery bag.Review of the food tray line temperature log during the initial tour on 09/02/2025 at 6:17 PM revealed the temperatures were not recorded for 08/31/2025, 09/01/2025, and 09/02/2025 breakfast. The temperature log for the walk-in refrigerator and freezer did not record the AM shift temperatures for 09/02/2025.In an interview with the Dietary Manager (DM) on 09/02/2025 at 6:47 PM, he stated staff was supposed to keep the dented cans on the bottom shelf. Review of the lunch tray line temperature log on 09/03/2025 at 11:00 AM revealed breakfast temperatures were filled in for 08/31/2025, 09/01/2025, and 09/02/2025. Observation on 09/03/2025 at 11:15 AM revealed a black backpack and jacket lying on top of the #10 cans, by the dry storage room door. Observation of the kitchen ceiling on 09/03/2025 at 11:21 AM revealed dripping condensation from the vent between the freezer door and the tray line. Observation also revealed peeling gray paint on the ceiling located behind the vent with condensation and in front of the freezer door. Observation of the tray line on 09/04/2025 at 11:13 AM revealed the Dietary Manager (DM) leaning over the line with his name badge dangling and dragging over food under preparation while working on production.Observation of the kitchen dry storage room on 09/04/2025 at 11:15 AM revealed three staff backpacks, one bottle of water, a sweat jacket, and an apron. Further observation revealed one backpack was resting on the shelf with canned goods. Also, there was one backpack, along with a water bottle and apron, resting on boxed produce and one backpack with one jacket hanging on a corner pole, supporting the shelving.Observation of the tray line in the kitchen on 09/04/2025 at 11:21 AM revealed water dripping from the vent in the ceiling above the space between the walk-in freezer door and the tray line. Further observation revealed chipping paint from the ceiling space by the vent.Observation of the nourishment refrigerator in the medication room by the 400-600 Halls on 09/05/2025 at 9:04 AM revealed one opened container of Med Pass Fortified Nutritional Shake, 2.0+, Butter Pecan flavor, had expired on 09/01/2025 and had no opened date marked.Review of the nourishment refrigerator temperature log in the medication room by the 100-300 Halls on 09/05/2025 at 8:52 AM revealed a recorded temperature of 42 degrees F on 09/04/2025. Further review revealed the form indicated the acceptable range for the refrigerator was 36 degrees F - 46 degrees F. During an interview with the Maintenance Director on 09/05/2025 at 2:00 PM, he stated a pipe ran through the attic above the tray line, and the condensation built up due to the attic being hot. He stated they tried to adjust the pipe and the insulation in the attic. During additional interview with the Dietary Manager (DM) on 09/05/2025 at 2:35 PM, he stated air conditioning produced condensation on the ceiling, and he was not sure why. He stated the condensation would be a concern for physical contamination. He stated the peeling paint on the ceiling was concerning for the same reason, and he would not want a paint chip in his food. He stated when food was delivered, they followed the process of first in, first out, bringing older items forward. He also stated the walk-in freezer was first priority with deliveries, and undated food could be expired and not be safe to consume. He stated he usually put away stock. He also stated when staff was stocking, and they took inner bags of food out of the box, they should put the date on the bag. He stated normally they would put a date on dry staples like thickener and flour and, if in bulk, still need to put the date on the package. He stated it was fair to say those might not be safe to use when not knowing the opened date. He stated they put dented cans on a dedicated shelf for vendors to take back. He stated any dented can should not be used, and especially dents on top could allow air in, allowing bacteria to grow, and the can could contain the botulinum toxin. He stated they do not have a break room or storage for personal items, but staff should not be storing items in the dry storage area because it could cause cross contamination. He stated the [NAME] was responsible to document tray line temperatures on the log. He stated they were expected to document those before beginning to serve, so immediately. He stated measuring the temperatures was important, so they knew the food was at a safe temperature and hot for palatability. He further stated, without measuring the temperature, staff could not know the food was safe to serve. The DM stated the cook was responsible to document the walk-in freezer temperature logs. He stated keeping the log was important to ensure the temperatures were in a safe range and not thawed. He also stated the safest temperature for refrigeration was between 32 degrees (F) and 41 degrees (F). He stated he checked the logs daily. He stated freezer temperature should be anything below 0 degrees (F). The DM stated pans and mixing bowls should be air dried before storing and should be stored top down. He also stated the problem with opened items such as cake mix was drawing infestation. He stated those should be dated even if sealed. He stated the hot sauce might have been someone's personal item, but it should not have been stored there, and if it had been used, it should have been dated. During an interview with the Infection Prevention Nurse on 09/05/2025 at 3:53 PM, she stated she felt there would be limited risk of cross contamination from staff personal items in the dry storage room. However, she stated there was breakroom space with lockers that kitchen staff should use for storing their personal items. During interview with the Director of Nursing (DON) on 09/05/2025 at 4:11 PM, she stated her expectation was that food served was not expired. She stated she expected food temperatures to be taken and be in the correct range, including temperatures for hot drinks, for safety, and so they would not be contaminated with bacteria. She stated she would want to know food expiration dates for safety, and the concept was the same as dating medications when opened. She stated she expected there would be a designated area to store personal items to keep food safe and free from cross contamination. She stated her expectation was that the food service staff followed policies for maintaining refrigerator and freezer temperatures. Overall, she stated she expected food service staff to follow policy and accepted procedures in the kitchen. During interview with the Administrator on 09/05/2025 at 4:03 PM, he stated he felt personal items kept in the dry storage room was not a potential infection control issue. He stated he did not see the risk because a jacket or backpack would not be in contact with the food items, only the outside of cans or other containers. Also, he stated he had no objections to the findings in the kitchen.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, sanitary, and comfortable environment, and to prevent the onset and transmission of communicable diseases and infections by failing to disinfect 1 of 9 Hoyer lifts observed.The findings include:Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, revealed reusable resident care equipment and durable medical equipment (DME) were cleaned and disinfected before reuse by another resident.Review of the facility's policy titled, Policies and Practices - Infection Control, revised 10/2018, revealed the objectives of the facility's infection control policies and practices were to prevent, detect, investigate, and control infections in the facility; and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.Observation on 09/03/2025 at 3:19 PM revealed Certified Nursing Assistant (CNA) 9 exited room [ROOM NUMBER] with a Hoyer lift (a mechanical lift used by staff to transfer a resident from surface to surface) and returned it to the equipment storage area on Unit One without ensuring the lift was disinfected.During an interview with CNA3 on 09/04/2025 at 3:00 PM, she stated their process was to clean the lifts after each use with either the purple top wipes or Virex disinfectant spray. CNA3 stated the wipes were stored in the medication room or with housekeeping. CNA3 stated it was important to clean the lifts after each use to prevent the spread of infection.During an interview with CNA5 on 09/04/2025 at 3:06 PM, when asked how the lifts were disinfected, she stated housekeeping cleaned the lifts. When asked how she knew for sure a lift was cleaned before she used it, she stated someone from housekeeping was always on the unit, and she just assumed it was cleaned. CNA5 stated it was important lifts were cleaned between each resident because of infection control reasons.During an interview with CNA6 on 09/04/2025 at 3:10 PM, she stated lifts should be cleaned between residents, so germs and bacteria were not spread from one person to anotherDuring an interview with CNA1 on 09/04/2025 at 3:18 PM, she stated she cleaned the lifts with the purple top wipes before and after she used them. She further stated she did not assume a lift was cleaned after the last time someone else used it because she did not know for sure. CNA1 further stated if the lifts were not properly disinfected between use, bacteria could be transferred from one person to another, which potentially caused sickness to residents.During an interview with CNA7 on 09/04/2025 at 3:31 PM, she stated staff received infection control training at least monthly, but typically training was more frequent than that. She stated she cleaned the lifts after each use, but not normally before each use. When asked how she knew the lift was clean before she used it, CNA7 stated she assumed the last person that used it cleaned it, but she did not know for sure. CNA7 further stated the lifts should probably be cleaned before use as well because of infection control concerns. CNA7 stated germs were potentially spread from one resident to another if the lifts were not properly cleaned. During an interview with CNA9 on 09/05/2025 at 1:22 PM, she stated she used either the Sani-Cloths with the purple top or Virex spray in the shower room when she cleaned the lifts. She further stated lifts were cleaned before and after use. When asked if she cleaned the lift on 09/03/2025 after it was used in room [ROOM NUMBER], she stated it was possible she failed to clean it before she returned the lift to its storage location. CNA9 stated it was important the lifts were cleaned before and after use so the spread of infection from one person to another was controlled. She further stated just because the lift was returned to storage, did not mean it had been properly disinfected.During an interview with the Infection Preventionist (IP) on 09/05/2025 at 1:32 PM, she stated staff training for infection control included handwashing, donning (putting on) and doffing (removing) personal protective equipment (PPE), and cleaning multi-use equipment. She stated staff had yearly checkoffs for infection control training, scheduled monthly in-services, and daily training if concerns were identified. The IP stated it was the expectation staff used the purple top wipes or Virex spray and cleaned multi-use resident equipment after use and when visibly dirty. She stated the purple wipes were located at the nurse's station and on the medication carts, and the Virex spray was in the shower room. She further stated staff were not instructed to clean the Hoyer lifts before use because it was the assumption the Hoyer lift was clean. When asked how she knew staff cleaned the lift after each use, the IP stated she trusted they cleaned it after each use. The IP was unaware CNA9 was observed by State Survey Agency (SSA) Surveyors when she exited a resident room on 09/03/2025 and failed to ensure the lift was disinfected before it was returned to its storage location. When asked what the facility policy stated on how multi-use equipment was cleaned and disinfected, the IP stated she could not speak to the policy, but it was important all multi-use equipment was cleaned prior to use on another resident to help prevent the spread of infection. During an interview with the Director of Nursing (DON) on 09/05/2025 at 2:11 PM, she stated the expectation was direct care staff was practicing infection prevention by handwashing and proper use of PPE. The DON stated multi-use equipment, including Hoyer lifts, were cleaned after each use and before the equipment was taken into another room. She stated the lifts were cleaned with the purple top Sani-Wipes or Virex spray. The DON stated it was important lifts were properly cleaned so germs and/or bacteria were not spread from one person to another. During an interview with the Administrator on 09/05/2025 at 2:25 PM, he stated it was his expectation staff followed policies and procedures related to infection prevention. He further stated he expected staff cleaned multi-use equipment, including Hoyer lifts, before and after each use for prevention of disease transmission from one person to another.

Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure prompt treatment of a pressure ulcer for one (1) of five (5) residents reviewed for pressure ulcers (Resident #264). Findings included: A review of a facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised in April 2018, revealed, The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The policy revealed, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. A review of a document titled [name of medical facility] Medical Partners, dated 05/07/2022 (prior to Resident #264's admission to the facility), revealed a Physical Exam that indicated Resident #264 had a deep tissue injury to the right heel. The document indicated that Resident #264's family member reported the wound had been present for a couple of years. A review of Resident #264's Admission Record revealed the facility admitted Resident #264 on 05/10/2022 with diagnoses that included chronic kidney disease, type two diabetes mellitus, idiopathic peripheral autonomic neuropathy, and hypertension. Further review of the Admission Record revealed a diagnosis of unstageable pressure ulcer of the right heel with an onset date of 10/01/2022. A review of Resident #264's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2022, revealed Resident #264 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. The MDS further indicated that Resident #264 was admitted with an unstageable pressure ulcer. A review of Resident #264's Baseline Care Plan, initiated on 05/10/2022, indicated Resident #264 had a deep tissue injury to the bottom of the foot. Interventions directed staff to obtain/provide physician orders and treatments related to skin, provide a pressure-reducing mattress to the bed, and a pressure-reducing cushion to the wheelchair. A review of Resident #264's Care Plan revealed a Focus area initiated on 05/23/2022 that indicated the resident had a wound. Interventions directed staff to apply bilateral heel lift boots when in bed and up in a wheelchair, apply pressure relieving cushion to wheelchair and pressure relieving mattress to bed, refer to a dietitian as needed for recommendations to promote wound healing, and provide treatments as ordered. A review of a facility document titled Nursing - Admission/Readmission Assessment for Resident #264 completed on 05/10/2022 and signed by Licensed Practical Nurse (LPN) #18 revealed Resident #264 had a small discolored deep tissue injury to the left heel. The nursing assessment indicated that povidone-iodine was applied to the wound, the nurse practitioner was notified, and the admission nurse was awaiting new orders. In an interview on 11/30/2023 at 11:01 AM, LPN #2 stated the admission nurse (LPN #18) had documented Resident #264's wound on the incorrect (left) heel and that the documentation was later corrected to the resident's (right) heel. A review of Resident #264's nursing Progress Note, dated 05/13/2022 at 6:20 PM, revealed documentation to indicate new orders were obtained for the wound to the resident's right heel from the wound care specialist for Betadine (povidone-iodine), abdominal pad dressing, and Kerlix gauze. A review of Resident #264's physician orders revealed an order for a pressure-reduction mattress with a start date of 05/10/2022 and an order for Betadine Solution 10% (povidone-iodine) to the right heel with a start date of 05/14/2022. A review of the physician order summary lacked evidence of a treatment order for the right heel prior to 05/14/2022. A review of Resident #264's Treatment Administration Record (TAR) for May 2022 revealed documentation to indicate a pressure reduction mattress was in place starting on 05/10/2022. The TAR documentation also indicated the right heel was treated with povidone-iodine, covered with an abdominal pad, and wrapped with Kerlix gauze daily starting 05/14/2022. The TAR lacked evidence of treatment to the right heel wound until 05/14/2022, four days after the resident was admitted with the wound. In a telephone interview on 11/30/2023 at 10:30 AM, LPN #17, a Unit Manager, stated it was important to get treatment orders immediately because the wound could get worse without treatment. LPN #17 stated Resident #264 had been admitted with a deep tissue injury but was unsure why no treatment was initiated on admission. In a telephone interview on 11/30/2023 at 11:36 AM, LPN #18 (admitting nurse for Resident #264) stated she could not recall Resident #264's admission. LPN #18 stated if the physician had declined to provide a treatment order, she would have documented it and notified the Director of Nursing and the treatment nurse. In an interview on 11/30/23 at 11:01 AM, LPN #2 stated the admitting nurse should have contacted the physician for a treatment order if a treatment was indicated. LPN #2 stated treatment to the wound should have started immediately and was unsure why she could not find documentation of the order or why any treatment was not started. In an interview on 11/30/2023 at 11:40 AM, the Wound Care Specialist stated that once a wound was identified, treatment should be initiated immediately. In an interview on 11/30/2023 at 12:17 PM, the Director of Nursing (DON) stated the expectation was that residents admitted with a pressure ulcer would be identified on admission with a head-to-toe skin assessment immediately. The DON stated the admitting nurse should notify the physician of the new admission and obtain needed orders. The DON said she was reviewing the documentation for Resident #264 to identify where the breakdown had occurred. In an interview on 11/30/2023 at 1:05 PM, the Administrator said he left decisions regarding pressure ulcers to the clinical team.

Based on interviews, record review, and facility policy review, the facility failed to develop an individualized, person-centered activities care plan for one (1) of twenty-three (23) sampled residents (Resident #56). Findings included: A review of a facility policy titled Care Plans, Comprehensive Person-Centered Policy, dated March 2022, revealed, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychological and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. The policy further revealed, 6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible. A review of Resident #56's Admission Record revealed the facility admitted the resident on 05/07/2021. The Admission Record revealed the resident had diagnoses that included cognitive communication deficit, contractures of the right and left shoulder and left hand, bilateral spastic hemiplegia, and functional quadriplegia. A review of Resident #56's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2023 revealed it was Somewhat important for the resident to listen to music they liked, be around animals such as pets, keep up with the news, do favorite activities, and participate in religious services or practices. Further review revealed it was important for the resident to go outside to get fresh air when the weather was good. A review of the care area assessment (CAA) summary revealed activities triggered and would be addressed in a care plan. A review of Resident #56's care plan, last reviewed by the facility on 09/26/2023 and printed on 11/30/2023, revealed no documented evidence the facility developed a care plan that addressed activities for the resident. During an interview on 11/30/2023 at 12:11 PM, the Director of Nursing (DON) stated there was no way to ensure Resident #56 was being provided with activities that were personalized if a care plan had not been created based on the resident's individualized interests. The DON stated she reviewed the resident's care plan, and it did not provide information about the resident's preferred likes and choices of activities of interest. She stated an activities care plan had not been completed. During an interview on 11/30/2023 at 1:11 PM, the Administrator stated the Activity Director notified him on 11/28/2023 that Resident #56 did not have a care plan for activities. However, he stated he felt activity staff were meeting residents' needs.

Based on interviews, record review, and facility policy review, it ws determined the facility failed to provide an ongoing program of activities designed to meet the resident's interests for one (1) of twenty-three (23) sampled residents, (Resident #56). Findings included: A review of a facility policy titled Activity Programs revised in August 2006, revealed, Activity programs designed to meet the needs of each resident are available on a daily basis. Policy Interpretation and Implementation 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. Residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interest of each resident. A review of Resident #56's Admission Record revealed the facility admitted the resident on 05/07/2021. The resident had diagnoses that included cognitive communication deficit, contractures of the right and left shoulder and left hand, bilateral spastic hemiplegia, and functional quadriplegia. A review of Resident #56's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2023 revealed it was Somewhat important for the resident to listen to music they liked, be around animals such as pets, keep up with the news, do favorite activities, and participate in religious services or practices. Further review revealed it was important for the resident to go outside to get fresh air when the weather was good. A review of Resident #56's quarterly MDS with an ARD of 09/08/2023 revealed the resident had moderately impaired cognitive skills for daily decision-making per the staff assessment for mental status (SAMS). According to the MDS, Resident #56 usually made themselves understood (had difficulty communicating some words or finishing thoughts) and usually understood others (comprehending most conversations). The MDS revealed the resident required extensive assistance of two staff members with bed mobility and toileting. The MDS revealed the resident required total assistance from two staff members for locomotion, dressing, eating, personal hygiene, transfers, and bathing. The MDS revealed the resident required a Hoyer lift for transfers. During an interview on 11/30/2023 at 10:04 AM, the Activity Director stated that when providing resident activities, she considered the residents' activity preferences listed on the MDS, which was the only activity assessment completed. She stated Resident #56 had never attended a group activity but was unsure why. The Activity Director stated she had provided one-on-one visits for the resident but could not find any documented evidence. The Activity Director stated she was the only staff member responsible for providing one-to-one visits. She stated she had not designated how often the visits were to be provided. According to the Activity Director, she thought the staff provided care every day and interacted with the resident during care. She stated the resident received visits from family a couple of times a month. The Activity Director stated Resident #56 could see a television if the resident was positioned facing the television. During an interview on 11/30/2023 at 11:57 AM, the Assistant Activity Director stated she was also responsible for providing one-to-one resident activities. She stated Resident #56 liked music but did not have a radio in their room. The Assistant Activity Director stated once in a while, they took a CD player to the resident's room to play music. She stated they did not have a regular schedule for providing one-to-one visits and just provided them when they had downtime. The Assistant Activity Director stated she did not know whether Resident #56 would like to attend a group activity. She added she thought the resident had gone to a group activity, but not in a very long time. During an interview on 11/30/2023 at 12:11 PM, the Director of Nursing (DON) stated she did not have an opinion about when one-to-one resident activities should be provided or documented. She stated she felt it would depend on the wishes of the resident. After reviewing Resident #56's care plan, she stated the care plan did not provide information about the resident's activities of interest. She did not know what type of activities were being provided for Resident #56. She stated she felt the resident should be offered the opportunity to attend group activities of choice and did not know why the resident did not attend group activities. During an interview on 11/30/2023 at 1:11 PM, the Administrator stated he believed activity staff were meeting the resident's needs but were not documenting the activities that were provided. The Administrator stated he believed an activity assessment should have been completed for Resident #56 but did not think the regulations indicated how often one-to-one visits should take place.

Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure one (1) of three (3) residents reviewed for Pre-Admission Screening and Resident Review (PASARR), (Resident #94) who had a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health or intellectual disability authority for review. Findings included: A review of the facility policy titled Admission Criteria, revised in March 2019, revealed, Our facility admits only residents whose medical and nursing care needs can be met. The policy revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The policy did not address a resident who previously had a negative Level I screening and who was later identified with a newly evident or possibly serious MD, ID, or a related condition. A review of Resident #94's Admission Record revealed the facility admitted the resident on 12/01/2022. A review of Resident #94's Nursing Facility Application for an admitted [DATE] revealed a PASARR level screening was included in the application. A review of the PASARR screening revealed the resident had no current or suspected mental health diagnoses, impairment, or intellectual disability. Further review of Resident #94's Admission Record revealed the resident was diagnosed with psychotic disorder with delusions with an onset date of 10/10/2023, dementia with an onset date of 08/30/2023, major depressive disorder with an onset date of 02/27/2023, and adjustment disorder with mixed anxiety and depressed mood with an onset date of 02/27/2023. A review of Resident #94's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2023, revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses that included depression and psychotic disorder with delusions due to a known physiological condition. Further review revealed the resident had taken antipsychotic medications daily during the seven-day lookback period. Per the MDS, Resident #94 was not considered by the state level II PASARR process to have a serious mental illness or related condition. A review of Resident #94's care plan revealed a focus area initiated on 03/12/2023 for the risk of side effects due to psychotropic medication use. Further review of the resident's care plan revealed a focus area initiated on 05/08/2023 that indicated the resident exhibited delusions. A review of Resident #94's November 2023 PACS-Medication Administration Record (MAR) revealed staff documented Risperdal Oral Tablet (an antipsychotic medication) 0.25 milligrams (mg), was administered every morning and at bedtime through 11/28/2023, related to dementia with other behavioral disturbance. During an interview on 11/28/2023 at 2:21 PM, the Social Services Director (SSD) stated a PASARR level 1 screening included answering questions regarding mental illness and treatment related to diagnoses such as depression, anxiety, schizophrenia, and mood disorders. The SSD stated Resident #94's PASARR did not reflect any of those diagnoses and did not trigger a level II evaluation to refer the resident to the appropriate state-designated mental health or intellectual disability authority for review. Per the SSD, if there was a change in diagnosis after admission, the facility submitted a significant change notification to the state authority; however, most of the time, a new diagnosis did not affect a resident's level of functioning and would not trigger a level II PASARR. During a follow-up interview on 11/29/2023 at 4:26 PM, the SSD stated another PASARR did not have to be completed due to a new diagnosis of a depressive disorder or a psychotic unless the diagnosis affected a resident's level of functioning. The SSD then stated she was not aware Resident #94 had new diagnoses of a depressive disorder or a psychotic disorder since admission. During an interview on 11/29/2023 at 4:34 PM, the MDS Nurse stated the facility never completed another PASARR unless a resident had a significant change or a psychiatric stay. During an interview on 11/30/2023 at 12:01 PM, the Director of Nursing (DON) stated PASARRs had to do with a resident's mental health diagnosis and assessments of what they might need. She stated she expected PASARRs to be completed per the regulations. During an interview on 11/30/2023 at 1:03 PM, the Administrator stated he expected PASARRs to be completed per the regulations.

Based on observation, interview, record review, review of the Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH Memo, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidelines, review of the Kentucky Department for Public Health's (KDPH) Long-Term Care Facility COVID-19 bi-weekly County Indicator Map, review of the BinaxNOW Covid-19 Ag Card Instructions, and review of the facility's policies, it was determined the facility failed to conduct COVID-19 testing, twice weekly, for unvaccinated staff based on the community's COVID-19 transmission levels and the facility's COVID-19 outbreak status. The facility failed to conduct testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests; and failed to follow established standard precautions to prevent the transmission of infectious organisms. Also, the facility failed to test newly-admitted residents immediately upon admission to the facility, affecting two (2) of thirty-two (32) sampled residents (Resident #41 and Resident #210). The findings include: Review of the Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH Memo, revised 03/10/2022, revealed Long Term Care (LTC) facilities must:1) conduct testing based on parameters set forth by the Secretary; 2) conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests; and 3) document that testing was completed and the results of each staff test and document in the residents' records that testing was offered, completed, and the results of each test. Further review revealed, the CDC recommended testing employees twice a week, even if they only work once a week, if they were unvaccinated or not up to date with COVID-19 vaccinations. Review of the CDC's, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes & Long-Term Care Facilities, Section, New Infection in Healthcare Personnel or Residents, updated 02/11/2022, revealed because of the risk of unrecognized infection among residents, a single new case of COVID-19 infection in any health care personnel (HCP) or a nursing home onset of COVID-19 infection in a resident should be evaluated as a potential outbreak. Review of the facility's staff COVID-19 testing results revealed the facility identified one (1) staff on 07/11/2022; one (1) staff on 07/12/2022; one (1) staff on 07/13/2022; one (1) staff on 07/20/2022; two (2) staff on 08/02/2022; and one (1) staff on 08/05/2022, as being positive for COVID-19. Review of the CDC's website, http://cdc.gov, on COVID-19 Testing, updated 08/11/2022, revealed, All instructions for performing the test must be followed. Instruction for proper Infection Prevention and Control (IPC) guidelines included that the user should follow IPC protocols and discard the specimen collection swab and test kit in the trash, clean all surfaces that the specimen might have touched, and wash hands. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Testing Criteria for Health Care Personnel, not dated, revealed all healthcare personnel (HCP) in the facility would be tested for SARS-COVID-19-2 virus based on CDC guidelines and recommendations and vaccination status. Further review revealed routine testing of healthcare personnel was based on the extent of the virus in the community and vaccination status. Per the policy, the county positivity rate was monitored every week. If the county positivity rate increased to a higher level of testing, increased frequency of testing began as soon as that data was assessed. Review of the Kentucky Department for Public Health's (KDPH) Long-Term Care Facility COVID-19 Bi-Weekly County Indicator Map, from 07/05/2022 to 08/12/2022, revealed that the (County's), Kentucky community transmission rate was high (red zone) requiring testing two (2) times a week of all unvaccinated and not up to date for COVID vaccinated staff. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, revised 08/2019, revealed hand washing was the primary means in preventing the transmission of infections. Per the policy, all health care workers would utilize hand hygiene frequently and appropriately. Further review revealed health care workers would use hand hygiene after contact with excretions or secretions, mucus membranes, or specimens. Review of the BinaxNOW Covid-19 Ag Card Instructions, revised 02/2022, for specimen collection and handling of test specimens, revealed appropriate personal protective equipment (PPE), including gloves, were to be worn when running each test and handling specimens. Further review revealed that users should wear suitable protective clothing, gloves, and eye/face protection when handling the specimen contents to reduce the risk of biohazard contamination, including treating all specimens, as well as the used test kit components as potentially biohazardous materials. Also the instructions stated that users should follow standard precautions when handling the test kit and its contents and should wash hands thoroughly after handling contaminated specimens. 1. Review of the facility's employee staffing and COVID-19 testing records for not up to date employees revealed:1) State Registered Nurse Aide (SRNA) #13 worked the evenings of 07/06/2022 and 07/20/2022, but was not tested until his/her shifts ended on 07/07/2022 and 07/21/2022; 2) SRNA #19 worked 07/17/2022 and 07/23/2022, but was not tested until his/her shift ended on 07/23/2022; 3) SRNA #15 worked the evenings of 07/19/2022 and 07/25/2022, but was not tested until his/her shifts ended on 07/20/2022 and 07/26/2022; 4) Physical Therapist (PT) #1 worked 07/11/2022 and 07/25/2022 but was not tested until his/her shifts ended on 07/12/2022 and 07/26/2022; 5) SRNA #16 worked the evening of 07/25/2022 but was not tested until his/her shift ended on 07/26/2022. Review of the facility's employee staffing and COVID-19 testing records for unvaccinated employees revealed:1) SRNA #14 worked 07/06/2022 but was not tested until 07/09/2022; and 2) SRNA #18 worked the evenings of 07/17/2022 and 07/23/2022, but was not tested until his/her shift ended on 07/23/2022. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/11/2022 at 4:45 PM, revealed she tested staff two (2) times per week if the staff member was unvaccinated or not up to date with his/her COVID-19 vaccination. She stated, If the employee does not work more than one day per week, I only test once per week. According to CDC, we should be testing employees twice a week even if they only work once a week, if they were not up to date with COVID-19 vaccination. Per the interview, the QA/IP Nurse stated she came early each morning to catch the night shift before they went home; however, she stated she did not come in to test employees on weekends. The QA/IP Nurse stated weekend staff were tested when there is a house supervisor. She stated the facility did not always have a house supervisor. She stated she would try to test those who were missed on the weekend before his/her next shift. She stated testing, according to CDC recommendations, was important for the safety of the residents and staff. Additional interview with the QA/IP Nurse, on 08/12/2022 at 9:50 AM, revealed she restated that night shift staff were usually tested for Covid-19 after they had worked their shift, and weekend staff were tested by house supervisors if they were present. Per the interview, the QA/IP Nurse stated that ideally the employee should be tested before the shift started to prevent exposing a resident or other staff to a potentially infected staff member. The QA/IP Nurse stated she did not want to answer whether testing after instead of before an employee's shift could expose the residents to the risk of possible COVID-19 exposure. Interview with the Administrator, on 08/12/2022 at 9:28 AM, revealed the County was in the red zone indicating a high COVID-19 community transmission rate. Per the interview, the Administrator stated the QA/IP Nurse was responsible for COVID-19 testing. He stated, We test by committee, meaning when the QA/IP was not available, supervisors would test staff as required. 2. Observation of the COVID-19 testing station, on 08/09/2022 at 4:30 PM, revealed six (6) contaminated COVID-19 rapid tests sitting on a bedside table located in the QA/IP's office. There was one (1) opened box containing multiple unused COVID-19 tests and two (2) folders, which contained papers also on the bedside table. There was no barrier covering the table, gloves, alcohol-based hand rub (ABHR) or disinfectant wipes on or near the testing station. The QA/IP Nurse picked up the contaminated COVID-19 rapid tests and moved them to place the tests together. Further observation revealed one (1) contaminated COVID-19 rapid test laying on top of paperwork on the QA/IP's work desk. Per the observation, she was not gloved when she touched the contaminated tests and did not perform hand hygiene after she handled the tests. Interview with the QA/IP Nurse, on 08/09/22 at 4:30 PM, revealed she had worked at the facility in the position of IP since July 2022. Prior to working in the role of IP, she stated, she was the Assistant Director of Nursing (ADON). The QA/IP Nurse stated she received IPC training upon hire and had been trained through in-services. The QA/IP Nurse stated she performed COVID-19 point-of-care (POC) testing earlier in the day, and she had placed the testing cards on the table so she could document the results. Per the interview, she stated that she had completed the CDC's Nursing Home Infection Preventionist Training Course on 12/23/2019. Further interview revealed she should have had a barrier cloth on the table to prevent contamination of the surface. She stated she had disinfectant wipes near the table, but observation during the interview revealed there were no disinfectant wipes in the vicinity of the table but were located behind the QA/IP Nurse's desk. She stated performing tests according to manufacturer's recommendations was necessary for the safety of all residents and staff. Additionally, she stated she followed established standard precautions to prevent the transmission of infectious organisms. She stated testing residents and staff according to CDC recommendations was important for the health and safety of all residents, staff, and visitors. 3. Review of COVID-19 tests results documented in the medical record for two (2) newly admitted residents, Resident #41, admitted on [DATE], and Resident #210, admitted on [DATE], revealed the results were not in their medical records. Multiple requests were made to the Administrator, Director of Nursing (DON), and the QA/IP Nurse to obtain COVID-19 testing results on 08/08/2022. However, documentation was not provided until 08/11/2022. According to the test results, Resident #41 received his/her first COVID-19 Rapid Test on 08/01/2022, five (5) days after admission. No COVID-19 Rapid Test results were provided for Resident #210. Interview with Unit Manager (UM) #1, on 08/09/2022 at 3:57 PM, revealed COVID-19 testing was done immediately on admission, and if it was negative, a rapid test was obtained again in five (5) days. She stated testing new residents for COVID-19 upon admission was a new protocol that began with the current DON. Previously, residents needed a negative COVID-19 test at the hospital before admission. Continued interview revealed that the facility utilized Point of Care (POC) Rapid COVID-19 testing. She stated test results were not entered into the electronic medical record (EMR) because recently hired nursing staff were not aware they could enter results. She stated nursing staff was still being trained on how to enter the POC Rapid test results into the EMR. Interview with the Regional Director of Clinical Services (RDCS), on 08/10/2022 at 11:42 AM, revealed her role in the facility was to consult, train, and tell them what is expected. She stated she had been working closely with the current Director of Nursing (DON) since her hire on 07/13/2022. The RDCS stated the former DON, who resigned in 06/2022, was tracking all COVID-19 testing and vaccinations for staff and residents. She stated they had been testing and vaccinating per CDC guidance. Per the interview, the RDCS stated, The infection control binder is a mess with handwritten notes and unorganized. She stated further that she did not know when the breakdown happened. Further interview revealed she first realized there was an issue with testing documentation after the former DON left, and while she was training the current DON and QA/IP Nurse. She stated during the time the former DON was responsible for testing, the facility had been testing based on an old QSO memo. The RDCS stated she educated the new QA/IP Nurse to test based on the 03/22/2022 QSO memo. Per the interview, the RDCS stated she revised the staff and resident testing plan because she couldn't make heads or tails of the Covid book. She stated the facility came up with a vaccination and positive COVID-19 status list, which she stated was up to date. The RDCS stated the Administrator had the ultimate oversight to ensure all facility policies and protocols, especially as they related to adherence to current CDC recommendations, were being addressed and followed. She stated following IPC standards was important to prevent the spread of infection. Continued interview revealed testing residents and staff according to CDC recommendations was important for the health and safety of all residents, staff, and visitors. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed she had been employed at the facility in her current role since 07/13/2022. She stated she had been monitoring to ensure the QA/IP Nurse had been testing staff per CDC guidelines and that IPC policies and protocols were followed. She stated she had focused on understanding everyone's roles and providing direction and oversite of IPC compliance. The DON stated she was aware of issues related to the facility's failure to accurately document and track COVID-19 testing per CDC guidelines. She stated she developed an agenda for an ad hoc QAPI Meeting, which was supposed to have taken place on 07/25/2022, but did not. She stated that IPC issues, including COVID-19 testing of residents, staff, and new admissions, and COVID-19 vaccination status were on the agenda to be addressed during the meeting. No explanation was provided as to why the meeting did not take place. Additional interview with the DON, on 08/12/2022 at 3:03 PM, revealed the QA/IP Nurse was trained to perform COVID-19 tests and should follow manufacturer's testing protocols and Standard Precautions, which included wearing gloves when handling contaminated test cards and following proper hand hygiene practices. Per the interview, the DON revealed it was her expectation that nurses followed the facility's policies regarding IPC policies and protocols. She stated it was important to follow IPC policies and testing protocols to prevent the spread of infectious disease. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed it was the Administrator's expectation that all staff followed the facility's IPC policies and complete COVID-19 testing according to the manufacturer's recommended protocols. The Administrator stated adhering to IPC protocols helped maintain the health and safety of all residents, staff, and visitors, and testing was important to help prevent the transmission of COVID-19 in the facility. 46651

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to serve and store food under sanitary conditions. Observations, on 08/08/2022 and 08/09/2022, revealed dry storage with dented cans; no label on a can; ingredient bins with food thickener, lids not closed; vents in dry storage with dust accumulation; vents in kitchen ceiling with dust and dripping water in front of the walk-in refrigerator and walk-in freezer. Further observations, on 08/11/2022, of the nourishment refrigerator on Unit 1, revealed it was not clean on the lower shelf; no identification on a frozen resident meal, and the boxed cookies were not dated. The findings include: Review of the facility's policy titled, Safe Dietary Practices, dated 10/2017, revealed all foods and fluids would be labeled by Dietary with two (2) dates; one (1) for the stock date and one (1) for the use by date, the manufacture's expiration date. The policy stated, if a food or fluid product did not have an expiration date, once it was opened, it must be labeled with a three (3) day discard date. Per the policy, all foods belonging to residents must be labeled with the resident's name, the item, and the use by date. Further review revealed it was housekeeping's responsibility to clean the nourishment refrigerators on a daily basis and, as necessary when soiled. Observation of the kitchen, on 08/08/2022 at 3:36 PM, revealed in the dry storage area: a dented spaghetti sauce #10 can on the shelf and a #10 can on the shelf with no label. Two (2) dry storage small ingredient bins, that contained food thickener, had the lids left open. In addition, observation of the intake and output vents in the ceiling of the dry storage area revealed an accumulation of dust and debris. Continued tour of the kitchen revealed vents in the kitchen ceiling with dust and dripping water in front of the walk-in refrigerator and near the walk-in freezer, between the walk-in freezer and production line. Additional observation of the kitchen, on 08/09/2022 at 9:45 AM, in the dry storage area, revealed five (5) packages of yellow cake mix, that had no box, label, or date; and a dented #10 spaghetti can and a #10 can with no label remained on the shelf. Further observation revealed two (2) gallons of lite mayonnaise and two (2) coleslaw dressing containers with no dates; one (1) barbeque sauce, sixty-four (64) fluid ounces, not dated; and one (1) outdated Silk milk shelf stable product, dated 12/06/2020. Additional observation of the kitchen, on 08/11/2022 at 12:00 PM, revealed a vent in front of the walk-in refrigerator dripping water onto the floor and the tray line. Observation of the Unit 1 Nourishment Room (for 100, 200, and 300 Halls), on 08/11/2022 at 10:15 AM, revealed frozen Grande Chicken and Ricotta Cheese Cannelloni with Alfredo Sauce with no resident identification and a to-go clear container of unknown food with no label, date, resident name, or room number. Inside the nourishment refrigerator, on the lower right shelves, was a dried stain of an unknown substance. The packaged cookies, fudge rounds, and oatmeal cookies were not dated, and four (4) packages of Teddy Grahams were outdated, as of 07/24/2022. Interview with Cook #1, on 08/12/2022 at 8:23 AM, revealed she checked the dry storage for stock dates and the condition of the cans. She stated that she took any dented cans or unlabeled food products to the Dietary Manager's office. Cook #1 stated it was important to date, rotate, and label foods to keep foods safe, so as not to make a resident sick. Continued interview revealed the lids on the ingredient bins should always be shut to prevent bugs and other things from getting into the food thickener. Interview with Cook #2, on 08/12/2022 at 8:31 AM, revealed dented cans were removed from the shelf and taken to the Dietary Manager's office, for the Manager to dispose of the cans. Cook #2 stated, if foods were not dated or labeled, staff would not know how long they had been on the shelf; and dented cans could allow bacteria to grow in the food product. Cook #2 stated the food thickener lid must always be closed to keep rodents and other pests out of it. Interview with Dietary Aide #1, on 08/12/2022 at 8:40 AM, revealed any cans or food products in dry storage that were dented or not labeled should be reported to the Dietary Manager. The aide stated dented cans could allow bacteria to grow, and food products with no date and/or no label or which were outdated, should be thrown away. Dietary Aide #1 stated food thickener for drinks must have the lid closed to protect against dust, bugs, or anything that could fall into it. Dietary Aide #1 stated food thickener that was not identified by a label or date should be thrown away. Interview with the Dietary Manager, on 08/12/2022 at 8:58 AM, revealed any dry storage dented cans should be taken to the office because dented cans could allow air into the can and get contaminated with bacteria. He stated the outdated soy milk could make a resident sick and had been thrown out. Further interview revealed food thickener ingredient bins must have a cover with a lid to prevent cross contamination from spills or debris from sweeping or mopping near the lower dry storage shelf. He stated all food items needed to be labeled and dated. Continued interview revealed the nourishment refrigerators were cleaned by nursing or housekeeping, and the cookie packages should be dated and rotated. The Dietary Manager stated the vents over the kitchen area should not contain dust or water condensation to prevent cross contamination of food in the production areas. Interview with the Maintenance Director, on 08/12/2022 at 9:36 AM, revealed he tried to walk through the dietary department daily. He stated the vent filters were changed monthly. Continued interview revealed he did not know the drips were coming down from the ceiling due to condensation on a hot surface hitting the hot attic. Interview with Licensed Practical Nurse (LPN)/Unit Manager #2, on 08/12/2022 at approximately 10:00 AM, revealed cleaning of the nourishment refrigerator was done by the night shift. LPN #2 stated food for residents was dated and timed with the resident's room number or name. Interview with the Registered Nurse (RN)/Director of Nursing (DON), on 08/12/2022 at 10:54 AM, revealed her expectations for Dietary Staff to follow the Health Department and State Regulation guidelines. Interview with the Administrator, on 08/12/2022 at 3:35 PM, revealed his expectations for Dietary Staff to follow food preparation guidelines and for foods to be labeled and stored with expiration dates.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention guidelines, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Review of the facility's testing results revealed from 07/11/2022 to 08/05/2022, seven (7) staff members tested positive for COVID-19. Observations throughout the survey revealed multiple breaches in Infection Prevention and Control (IPC) practices and protocols. These observations included: staff with masks below their noses and chins; failure to perform hand hygiene; failure to don (put on) PPE prior to entering transmission-based precaution (TBP) rooms; failure to doff (remove) PPE prior to exiting TBP rooms; failure to dispose of contaminated linen, and trash according to facility policy. Furthermore, the facility failed to place newly admitted residents in quarantine, placed residents in quarantine without a documented reason, and failed to place residents in ordered contact precautions. Continued observation revealed staff failed to perform hand hygiene between each resident encounter and after resident care was provided. Additional observations revealed staff left dirty laundry on the floor of a resident's room. These failures had the potential to affect all residents, but specifically, Residents #9, #19, #22, #32, #41, #48, #74, #94, #97, #101, #110, #162, #210, #212, and #360. The findings include: Interview with Licensed Practical Nurse (LPN) #2/Unit 1 Manager (UM), on 08/09/2022 at 8:40 AM, revealed she knew of no policy on quarantine of residents. However, she stated all new admissions were placed in Quarantine TBP for fourteen (14) days, and personnel were required to wear an N-95 respirator, face shield/goggles, gown, and gloves when giving care to these residents. Review of the CDC's, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/2022, revealed new admissions and readmissions should be placed in quarantine, even if they had a negative COVID-19 test upon admission. Review of the Centers for Disease Control and Prevention's (CDC) Infection Control Basics, Standard Precautions for All Patient Care, dated 01/26/2016, revealed Standard Precautions were used to prevent the transmission of infectious organisms. In addition to standard precautions, staff was to use appropriate personal protective equipment (PPE) as a barrier to exposure whenever there was an expectation of possible exposure to infectious material. Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, not dated, revealed hand hygiene reduced the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Continued review revealed multiple opportunities for hand hygiene could occur during a single care episode. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when hands were visibly soiled, and before preparing or handling medications. Review of the CDC's guideline titled, How to Safely Remove Personal Protective Equipment (PPE), no date, revealed all PPE should be removed before exiting the patient room except a respirator, if worn. Per the recommendations, there were two (2) examples to doff PPE:1) remove gloves, goggles or face shield, gown, and finally the mask or respirator; and 2) remove gown and gloves, goggles or face shield, then mask or respirator. Per the CDC, if hands became contaminated during PPE removal, healthcare personnel (HCP) were to immediately perform hand hygiene. Finally, wash hands or use an alcohol-based hand sanitizer immediately after removing all PPE. Review of the CDC's How to Use Your N95 Respirator, dated 03/16/2022, revealed the N95 mask must form a seal to the face to work properly. Per the recommendation, surgical masks were not to be worn with other masks or respirators. Review of the CDC's, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, last reviewed 03/02/2011, revealed blood glucose meters should be cleaned and disinfected after every use per the manufacturer's instructions. Review of the facility's policy, Isolation - Initiating Transmission Based Precautions, revised 08/2019, revealed the purpose of the policy was to initiate TBP's when a resident developed signs and symptoms of transmissible infection; arrived for admission with symptoms of an infection; or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. Per the policy, if a resident was suspected of or identified as having a communicable infectious disease, nursing supervisors would notify the Infection Preventionist (IP) for evaluation of appropriate transmission based precautions. TBP's were utilized when a resident met the criteria for transmissible infection, and the resident had risk factors that increased the likelihood of transmission. Further review revealed when TBP's were implemented, the IP identified the type of precaution needed, the duration, and the PPE that must be used. It stated the IP provided and or oversaw the education of the staff, resident, representative, and or visitors regarding the precautions and the use of PPE. In addition, the IP ensured the proper PPE was maintained outside the resident's room so that anyone entering the room could apply the appropriate equipment and ensured the suitable linen hamper and waste container, with an appropriate liner, were placed in the resident's room. Review of the facility's policy, Isolation - Notices of Transmission-Based Precautions, revised 08/2019, revealed the purpose of the policy was to alert personnel and visitors of TBP's. Per the policy, when TBP's were implemented, the IP determined the appropriate notification to be placed on the resident's room so personnel and visitors were aware of the need for and type of precaution. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2019, revealed the single most effective means of preventing transmission of infection from one (1) person to another was proper hand hygiene. It stated facility personnel were required to wash their hands after each direct or indirect resident contact, for which hand washing was indicated by acceptable standards of practice. Also, it stated hand hygiene should be performed after touching inanimate sources that were likely to be contaminated; between resident contacts; between tasks and procedures to prevent cross contamination; and when otherwise indicated to avoid transfer of microorganisms to other residents and environments. Additionally, it stated hand hygiene should be performed when in contact with a resident, or the equipment or environment of a resident, who was on contact precautions. Review of the facility's policy titled, Linen Handling, no date, revealed the purpose of the policy was to ensure that all linen should be handled, transported, and processed according to best practices for IPC. Per the policy, all laundry was handled as potentially contaminated until it was bagged properly. Additionally, linen should be bagged or placed in containers at the location where it was used. It stated soiled linen should be handled as little as possible and within minimum agitation to prevent microbial contamination of the air and of the staff handling the linen. It stated contaminated laundry was placed in a bag or container at the location where it was used and not sorted at the location of use. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, revealed resident-care equipment would be cleaned and disinfected according to current CDC recommendations for disinfection. Review of documentation provided by the facility titled, COVID Guidance, no date, revealed staff was to wash hands after touching blood, body fluids, secretions, excretions and contaminated items, and between residents. Per the policy, good hand hygiene was essential to prevent the spread of infection. It stated linens must be handled and transported in a manner that prevented contamination and that avoided the transfer of microorganisms to other residents and environments. Further review of the guidance revealed Standard Precautions assumed all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes might contain transmissible infection agents. It stated Standard Precautions applied to all patients regardless of suspected or confirmed infection status and included hand hygiene and the use of gloves, gown, mask, eye protection or face shield. Per the guidance, TBP's, including Contact Precautions and Droplet Precautions were used when the route of transmission was not completely interrupted using Standard Precautions. Review of the facility's staff COVID-19 testing results revealed the facility identified one (1) staff on 07/11/2022; one (1) staff on 07/12/2022; one (1) staff on 07/13/2022; one (1) staff on 07/20/2022; two (2) staff on 08/02/2022; and one (1) staff on 08/05/2022, as being positive for COVID-19. Review of the facility's manufacturer instructions titled Cleaning and Disinfecting Procedures, not dated, revealed to: 1) thoroughly wipe the entire surface of the meter with disinfecting wipes listed to clean any possible dirt, dust, blood, and other body fluids; and 2) take another disinfecting wipe and wipe the meter thoroughly. Review of the facility's Listed Wipes sheet, not dated, revealed Sani-Cloth was the wipe the facility used. 1. Observation, on 08/08/2022 at 3:10 PM, of the 100 Hall revealed personal protective equipment (PPE) bins outside of Rooms #105 and #108. Further observation revealed there were no signs on either door indicating the type of transmission based precautions (TBP) in use. Interview with the Director of Nursing (DON), on 08/08/2022 at 3:10 PM, upon entrance to the facility, revealed there were no residents on transmission based precautions (TBP), and there were no current COVID-19 positive residents or staff. 2. Observation of Unit 1 and Unit 2, on 08/09/2022 at 8:00 AM, revealed thirteen (13) residents (Residents #19, #22, #32, #41, #48, #74, #94, #97, #101, #162, #210, #212, and #360 had been placed on TBP. a. Review of Resident #19's medical record revealed the facility admitted the resident, on 02/25/2022, with diagnoses that included Parkinson's Disease, Dementia with Lewy Bodies, Muscle Weakness, Hypertension, Dysphasia, Malignant Neoplasm of the Prostate, and Hyperlipidemia. Further review revealed the resident was placed on TBP on 08/09/2022, but there was no order or documented reason in the medical record for Quarantine Precautions. Review of the Care Plan, last reviewed on 06/16/2022, revealed the resident was care planned for being at risk for COVID-19, with goals to include limiting the resident's exposure to potential sources of COVID-19. Interventions, dated 07/21/2022, included Quarantine Precautions: gown, gloves, N95 respirator, and eye protection, but the fourteen (14) day quarantine period had ended on 08/04/2022. b. Review of Resident #22's medical record revealed the facility admitted the resident, on 09/28/2017, with diagnoses that included Cerebral Palsy. Further review revealed the resident was placed on TBP on 08/09/2022. There was an order in the medical record for TBP, dated 08/08/2022, for Contact Precautions due to extended spectrum beta-lactamase (ESBL) in the urine diagnosed on [DATE]. Continued review revealed orders for Resident #22 to have antibiotic therapy on 08/05/2022. c. Review of Resident #32's medical record revealed the facility admitted the resident, on 05/10/2022, with diagnoses that included Chronic Kidney Disease, Idiopathic Peripheral Autonomic Neuropathy, and Type 2 Diabetes Mellitus. The resident was placed in TBP on 08/09/2022, for no documented reason. Additionally, there was no order in the medical record for Quarantine Precautions, and review of the care plan, dated 05/10/2022, revealed the resident was not care planned for TBP. d. Review of Resident #41's medical record revealed the facility admitted Resident #41, on 07/27/2022, with diagnoses that included Acquired Absence Of Left Leg Below Knee, Sepsis, Weakness, Type 2 Diabetes Mellitus, and End Stage Renal Disease. Further review revealed the resident was placed on TBP on 08/09/2022. On 08/08/2022 at 11:00 PM, an order was entered in the medical record for Quarantine Precautions. Review of the Care Plan, dated 07/27/2022, revealed Resident #41 was care planned for being at risk for COVID-19 on 08/08/2022, with goals to include limiting the resident's exposure to potential sources of COVID-19. Interventions included Quarantine Precautions: wearing a gown, gloves, N95 respirator, and eye protection. e. Review of Resident #48's medical record revealed the facility admitted the resident, on 08/26/2020, with diagnoses that included Hemophilia and Hematopoiesis Following Cerebral Infarction Affecting Right Dominant Side and Dysphasia. The resident was placed on TBP on 08/09/2022. However, there was no order entered in the medical record or documented reason for Quarantine Precautions. Review of the Care Plan, dated 07/21/2022, revealed the resident was not care planned for TBP. f. Review of Resident #74's medical record revealed the facility admitted the resident, on 10/26/2016, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Atherosclerotic Heart Disease, and Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant Side. The resident was placed on Quarantine TBP on 08/09/2022. However, there was no order in the medical record or documented reason for Quarantine Precautions. Review of the care plan, last reviewed 06/16/2022, revealed the resident was not care planned for TBP. g. Review of Resident #94's medical record revealed the facility admitted the resident, on 03/18/2021, with diagnoses that included Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Muscle Weakness, ESBL Resistance, and Contact with an Exposure to COVID-19. The resident was placed on Contact Precautions on 08/09/2022. However, there was an order in the medical record, dated 08/01/2022, for Contact Precautions for ESBL in the urine diagnosed on [DATE]. Review of the care plan, last reviewed 08/05/2022, revealed the resident was care planned for Contact Precautions, initiated 08/02/2022. Interventions, dated 08/02/2022, included contact precautions related to ESBL; signs for contact precautions per the facility's policy; disposable nursing equipment to be used per the facility's policy; wear PPE per the facility's policy; and use biohazard waste disposal per the facility's policy as indicated. h. Review of Resident #97's medical record revealed the facility admitted the resident, on 04/28/2022, with diagnoses that included Chronic Respiratory Failure With Hypoxia, Atherosclerotic Heart Disease, and Type 2 Diabetes Mellitus Without Complications. Review of the care plan, no date, revealed the resident was not care planned for TBP. i. Review of Resident #101's medical record revealed the facility admitted the resident, on 06/14/2022, with diagnoses that included Encounter for Surgical Aftercare Following Surgery on the Digestive System and Contact with and Suspected Exposure to COVID-19 on 07/21/2022. Further review revealed the resident was placed on Quarantine TBP on 08/09/2022, nineteen (19) days from the exposure. However, there was no order in the medical record or documented reason for Quarantine Precautions. j. Review of Resident #162's medical record revealed the facility admitted the resident, on 08/05/2022, with diagnoses that included Chronic Venous Hypertension, Methicillin Resistant Staphylococcus Aureus Infection, and Muscle Weakness. Further review revealed the resident was placed in Contact/Droplet Precautions on 08/09/2022; however, there was an order for Contact/Droplet Precautions dated 08/05/2022. k. Review of Resident #210's medical record revealed the facility admitted the resident, on 08/08/2022, with diagnoses that included Type 2 Diabetes Mellitus and Adult Failure To Thrive. Further review revealed the resident was placed in Quarantine TBP on 08/09/2022, but there was an order for Quarantine Precautions, dated 08/08/2022, for fourteen (14) days requiring a gown, gloves, N95 respirator, and eye protection. l. Review of Resident #212's medical record revealed the facility readmitted the resident, on 07/30/2022, with diagnoses that included Coronary Artery Disease and Diabetes Mellitus. Resident #212 was not in Quarantine Precautions on 08/08/2022, even though it had been only ten (10) days since he/she returned to the facility. The resident was discharged on [DATE]. m. Review of Resident #360's medical record revealed the facility admitted the resident, on 07/28/2022, with diagnoses that included Malignant Neoplasm of Lower Lobe of the Lung, Secondary Malignant Neoplasm of the Brain, and Secondary Malignant Neoplasm of the Bone. Further review revealed the resident was placed on Quarantine TBP on 08/09/2022, instead of on admission, on 07/28/2022. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/09/2022 at 4:30 PM, revealed when asked why thirteen (13) residents were now in TBP but were not at the time of the State Survey Agency's (SSA) entrance on 08/08/2022, she stated, The facility realized they were not in compliance and fixed it. 3. Observation of Unit 1 and Unit 2, on 08/10/2022 at 8:00 AM, revealed two (2) residents (Residents #9 and #110) had been placed on TBP's. a. Review of Resident #9's medical record revealed the facility admitted the resident, on 04/03/2022, with diagnoses that included heart failure and COPD. Further review revealed the resident was placed on Quarantine TBP on 08/10/2022, but there was no order in the medical record or documented reason for Quarantine Precautions. Review of the care plan, last reviewed 06/16/2022, revealed the resident was not care planned for TBP. b. Review of Resident #110's medical record revealed the facility admitted the resident, on 10/25/2021, with diagnoses that included COPD, Pneumonitis, and Type 2 Diabetes Mellitus. Further review revealed the resident was placed on Quarantine TBP on 08/10/2022, but there was no order in the medical record or documented reason for Quarantine Precautions. Review of the care plan, no date, revealed the resident was not care planned for TBP. Interview with Licensed Practical Nurse, (LPN) #9, on 08/08/2022 at 3:18 PM, revealed she had just arrived at the facility, and she did not think any residents on the 100 Hall were on TBP. Interview with Kentucky Medication Aide (KMA) #6, on 08/09/2022 at 8:35 AM, revealed that residents on TBP were new admissions to the facility. She stated, per IPC polices, an N95 mask, face shield/goggles, gown, and gloves were required for Quarantine TBP. Continued interview with LPN #2/Unit 1 Manager (UM), on 08/09/2022 at 8:40 AM, revealed she received IPC education and training upon hire, annually, and frequent in-service updates. She stated following the facility's policy was important for the safety of residents and staff and to prevent the spread of infectious disease. 4. Observation of KMA #6, on 08/08/2022 at 3:20 PM, at the medication cart on 200 Hall, revealed her mask was below both nares. Interview with KMA #6, on 08/08/2022 at 3:25 PM, revealed the mask was too big and it would not stay up. She stated it was the facility's policy to wear a mask at all times while in the facility. KMA #6 stated she received IPC training upon hire and through frequent in-service updates. She stated following the facility's policies was important to keep germs from spreading. 5. Observation of room [ROOM NUMBER], on 08/08/2022 at 3:33 PM, revealed the Speech Therapist (ST) was sitting on the resident's bed. She was not wearing a mask. The ST exited the room without wearing a mask and without performing hand hygiene. Further observation, on 08/08/2022 at 4:47 PM, revealed the ST with her mask below her chin. The ST pulled the mask up over her nose when she saw the SSA Surveyor. Interview with the ST, on 08/08/2022 at 3:33 PM, revealed she did not perform hand hygiene. She stated there was nowhere to sit when providing care in the resident's room other than the resident's bed. The ST stated she should not have sat on the bed due to IPC concerns. She also stated she was working with the resident, and it was difficult to communicate while wearing a mask. Further interview revealed she should have used hand hygiene when exiting the room. The ST stated it was the facility's policy to wear a mask at all times while in the facility. She stated she received IPC training upon hire and through frequent in-service updates. The ST stated adhering to IPC requirements was important to prevent the spread of infection. 6. Observation of the Laundry Supervisor, on 08/10/2022 at 12:20 PM, revealed she had one (1) face mask strap hanging free, and the mask was below both nares. Interview with the Laundry Supervisor, on 08/10/2022 at 12:20 PM, revealed she was trained on how to don (apply) and doff (remove) PPE by the QA/IP Nurse, Sometime this year. However, she did not recall when. She stated, I know I am supposed to always gown up and wear goggles and gloves if I go into any isolation room. I do hand hygiene when I come out of a patient room, out to smoke, go to lunch, push a patient in the hall, or leave the floor for any reason and return. I know I should probably do it normally. She stated, I know I just went into a room without doing it [placing mask securely over the mouth and nares]. I was trained to put both straps on, but I just didn't do it. 7. Observation of KMA #6, on 08/09/2022 at 8:10 AM, revealed she was in a Quarantine TBP room without wearing PPE. Interview with KMA #6, on 08/09/2022 at 8:11 AM, revealed she did not know why the resident was on Quarantine TBP's. She stated, according to the facility's policy, an N95 respirator, face shield/goggles, gown, and gloves were required for Quarantine TBP. 8. Observation of the Social Service Director (SSD), on 08/09/2022 at 8:12 AM, revealed she was going to enter Quarantine TBP room [ROOM NUMBER]. The SSD was wearing an N95 respirator over her surgical mask. Further observation revealed the SSD and the DON exited the Quarantine TBP room [ROOM NUMBER]. Both the DON and SSD doffed their PPE (gown, gloves, N95 respirator, and face shields) while standing in the hallway outside of room [ROOM NUMBER]. The DON and SSD untied their gowns and removed the face shields with contaminated gloved hands. They did not bag the contaminated PPE. Before disposing of the contaminated PPE, the DON touched supplies on the PPE cart with the contaminated gloves. Further observation revealed the DON did not remove the glove, but used alcohol-based hand rub (ABHR) on the contaminated gloves, then removed them and donned new gloves, while holding contaminated PPE against her clothing. The DON walked down the hall to the dirty utility room, and while continuing to hold her unbagged, contaminated PPE, she unlocked the door. Interview with the SSD, on 08/09/2022 at 8:12 AM, revealed she was unaware of the CDC's recommendation not to wear anything under the N95 respirator. She stated she received IPC training upon hire and with updates. Interview with the DON, on 08/09/2022 at 8:12 AM, revealed there was a trash receptacle inside the room, but stated, There was stuff in it. The DON stated, The TBP rooms weren't set up properly. Furthermore, she stated she should have doffed her PPE prior to exiting the resident's room and disposed of the contaminated PPE in the proper receptacle. She stated following the IPC requirements was important to prevent the spread of communicable diseases and for the safety of residents and staff. The DON stated she and all facility employees received IPC training upon hire and with updates. 9. Observation of State Registered Nurse Aide (SRNA) #5, on 08/09/2022 at 9:16 AM, revealed she walked out of a resident's room without performing hand hygiene. SRNA #5 walked to the dirty utility room and came out of the dirty utility room without performing hand hygiene. Interview with SRNA #5, on 08/09/2022 at 9:20 AM, revealed she should have performed hand hygiene after exiting the resident's room and the dirty utility room. She stated she received IPC training upon hire and with updates. SRNA #5 stated following IPC policies was important to prevent illness and the spread of infection. 10. Observation of SRNA #8, on 08/09/2022 at 10:10 AM, revealed she entered a Quarantine TBP room (room [ROOM NUMBER]) without donning PPE. When she saw the SSA Surveyor, she exited the room and began to don PPE. She did not use ABHR or perform hand hygiene. Continued observation revealed SRNA #8 doffed her PPE and picked up four (4) large bags of dirty linen and trash and removed them from the room; and placed all four (4) bags on the floor outside of room [ROOM NUMBER] on the 100 Hall. The SRNA opened one (1) bag, which contained linen and trash, and poured the contents of the bag, which included contaminated gowns, gloves, and a face shield out on the floor. She then sorted the trash into an empty bag. The SRNA did not don PPE before she separated the trash and laundry. SRNA #8 tied up the bags and proceeded down the 100 Hall with the bagged trash and linen. Further observation revealed SRNA #8 failed to perform hand hygiene after handling the contaminated trash and linen. Interview with SRNA #8, on 08/09/2022 at approximately 10:15 AM, revealed when interviewed if she should wear PPE to enter a Quarantine TBP room, she stated, I don't know. Nobody told me anything. I'm just picking up the bags. SRNA #8 stated someone else had put trash in with the linens, and she was separating the items. She stated she received IPC training upon hire and through frequent in-service updates, but no one told her about all these residents being on isolation. When interviewed why it was important to wear PPE in a TBP room and not to sort linen and trash in resident care areas, SRNA #8 did not answer and walked away. Interview with the QA/IP Nurse, on 08/09/2022 at 10:50 AM, regarding SRNA #8 not wearing PPE in a TBP room and sorting trash in the hall revealed staff were trained to follow the facility's policies related to IPC practices. She stated linen and trash should never be sorted at the point of care. The QA/IP Nurse stated SRNA #8 should have contacted housekeeping to clean and disinfect the floor. Furthermore, the QA/IP Nurse stated all staff should don the appropriate PPE before entering a TBP room and should doff prior to exiting the room. She stated each TBP room should be equipped with trash receptacles for disposing of contaminated PPE. She stated further that it was not appropriate to wear soiled PPE, including gloves in the hall. Interview with the QA/IP Nurse, on 08/11/2022 at 4:12 PM, revealed trash was considered contaminated and should be placed in the appropriate container in the dirty utility room. Further interview revealed there was a separate container, lined with a red bag, for biohazard trash. She stated all soiled linen and trash bags should be tied before leaving the resident's room and taken directly to the dirty utility room. 11. Observation of the Hospitality Aide (HA), on 08/09/2022 at 10:18 AM, revealed the HA walked out of a Quarantine TBP room (room [ROOM NUMBER]) wearing an untied isolation gown and gloves. He stood in the hall for several minutes talking to other staff. He removed his gown and gloves after several minutes and reached back into the room to discard the contaminated PPE in the trash receptacle. The HA did not perform hand hygiene. He proceeded to touch walls and handrails in the hallway. Further observation of HA, on 08/09/2022 at 2:30 PM, revealed he entered a Quarantine TBP room (room [ROOM NUMBER]) without PPE, removed a resident's reusable water cup, brought it out into the hall and filled it with ice from Unit 1's ice cooler. The HA then entered room [ROOM NUMBER] with the cup, but without donning PPE. The HA was observed leaving room [ROOM NUMBER] and walked across the hall to another Quarantine TBP room (room [ROOM NUMBER]) and entered without donning PPE. He removed another resident's reusable water cup, brought it out into the hall, filled it with ice, and returned it back to room [ROOM NUMBER]. The HA failed to perform hand hygiene, using sanitizer, in either room or in the hallway. Interview with the HA, on 08/09/2022 at 10:25 AM and 2:40 PM, revealed the HA stated he was getting ice for a resident in quarantine. He stated he entered the room to get the ice pitcher so he would not contaminate the cooler. Throughout the interview, the HA proceeded to touch walls and rails on the walls. He stated his job duties included: feeding residents, cleaning up the sink areas, and generally getting residents their requested belongings and ensuring the residents had what they needed. Further interview revealed he received IPC training upon hire and through frequent in-service updates. He stated he was unaware that he did not don his PPE correctly or that he failed to perform hand hygiene. He stated wearing PPE and performing hand hygiene was important to stop germs from spreading. Continued interview revealed he did not provide direct care to any resident while he passed ice. 12. Observation of the Assistant Director of Nursing/Staff Development Coordinator (ADON/SDC), on 08/09/2022 at 10:35 AM, revealed she entered a Quarantine TBP Room, room [ROOM NUMBER], and failed to don the required PPE before entering the room. Interview with the ADON/SDC, on 08/09/2022 at 10:35 AM, revealed she had been in her role as ADON/SDC since June 2022. She stated she was answering a call light when she entered room [ROOM NUMBER]. She stated, I 100% should have donned PPE before entering a TBP room. She stated, according to the facility's policy, an N95 respirator, face shield/goggles, gown, and gloves were required for Quarantine TBP's. Continued interview revealed she had received IPC training upon hire and through frequent in-service updates. The ADON/SDC stated as the facility's SDC, she was responsible for educating the staff on IPC policies and protocols. Interview with LPN #9, on 08/09/2022 at 10:30 AM, revealed all linen was to be bagged in the room, then tied, and taken to the dirty utility room. She stated SRNA #8 should not have emptied the bags in the hall to sort linen from trash. LPN #9 stated the facility's policy was to perform hand hygiene before entering and when leaving a resident's room. She stated staff should follow instructions posted on all TBP rooms to determine appropriate PPE to don. LPN #9 stated staff should don PPE before entering a TBP room and should doff prior to exiting the room. Also, she stated it was not appropriate to wear soiled PPE, including gloves in the hall. 44000 13.a. Observation, on 08/09/2022 at 3:58 PM, revealed LPN #1, after performing a blood glucose check on Resident #34, returned to the medication cart and opened the top right drawer. He picked up an alcohol pad and wiped only the end of the glucometer and placed the glucometer back in the drawer. Interview with LPN #1, on 08/09/2022 at 3:59 PM, revealed he cleaned the glucometer after each use with an alcohol pad. b. Observation, on 08/11/2022 at 9:00 AM, revealed LPN #3 sanitized her hands and put [TRUNCATED]

Based on observation, interview and record review, it was determined the facility failed to have documented evidence of COVID-19 vaccination exemptions for those employees who declined to be vaccinated or whose vaccination status was unknown, for State Registered Nurse Aides (SRNA) #19, #20, #21, and Licensed Practical Nurse (LPN) #10. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) memo titled, Long-Term Care and Skilled Nursing Facility Attachment A Revised, supplement to the QSO 22-07-ALL memorandum, revised 01/22/2022, revealed the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Per the memorandum, staff was considered fully vaccinated if it had been two (2) weeks or more since they completed a primary vaccination series for COVID-19. Furthermore, the policies and procedures must include a process for ensuring all staff, except for those that had been granted exemptions to the vaccination requirements of this section, had received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multidose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents Review of the facility's policy titled, COVID-19 Vaccine, not dated, revealed, if an employee refused the vaccine for medical contraindications or religious exemptions, it would be documented on the appropriate exemption form. Review of the facility's record of COVID-19 employee vaccination status, dated 08/08/2022, revealed the facility employed one hundred and twenty-three (123) staff. Eighty-four percent (84%) or one-hundred three staff were fully vaccinated; and sixteen percent (16%) or twenty (20) staff members had been granted a religious exemption from receiving the vaccination. Review of the Facility COVID-19 Vaccine Acceptance/Declination Form, updated 01/24/2022, revealed twenty (20) employees declined the COVID-19 vaccination based on religious belief. Further review revealed five (5) of the twenty (20)employees did not date the acceptance/declination form. However, the facility did not provide documentation of declination for State Registered Nurse Aides (SRNA) #19, #20, and #21, or for Licensed Practical Nurse (LPN) #10. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/11/2022 at 4:12 PM, revealed she had worked at the facility in the position of IP since July 2022. She stated prior to working in the role of IP, she was the Assistant Director of Nursing (ADON). The QA/IP Nurse stated the facility required that staff received his/her primary COVID-19 vaccination or requested a medical or religious exemption per CDC guidelines. She stated vaccination was important to prevent the transmission and spread of COVID-19. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed the Administrator kept records of the staffs' and residents' COVID-19 vaccinations. Interview with Administrator, on 08/10/2022 at 9:28 AM, revealed he had been in his position for two (2) years. He stated he had reported COVID-19 vaccination data to the CDC's National Healthcare Safety Network, most recently, on 08/08/2022. Additional interview with the Administrator, on 08/12/2022 at 9:40 AM, revealed he did not provide further information as to why the facility had not kept accurate records of employee COVID-19 vaccination declination forms. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed it was the Administrator's expectation that staff adhered to infection prevention and control protocols to help maintain the health and safety of all residents, staff, and visitors. The Administrator stated vaccination was important to help prevent the transmission of COVID-19 in the facility.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Multiple breaches of infection prevention and control practices, as stipulated by the Centers for Disease Control and the facility's policies, was observed from 08/08/2022 to 08/11/2022. In addition, COVID-19 testing was not conducted per established local, state, and federal regulations. Furthermore, all staff had not received his/her primary vaccine series for COVID-19 per CDC guidelines because four (4) declination forms could not be found; and two (2) newly-admitted residents were not tested for COVID-19 immediately upon admission to the facility. Refer to F-880, F-886, F-888. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed the purpose of the policy was to ensure the facility developed, implemented, and maintained an ongoing facility wide QAPI program that was focused on care and quality of life for their residents. The objectives of the policy included: 1) provide a means to measure current and potential indicators for outcomes of care and quality of life; 2) provide a means to establish and implement performance improvement projects to correct identified deficiencies; and, 3) establish a system to monitor and evaluate corrective action. Further review revealed the facility's governing board was ultimately responsible for the QAPI program; and, the administrator was responsible for assuring that the QAPI program complied with federal, state, and local regulatory agency requirements. Per the policy, the QAPI committee oversaw implementation of the QAPI plan and identified and corrected quality deficiencies through 1) tracking and measuring performance; 2) establishing goals and thresholds for performance; 3) identifying and prioritizing quality deficiencies; 4) systematically analyzing underlying causes of systemic quality deficiencies; 5) developing and implementing corrective actions or performance improvement activities; and 6) monitoring effectiveness of the corrective actions and performance improvement activities. Review of the facility's QAPI Committee meeting documentation revealed a meeting had been held, on 04/27/2022, and attendees included but were not limited to the Administrator, the Medical Director, the Regional Director of Clinical Services (RDCS), the Director of Nursing (DON), the Infection Preventionist (IP), and the Unit I and Unit II Nurse Managers. Review of the Agenda revealed a mock survey, conducted on 04/06/2022 and 04/07/2022, had identified concerns related to infection prevention and control (IPC). The Medical Director voiced no concerns and/or recommendations regarding IPC. Review of the facility's QAPI Committee meeting documentation revealed a meeting had been held, on 05/25/2022, and attendees included but were not limited to the Administrator, the Medical Director, the RDCS, the DON, and the Infection Preventionist (IP). Review of the Agenda revealed IPC was not discussed. Review of the QAPI Committee meeting agendas, revealed the last QAPI meeting was held on 05/25/2022. 1.a. Review of medical records revealed seven (7) residents had been placed untimely on Quarantine Transmission Based Precautions (TBP) or Contact Precautions. b. Review of medical records revealed eight (8) residents had been placed on Quarantine TBP without documented evidence that it was warranted. c. Observations, from 08/08/2022 to 08/11/2022, revealed multiple infection prevention and control (IPC) breaches of protocol by staff. Twelve (12) observations involved staff not wearing or disposing of personal protective equipment (PPE) correctly; five (5) observations involved improper hand hygiene by staff; and five (5) observations involved incorrect disinfection of glucometers by staff. 2. During a COVID-19 outbreak, and with a high COVID-19 community transmission rate, the facility failed to test two (2) unvaccinated staff and five (5) staff whose COVID-19 vaccinations were not up to date prior to beginning his/her shift, allowing these staff to work a full shift before his/her bi-weekly COVID-19 test was performed. 3. Observation of the COVID-19 testing station, on 08/09/2022 at 4:30 PM, revealed multiple breaches in IPC protocol by the Quality Assurance/Infection Prevention (QA/IP) Nurse, who performed the testing. 4. Review of Resident #41's medical record revealed he/she received his/her first COVID-19 Rapid Test on 08/01/2022, five (5) days after admission on 07/27/2022. Review of Resident #210's medical record, whom the facility admitted on [DATE], revealed no COVID-19 Rapid Test results and none were provided by the facility's staff. 5. Review of the Facility COVID-19 Vaccine Acceptance/Declination Form, updated 01/24/2022, revealed twenty (20) employees declined the COVID-19 vaccination based on religious belief. Further review revealed five (5) of the twenty (20) employees did not date the acceptance/declination form. However, the facility did not provide documentation of declination for State Registered Nurse Aides (SRNA) #19, #20, and #21, or for Licensed Practical Nurse (LPN) #10. Interview with the Quality Assurance/Infection Preventionist (QA/IP) Nurse, on 08/11/2022 at 4:12 PM, revealed she had been the QA/IP Nurse since April 2022 and was the facility's Assistant Director of Nursing (ADON) prior to accepting her new role. Per the interview, she stated the facility failed to comply with infection prevention and control (IPC) protocols when staff failed to don/doff PPE or wear it correctly, according to recommended guidelines; failed to perform hand hygiene; failed to place new admissions immediately in TBP; and, failed to have the proper PPE or signage on the door for the type of TBP. She stated, Nursing staff should be supervising their aides. We do expect our nurses to monitor infection prevention and control compliance and ensure their aides are following our policies and guidelines for infection control; and nursing leadership should be monitoring the nurses for compliance. The QA/IP Nurse stated she was not aware of formal IPC compliance audits being conducted. Interview with the DON, on 08/10/2022 at 11:42 AM, revealed she had been in her current role since 07/13/2022. She stated she had been monitoring to ensure that IPC policies and protocols were followed. The DON stated she had focused on understanding everyone's roles and providing direction and oversite of IPC compliance. She stated nursing leadership, to include the DON, Assistant DON, QA/IP Nurse, and Unit Managers actively monitored staff for IPC compliance. Continued interview revealed there were no formal audits occurring, but if nursing leadership saw non-compliance, the staff involved was educated immediately. The DON stated she was aware of issues related to the facility's failure to accurately document and track COVID-19 testing. She stated she developed an agenda for an ad hoc QAPI Meeting, which was supposed to have taken place on 07/25/2022, but did not. She stated that IPC issues, including COVID-19 testing of residents, staff, and new admissions, and COVID-19 vaccination status were on the agenda to be addressed during the meeting. No explanation was provided as to why the meeting did not take place. Interview with the Medical Director (MD), on 08/12/2022 at 1:15 PM, revealed he attended ad hoc and monthly Quality Assurance and Performance Improvement (QAPI) meetings. He stated he had worked closely with the Administrator to assure the infection control process was adequate in preventing the spread of infection. He stated as MD, it was his expectation that staff was following IPC protocols, and leadership was monitoring compliance. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed the QAPI Committee had conducted monthly QAPI Meetings in the past, and planned to do so moving forward. However, he stated the last time the QAPI Committee met was at the end of April 2022. Per the interview, the Administrator stated discussion of COVID-19 testing documentation and infection control were slated for the ad hoc meeting on 07/25/2022, but the meeting did not occur. According to the Administrator, he stated there was a need to immediately address the COVID-19 testing documentation at the next ad hoc meeting. He stated ad hoc meetings had determined there were issues with IPC and COVID-19 testing. He stated, Infection control is discussed at every meeting for QA. 44001

Based on observation, interview, record review, review of the Director of Nursing and the Administrator's Job Descriptions, and review of the facility's policy, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and, failed to ensure infection prevention and control policies and protocols were adhered to for the safety and well being of residents, staff, and visitors. The Administration failed to ensure staff followed the Centers for Disease Control and Prevention (CDC) guidelines and the facility's policies for infection control and prevention (IPC); and COVID-19 testing was conducted per established local, state, and federal regulations. In addition, the Administration failed to ensure that all staff had received his/her primary vaccine series for COVID-19 per CDC guidelines because four (4) declination forms could not be found; and the Administration failed to ensure the facility tested two (2) newly-admitted residents immediately upon admission to the facility. Refer to F-880, F-886, F-888. The findings include: Review of the facility's Job Description for the Administrator, undated, revealed the Administrator's responsibilities included the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations governing nursing facilities to ensure residents were provided the highest degree of quality of care. Continued review revealed the Administrator was to ensure that all facility personnel followed established safety regulations to include infection control. Furthermore, the Administrator was responsible to plan, develop, organize, implement, evaluate, and direct the facility's programs. Review of the facility's Job Description for the Director of Nursing (DON), undated, revealed the DON oversaw and supervised the care of all residents. It stated the DON was responsible for the overall management of the entire nursing department. Per the Job Description, the DON's job duties included developing and implementing nursing policies and procedures and to ensure compliance. Furthermore the DON was responsible to ensure the safety of all residents. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, revealed the Administrator was responsible for assuring the facility complied with federal, state, and local regulatory agency requirements. 1.a. Review of medical records revealed seven (7) residents had been placed untimely, on Quarantine Transmission Based Precautions (TBP) or Contact Precautions. b. Review of medical records revealed eight (8) residents had been placed on Quarantine TBP without documented evidence that it was warranted. c. Observations, from 08/08/2022 to 08/11/2022, revealed multiple infection prevention and control (IPC) breaches of protocol by staff. Twelve (12) observations involved staff not wearing or disposing of personal protective equipment (PPE) correctly; five (5) observations involved improper hand hygiene by staff; and five (5) observations involved incorrect disinfection of glucometers by staff. 2. During a COVID-19 outbreak, and with a high COVID-19 community transmission rate, the facility failed to test two (2) unvaccinated staff and five (5) staff whose COVID-19 vaccinations were not up to date prior to beginning his/her shift, allowing these staff to work a full shift before his/her bi-weekly COVID-19 test was performed. 3. Observation of the COVID-19 testing station, on 08/09/2022 at 4:30 PM, revealed multiple breaches in IPC protocol by the Quality Assurance/Infection Prevention (QA/IP) Nurse, who performed the testing. 4. Review of Resident #41's medical record revealed he/she received his/her first COVID-19 Rapid Test on 08/01/2022, five (5) days after admission on 07/27/2022. Review of Resident #210's medical record, whom the facility admitted on [DATE], revealed no COVID-19 Rapid Test results and none were provided by the facility's staff. 5. Review of the Facility COVID-19 Vaccine Acceptance/Declination Form, updated 01/24/2022, revealed twenty (20) employees declined the COVID-19 vaccination based on religious belief. Further review revealed five (5) of the twenty (20) employees did not date the acceptance/declination form. However, the facility did not provide documentation of declination for State Registered Nurse Aides (SRNA) #19, #20, and #21, and for Licensed Practical Nurse (LPN) #10. Interview with the Regional Director of Clinical Services (RDCS), on 08/10/2022 at 11:42 AM, revealed her role in the facility was to consult, train, and tell them what is expected. She stated the Administrator had ultimate oversight to ensure all the facility's policies and protocols, especially as they related to adherence to regulatory recommendations, were being addressed and followed. She stated staff following infection prevention and control (IPC) procedures was important to prevent the spread of infection. Interview with the Director of Nursing (DON), on 08/10/2022 at 11:42 AM, revealed she had been in her current role since 07/13/2022. She stated she had been monitoring to ensure that IPC policies and protocols were followed. She stated she had focused on understanding everyone's roles and providing direction and oversite for IPC compliance. The DON stated nursing leadership, to include the DON, Assistant DON, IP Nurse, and Unit Managers, actively monitored staff for IPC compliance. She stated there were no formal audits occurring, but if nursing leadership saw non-compliance, the staff was educated immediately. She stated IPC was important to prevent the spread of infection. The DON stated she was aware of issues related to the facility's failure to accurately document and track COVID-19 testing. Additional interview with the DON, on 08/12/2022 at 3:03 PM, revealed it was her expectation that all IPC policies and protocols were followed by all staff. Per the interview, the DON stated she and the Assistant DON/Staff Development Coordinator were responsible for educating staff on IPC policies and protocols. She stated the facility used the train the trainer method to train on IPC practices: first to train the facility's department heads, and then for the department heads to educate and train support staff and allied health employees. She stated each department had its own IPC in-service book. She stated there was immediate intervention by leadership if any breach in IPC practices was observed. Per the DON, leadership would provide reeducation of staff, if needed. The DON stated compliance with IPC protocols was important to prevent the spread of communicable diseases among residents and staff. She stated it was her expectation that staff followed all facility infection prevention and control practices. Interview with the Administrator, on 08/12/2022 at 3:30 PM, revealed discussion of COVID-19 testing documentation and infection control were slated for the Quality Assurance Performance Improvement (QAPI) ad hoc meeting on 07/25/2022, but the meeting did not occur. According to the Administrator, there was a need to immediately address the COVID-19 testing documentation at the next ad hoc meeting. He stated ad hoc meetings had determined there were issues with IPC and COVID-19 vaccination and testing. 44001

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment. Residents complained during resident council of staff smoking outside on facility grounds. Observation revealed evidence of smoking off the Unit 2 exit, in the back parking lot, and at the back stairs. The findings include: Review of the facility's policy titled, Smoking Policy - Residents, not dated, revealed the facility was a no smoking facility. The policy stated smoking was only permitted if residents were off the premises. Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to a safe, clean, comfortable, and homelike environment. Interview with the Resident Group, on 08/09/2022 at 2:00 PM, revealed Residents #65, #88, #29, and #57 complained of staff that provided care for them smelled of smoke, and they, as residents, were not allowed to smoke. Resident #88 stated he/she had observed four (4) or five (5) staff smoking outside the after hours entrance (Unit 2 exit) and had complained, but could not remember who he/she had complained to. Resident #29 stated there were cigarette butts all around outside the emergency exit door where staff smoked. Resident #29 stated staff used to have to go a certain distance away from the facility to smoke. Observation, on 08/10/2022 at 3:41 PM, revealed the Unit 2 exit parking lot, directly around the emergency ramp, had in excess of forty-three (43) cigarette butts, with at least a dozen more in the bushes on each side of the door. Additional observation, on 08/10/2022 at 3:44 PM, revealed the back parking lot was littered with cigarette butts, and multiple cigarette butts also were observed at a back exit with stairs. Interview with the Director of Maintenance, on 08/11/2022 at 3:27 PM, revealed he had observed staff smoking around the building, at the picnic tables. He stated at night in this neighborhood, staff did not like to get too far away from the building. He stated it was posted at the entrance that this was a non-smoking facility. Continued interview revealed he tried to sweep things up around the ambulance (Unit 2) entrance. Further review revealed he was unaware of any resident complaints, and no residents had complained to him about staff smoking outside. Interview with State Registered Nurse Aide (SRNA) #4, on 08/11/2022 at 3:42 PM, revealed she had observed staff members smoking outside of the building, either in their cars or in smoking areas, to include the picnic table under the tree out back. She stated staff had a metal bucket to dispose of cigarettes at the picnic table. SRNA #4 stated she usually worked on Unit 1 which did not have an exit. She stated she did not know what happened on Unit 2. The SRNA stated she had not seen anyone smoking in the back parking lot. Interview with SRNA #10, on 08/11/2022 at 3:56 PM, revealed as a smoker, staff go off the premises down by the road to smoke. She stated she had never seen anyone smoking outside of the exits or in the back parking lot. She stated the building had been non-smoking since she had been at the facility. Interview with the Administrator, on 08/11/2022 at 4:45 PM, revealed he had not heard residents complain about staff smoking outside, although he had heard residents express their desire for the facility to be a smoking facility. He stated he had not seen staff smoking outside on the premises and would correct it immediately if he did. He stated he did not know who was responsible for producing the multiple cigarette butts observed outside. The Administrator stated, prior to admission, staff ensured that residents knew they were coming to a non-smoking facility. Continued interview revealed his expectation was that no one smoked on the premises, aside from one (1) designated area. He reiterated his expectation would be that nobody smoked on the premises.

Based on interview and review of the facility's policy, it was determined the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to send and receive mail, and the facility was responsible for protecting and facilitating the resident's right to communicate with individuals and entities within and external to the facility. During the Resident Group Interview, on 08/09/2022 at 2:00 PM, the State Survey Agency (SSA) Surveyor interviewed the residents to see if they received mail at the facility, to include mail on Saturdays. The general consensus was residents did not receive mail on Saturdays, with the only exception being when mail or packages were delivered for special occasions such as residents' birthdays. Resident #29 stated and other residents agreed that staff did not generally deliver mail on Saturdays. Resident #29 stated during the week, mail was delivered by the Activities staff, but they were not available on weekends to deliver mail. Interview with the Director of Social Services, on 08/09/2022 at 4:14 PM, revealed she was not sure what the procedure was for delivery of mail on the weekends. The Director stated that no residents had brought up any concerns regarding this. Interview with the Activities Director, on 08/09/2022 at 4:38 PM, revealed resident rights were discussed in resident council. She stated the weekend receptionist had given out mail on Saturdays in the past if she was not extremely busy, especially if it was important mail. The Activities Director stated mail was not passed out every weekend. She stated no residents had complained to her about not receiving mail on Saturdays. Continued interview revealed there was no facility policy regarding mail delivery. Interview with the Weekend Receptionist, on 08/11/2022 at 4:33 PM, revealed one (1) of her duties was to sort mail, and place any resident mail in the Activities Mailbox. She stated she did not deliver mail on Saturdays and was uncertain whether or not anyone else delivered mail to residents on Saturdays. Continued interview revealed she used to work through the week, and the procedure had always been to place residents' mail in the Activities mailbox for Activities to deliver. Interview with the Administrator, on 08/11/2022 at 4:45 PM, revealed he knew the weekend receptionist sorted mail. He stated he believed the weekend supervisor delivered resident mail on Saturdays. Continued interview revealed when he learned mail was not being delivered to residents on Saturdays, he expected the receptionist to sort mail and the weekend supervisor to deliver the mail.

Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of the United States Pharmacopoeia Standards, review of a medication package insert, https://www.humalog.com/u100, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in two (2) of two (2) medication storage rooms and one (1) of three (3) medication carts. Observation of two (2) medication storage refrigerators located on Unit 1 and Unit 2, on [DATE], revealed the medication refrigerators' temperatures were not maintained between 36- and 46-degrees Fahrenheit (F). Further observation of Unit 1's medication storage refrigerator revealed vaccines and medications were stored improperly in the door of the refrigerator. Continued observations revealed a medication bottle that did not have a pharmacy label, was not dated with an open date, and did not have an expiration date; and one (1) open vial of Tubersol, which was not dated when opened. Observation, on [DATE], of the 400 Hall medication cart revealed one (1) unopened vial of Humalog insulin in the drawer, and its labeling stated to refrigerate the insulin until opened. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) document, Vaccine Storage and Handling, updated [DATE], revealed vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy (result), creating limited protection, and exposure to temperatures thirty-two (32) degrees Fahrenheit or colder could destroy potency. Per the document, vaccine temperatures should be monitored and documented at least twice daily if the refrigerator did not have a temperature monitoring device, which read minimum and maximum temperatures. Further review revealed best practices for storage of vaccines was to ensure that vaccines were not stored on the top shelf, floor, or door of the refrigerator as the temperature in these areas might differ significantly from the temperature in the body of the unit. Per the document, exposure to any inappropriate conditions can effect potency of any refrigerated vaccine, but a single exposure to freezing temperatures (zero (0) degrees Celsius or thirty-two (32) degrees Fahrenheit or colder) could actually destroy potency. The document also stated liquid vaccines containing an adjuvant (substance which could increase potency of a drug) could permanently lose potency when exposed to freezing temperatures. Review of the United States Pharmacopoeia Standards (UPS) Chapter 1079: Good Storage and Distribution Practices for Drug Products, updated [DATE], revealed the standard provided guidance concerning storage of refrigerated medications. According to UPS standards, temperature-controlled storage environments must maintain appropriate conditions for temperature sensitive drugs and to ensure drugs were stored according to the manufacturer's instructions. USP standards reinforced that refrigerator storage temperatures should be maintained between thirty-six (36) and forty-six (46) degrees Fahrenheit, which was two (2) degrees and eight (8) degrees Celsius. Review of the facility's policy titled, Storage of Medications, revised [DATE], revealed drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls. Further review revealed medications requiring refrigeration would be stored in a refrigerator in the medication room. Per the policy, the nursing staff was responsible for maintaining medication storage. In addition, the policy stated compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals were locked when not in use. Review of the medication package insert for Humalog U-100 units/milliliter (insulin taken for Diabetes) at https://www.humalog.com/u100, revealed an unopened insulin vial should be stored in a refrigerator at thirty-six (36) to forty-six (46) degrees Fahrenheit or two (2) to eight (8) degrees Celsius. 1. Observation, on [DATE] at 3:24 PM, of the Unit 1 Medication Storage Room revealed it was locked. The thermometer was located on a shelf in the door of the refrigerator. The temperature of the refrigerator registered thirty-two (32) degrees Fahrenheit. The door to the freezer compartment would only open slightly as it was adhered to a large amount of ice build-up on the inside of the freezer compartment. Per the observation, stored on shelves on the door included: two (2) boxes of unopened Tubersol, a medication used to perform tuberculin skin tests, (TU) (5 TU/0.1 milliliters (ml)) 5 ml multi-dose vial; and seven (7) vials of Pneumococcal Conjugate Vaccine. Medications stored in the refrigerator compartment and unopened, which required refrigeration from thirty-six (36) to forty-six (46) degrees Fahrenheit included: one (1) bottle of Calcitonin Nasal Spray, used to treat postmenopausal osteoporosis; one (1) bottle of Omeprazole Oral Solution, used to treat gastrointestinal (GI) conditions; one (1) bag of Cephalexin IV, used to treat infections; multiple Acetaminophen suppositories, used to treat fever and pain; multiple Bisacodyl suppositories, used to treat constipation; two (2) bottles of Latanoprost Ophthalmic Solution, used to treat increased pressure in the eye; two (2) Humalog Kwik Pens, used to treat Diabetes (high blood sugar); one (1) Novolog Flex Pen, used to treat Diabetes; two (2) Basaglar Injection Pens, used to treat Diabetes; one (1) Insulin Glargine Pen, used to treat Diabetes; two (2) Ozempic Injection Pen, used to treat Type 2 Diabetes; and two (2) vials of Lorazepam 2.0 milligrams (mg)/milliliter, used to treat anxiety. In addition, one (1) bottle of Ibuprofen, used to treat fever, pain, and inflammation, with approximately thirty (30) tablets, which was located in a cupboard in the medication storage room. The Ibuprofen bottle was not labeled and did not have a visible expiration date. 2. Observation, on [DATE] at 3:42 PM, of the Unit 2 Medication Storage Room refrigerator revealed the temperature was at thirty-two (32) degrees Fahrenheit. Medications stored in the refrigerator compartment, unopened unless otherwise indicated, which required refrigeration from thirty-six (36) to forty-six (46) degrees Fahrenheit included: twelve (12) Acetaminophen suppositories; multiple Bisacodyl suppositories; one (1) opened Tubersol (5 TU/0.1 ml) 5 ml vial, where the packaging was dated, but there was not an opened date label; one (1) Trulicity Injection Pen, used to treat Type 2 Diabetes; one (1) bottle of Latanoprost Ophthalmic Solution; one (1) Novolog Flex Pen; one (1) Insulin Glargine Pen; one (1) Lansoprazole oral suspension, used to treat GI conditions; and twelve (12) Promethazine 25 mg suppositories, used to treat nausea. Review of the facility's form, Refrigerator Temp Log, dated ,d+[DATE], for the medication storage refrigerators, revealed staff was to monitor the refrigerator temperature once daily and check for expired items and opened dates on items. Further review of the temperature log, for the Unit 2 medication storage refrigerator revealed there was no temperature logged for [DATE]. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 3:24 PM, revealed she did not know at what temperature the medication refrigerator should be maintained. She stated she was unaware that medications and vaccines should not be stored in the door of the refrigerator. Per the interview, LPN #9 stated the night nurse was responsible for monitoring the temperature of the medication refrigerators and the temperatures were monitored weekly. LPN #9 stated she was educated by nurse leadership on medication storage and labeling. Interview with Registered Nurse (RN) #1, on [DATE] at 3:45 PM, revealed the night shift nurse was responsible for monitoring the temperature of the medication refrigerators and temperatures were monitored once daily. She stated refrigerator temperatures should be maintained between thirty-six (36) and forty-six (46) degrees Fahrenheit. RN #1 stated she believed the Unit Managers (UM) audited the temperature log sheet for compliance. Per the interview, she stated storing medications according to manufacturer's recommendations was necessary for the safety of all residents and the stability of the medications. 3. Observation, on [DATE] at 9:54 AM, of the medication cart on the 400 Hall revealed one (1) unopened vial of Humalog U-100 units/ml. Per the label instructions, the insulin vial should be stored in a refrigerator prior to opening. Interview with LPN #7, on [DATE] at 9:55 AM, revealed the unopened vial of insulin should have been stored according to the manufacturer's instructions and stored in the refrigerator prior to opening. Interview with Unit 1 Manager/LPN #2, on [DATE] at 2:15 PM, revealed it was the responsibility of the nursing staff to ensure medications were stored according to the facility's policy. She stated she had been educated by the facility on medication storage and labeling. LPN #2 stated the night shift nurse was responsible for monitoring the temperature of the medication refrigerators, and then she audited the temperature logs to make sure the task had been completed. When asked at what temperature the medication storage refrigerator should be maintained, LPN #2 stated, Between thirty-six (36) and forty-two (42) degrees, I guess. Vaccines have different temperature requirements, but I'm not sure what that is. She stated she was not aware of any one (1) person in leadership who monitored the staff for medication storage and labeling compliance. Further interview revealed that all nurses were responsible for ensuring the refrigerator/freezers were maintained in proper working order, including defrosting the freezer. LPN #2 stated that she would defrost the freezer as needed. Continued interview revealed she was unaware that Unit #1's medication storage freezer compartment needed to be defrosted. Per the interview, she stated storing medications according to manufacturer's recommendations was necessary for the safety of all residents and the stability of the medications. Interview with Unit 2 Manager/RN #2, on [DATE] at 2:15 PM, revealed it was the responsibility of the nursing staff to ensure medications were stored according to the facility's policy. Per the interview, RN #2 stated the night shift nurse was responsible for monitoring the temperature of the medication refrigerators, and then she monitored the temperature logs to make sure the task had been completed. She stated the refrigerator should be maintained between thirty-six (36) and forty (40) degrees to forty-six (46) degrees Fahrenheit. Per the interview, defrosting was important to maintain the temperature. RN #2 stated storing medications according to the manufacturer's recommendations was necessary to ensure the medications were effective and safe to administer. Interview with the Director of Nursing (DON), on [DATE] at 3:03 PM, revealed it was her expectation that nurses followed the facility's policy regarding medication storage and labeling. She stated medications and vaccines should be stored according to manufacturer's recommendations and CDC guidelines to ensure the safety of all residents and to maintain medication effectiveness. Interview with the Administrator, on [DATE] at 3:30 PM, revealed it was his expectation that nurses followed the facility's policy regarding medication storage and labeling. He stated that it was important to follow manufacturer's recommendations to maintain medication and vaccine efficacy and ensure the safety of all residents and staff.

Based on interview, record review, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan in the care area of nutrition, for one (1) of thirty-two (32) sampled residents (Resident #26). The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised December 2016, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2017, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's policy titled, Nutritionally At Risk (NAR) Committee, last updated 12/30/2014, revealed its purpose was to monitor and intervene in the care of patients as it related to weight loss and weight gains. The criteria for NAR monitoring included: significant weight loss; if the resident consumed less than fifty (50) percent of meals and weight loss had been identified; recent acute illness; identified as being a total assist for feeding and meals; and received Speech Therapy services for swallowing and self-feeding issues; and documentation of the NAR Committee's recommendations. It further revealed a care plan would be developed with person centered interventions for residents identified to be nutritionally at risk. Review of Resident #26's Electronic Medical Record (EMR) revealed the facility admitted the resident on 03/01/2022. Further review revealed the facility discharged the resident on 03/08/2022 to an acute care hospital; and readmitted the resident, on 03/21/2022. The resident's diagnoses included Activities of Daily Living and Mobility Deficits secondary to a Right Hemispheric Stroke with Left Hemiparesis and Dysphagia; History of Chronic Pain; Type 2 Diabetes; Gastroesophageal Reflux Disease; Osteoporosis; Hypertension; Hyperlipidemia; and Osteoarthritis. The record also stated Resident #26 was oriented to person only and often refused his/her meals. Review of Resident #26's Admission Minimum Data Set (MDS) Comprehensive Assessment, dated 03/05/2022, revealed Resident #26's Brief Interview for Mental Status (BIMS) was unable to complete related to memory problems. Continued review revealed Resident #26 required cues and supervision for daily decision making. Resident #26 was totally dependent for eating and drinking. Review of a Nutrition Note, dated 03/27/2022, revealed the facility assessed Resident #26 as nutritionally at risk related to requiring a mechanically altered or therapeutic diet; being a total assist with meals; diagnoses of Cerebral Vascular Accident (stroke) and Type 2 Diabetes; a history of aspiration; an oral intake of approximately thirty-five percent (35%); and meeting only twenty-six to seventy-five percent (26-75%) of caloric needs. Review of Resident #26's active Physician's Orders, revealed House Nutritional Supplements were ordered with meals on 04/04/2022; Hi-Cal Snacks two (2) times daily were ordered on 06/09/2022; and weigh resident daily for three (3) days, beginning on 03/02/2022, and daily for three (3) days, beginning on 03/21/2022. Review of Resident #26's Dietary Progress Note, dated 03/21/2022, revealed the diet order was NAS (no added salt), CCHO (controlled carbohydrate) pureed with NTL (nectar thick liquids) and extra sauce/gravy. Review of Resident #26's Comprehensive Care Plan (CCP), dated 03/21/2022 and revised on 06/05/2022, revealed no documentation the facility developed a care plan with a focus on Nutrition which included nutritional monitoring, weight monitoring and ordered supplements and snacks for Resident #26. Review of Resident #26's Dietary Note, dated 06/07/2022, revealed Resident #26's current diet order was a pureed, NAS, CCHO diet and supplemental shakes with meals. Per the Note, the resident was a total assist for eating with aspiration precautions. The Note stated an added intervention of snacks two (2) times daily for increased calories and weight gain/stability was recommended and ordered. However, this order was not reflected on Resident #26's care plan as the facility had not developed a care plan for being nutritionally at risk. Interview with Licensed Practical Nurse (LPN) #8/MDS Coordinator (MDSC), on 08/12/2022 at 1:45 PM, revealed it was the MDS Coordinator's responsibility to develop the resident's care plan on admission/re-admission and to update the resident's care plan with new orders. She stated a list of new orders was printed off by Registered Nurse (RN) #3 and given to the MDSC at the morning IDT meeting. She stated, at the meeting, all new orders were reviewed and discussed; placed on the Community Board (CB), which could be viewed by all staff; and Unit Managers put the new orders into Point Click Care (PCC), a computer software program. She further stated a Nutritional at Risk Care Plan should have been developed for Resident #26. Interview with LPN #2/Unit 1 Manager, on 08/12/2022 at 2:14 PM, revealed Resident #26 should have had a care plan related to being Nutritionally at Risk. she said all orders from the Physician such as diet, snacks, supplements, and weekly or monthly weights for each resident should be included on the Comprehensive Care Plan. Interview with RN #2/Unit 2 Manager, on 08/12/2022 at 2:30 PM, revealed new orders were discussed in IDT meetings, and the Unit Manager for each unit put the new orders into PCC and on to the CB. She stated the MDSC developed and updated the residents' care plans with new orders. Interview with RN #6/Assistant Director of Nursing (ADON), on 08/12/2022 at 2:30 PM, revealed new orders were reviewed in the IDT meeting from a list which was printed off by RN #3. She stated the Unit Managers put the new orders for the residents on their unit into the PCC and on the CB. She stated it was the MDSC's responsibility to develop residents' care plans for new admissions and to update the existing resident care plans. Interview with the Director of Nursing (DON), on 08/12/2022 at 3:06 PM, revealed she tracked the monthly weights for residents and ensured they were obtained. She further stated a care plan should have been developed for Resident #26 because she was being followed by the NAR Committee. The DON stated care plans were developed for new residents by the MDSC on admission/re-admission and updated by the MDSC during the IDT meetings. The DON stated it was her expectation that resident care plans were developed, updated, and reviewed to reflect the resident's current care needs. Interview with the Administrator, on 08/12/2022 at 3:45 PM, revealed it was his expectation care plans for residents were developed on admission/re-admission and updated quarterly and as needed, to reflect the current care needs of each resident.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as was possible for two (2) out of four (4) sampled residents (Resident#1 and Resident #2). The facility failed to maintain their keypad door locking system to ensure residents were unable to access the code and exit the facility. The findings include: Review of facility's Policy, titled Safety and Supervision of Residents, revised July 2017, revealed the facility strives to make the environment as free from hazards as possible. Continued review revealed facility and resident oriented approaches to safety were used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then interventions are to be adjusted accordingly. Review of facility's Policy, titled Resident Sign Out Process, revised August 2006, revealed each resident leaving the premises must be signed out. Interview with the Administrator, on 01/22/2020 at 3:45 PM, revealed the facility does not have a policy related to the Door Keypad Codes. Review of facility's Door and Keypad maintenance for calendar year 2019 and January of 2020, revealed no issues with facility doors or keypads that required replacement or complete overhaul of the keypad security system. Further review revealed one (1) of the door keypad codes changed at the beginning of each month and the other was a master code that the facility did not change. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 01/23/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BI[CONDITION]) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed Resident #1 was assessed for not exhibiting wandering behavior at the time of the assessment. Review of facility's Investigation, dated 0[DATE]20, revealed on 0[DATE]20 around lunchtime, Licensed Practical Nurse (LPN) #1 was outside the facility during her lunch period. Continued review revealed while on her lunch period, she found Resident #1 outside the facility on the back stair case porch. Per the investigation, Resident #1 had not descended the stairs and was brought back into the facility by LPN #1. Staff were not aware Resident #1 had exited. Further review revealed the resident was assessed for injury, cognitive status, and elopement. Per the report, Resident #1 wanted some fresh air. Interview with Resident #1, on 01/21/2020 at 1:00 PM, revealed, Resident #1 remembered the event and stated his/her reason was that he/she needed some air and was having a bad day. Further interview revealed Resident #1 did not notify anyone he/she was going outside. Resident #1 declined to reveal how he/she exit the facility. Interview with Resident #1's daughter, on 01/21/2020 at 3:00 PM, revealed she was contacted about the incident directly after it happened. She stated Resident #1 was having a difficult time due to an anniversary of a death in the family. Continued interview revealed she would visit Resident #1 two (2) to three (3) times a week and would take the resident outside or off the grounds. Further interview revealed she utilized the master code to gain access to the facility and to exit the facility. She stated she has never told Resident #1 the code but it was possible Resident #1 watched her enter the code on many occasions. She concluded Resident #1 was very capable of memorizing the code. Interview with LPN #1, on 01/21/2020 at 1:30 PM, revealed, on 0[DATE]20, she was in her car on her lunch break around 12:30 PM. LPN #1 stated she looked up and saw Resident #1outside the facility and standing at the top of the stairs. Continued interview revealed she immediately got out of her car and escorted the resident back inside and began the process of communication with the Director of Nursing. Further interview revealed Resident #1 was a former smoker, and that his/her daughter would come in twice a week to take him/her outside. LPN #1 stated Resident #1 should not know the keypad code to exit, but most family members do. LPN #1 stated the code previously before this event, changed monthly, but that there was a permanent (master) code in place that never changed. LPN #1 stated the master code was code give to most families and was used by staff. Per interview, Resident #1 did not tell her how he/she got out of the facility; however, the resident was good at problem solving and may have figured out the code. Interview with State Registered Nurse Aide (SRNA) #1, on 01/21/2020 at 1:15 PM, revealed she was assigned to care for Resident #1 on 0[DATE], but did not see Resident #1 leave the facility. SRNA #1 stated Resident #1 was having a hard time due to an anniversary of a family death. SRNA #1 stated on the day of the event, the resident was upset regarding a miscommunication over a lunch order, and had sat his/her lunch tray in the hallway. Per interview, she did not know the resident had exit the facility until she saw LPN #1 escorting him/her back inside the facility. Further interview revealed the keypad codes were the same on all doors, both inside and outside. Per interview, the code would change monthly; however, a master code could be used to open all the doors. SRNA #1 states family members are given the master code, but residents should not have access to the codes. Interview with LPN # 2, on 01/21/2020 at 2:00PM, revealed Resident #1 goes outside with her daughters weekly. Per interview, the daughters follow protocol and sign the resident out. Continued interview revealed Resident #1 has not exhibited elopement behaviors while under her care. Further interview revealed doors to the facility utilize a keypad code system. Per interview, one of the codes changes monthly and one is a master code that does not change. LPN #2 stated most families know the master code, but the facility discourages the residents from knowing the code. Interview with Director of Nursing (DON), on 01/22/2020 at 10:00 AM, revealed Resident #1 did not have any injuries, and refused to wear a wander guard after the incident. The resident was placed on frequent monitoring and it was noted, no additional elopement behaviors were exhibited. Further interview revealed Resident #1 did not say how he/she got outside the door, nor did the daughter say she gave Resident #1 the code. 2. Record Review of Resident #2's medical record revealed the facility admitted the resident on 11/17/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/03/19, revealed the facility assessed Resident #2 to have a Brief Interview of Mental Status Score (BI[CONDITION]) of fifteen (15) out of fifteen (15), indicating the resident to be cognitively intact. Further review revealed the facility assessed the resident to not have exhibited wandering behavior at the time of the assessment. Review of the facility Investigation, dated 01/04/2020, revealed on 01/04/2020 around 9:45 AM, Resident #2 exit the facility being followed by nursing staff. Per the report, Resident #2 ignored staffs request to come back into facility and his motorized wheelchair went off the curb and tipped over. Continued review revealed E[CONDITION] were called to the scene and Resident #2 was taken to the hospital. No injuries were reported and Resident #2 was sent back to facility on 01/04/20 at 7:15 PM. Interview with Resident #2, on 01/21/2020 at 3:45 PM, revealed he/she exited the facility on 01/04/2020, after an issue over [MEDICAL TREATMENT]. Per interview, the [MEDICAL TREATMENT] transportation arrived at 7:30 AM for pick up, which he/she is normally picked up at 8:30 AM. Continued interview revealed he/she became upset when the transportation vehicle did not wait for him/her to finish breakfast. At this point Resident #2 stated he became very angry and began to drive his/her wheelchair around the facility. Resident #2 stated he/she went to the ambulance bay exit door and exited the facility with staff directly behind him. Resident #2 stated the staff were trying to redirect him/her back into the facility but he/she was ignoring their request. Resident # 2 stated he/she got too close to the curb and rolled his/her wheel chair off it. Per interview, he/she was sent to the hospital where he/she was examined, received [MEDICAL TREATMENT] and returned to the facility the same day. Further interview revealed Resident #2 obtained the keypad code to exit the facility by watching families and staff enter the code. Interview with LPN #3, on 01/21/2020 at 2:00 PM, revealed Resident #2 has some anger issues and was very upset on 01/04/2020 about [MEDICAL TREATMENT] transportation leaving him/her. Resident #2 exited the building on his/her own without warning and was quickly followed by LPN #3 and other staff. Per interview, Resident #2 ignored redirection and went off the curb in his/her wheel chair. Further interview revealed, the ambulance bay door was the door used in the exit and required a keypad code to open. Interview with Director of Nursing (DON), on 01/22/2020 at 4:15 PM, revealed Resident # 2 had no injuries from the incident and was released by the hospital. Per interview, Resident #2 did receive [MEDICAL TREATMENT] at the hospital so no treatments were missed, all parties involved with Resident #2 were contacted about the incident, and the resident's Physician was notified. Further interview revealed the resident admitted to using the keypad code, but has no history of exit seeking behaviors. Resident #2 is currently seeing Occupational Therapy for continued treatment and evaluation in regards to using motorized a wheelchair. Interview with Resident #3, on 01/22/2020 at 1:00 PM, revealed that he/she knew the master code and that members of her family knew the master code. Further interview revealed Resident #3 obtained the master code from family and visual confirmation from staff and family when they entered the code. Interview with Resident # 4's private caregiver, on 0[DATE]20 at 1:15 PM, revealed Resident #4 had only been in facility a short time. The caregiver revealed that she knew the master door code to enter the facility and has witnessed other families and visitors using the code with residents present. Interview with RN #1, on 01/22/2020 at 10:00 AM, revealed staff were instructed to not give the key code to residents, but that some family members do know the codes. Further interview revealed she utilized the master code to enter and exit the facility and that code has been active since she has been employed. Further interview revealed although there is a code that changes monthly, to her knowledge most employees and families use the master code that does not change. Interview with LPN # 4, on 01/22/2020 at 10:00 AM, revealed staff were instructed to not give out the keypad code to residents, but that family members were able to obtain code upon request. Further interview revealed, LPN #4 uses the master code for convenience due to it never changing and it was easier to remember. LPN #4 stated most families she talks to know the master code. Interview with SRNA #2, on 01/22/2020 at 10:15 AM, revealed she uses the master code and that it has been in place since the time of her employment. Further interview revealed she has given the code to families and that families use the codes on all doors. She was instructed to not give the code to residents, but has heard some residents repeating the permanent key code. Interview with SRNA #3, on 01/22/2020 at 10:30 AM, revealed has been employed for three (3) years and has not seen a resident use keypad, but has seen numerous families using the key pad with residents beside them and able to see them enter the code. Continued interview revealed it was the facility's policy to not give the code to residents. Further interview revealed she uses the master code, which did not change. Per interview, most families and employees use the master code. Interview with Housekeeper #1, on 01/22/2020 at 1:00 PM, revealed only employed for short time frame but was aware of the master code and had observed families utilizing the code with residents present. Interview with the Maintenance Assistant, on 01/22/2020 at 2:00 PM, revealed he had been employed for eleven (11) years and was responsible for upkeep on the doors. Per interview, the doors were checked weekly. Continued interview revealed the keypad code would change monthly; however, the master code did not change and had not changed for over one (1) year. Further interview revealed the master code was given to resident families and staff for purposes of visiting and getting in and out of the facility. Per interview, he has not witnessed any residents using the code but has seen families with residents accompanying them use the code. Interview with the Maintenance Director, on 01/21/2020 at 3:00 PM, revealed the doors are checked periodically. Further interview revealed there were two (2) functional codes for the door. One code changed monthly and one remained the same (master) that resident families used most of the time. Interview with Assistant Director of Nursing (ADON), on 01/22/2020 at 3:15 PM, revealed she had been employed for five (5) years. Per interview, Resident #1 and Resident #2 do not actively attempt to exit seek. Continued interview revealed one of the keypad codes changed monthly; however, one was kept in place and did not change. Per interview, staff were allowed to give the master code to family members but not residents. Family members and other visitors usually come in the front door or ambulance entry door. Further interview revealed, staff have been trained and drills are conducted on elopements and accident preventions. Per interview, the facility has had no past issues with elopements, and there had been no previous discussion to change the master code. The ADON states residents have the right to have a safe environment, and that the facility should be looking at and doing everything possible to maintain a safe environment to prevent accidents. Interview with Director of Nursing (DON), on 01/22/2020 at 3:30 PM, revealed she has been the DON for seven (7) months. Per interview, the previous keypad code was changed monthly while the master code was never changed and was used as a failsafe code. Continued interview revealed the facility policy was for residents to sign out prior to exit and for staff to escort the family and resident out. Per interview, some long-standing resident's family members did have the master code. Further interview revealed there has been no resident elopements since employment. In addition, there had been no discussion of changing the master code before the incident even though a majority of families and all staff utilized that code. She stated residents have the right to have a safe environment. The facility should do everything possible to maintain a safe environment. Per interview, keeping a two (2) code system, with one (1) code not changing was not a system that promoted a safe environment. Interview with the Administrator, on 01/22/2020 at 3:45 PM, revealed he has been the Administrator for two years. Continued interview revealed the keypad code was changed every month; however, the master code was not changed. Per interview, the master code was initially intended for maintenance only but was given to families, visitors and staff. Further interview revealed residents have the right to have a safe environment and the facility should do everything in their power to maintain that. He stated, utilizing a two (2) code system where one (1) code changed monthly and the other code that was utilized by staff, visitors and family did not change, did not promote a system, which provided the safest environment for all residents. Further, he revealed the facility has now instituted a one (1) code system that will change on a monthly basis or as needed. Per interview, he will monitor to ensure the safety of the residents.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to provide a safe, clean, comfortable, and homelike environment affecting seven (7) residents, (Resident #1, #14, #19, #31, #34, #60 and #64). Observations of the lunch meal, on 08/20/19 at 11:30 AM, revealed Residents #1, #14, #19, #31, #34, #60 and #64 were sitting at U shaped assist tables facing the walls. Continued observation revealed the tables were without tablecloths, table runners or centerpieces. The findings include: Review of the facility's Policy titled, Homelike Environment, dated 2001, revised (MONTH) (YEAR), revealed Residents are provided with a safe, clean, comfortable homelike environment. Continued review revealed staff shall provide person centered care that emphasizes the residents' comfort, independence and personal needs and preferences, with inviting colors and decor. Review of the facility's Policy titled, Resident Rights, dated 2001, revised (MONTH) (YEAR), revealed residents' rights include the right to a dignified existence, and to be treated with respect, kindness and dignity. Observation of the Dining Room, on 08/20/19 11:30 AM, revealed Resident #1, Resident #14, Resident #19, Resident #31, Resident #34, Resident #60, and Resident #64 were seated at a U shaped assist table. Continued observation revealed the residents were all facing away from the dining room and towards the wall. Further observation revealed there were no tablecloths, table runners or centerpieces on the tables. 1. Record review revealed Resident #1 was admitted by the facility on 06/09/18 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 07/12/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15), indicating the resident to be moderately impaired for decision making. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive physical assist by one (1) staff for eating. 2. Record review revealed Resident #14 was admitted by the facility on 05/10/17 with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly MDS Assessment, dated 08/15/19, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident to require extensive physical assistance with one (1) staff member for eating. 3. Record review revealed Resident #19 was admitted by the facility on 02/20/19 with [DIAGNOSES REDACTED]. Review of Resident #19's Quarterly MDS Assessment, dated 05/30/19, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review revealed the facility assessed the resident to require extensive physical assistance with one (1) staff member for eating. 4. Record review revealed Resident #31 was admitted by the facility on 05/27/19 with [DIAGNOSES REDACTED]. Review of Resident #31's Quarterly MDS Assessment, dated 08/12/19, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive physical assistance with one (1) staff member for eating. 5. Record review revealed Resident #34 was admitted by the facility on 01/29/04, with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #34's Quarterly MDS Assessment, dated 06/13/19, revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed the resident to require the support of one (1) staff member physical assist for eating. 6. Record review revealed Resident #60 was admitted by the facility on 07/14/17 with [DIAGNOSES REDACTED]. Review of Resident #60's Annual MDS Assessment, dated 07/06/19, revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed the resident to require extensive physical assist with one (1) staff member for eating. 7. Record review revealed Resident #64 was admitted by the facility on 01/04/19 with [DIAGNOSES REDACTED]. Review of Resident #64's Quarterly MDS Assessment, dated 07/13/19, revealed the resident was assessed by the facility to have a BIMS score of eight (8) out of fifteen (15), indicating the resident to be moderately impaired. Continued review revealed the resident did not have a documented upper extremity impairment. Further review of the MDS Assessment, revealed the facility assessed the resident to require one (1) staff physical assistance with eating. Interview with State Registered Nursing Assistant (SRNA) #8, on 08/23/19 at 10:28 AM, revealed all residents who are assisted with meals should have the same provisions and services as other residents, such as table cloths and tables. Per interview, the U assist tables could be seen as institutional, but they were using them because the smaller tables were not as tall for the wheelchairs. Per interview, the U shaped tables faced the wall and not the rest of the dining room and could be seen as isolating the residents. Continued interview revealed the tables should have been arranged for the residents to be able to face the dining room and the table should have tablecloths and centerpieces. Per interview, the facility did provide training related to resident rights and providing a homelike environment and the staff was trained to view the facility as the resident's home. Interview with the Quality Assurance Nurse, on 08/23/19 at 11:00 AM, revealed all residents should have the same care and services and be provided the same goods in a safe homelike environment. Continued interview revealed the facility may need to provide a variety of tables to provide for resident needs and preferences. Further interview revealed residents should not be singled out for a different type of furniture solely based on the type of assistance they required such as with meals. Per interview, the facility did have a policy related to dignity and resident rights. Interview with the Assistant Director of Nursing (ADON), on 08/23/19 at 10:59 AM, revealed the facility did have a policy related to homelike environment and resident rights. Continued interview revealed residents who were assisted with dining should receive the same goods and services as residents who were independent diners. Further interview revealed she was not aware of any reason the residents who were assisted with dining during the lunch meal, on 08/20/19, were assisted using institutional U shaped tables without table linens or centerpieces. Interview with the Director of Nursing (DON), on 08/23/19 at 2:45 PM, revealed all residents should be provided with the same provisions and services whether they were assisted or independent for dining. Continued interview revealed it would be her expectation for staff to follow the facility's Policy for homelike environment and for dignity and respect. Per interview, having a consistent environment that was the same for all residents was important to provide a homelike environment and should be done unless there was a medical or behavioral reason. Interview with the Administrator, on 08/23/19 at 2:52 PM, revealed he had been employed by the facility since (MONTH) (YEAR). Continued interview revealed residents that need assistants with dining should receive the same provisions and services as residents that were independent, to make everyone feel equal. Continued interview revealed it could be a possible dignity issue if the dependent residents did not receive the same services. Further interview revealed the facility had a policy and all residents should be afforded a homelike environment and person centered care.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. There were four (4) residents affected, (Resident #14, Resident #31, Resident #39 and Resident #64). Observation of the lunch meal, on 08/20/19, revealed Resident #39, Resident #14, and Resident #31 were assisted with dining by staff while staff was standing. Additional observations of the lunch meal, on 08/20/19, revealed Resident #64 requested coffee and was denied related to his/her level of assistance; however, the resident's Comprehensive Care Plan and further observations during survey revealed the resident was independent with drinking from a cup after set up. The findings include: Review of the facility's Policy titled, Assistance with Meals, revised (MONTH) (YEAR), revealed facility staff will serve resident trays and will help residents who require assistants with eating. Continued review revealed residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals. Review of the facility's Policy titled, Resident Rights, revised (MONTH) (YEAR), revealed residents have a right to be treated with respect, kindness and dignity, and communication to and access to people and services, both inside and outside the facility . 1. Record review for Resident #14 revealed the resident was admitted by the facility on 05/10/17, with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/15/19, revealed the facility assessed Resident #14 to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review of the MDS Assessment, revealed the facility assessed Resident #14 to require extensive physical assistance with one (1) staff member for eating. Observation of the noon meal, on 08/20/19 at 12:34 PM, revealed Resident #14 was at a U shaped assist table. Continued observation revealed State Registered Nursing Assistant (SRNA) #8 was assisting Resident #14 with his/her meal. Further observation revealed SRNA #8 was standing across the table while assisting the resident with his/her meal. Interview with SRNA #8, on 08/23/19 at 11:15 AM, revealed she had been employed by the facility for one (1) year. Continued interview revealed the facility has a policy for assisting residents with dining and for resident rights. Per interview, she usually sat while assisting residents in the dining room. She stated she would sit on the stools so she could be at eye level, to make the residents feel better and so they don't feel different than everyone else. Per interview, it would be important for the residents dignity and it would be the way she would want to be treated. Further interview revealed she should not have been standing, and should have followed the facility's policy like she normally did and sat while she assisted Resident #14 with dining during the whole meal. 2. Record Review for Resident # 31 revealed the resident was admitted by the facility on 05/27/19 with [DIAGNOSES REDACTED]. Review of Resident #31's Quarterly MDS Assessment, dated 08/12/19, revealed the facility assessed the resident to have a BIMS of three (3) out of fifteen (15), indicating the resident to be severely cognitively impaired. Continued review revealed the facility assessed Resident #31 to require extensive physical assistance with one (1) staff member for eating. Observation of the noon meal, on 08/20/19 at 12:35 PM, revealed Resident #31 was assisted with dining by Quality Assurance Nurse (QA) #1. Continued observation revealed QA #1 stood to the left side of Resident #1 at the U shaped table while he assisted with the resident's meal. Interview with QA #1, on 08/23/19 at 11:00 AM, revealed he had been employed by the facility for five (5) years. Continued interview revealed the facility did have a policy for assisting residents with dining and resident rights. Per interview, if possible staff should attempt to assist residents with dining at eye level and sit while assisting most of the time, to facilitate communication with the resident and for the resident's dignity. Per interview, the facility reviewed trainings on resident rights and assisting with meals annually at competencies and at orientation. 3. Record Review for resident #39 revealed the resident was admitted by the facility on 01/07/19 and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #39's Quarterly MDS Assessment, dated 06/15/19, revealed the facility assess the resident to have a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed the facility assessed Resident #39 to require extensive physical assist of one (1) staff member for eating. Observation of the noon meal, on 08/20/19 at 12:12 PM, revealed Resident #39 was being assisted with his/her meal by SRNA #8. Continued observation revealed SRNA #8 stood while assisting the resident from 12:12 PM to 12:16 PM. Further observation revealed at 12:16 PM, SRNA #8 pulled a chair over to the table and sat down to assist the resident. Interview with SRNA #8, on 08/23/19 at 10:28 AM, revealed you should sit while assisting residents with feeding and be at eye level so as not to be intimidating to the resident. SRNA #8 stated, for Resident #39 it would be important because at times he/she could be a handful and it may set him/her off if he/she felt intimidated. Per interview, staff should know the resident's needs and care plan. She stated staff should know the residents that require physical assistance with meals and staff should be sitting with the residents when assisting with meals. Interview with the Unit Manager for Unit Two (2), on 08/23/19 at 10:45 AM, revealed it would be her expectation staff follow the policy and regulations related to resident rights and assistance with meals. Per interview, the policy is in place for the residents' dignity and staff should be at the residents' eye level for assisting with meals to make a bond with the residents. Continued interview revealed all residents should be provided with the same services and provisions unless medically or behaviorally indicated. Interview with the Assistant Director of Nursing, on 08/23/19 at 10:59 AM, revealed she had been employed by the facility for five (5) years. Per interview, the facility did have a policy in regards to assisting residents with meals. Continued interview revealed it was her expectation for staff to follow the facility's policy. Further interview revealed residents should be assisted with meals while staff was seated and at the residents eye level so residents' did not feel intimidated, and because it was more personal. Per interview, it could be a dignity issue if the staff was standing over the resident while assisting them with dining. 4. Review of Resident #64's Medical Record, revealed the facility admitted the resident on 01/04/19, with [DIAGNOSES REDACTED]. Review of Resident #64's Comprehensive Care Plan (CCP), revealed the Resident needed assistance with Activities of Daily Living (ADL) related to chronic illness, fracture left femur, pain and weakness, initiated 01/15/19. The goal stated the resident would have no decline in ADLs and participate in care to the highest ability and have no decline in limited Range of Motion (ROM). Interventions included but were not limited to setup assistance with eating. Additional interventions included encourage resident to participate in care to promote independence. Further, review of the SRNA Kardex (SRNA Care Plan), dated 08/23/19 revealed the Resident required setup assistance with meals and a divided plate. Observations of the lunch meal, on 08/20/19 at 12:08 PM, revealed Resident #64 was sitting at a U shaped assist table facing the wall with three (3) other residents. Additional observation revealed Resident #64 requested coffee at 12:11 PM and the State Inspector informed Licensed Practical Nurse (LPN) #6 of Resident #64's request. LPN #6, stated Resident #64, was a total feed and {he/she} would have to wait until someone could assist him/her to have coffee. Continued observation, at 12:13 PM, revealed Resident #64 asked the State Inspector if staff knew he/she requested coffee, and the State Inspector replied she had informed the facility staff of his/her request for coffee. Observation at 12:14 PM, revealed the facility Director of Nursing (DON) who was also in the dining room, overheard the State Inspector and Resident #64's conversation and asked LPN #6 to get Resident #64's coffee. Again, LPN #6 stated the resident could not have coffee and it would be on his/her tray when the tray arrived. The DON acknowledged LPN #6 and did not question the statement or get the resident's coffee. Further observation at 12:23 PM, revealed Resident #64 was served coffee with a lid and straw setup. Resident #64 held the coffee mug independently, and drank the beverage independently with his/her left hand. Observation, on 08/21/19 8:00 AM, revealed Resident #64 was at an independent table in the dining room drinking coffee independently from a coffee mug with a lid and straw setup. Resident #64 stated the coffee was good this morning. Further observation revealed no noted difficulties with eating and no facility staff were assisting the resident with greater than fifty (50) percent of the meal consumed. Interview with Resident #64, on 08/21/19 at 9:20 AM, revealed he/she did not know why there was a delay in getting coffee yesterday during lunch. Additionally, he/she stated the facility was usually pretty good with getting requested items to him/her timely. Further, the resident had no concerns with dining services other than having to wait for coffee yesterday. Interview with SRNA #2, on 08/23/19 at 10:39 AM, revealed he had worked at the facility for twelve (12) years and worked on first and second shift; and was assigned to the hallway for Resident #64. Per interview, Resident #64 was independent with meals after setup, and often ate meals in his/her room. Interview with SRNA #1, on 08/23/19 at 10:05 AM, revealed she had been employed by the facility for two ( 2) years and had worked every shift. SRNA #1 stated the staff utilized the care plan to know what kind of care the residents' needed and the care plan was on the computer/online. Per interview, the care plan provided instructions about Activities of Daily Living, which would include assistance with meals. Continued interview revealed Resident #64 required setup only with meals as he/she could eat and drink independently. Per interview, Resident #64 dined at a regular table in dining room. Further interview revealed residents should be given coffee if they were not on fluid restriction, and were able to drink it as long as it was suitable for their diet because it provided hydration. Additionally, SRNA stated she would be upset to see a resident not able to get requested services as this was important to ensure resident rights. SRNA #1 further stated the facility provided training on care for the residents, which did include assistance with meals and resident rights upon hire and annually. Interview with Licensed Practical Nurse (LPN) #1, on 08/23/19 at 11:00 AM, revealed she had been employed by the facility for three (3) years. Continued interview revealed staff was educated by the facility related to resident rights. Continued interview revealed, one of the rights would be for the residents to have the right to have beverages as they request and at the same time as residents who were able to assist themselves. Per interview, it was important to maintain resident rights, as this was the residents home and residents who were not independent with Activities of Daily Living, could still make decisions and choices to enhance their quality of life. Interview with the Assistant Director of Nursing (ADON), on 08/23/19 at 2:02 PM, revealed she had been employed by the facility for five (5) years in December. She stated she expected resident rights to be maintained, and all staff was in-serviced on resident rights. Further interview revealed residents had the right to choices and preferences. Per interview, residents should be provided a drink upon request. She stated it was important to maintain resident rights as this was their home they should be afforded all rights unless their requests infringed on the rights of other residents. Interview with the Director of Nursing (DON), on 08/23/19 at 2:45 PM, revealed she started as Director of Nursing at the facility in (MONTH) 2019. Per interview, the facility did provide training for staff during orientation and annually competencies, to include resident rights and dignity and how to assist resident with meals. Continued interview revealed staff should be sitting while assisting residents with dining. Per interview, it would be against policy and a dignity issue for staff to assist residents with dining while standing. The DON stated, resident rights should always be honored and maintained. Per interview, honoring resident rights was important, as residents come to long term care losing some independence, and adjustments should be made to ensure the residents have options and choices while at the facility. Interview with the Administrator, on 08/23/19 at 2:52 PM, revealed he had been employed by the facility since since (MONTH) of (YEAR). Per interview, the facility did have policy for assisting residents with dining and it was his expectation staff follow the facility's policy. Per interview, staff should sit when assisting to provide person centered care, dignity and respect. Per interview it would be against policy to stand while assisting residents with dining. Further, Resident #64 should have been given coffee at his/her request and assistance as necessary. The Administrator stated he expected Resident Rights to be honored for all residents related to dignity during meal service. Continued interview revealed training was provided to staff regarding policies at orientation and annually and as needed.

Based on observation, interview and record review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident, that includes measurable objectives and timeframes to meet a resident's needs related to Restorative Nursing. Although Resident #69 was discharged from Physical Therapy (PT), on 07/30/19, with recommendations for the Restorative Nursing Program (RNP) to include routine exercise to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) and exercises to maintain bed mobility; there was no documented evidence the facility developed or implemented a Plan of Care related to therapy recommendations. Furthermore, although Resident #111 was discharged from Occupational Therapy (OT), on 03/11/19, with recommendations for the RNP related to a right wrist splint and an exercise plan, there was no documented evidence the facility developed or implemented a Plan of Care related to therapy recommendations. (Refer to F-688) The Findings include: Review of the facility's Care Plan (CP), Comprehensive Person Centered Policy, dated Dec. (YEAR), revealed a person center care plan will include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, the care plan process will include a resident's personal preferences. Further, the CP will describe the services to be provided to maintain or attain the residents highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. 1. Review of Resident #69's Clinical Record, revealed the facility admitted the resident on 07/09/19 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#69 to have Physical Therapy (PT) five (5) times per week for four (4) weeks for therapeutic exercise, therapeutic activity, manual therapy and gait. Review of the Admission Minimum Data Set (MDS) Assessment, dated 07/16/19, revealed the facility assessed Resident #69 as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Further, the facility assessed the resident as requiring extensive assistance of two (2) staff for all Activities of Daily Living (ADLs). Per the MDS Assessment, the resident had no Limitations in Functional Range of Motion (ROM) to his/her bilateral upper extremities (BUE), but had Limitations in Functional ROM to bilateral lower extremities (BLE). Review of Resident #69's Comprehensive Care Plan (CCP), initiated on 07/18/19, revealed the resident required assistance with ADLs related to Dementia, fluctuating ADLs, hearing problems, limited ROM- bilateral knee [MEDICAL CONDITION] with contractures, pain, vision problems, and weakness. The goals stated the resident would not have a decline in ADLs and would participate in care to the highest ability; and the resident would have acceptable pain management and reduced risk of limitations of ROM. The interventions included: monitor for declines in ADLs and refer to therapy services as needed; Restorative Nursing Program (RNP) as indicated; observe for pain and give [MEDICATION NAME] as ordered; and therapy referral and treat as indicated. All interventions were initiated on 07/18/19. Review of the Physical Therapy (PT) Discharge Summary, dated 07/30/19, revealed recommendations for Resident #69 to transition to a RNP to maintain gains in PT. Review of the Functional Maintenance Program, dated 07/30/19, revealed the resident would benefit from the following activities to maintain current functional status: bed mobility, and routine exercise BUE and BLE. However, there was no documented evidence the CCP was developed and implemented related to the RNP related to interventions to maintain current functional status: bed mobility, and routine exercise BUE and BLE as per the PT Discharge Summary dated 07/30/19. Review of the State Registered Nurse Aide (SRNA) Kardex (Care Plan), dated 08/23/19, revealed no documented evidence of a RNP related to bed mobility, or routine BUE and BLE exercises for Resident #69. 2. Review of Resident #111's Clinical Record, revealed the facility admitted the resident on 04/14/17 with [DIAGNOSES REDACTED]. Review of the CCP, dated 06/13/18, revealed the resident required assistance with Activities of Daily Living (ADL) related to chronic illness, fluctuating ADLs, limited ROM, [DIAGNOSES REDACTED], history of lower extremity [MEDICAL CONDITION], vision problems, and weakness. The goal revealed all needs would be anticipated and met by staff. Interventions initiated on 06/13/18 included: Restorative Program if indicated; assist with morning (AM) and night (PM) care; assist of two (2) staff for bed mobility; monitor for declines in ADLs; and refer to therapy services as needed. Further review of Resident #111's CCP, revealed a problem of Contracture/limited ROM to left knee and right hand, dated 01/04/19. The goal revealed the resident would have reduced risk of limitation of ROM. Interventions initiated 01/04/19 included: apply splint as ordered; assess skin under splint for redness, skin integrity and circulation every two (2) hours; ensure correct alignment of splints/braces; ROM provided as indicated; Therapy referral and treat as indicated; and use positioning devices as needed to promote comfort and proper alignment. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #11 as having a BIMS of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff with bed mobility and total assist of two (2) staff for transfers. Further review revealed the facility assessed the resident as having Functional Limitations in ROM of one (1) upper extremity and Functional Limitations in ROM of both lower extremities. Per this MDS Assessment, the resident received no RNP. Review of Resident #111's Occupational Therapy (OT) Discharge Summary, dated 03/11/19, revealed the nursing staff received education related to Resident #111's Right Upper Extremity wrist splint and the importance of wearing the splint. Further review revealed a Restorative Nursing Plan related to the Right wrist splint and an exercise plan was developed to be utilized after OT discharge. Additional review revealed no documented evidence the CCP was developed and implemented related to the RNP for the Right wrist splint and exercise plan related to the OT recommendations after the resident was discharged from OT on 03/11/19. Physician orders, dated 06/01/19 through 08/31/19, revealed no documented evidence of physician's orders [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #1, on 08/23/19 at 10:05 AM revealed she was often assigned to the hallway for Resident #69 and #111. Additionally, she knew how to provide care to each resident by using their Kardex (Nurse Aide Care Plan) before assisting a resident. However, per interview the Kardex did not include which residents were on RNP or had contractures; and she was not aware of another resource the facility provided to denote which residents were on RNP. Per interview, the Kardex should include if a resident was receiving a RNP or had contractures or required a splint. Interview with SRNA #2, on 08/23/19 at 10:39 AM, revealed he worked on first and second shift and was assigned to Resident #69 and #111. He stated he used the Kardex (Care Plan) on the computer to guide him in the level of assistance and as well as devices a resident needed. Per interview, the Kardex should have all devices (splint/braces) listed and should also state if a resident had contractures and required ROM or was on the RNP. However, he stated this information was not always on the Kardex. Further interview revealed there was a RNP binder at each nurse's station with Plans of Care for those Residents who received RNP by the Restorative SRNAs and Resident #69 and Resident #111's information was not in the binder and therefore these residents were not in the RNP. Interview with Licensed Practical Nurse (LPN) #1, on 08/23/19 at 11:00 AM, revealed she was assigned to Resident #69 and #111's hallway. Per interview, the CCP should be a current, accurate reflection of the residents because it was used by the interdisciplinary team (IDT) and direct care givers to ensure residents received safe quality care to meet their needs. She stated if Resident #69 and Resident #111 had recommendations from therapy upon discharge for the RNP, the CCP should be developed and implemented with interventions specific to the recommendations. Continued interview revealed there was a RNP binder and certain residents were provided a Plan specific to their needs at least five to seven (5-7) days a week by a Restorative SRN[NAME] Additionally, she stated it was important the CCP was implemented related to RNP and residents were provided necessary care and devices to ensure they contractures did not worsen and to ensure they kept moving to improve quality of life. Interview with the facility Occupational Therapist and Physical Therapist , on 08/23/10 at 9:35 AM, revealed upon a residents discharged from skilled therapy a Therapy/ Nursing Communication Form was completed for devices. Per interview, this form was given to the direct care nurse who entered the device (ordered) in the Electronic Medical Record. Additional interview revealed a Functional Maintenance Program form was completed for each resident discharged from skilled therapy with recommendations for the resident on how to maintain gains from therapy. Per interview, the Assistant Director of Nursing (ADON) was then responsible to take that information and implement a RNP Plan of Care for these residents as soon as possible. Interview with the ADON, on 08/23/19 at 2:02 PM, revealed she was responsible to develop the RNP Plan of Care. Further, the ADON stated she based the RNP on the therapy recommendations for residents who were discharged from skilled therapy to maintain their gains from therapy or to assist with getting them back to their functional baseline. Additional interview revealed Resident #69's RNP was not developed because the resident historically was combative and refused care. However, she further stated there was no documented evidence, the ADON developed a RNP and attempted approaches with the resident nor was there documented evidence the resident was not receptive or did not participate in the RNP. Continued interview revealed Resident #111's RNP was not implemented because his/her referral from therapy was lost and there was no documented evidence of recommendations for the RNP. Interview with the MDS Coordinator, on 08/23/19 at 2:23 PM, revealed she gathered information/data from the Medical Record to ensure she developed/implemented and revised the Care plans. Further, she attended a morning meeting with department heads (except therapy) which reviewed all new orders, changes in conditions, incidents, illness, and progress notes in the last twenty-four (24) hours. Continued interview revealed it was important to ensure the CCP was developed and implemented related to restorative nursing interventions based on therapy recommendations to ensure quality of care. Per interview, the ADON developed the RNP CCP. Interview with the Director of Nursing (DON), on 08/23/19 at 3:12 PM, revealed if there were recommendations in place for RNP from therapy, the facility was responsible and accountable to develop and implement the RNP Plan of Care. Additionally, the DON stated this was very important to ensure residents maintained quality of life, current function, and to prevent further issues such as muscle weakness. Interview with the Administrator, on 08/23/19 at 3:45 PM, revealed he expected the CCP to be developed and implemented related to therapy recommendations upon a resident's discharge from therapy. Per interview, this was important to ensure residents received restorative nursing to ensure their individualized needs were met.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of twenty-two (22) sampled residents (Resident #8 and #11). The facility did not have an effective system in place to ensure bed alarms and chair alarms were checked for function and placement to ensure they sounded in the event a resident attempted to stand or transfer unassisted. In addition, the facility failed to do a thorough investigation of Resident #8's fall on 04/17/15, and the investigation did not recognize the bed alarm was not sounding at the time of the fall. On 04/17/15 at 7:50 AM, Resident #8 sustained an unwitnessed fall, and the resident was transferred to the hospital emergency room (ER) where he/she was admitted to the hospital with [REDACTED]. Interviews with the nurse and Certified Nursing Assistant (CNA) assigned to the resident at the time of the fall, revealed Resident #8 had a bed alarm in place which was not sounding prior to the fall. The nurse and CNA stated however, they had not checked the bed alarm for function at the beginning of the shift, prior to the resident's fall. Policy review revealed there was no guidance for staff on when or how often they were to check the alarms. Staff interviews revealed bed and chair alarms were checked during their shift; however, not necessarily at the beginning of each shift. Resident #8's Comprehensive Care Plan was not individualized or specific, and had no interventions related to the resident's bed alarm or for checking the bed alarm for placement and function. After the fall and resulting fractures, Resident #8 had a noted decline in his/her physical status, from being able to ambulate forty (40) feet with a rolling walker, to bed rest and palliative care. Additionally, observation on 04/29/15 of Resident #8 being turned and repositioned revealed the resident's bed alarm was not sounding, which staff revealed was not working. Also, the facility failed to ensure Resident #11 received adequate supervision after an episode of exit seeking behavior on 03/30/15. Although Resident #11 was to be placed on fifteen (15) minute checks for twenty-four (24) hours to ensure closer supervision by staff after the episode, record review revealed no documented evidence of observations from 5:00 PM on 03/30/15 until 11:00 PM to ensure the resident remained safe. In addition, per interview if a resident experienced wandering and exit seeking behavior he/she was to have a pink bracelet placed on him/her. However, even though Resident #11 experienced two (2) episodes of exit seeking behavior, observation revealed the resident was not wearing a pink bracelet. Staff interview revealed Resident #11 took the pink bracelet off and the facility failed to ensure he/she wore the pink bracelet to identify the resident as a wanderer with exit seeking behavior, as per the facility's process. Furthermore, the facility failed to ensure the resident's environment remained as free of accident hazards as possible as evidenced by: observation on 04/28/15, revealed the beauty shop was left unattended with the door unlocked from 12:25 PM to 12:38 PM, with containers of potentially hazardous chemicals stored on the sink counter. The findings include: 1. Review of the facility's policy titled, Safety Alarms, undated, revealed it was the policy of the facility to utilize bed and/or chair alarms to alert staff when a resident was trying to get up unassisted. Per the Policy, the Interdisciplinary Team (IDT) or the floor nurse could decide a bed/chair alarm might alert staff a resident was trying to get up out of the bed or chair unassisted. Further review revealed if an alarm was to be placed, the Physician was to be notified and the resident's care plan updated to include the alarm. However, there was no documented evidence the policy provided guidance to staff on when and how often to check the alarms. Review of the facility's, Fall Management Program document, undated, revealed it was the policy of the facility to safeguard residents while promoting the highest possible level of independence and quality of life. The Policy revealed the facility would accomplish this through assessment to establish a risk for falls, care planning and implementing appropriate interventions to minimize falls and injuries related to falls. Per the document, a resident's Comprehensive Care Plan would reflect the fall risk and interventions for falls and would include goals and interventions which were resident specific. Continued review revealed the Director of Nursing (DON) would review the incident investigation and the incident report for appropriate interventions and documentation after a resident's fall. The Policy noted the findings and recommendations would be submitted to the IDT meetings for revision or adoption of interventions according to the root cause analysis identified for the resident's fall. Review of Resident #8's medical record revealed the facility admitted the resident on 03/04/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #8 as having a Brief Interview for Mental Status (BIMS) of a ten (10) out of fifteen (15) indicating moderate cognitive impairment. Further review of the MDS Assessment revealed the facility also assessed Resident #8 as being able to transfer with extensive physical assistance of two (2) persons, and as able to ambulate in the corridor with extensive assistance of two (2) persons. Review of the monthly April 2015 physician's orders [REDACTED]. Review of the Resident Fall Risk dated 03/04/15, revealed Resident #8 was assessed as at risk for falls related to a history of falls in the past six (6) months, the use of medications which had the potential to predispose to falls, and problems with functional status. Review of Resident #8's Comprehensive Care Plan dated 03/17/15, revealed the resident was at risk for an accident, injury or fall related to impaired mobility and weakness, with interventions which included to orient the resident to the facility as needed, and ensure use of sensory aides. However, continued review of the Care Plan revealed no documented evidence it was not specific and individualized related to Resident #8's bed alarm or the need to check the alarm for placement and function. Review of the CNA Care Plan Record for April 2015, revealed Resident #8 was to have a sensor alarm to the bed. Interview, on 05/01/15 at 4:00 PM, with the Physical Therapist (PT) revealed upon admission Resident #8 was walking down the hall one hundred (100) feet with the assistance of one (1) person and another person pushing the wheelchair behind him/her in case the resident needed to sit down. The PT stated after Resident #8 reached his/her maximum potential the resident was discharged from Physical Therapy to the facility's Restorative Nursing Program (RNP). Review of the RNP Plan of Care revealed it was initiated 03/20/15. Review of the April 2015 RNP Plan of Care revealed the interventions included: assisting and cueing Resident #8 to perform Active Range of Motion (AROM) to the bilateral upper extremities for fifteen (15) minutes a day for six (6) days a week; and assisting and cueing the resident to ambulate forty (40) feet with minimum assistance of one (1) for fifteen (15) minutes a day for six (6) days per week. Further review of the April 2015 RNP Plan of Care revealed the interventions were initialed as completed from 04/01/15 through 04/07/15, and the resident was transferred to the hospital on [DATE]. Review of a Hospital Discharge Summary, dated 04/16/15, revealed Resident #8 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. Review of the Re-admission physician's orders [REDACTED].#8's bed sensor alarm and chair tab alarm had not been carried over. Review of the Nurse's Note dated 04/17/15 at 7:50 AM, revealed the nurse heard Resident #8 fall and immediately ran into the room and found the resident on the floor lying on her/his left side, beside the roommate's bed. Continued review of the Note revealed there were alarm sensors on Resident #8's bed and wheelchair which had not sounded. According to the Note, Resident #8 stated he/she was going to the bathroom prior to the fall and complained of severe pain of the left hip. Review of the Note revealed a pillow was placed under Resident #8's head and he/she was left lying on the floor, and the Physician and 911 were notified. Further review of the Note revealed the EMT (Emergency Medical Technicians) arrived at 8:15 AM and transferred Resident #8 to the hospital. Review of the Hospital Discharge Summary dated 04/22/15, revealed Resident #8 was admitted to the hospital on [DATE], after sustaining a fall at the facility. Review of the Assessment portion of the Discharge Summary, revealed Resident #8 had been diagnosed with [REDACTED]. The Discharge Summary further revealed Resident #8 was seen by Orthopedics while in the hospital, and Orthopedics had deemed the resident not a surgical candidate. Further review of the Discharge Summary revealed Resident #8's family wanted the resident to have palliative care (specialized medical care for people with serious illnesses which focuses on providing patients with relief from symptoms and stress of a serious illness to improve the quality of life). Observation of Resident #8 on 04/28/15 at 2:55 PM, revealed the resident was lying on the bed on his/her back with a bed alarm at the head of the bed, and two (2) and a half padded side rails were up at the head of the bed. Interview was attempted with Resident #8 at the time of observation; however, the resident spoke very quietly and was difficult to understand. Interview, on 04/29/15 at 9:50 AM, with CNA #27 revealed the CNA's were to check residents' bed and chair alarms at the end of the shift and also, during their shift when assisting the resident up out of bed for the day. She stated on 04/17/15, she came on shift at 7:00 AM, but did not get to check on Resident #8 before breakfast as the meal trays came out out early at 7:10 AM that morning. CNA #27 revealed she was passing a breakfast tray to a room nearby Resident #8's room when she heard a loud crash and entered Resident #8's room where she observed the resident lying on the floor near his/her roommate's bed. Per interview, LPN #12 was already in Resident #8's room when she entered and the resident's bed alarm was not sounding. Continued interview revealed Resident #8 told staff he/she was trying to go to the bathroom when the fall occurred. CNA #27 revealed Resident #8's roommate's wheelchair was in front of the bathroom door and the resident was lying on his/her left hip on the floor in front of the wheelchair as she recalled. She stated she checked Resident #8's roommate's wheelchair, which also had an alarm on it, and that alarm was not functioning either. Interview, on 04/28/15 at 12:45 PM, with Licensed Practical Nurse (LPN) #12, during initial tour, revealed Resident #8 had experienced a recent fall at the facility and had sustained a fractured pelvis and hip. She stated she was assigned to Resident #8 on 04/17/15, at the time of the resident's fall. Per interview, she was in the hall near Resident #8's room when she heard a loud noise and she was the first person to respond to the resident's room. LPN #12 stated Resident #8 was lying on the floor on his/her left side and the resident must have gotten out of bed on his/her own. Continued interview revealed Resident #8's call bell was not ringing at the time of the fall, and the resident's bed alarm was not sounding. She stated if Resident #8's bed alarm had been working she would have heard the alarm and responded, because she was near the resident's room and might have been able to prevent the fall. According to LPN #12, CNA #27, who was assigned to Resident #8 at the time of the fall, and the Unit Coordinator (UC) of Unit 2 came to the resident's room to assist her the morning of the fall. LPN #12 revealed she completed an Incident Report after the fall, but did not remember being questioned about the fall details by administrative staff or the DON. Per LPN #12, the CNA's coming on at change of shift and the offgoing CNA were to check the bed and chair alarms during shift change when they did the walk through. She revealed the CNA's were to check the alarms for placement and function. LPN #12 stated nurses did not routinely check the residents' alarms; however, residents' Treatment Administration Records (Tars) had a place for an FYI (for your information) to alert the nurses when residents had alarms. She clarified she had not checked Resident #8's bed alarm on the day shift prior to the fall at 7:50 AM, and stated her shift started at 7:00 AM. Review of the Incident Report, dated 04/17/15, completed by LPN #12, revealed Resident #8 was found lying on the floor beside the roommate's bed on his/her left side and was barefooted. Continued review revealed the section marked recommended steps to prevent recurrence, noted to remind Resident #8 to utilize staff's assistance and to utilize call light and the resident was sent to the hospital for evaluation and treatment. Review of the Falls Investigation Worksheet completed by LPN #12, revealed on 04/17/15 at 7:50 AM, Resident #8 had experienced an unwitnessed fall when up walking alone not using an assistive device and was found on the floor. Review of the second page of the Falls Investigation Worksheet revealed no documented evidence it had been completely filled out, as it was left blank including an section marked Environmental which asked if a safety intervention was in use at the time. Interview, on 05/01/15 at 12:09 PM, with the DON revealed she, the Quality Assurance (QA) Nurse and the UCs all assisted with the fall investigations. The DON reviewed the fall investigation completed by LPN #12 for Resident #8's fall, and stated the Fall Investigation Worksheet back page was not complete and the nurse should have ensured this was completed. Continued interview revealed the back page of the Worksheet included a section labeled Environmental which asked if safety intervention were in use at the time of the fall, and this would have specified if alarms were in place and functioning. Interview, on 04/28/15 at 8:00 PM and 04/30/15 at 11:00 AM, with the UC for Unit 2, revealed on 04/17/15 shortly after the day shift had began, LPN #12 heard a noise in Resident #8's room and went to check. Per interview, by the time she got there LPN #12 and CNA #27 were already in Resident #8's room. She stated Resident #8 was telling LPN #12 and CNA #27, he/she had gotten up off the bed to go visit his/her roommate when the fall occurred, and had hit his/her head on the dresser. According to the UC, later on Resident #8 also told her he/she fell after getting out of bed. The UC stated she did not check the bed alarm to see if it was functioning properly at the time of Resident #8's fall and was not sure if it had sounded at that time. She stated the Physician was in house and said to send Resident #8 to the hospital ER, because the resident was complaining of hip and leg pain. Continued interview revealed the process for alarms was the nurse checked alarms each shift, but not necessarily at the beginning of their shift. Per the UC, there was no set time for the CNA's to check the alarms, but the CNA's typically checked the alarms as they assisted residents up out of bed in the mornings. She stated it would be best for the nurses and CNA's to check the alarms for placement and functioning during their first rounds on their shifts to ensure the alarms were working properly. Further interview and review of the record with the UC, revealed Resident #8 had a care plan in place for sensory aides which could possibly mean bed/chair alarms, but the care plan should be more specific and say bed and chair alarm. She stated the physician's orders [REDACTED].#8 was readmitted to the facility after hospitalization for a UTI, Pneumonia and Hydro[DIAGNOSES REDACTED], had not had the bed and chair alarms carried over. The UC reviewed Resident #8's TAR for 04/16/15 and 04/17/15, and noted the bed alarm and chair alarms was not on the TAR for those dates. However, per the UC, the orders for the alarms should have been carried over as the alarms would have still been in place on 04/17/15, at the time of the fall, because they had not been discontinued. Interview, on 04/29/15 at 6:00 PM, with LPN #13, who was assigned to Resident #8 on the night shift on 04/16/15 up to 7:30 AM on 04/17/15, revealed she checked the bed and chair alarms herself when she came on shift to make sure the alarms were present and working properly. She stated she also checked Resident #8's bed alarm when she arrived at work on 04/16/15. Continued interview revealed she did not recall Resident #8 ever attempting to get out of bed on his/her own. LPN #13 revealed she knew Resident #8 was taken to the bathroom to be toileted between 5:00 AM and 6:00 AM on 04/17/15, and assisted back to bed afterwards. Further interview revealed she was never interviewed by the DON or any administrative staff regarding Resident #8's fall on 04/17/15. Interview, on 04/30/15 at 11:30 PM, per telephone call, with CNA #28, who was assigned to Resident #8 on the night shift on 04/16/15 until 7:30 AM on 04/17/15, revealed she checked the residents' bed and chair alarms at the beginning of her shift to see if they were working properly. Per interview, she also checked the alarms with each round during her shift. CNA #28 revealed Resident #8 was checked and changed during her shift for incontinence care while lying on the bed. She stated on her shift at night, Resident #8 was not gotten up out of bed because the resident was not on the list of residents who were to be assisted to the dining room for breakfast. Further interview revealed she performed her last rounds on her residents between 5:00 AM and 6:00 AM, and completed her rounds by 6:30 AM each morning. In addition, CNA #28 stated Resident #8 would have still been in bed when she completed her last rounds on 04/17/15. Interview, on 05/01/15 at 4:43 PM, with MDS Coordinator #1, revealed she and another MDS Coordinator were responsible for developing residents' Care Plans. After reviewing Resident #8's medical record, MDS Coordinator #1 revealed the resident was ordered to have a bed and chair alarm on admission. However, review of the care plan revealed no documented evidence of a care plan for the alarms until a care plan update was added on 04/28/15. Continued interview with MDS Coordinator #1 revealed a care plan should have been developed with approaches for a bed and chair alarm. Further interview revealed the sensory aides intervention on the care plan was in reference to glasses or hearing aides if the resident wore those. Review of the Resident Investigation Report Form (RIRF), completed by the DON, dated 04/18/15, revealed a section labeled summaries of interviews with persons reporting the incident. Review of the RIRF revealed a written statement from LPN #12, which noted the nurse had heard a loud crash sound, went to see what happened and found Resident #8 lying on the floor complaining of pain in the head and hip. Review of the written statement from CNA #27 revealed the CNA heard an alarm and went to Resident #8's room where she found the resident lying on the floor and other staff were in the room. Continued review of the RIRF, of the summary of findings section, revealed the information gathered noted: Resident #8 had gotten up unassisted and fell in his/her room; the call light was not used; and request for help was not made. Interview, on 05/01/15 at 12:09 PM, with the DON revealed she did not have staff write out their own written statements and had documented the staff's statements herself. Per interview, she thought CNA #27 had indicated she heard Resident #8's alarm sounding at the time of the fall. Even though Surveyor interview with CNA #27 and LPN #12 revealed the bed alarm was not sounding, and review of the LPN's Nurses's Note dated 04/17/15, revealed the bed alarm was not sounding. Continued interview with the DON on 05/01/15 at 12:09 PM, revealed she had not recognized during the investigation of Resident #8's fall the bed alarm was not sounding. The DON stated Resident #8 might not have sustained a fall if the bed alarm had been functioning and had sounded on 04/17/15, because staff would have heard the alarm and responded. Interview, on 05/04/15 at 11:10 AM, with the Quality Assurance (QA) Nurse revealed the CNA Care Plans, as well as, residents' Comprehensive Care Plans should have interventions which stated the bed and chair alarms were to be checked each shift for placement and function. Per interview, the nurses, as well as, the CNA's should be checking residents' bed and chair alarms. The QA Nurse revealed she kept an updated list of physician's orders [REDACTED]. She stated the QA CNA then checked all bed and chair alarms on day shift once a week to ensure the alarms were in place and functioning. The QA Nurse called the QA CNA into the interview. Interview with the QA CNA, in conjunction with the QA Nurse, revealed she (the QA CNA) checked the room of each resident who had alarms on Thursdays. The QA CNA stated during the room checks she ensured the bed and chair alarms were in place and functioning, and ensured the alarm batteries did not need to be replaced. Per the QA CNA, if the alarm battery needed to be replaced it would make a continuous beeping noise; however, she had no set schedule to change the batteries. According to the QA CNA, she also checked four (4) to five (5) resident's rooms daily to ensure the alarms were in place and functioning on the day shift. During the interview, the QA CNA reviewed her alarm check log, and stated the last time she had checked Resident #8's bed and chair alarms was on 04/15/15, while the resident was in the hospital. The QA Nurse also had the Central Supply Clerk (CSC) come into the interview. Per the CSC, she randomly checked bed and chair alarms, but did not keep an audit tool and did not check the room of each resident who had alarms daily. The CSC stated she did not keep up with when the sensor strips to the alarms needed to be changed; however, revealed the alarm sensor strips were good for a year per the manufacturer's recommendations written on the sensor strips. Further interview with the QA Nurse revealed the facility's system was not effective by just auditing residents' bed and chair alarms on the day shift. Per the QA Nurse, the facility should have been auditing all the alarms on all shifts to make sure they were in place and functioning properly. Further interview, on 05/01/15 at 12:09 PM, with the DON revealed it was both the nurses and the CNA's responsibility to check placement and function of the bed and chair alarms and the alarms should be checked during first rounds and throughout the shift. She stated Resident #8's chair and bed alarm should have been included on his/her Comprehensive Care Plan. Continued interview revealed the bed alarm should have been written on the 04/16/15 re-admission physician's orders [REDACTED]. The DON stated she had conducted the investigation for the fall Resident #8 sustained on 04/17/15 resulting in the fractures. According to the DON, she was to be notified as soon as a resident experienced a fall, and the nurse assigned to the resident was to put in an immediate intervention to prevent further falls. Per interview, the day after falls occurred, Monday through Friday, the falls were brought to the Interdisciplinary Team (IDT) Meeting for discussion, and this meeting included the UCs and herself. She stated after the IDT Meeting, falls were further discussed in the facility's morning meeting, Monday through Friday, which included the UCs, the QA Nurse, the Activities Director, Human Resources (HR) staff, the Rehab Therapy Director, the Staffing Coordinator and the Administrator. The DON revealed during the morning meeting the different disciplines discussed the falls and came up with interventions to prevent further falls. She stated during the meeting they also reviewed the interventions which were already in place for the residents to ensure they were still appropriate and effective. The DON revealed the facility also had a weekly standards of care meeting which included the UCs, QA Nurse, Social Services (SS) Director, Assistant Director of Nursing (ADON), Dietary Manager, Dietician, Treatment Nurse and herself. Per the DON, in the standards of care meeting they also discussed falls which had occurred during the past week and interventions were also reviewed then to ensure they were effective. The DON revealed Resident 38 had started declining when hospitalized from [DATE] to 04/16/15; however, had further declined since the fall with fractures on 04/17/15, and was now on bed rest and palliative care. Interview, on 05/04/15 at 4:30 PM, with the Administrator revealed he did not conduct the falls investigations and relied on department heads which he had hired to do the investigations. He stated they had hired a QA CNA to ensure residents' alarms were checked and functioning properly. However, the Administrator stated the facility would make any changes needed to ensure there was an effective system in place to make certain residents' bed and chair alarms were checked for placement and function. 2. Continued observation of Resident #8 on 04/29/15 at 10:50 AM, during a skin assessment performed by LPN #2 with CNA #5 assisting, revealed two (2) bed alarm boxes at the head of the resident's bed. Observation revealed one (1) of the alarm boxes had a sensor strip hanging down from the box and was not attached to Resident #8's bed. It was observed by the Surveyor, when the LPN and CNA where turning and repositioning Resident #8 during the skin assessment, the bed alarms did not sound. After the skin assessment was completed and the staff asked if there was anything else, the Surveyor interviewed LPN #2 and CNA #5 as to why Resident #8's alarm did not sound. Further observation and interview revealed LPN #2 checked the alarm and the sensor strip, and stated the alarm which was attached to the sensor strip under Resident #8 was not working. Further interview with LPN #2 revealed he checked the bed and chair alarms when he entered residents' rooms to administer medication or to perform treatments and he did not necessarily check them at the beginning of his shift. Interview, on 04/29/15 at 11:20 AM, with CNA #5 revealed he had checked Resident #8's bed alarm earlier at change of shift with the previous CNA assigned and the alarm was functioning then. He stated he usually checked the alarms every two (2) hours with rounds, and he was unsure why there was two (2) alarm boxes at the head of Resident #8's bed. 3. Review of the facility's policy titled, Accident Prevention Policy, revised December 2007, revealed resident safety and supervision and assistance to prevent accidents were facility wide priorities. Further review of the Policy revealed resident supervision was a core component of the systems approach to safety and the type of resident supervision was determined by the individual resident's assessed needs. Review of the facility's policy titled, Wandering, Unsafe Resident, revised February 2014, revealed the facility strived to prevent unsafe wandering for residents who were at risk for elopement. Further review of the Policy revealed if a resident was identified as a wandering risk, interventions to maintain safety, such as, a detailed monitoring plan was put in place on the resident's care plan. Review of Resident #11's medical record revealed the facility admitted the resident on 03/11/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated , 03/18/15, revealed the facility assessed Resident #11, through the use of the Brief Interview for Mental Status assessment, as severely cognitively impaired. Review of the facility's incident reports revealed Resident #11 had experienced exit seeking behaviors and tried to get out an exit door on 03/30/15 at 11:40 AM, and on 04/10/15 at 4:00 PM. Continued review revealed the facility initiated fifteen (15) minute checks of Resident #11, after each episode, for a twenty-four (24) hour period. Interview, on 05/01/15 at 4:05 PM, with the DON revealed after a resident had an episode of exit seeking behavior, a pink bracelet was placed on the resident and his/her picture was put in the facility's wander book located on each unit. The DON revealed the purpose of the pink bracelet was to ensure auxiliary staff were aware the resident wandered and had experienced exit seeking behavior. Per interview, an order was written and transcribed to the resident's Medication Administration Record (MAR) to ensure nurses checked the pink bracelet to ensure it was in place. In addition, the DON revealed fifteen (15) minute checks were put in place to ensure a resident was monitored more closely after experiencing an episode of exit seeking behavior. However, observation of Resident #11, on 05/01/15 at 2:14 PM, with Registered Nurse (RN) #1/UC revealed Resident #11 had no pink bracelet on his/her body, even though the resident had experienced two (2) episodes of exit seeking behavior for which the DON indicated residents should have a pink bracelet in place. Continued observation of Resident #11 and his/her room, with RN #1/UC, revealed a pink bracelet in the first drawer of the resident's bedside chest which the RN placed on the resident's right arm. Additionally, review of Resident #11's April 2015 physician's orders [REDACTED]. Continued review revealed no documented evidence the nurses were monitoring placement of Resident #11's pink bracelet to ensure it was on the resident as indicated by the DON. Interview, on 04/30/15 at 2:10 PM and on 05/04/15 at 2:46 PM, with LPN #1 revealed on 03/30/15, Resident #11 was on Unit 2 and had attempted to go outside, but had not gotten out the door. LPN #1 revealed after that incident; however, the facility's process was not followed as there was no order for a pink bracelet placed on the resident's TAR to ensure the nurses monitored the placement of the bracelet on the resident. Continued interview revealed Resident #11 also had another elopement attempt, but there was no order placed on the TAR again for a pink bracelet to be placed on the resident and monitored by the nurses. Further interview with LPN #1 revealed after Resident #11's exit seeking episode on 03/30/15, she started the fifteen (15) minute monitoring intervention of the resident which was completed by the nurses. However, review of the facility's Observation Charting form, dated 03/30/15, of the every fifteen (15) minutes checks which were implemented because Resident #11 sounded the door alarm, revealed no doc

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a Comprehensive Care Plan was developed for each resident which included measurable objectives and timetables to meet a resident's medical and nursing needs identified through the comprehensive assessment for one (1) of twenty-two (22) sampled residents (Resident #8). Review of Resident #8's Comprehensive Care Plan revealed the facility had assessed and care planned the resident as at risk for injury. Review of the risk for injury care plan revealed no documented evidence it was developed to be individualized and specific regarding Resident #8's Physician ordered bed alarm which was in place; the need for checking the alarm for placement and function; or, when and how often the bed alarm needed to be checked. Staff interviews revealed Resident #8 had a bed alarm; however, the bed and chair alarms were not always checked at the beginning of their shifts to ensure the alarms were functioning properly. On 04/17/15, Resident #8's bed alarm was not checked at the beginning of day shift by Licensed Practical Nurse (LPN) #12 and Certified Nursing Assistant (CNA) #27, who were assigned to the resident's care. At 7:50 AM on 04/17/15, Resident #8 experienced an unwitnessed fall which resulted in the resident being transferred to the hospital emergency room (ER) and admitted to the hospital with [REDACTED]. The findings include: Review of the facility's policy titled, Safety Alarms, undated, revealed it was the facility's policy to utilize bed and/or chair alarms to alert staff when a resident was trying to get up unassisted. The Policy revealed the facility's Interdisciplinary Team (IDT) or the nurse could decide whether a resident needed a bed/chair alarm which might alert the staff if the resident was trying to get up out of the bed or chair unassisted. Further review of the Policy revealed the Physician was to be notified and the resident's care plan was to be updated if alarms were to be used. Additional review of the Policy, revealed no documented evidence of when and how often alarms were to be checked to ensure the alarms were functioning properly. Review of the facility's, Fall Management Program, undated, revealed residents' Comprehensive Care Plans would reflect the resident's risk for falls and include goals and intervention which were resident specific. Review of the facility's, Care Plans-Comprehensive Policy, revised September 2010, revealed an individualized Comprehensive Care Plan which included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Per the Policy, each resident's Comprehensive Care Plan was designed to: incorporate identified problem areas; incorporate risk factors associated with identified areas; reflect treatment goals, timetables and objectives in measurable outcomes; and aid in preventing or reducing declines in the resident's functional status and/or functional level. Record review revealed the facility admitted Resident #8 on 03/04/15, with [DIAGNOSES REDACTED]. Review of Resident #8's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #8 to have a Brief Interview for Mental Status score of ten (10) out of fifteen (15) which indicated moderate cognitive impairment. Continued review of the MDS revealed the facility was unable to determine if Resident #8 had experienced a fall in the past six (6) months prior to admission. Further review of the MDS Assessment revealed the facility assessed Resident #8 to require extensive physical assistance of two (2) staff for transfers and for ambulation in the corridors. Review of the MDS Care Area Assessment (CAA) Worksheet, dated 03/1715, revealed falls had triggered due to Resident #8's unsteady gait and balance. Continued review of the CAA Worksheet revealed Resident #8 was noted to have generalized weakness from her/his medical conditions and was receiving assistance with all Activities of Daily Living (ADL's). Per the CAA Worksheet, Resident #8's primary mode of locomotion was a wheelchair and the resident was ambulating with Physical Therapy. Further review of the CAA Worksheet revealed safety measures were in place as per the physician's orders [REDACTED]. Review of the Resident #8's Resident Fall Risk dated 03/04/15, revealed the facility assessed the resident as at risk for falls due to problems with functional status, a history of falls in the past six (6) months and the use of medications which potentially predisposed him/her to falls. Review of Resident #8's monthly April 2015 physician's orders [REDACTED]. Review of Resident #8's Comprehensive Care Plan dated 03/17/15, revealed the facility had care planned the resident as at risk for an accident, injury, or fall related to his/her weakness and impaired mobility. Continued review of the at risk for accident, injury or fall revealed interventions which included: staff to orient the resident to the facility as needed; educate him/her about safety and help maintain safe environment; ensure correct use of sensory aides; observe for safety and intervene as needed; and ensure appropriate assistance with care and mobility. Further review revealed no documented evidence however, Resident #8's at risk for accident, injury or fall care plan was specific and individualized with interventions to include the resident's Physician ordered bed alarm. Review of the CNA Care Plan Record for April 2015, revealed Resident #8 was to have a sensor alarm to the bed; however, there was no documented evidence it addressed the need for checking the alarm for placement and function, or for when and how often to do alarm checks. Review of a Hospital Discharge Summary dated 04/16/15, revealed Resident #8 had been admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. Further review of the Discharge Summary revealed Resident #8 was discharged back to the facility on [DATE]. Review of Resident #8's Re-admission physician's orders [REDACTED]. Review of the Nurse's Note dated 04/17/15 at 07:50 AM, revealed the nurse heard Resident #8 fall and immediately ran into the resident's room. Continued review of the Note revealed the nurse found Resident #8 lying on his/her left side on the floor beside the roommate's bed. The Note revealed there were alarm sensors on the bed and wheelchair which had not sounded. Further review of the Note revealed EMT (Emergency Medical Technicians) arrived at 8:15 AM and transferred Resident #8 to the hospital. Review of the Hospital Discharge Summary dated 04/22/15, revealed Resident #8 was admitted on [DATE] after experiencing a fall in the facility. Continued review revealed Resident #8 was diagnosed at the hospital with Acute Left Inferior Pubic Ramus Fracture (pelvis fracture), and a Mildly Displaced [MEDICATION NAME] Fracture through the superior portion of the Left Greater Trochanter ([MEDICAL CONDITION]). Interview with LPN #12 on 04/28/15 at 12:45 PM, during initial tour, revealed Resident #8 had experienced a recent fall at the facility which had resulted in fractures of the resident's pelvis and hip. LPN #12 revealed she was the nurse assigned to Resident #8 on 04/17/15, at the time of the fall. According to LPN #12, on 04/17/15, she was near Resident #8's room in the hallway and heard a loud noise in the resident's room. Per interview, she went to Resident #8's room and was the first person there. She stated she found Resident #8 lying on his/her left side on the floor. Continued interview revealed Resident #8 must have gotten out of bed on his/her own without assistance. She stated Resident #8's call bell was not ringing and the bed alarm was not sounding when she entered the resident's room. Per LPN #12, if Resident #8's bed alarm had been sounding she would have heard it in the hallway and responded to it which might have prevented the resident's fall. She clarified she had not checked Resident #8's bed alarm when she started work on the day shift at 7:00 AM, prior to the resident's fall at 7:50 AM. Interview with CNA #27 on 04/29/15 at 9:50 AM, revealed when she came to work on day shift at 7:00 AM on 04/17/15, she did not get to check on Resident #8 as the breakfast trays came out early that morning, at 7:10 AM. According to CNA #27, she was assigned to Resident #8 that day, and had been delivering a breakfast tray to a room near Resident #8's room, when she heard a loud crash and entered the resident's room. Per interview, when she went into Resident #8's room, LPN #12 was already there. CNA #27 revealed Resident #8's roommate's wheelchair was in front of the bathroom door and the resident was lying on his/her left hip in front of the wheelchair near the roommate's bed. She revealed Resident #8's bed alarm was not sounding when she entered the resident's room. Per CNA #27, Resident #8 told her and LPN #12 he/she was trying to go to the bathroom at the time of the fall. Interview with LPN #13 on 04/29/15 at 6:00 PM, who was assigned to Resident #8 on the night shift on 04/16/15 until 7:30 AM on 04/17/15, revealed she checked the residents' bed and chair alarms herself at the beginning of her shift to make sure the alarms were hooked in and were working. She stated this would have included Resident #8's bed alarm on 04/016/15 when she began her shift. According to LPN #13, she could not recall Resident #8 ever attempting to get out of bed on his/her own without assistance. Further interview revealed she recalled Resident #8 being taken to the bathroom for toileting on 04/17/15 between 5:00 AM and 6:00 AM, and then was assisted back to bed. Phone interview with CNA #28 on 04/30/15 at 11:30 PM, who was assigned to Resident #8 on the night shift on 04/16/15 until 7:30 AM on 04/17/15, revealed she checked her residents' bed and chair alarms at the beginning of her shift to make sure they were working properly and then also checked the alarms with each round performed. According to CNA #28, night shift did not ever get Resident #8 out of bed, and checked and changed the resident in the bed for incontinence care during the night. Per interview, she started her last rounds on her residents between 5:00 AM and 6:00 AM and completed her rounds by 6:30 AM each morning. Further interview revealed Resident #8 was still in bed when she performed her last rounds. Interview with the Unit Coordinator (UC) for Unit 2 on 04/28/15 at 8:00 PM and 04/30/15 at 11:00 AM, where Resident #8 resided, revealed nurses checked the residents' alarms each shift, but not necessarily at the beginning of their shift. The UC stated CNA's also checked residents' alarms; however, there was no set time for them to check the alarms. According to the UC, it was best if the nurses and CNA's checked the alarms during their first rounds on their shift, for placement and functioning. Per interview and review of the record, the UC revealed Resident #8 had the care plan in place noting sensory aides which could possibly mean his/her bed and chair alarms. The UC revealed however, the care plan should be specific to include the bed and chair alarms which had not been discontinued. Interview with MDS Coordinator #1 on 05/01/15 at 4:43 PM, revealed the MDS Coordinators had the responsibility for development of residents' Comprehensive Care Plans. MDS Coordinator #1 review Resident #8's medical record and stated the resident had orders for bed and chair alarms. Per interview, she was unable to find a care plan regarding the alarms until 04/28/15, when a care plan update was added. Continued interview revealed the MDS Coordinators should have developed a care plan which included interventions for the bed and chair alarms though when the alarms were ordered in March 2015. According to MDS Coordinator #1, the sensory aides intervention on Resident #8 care plan was in reference to glasses or hearing aides if the resident had those in use. Further interview revealed when the MDS Coordinators were developing a resident's care plan, they reviewed the resident's entire chart, especially physician's orders [REDACTED]. MDS Coordinator #1 revealed the residents' Comprehensive Care Plans should be developed to be individualized and specific for each resident. Interview, on 05/04/15 at 11:10 AM, with the Quality Assurance (QA) Nurse, revealed residents' Comprehensive Care Plans, as well as, the CNA Care Plans should state bed and chair alarms were to be checked at the beginning of each shift for placement and function. Per interview, nurses and CNA's should be performing the alarm checks. Interview with the DON on 05/01/15 at 12:09 PM, revealed nurses and CNA's both had the responsibility for checking alarms for placement and function which should be performed during the first rounds of their shifts and throughout the shift. Per interview, Resident #8's Comprehensive Care Plan should have included the chair and bed alarms since the alarms were ordered on the admission orders [REDACTED]. She stated Monday through Friday, after the IDT Meeting, falls were also further discussed in the morning meeting to review the interventions in place and to come up with additional interventions to try to prevent further falls. The DON revealed falls were also discussed in the facility's weekly standards of care meeting with the interventions reviewed to ensure they were effective. Further interview revealed however, the facility staff present in the meetings had not recognized during the review of residents' care plans interventions, that the care plan interventions did not include interventions for the use of the bed and chair alarms. Interview, on 05/04/15 at 4:30 PM, with the Administrator revealed all residents' Comprehensive Care Plans should be developed to be individualized, thorough, and according to the resident's assessed needs.

Based on interview, record review, facility policy review, and review of the Kentucky Board of Nursing "Accountability and Responsibility of Nurses" document, it was determined the facility failed to ensure services provided met professional standards for one (1) of eleven (11) sampled residents (Resident #2). The facility failed to ensure professional staff provided timely necessary care and services to Resident #2 who had been identified as having a change of condition and failed to ensure they documented accurately in the medical record per Kentucky Board standard of practice and per the facility's policies and procedures. On [DATE], Licensed Practical Nurse (LPN) #1 found Resident #2 pale and without respirations on [DATE]. Review of the video camera data for the date of [DATE] revealed LPN #1 was in the room for thirty (30) seconds. LPN #1, through interview revealed that he did not "touch" the resident, attempt to suction or conduct a physical assessment at the time he identified Resident #2 had a change in condition; rather, he exited the room and returned approximately six (6) minutes later with the Assistant Director of Nursing (ADON), per video camera data. Interview with LPN #1 confirmed that no physical assessment was performed and no care and services were provided for approximately six minutes after LPN #1 identified the condition change. At which time, the ADON was unsuccessful in obtaining vital signs after suctioning the resident. The resident was noted to be pronounced as deceased at 9:00 AM on [DATE]. Furthermore, LPN #1 failed to document accurately in the medical record as the Nurse's Notes, on [DATE] at 7:45 AM, detailed that the LPN had performed physical assessment of the resident's lungs sounds, pulse, blood pressure, and suctioning Resident #2's oral cavity. However, interview with LPN #1 validated this was incorrect and that no assessment had been performed until the ADON entered the resident's room. The facility's failure to ensure services provided met professional standards placed residents at risk for serious injury, harm, impairment, or death. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] prior to exiting the facility on [DATE] with remaining non-compliance at 42 CFR 483.20 Resident Assessment, with a scope and severity of a "D", while the facility's Quality and Assurance continues to monitor and ensure residents remain free from neglect. The findings include: Review of the Kentucky Board of Nursing's "Accountability & Responsibility of Nurses" document, last updated on [DATE], revealed nurses are individually responsible and accountable for "rendering safe, effective nursing care to clients and for judgments exercised and actions taken in the course of providing care". Review of the facility's "Emergency Care, General Guidelines For", not dated, revealed it was the basic responsibility of the Licensed Nurse to "always take, report and record vital signs when a resident's condition has changed" and record the details and exact time of the condition change of a resident. On [DATE] at 11:07 AM, interview with the Director of Nursing (DON) confirmed this was the facility's policy. She stated her expectations were that nurses would assess residents when a change of condition was noted; this would include assessing vital signs and ensuring accuracy of documentation. Review of Resident #2's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to be severely impaired with daily decision making. Further review of the MDS revealed the facility assessed Resident #2 as totally dependent on staff for all Activities of Daily Living (ADLs). Review of the [DATE] "My Daily Care Plan" utilized by the State Registered Nursing Assistants (SRNAs) revealed the resident was on thickened liquids, aspiration precautions and needed to be fed his/her meals by staff. Observation of the video camera data for [DATE] revealed LPN #1 was observed entering Resident #2's room at 8:03:15 AM and exiting the room at 8:03:45 AM, thirty (30) seconds later. On [DATE] at 2:07 PM, an interview with LPN #1 revealed when he went into Resident #2's room on [DATE], he observed the resident was pale and without respirations. An additional interview with LPN #1, on [DATE] at 11:10 AM, revealed his initial observation also revealed Resident #2 had mucous coming out of his/her mouth. He again stated twice that he did not "touch" the resident or attempt to suction him/her. Additionally, continued interview, on [DATE] at 9:20 AM with LPN #1, revealed he did not have a stethoscope with him when he found the resident pale and without respirations on [DATE]. He revealed he immediately exited the room to find the ADON. Further review of the video camera data revealed the LPN returned with the Assistant Director of Nursing (ADON) to Resident #2's room at 8:09:10 AM, approximately six (6) minutes later. Further interview with LPN #1 revealed the ADON came to the resident's room and immediately started to suction the resident as he/she had "foamy" secretions in his/her mouth. LPN #1 stated he and the ADON performed a physical assessment of the resident at that time and found that he/she had no pulse or respirations. Interview, on [DATE] at 3:25 PM with the ADON, revealed she was notified that she needed to observe Resident #2's condition. The ADON indicated when she entered Resident #2's room the resident had foamy secretions in his/her mouth. According to the ADON, she immediately suctioned the resident's mouth using a suction machine beside Resident #2's bed. The ADON was unaware as to whether the resident had been suctioned prior to her coming to the room, but stated "I don't think so". The ADON stated she donned gloves, performed a sweep of the resident's mouth and observed nothing in Resident #2's mouth. Additionally, the ADON stated she and LPN #1 attempted to obtain vital signs on Resident #2; however, they were unable to obtain vital signs. Review of the Nurse's Notes, dated [DATE] written by Licensed Practical Nurse (LPN) #1 revealed at 7:45 AM Resident #2 had been "cleaned up" and was in bed waiting to be "gotten up" for breakfast. The Nurse's Notes revealed that when he walked into Resident #2's room to provide care to the resident's roommate, he noted Resident #2 had a "pale looking color" and had no respirations. The Note further detailed LPN #1 auscultated for lung sounds with none heard and "no pulse and B/P" (blood pressure) could be obtained. LPN #1 documented Resident #2's head was "inclined" at thirty (30) degrees and he/she was suctioned using the suction machine at the bedside. Further review of the Nurse's Notes revealed the LPN documented at 7:50 AM the Assistant Director of Nursing (ADON) was notified of the change in Resident #2's condition and she suctioned the resident. However, continued interview with the LPN revealed no assessment was performed until the ADON was present in Resident #2's room. He stated when he documented the Note timed 7:45 AM it should have been included with the 7:50 AM Note, as he did not perform an assessment of the resident's vital signs until the ADON was present in the resident's room with him. Further review of the Nurse's Notes revealed a Note written by another nurse that stated Resident #2 was pronounced deceased at 9:00 AM. The Director of Nursing (DON), on [DATE] at 11:07 AM, revealed her expectations of her licensed nurses were if a resident experienced a change of condition the nurse would perform a complete assessment of the resident. She stated this would include obtaining vital signs. According to the DON if a resident was found without respirations the nurse should assess for a pulse and auscultate for lung sounds. Additionally, she stated nurses should document accurately in the resident's medical record. She stated nurses should not "falsify" their documentation. Interview on [DATE] at 5:40 PM with the Medical Director revealed if a resident experienced a change in condition as in the case of Resident #2, he would expect the nurse to assess for signs of life. He stated the nurse should assess for respiration, pulse, pallor (pale color) and rigidity. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE], based on the following: 1. LPN #1 was suspended pending completion of an investigation into the allegations. 2. The DON conducted a review on [DATE] of all resident's medical records who had expired in the facility in the past six (6) months. All records were found to be in compliance. 3. Medical record reviews were completed [DATE] of thirty-seven (37) individual charts of residents who had expired in the facility in the past six (6) months or who had been sent to the hospital due to a change in condition in the past six (6) months. 4. New policies and procedures were created and implemented immediately on [DATE]. A policy entitled "Assessment of Residents when found to have a Change in Condition" which addressed the immediate assessment of a resident exhibiting a change in condition. A revision of the policy, "Charting and Documentation" to emphasize the importance of timely and accurate charting in residents' medical records. Staff inservices were conducted on these policies. Re-inservices were conducted on the "General Guidelines for Emergency Care" and "Procedure for Nursing Report and Rounds" policies. All Registered Nurses and Licensed Practical Nurses were inserviced on all the above policies starting on [DATE], and completed on [DATE], with the exception of two (2) nurses. One nurse who is out of the country, and one currently on Family Medical Leave. These two (2) nurses will not be allowed to work on the floor with residents until they are inserviced on the policies as well. 5. The DON and ADON will audit medical records for any resident that expires in the facility. The audit will include review for compliance with the above cited policies and procedures. 6. Monitoring of nurse compliance with the existing and revised policies and procedures will be performed by including them in the nurse competency reviews. These reviews were started on [DATE], and were seventy-six (76) percent complete on [DATE]. 7. On [DATE], the facility also created and implemented a "Condition Change Documentation 24 Hour Report Follow-up" form that will be reviewed at the Interdisciplinary Team's (IDT) morning meeting. A new policy was implemented in regards to the new form. The form and policy revisions were implemented on [DATE] to utilize as tools for monitoring. 8. The facility will Quality Assurance (QA) condition change assessments by selecting five (5) resident medical records from the facility's two (2) units for a total of ten (10) records to review that accurate assessments were completed for the selected residents. If compliance is found during the initial six (6) month period, then five (5) records from the two (2) units will be reviewed on a quarterly basis from there on. These QA audits will be completed by the QA nurse. On [DATE] it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective [DATE] based on the following: Observation, on [DATE] from 10:45 AM until 11:00 AM revealed the new or revised policies were present in the Policies and Procedures books located at the Nurse's Station on each of the two (2) units. Interviews with staff including Registered Nurse (RN) #3 on [DATE] at 11:05 AM, RN #2 on [DATE] at 4:30 PM, Licensed Practical Nurse (LPN) #8 at 10:22 AM, LPN #6 at 10:40 AM, LPN #7 at 10:50 AM, LPN #10 at 10:56 AM, LPN #4 at 3:05 PM, LPN #9 at 3:41 PM revealed they all were aware of the new policies and procedures that had been implemented or revised: "Assessment of Residents when found to have a Change in Condition", "Charting and Documentation", "General Guidelines for Emergency Care" and "Procedure for Nursing Report and Rounds". They all were aware of the "Condition Change Documentation 24 Hour Report Follow-up" form and new policy related to it. Review of the facility's inservices and interview, on [DATE] at 9:25 AM, with the Staff Development Nurse and Director of Nursing (DON) revealed the facility had inserviced all licensed staff beginning [DATE] related to the new policies and procedures with the exception of two licensed staff who were out of the country or on medical leave and would not be allowed to return to work until inserviced. Further interview revealed to validate staff's competency related to the inservice, staff were given a change of condition scenario and they had to document a nurse's note describing their assessment of the change in condition, such as obtaining vital signs. Additionally, interview and review of the facility's chart audits revealed thirty-seven (37) individual charts of residents who had expired in the facility in the past six (6) months or who had been sent to the hospital due to a change in condition in the past six (6) months were reviewed to ensure there were no other residents effected related to not appropriately assessing a resident who had a change of condition. Interview, on [DATE] at 4:10 PM, with the Administrator revealed all but two (2) staff had been inserviced on the new or revised policies and procedures and new form. According to the Administrator, new employees will receive the information in orientation. He stated a new QA audit was in place to monitor residents' change of condition and ensure accurate assessments were completed by the licensed nursing staff. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure implementation of their written policy to prohibit mistreatment, neglect and abuse of residents for one (1) of eleven (11) sampled residents (Resident #1). The facility failed to follow their "Protection of Residents During Abuse Investigations" policy. On 03/14/12, the facility received an allegation of abuse alleging that Medical Records personnel witnessed State Registered Nursing Assistant (SRNA) #9 "slap" Resident #1 on top of his/her hand at approximately 5:30 AM. The facility allowed SRNA #9 to continue to work her shift without reassigning her duties from providing resident contact or immediately suspending the staff. The Supervisor/Licensed Practical Nurse (LPN) #3 allowed SRNA #9 to work with residents for approximately an hour to an hour and a half after being made aware of an allegation of abuse. The facility's failure to implement the written policy and protect residents from abuse placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 04/25/12 and was determined to exist on 03/14/12. The facility was notified of the Immediate Jeopardy on 04/25/12. Substandard Quality of Care (SQC) was identified at 42 CFR 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable credible Allegation of Compliance (AoC) on 04/27/12 with the facility alleging removal of the Immediate Jeopardy on 04/28/12. Observations, staff interviews, and in-service record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable AoC on 04/28/12 prior to exiting the facility on 04/28/12. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents remain free from abuse. The findings include: Review of the facility's policy titled, "Protection of Residents During Abuse Investigations", updated 10/99, revealed "employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by administrator". Review of Resident #1's medical record revealed the facility admitted the resident on 07/06/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was severely impaired cognitively. Further review of the MDS revealed the facility assessed the resident as requiring limited to extensive assistance with his/her Activities of Daily Living (ADLs), and was occasionally incontinent of urine. Review of the facility's investigation revealed on 03/14/12 a Medical Records personnel reported that she had witnessed SRNA #9 "swat" Resident #1 on top of his/her hand at approximately 5:30 AM. The Medical Records personnel immediately notified the Supervisor/LPN #3 per the investigation report. The report indicated the Medical Records personnel was walking past Resident #1's room where SRNA #9 and SRNA #10 were providing care to Resident #1's roommate when she heard Resident #1 asking for help. The report states the Medical Records personnel heard SRNA #9 tell Resident #1, "you have to wait". The Medical Records personnel turned around and headed back towards the room watching through the door which was half open. The report stated as she watched the SRNA's giving care to the roommate, Resident #1 called out for help again and was getting out of the bed. SRNA #9 went over to Resident #1 and told the resident to sit down in a firm voice. Resident #1 put his/her hand down on the bed in the wet area and SRNA #9 swatted his/her hand away and told him/her not to put his/her hand in the wet area. Further review of the report revealed the Supervisor was immediately notified by the Medical Records personnel. Review of the Medical Records personnel's written statement, attached to the report, revealed when Resident #1 put his/her hand in the wet area on the bed, SRNA #9 firmly said "No don't do that, look you've already made a mess, and I said keep you hand out". Review of the written statement revealed this is where SRNA #9 slapped Resident #1's hand and said "quit". The written statement further indicated when SRNA #9 saw the Medical Records personnel at the door she instructed SRNA #10 to shut the door. Her statement indicated she went immediately and told the Supervisor/LPN #3. Interview, on 03/26/12 at 3:55 PM, with the Supervisor/LPN #3 revealed the Medical Records personnel reported to her on 03/14/12 that SRNA #9 had chastised the resident and pushed the resident's hand. She stated she spoke to SRNA #9 and SRNA #10, who was also in the resident's room at the time of the incident, and they denied the allegation. She stated, she instructed both SRNA's to write up a statement. Interview, on 03/26/12 at 4:38 PM, with SRNA #9 revealed on 03/14/12 Resident #1 had been incontinent of urine on him/herself and the bed. She stated the resident had attempted to put his/her hand in a wet spot on the bed and she had moved Resident #1's hand to his/her lap. She stated she and SRNA #10 informed the Supervisor/LPN #3 this allegation did not occur. SRNA #9 stated she finished caring for Resident #1 and then went on to care for the other residents assigned to her on the 400 hall. Interview, on 03/26/12 at 4:53 PM, with SRNA #10 revealed she and SRNA #9 had been in Resident #1's room somewhere between 5:30 AM and 6:00 AM on 03/14/12. SRNA #10 stated she did not witness SRNA #9 do this and that she was caring for Resident #1's roommate and had her back to SRNA #9 and Resident #1. According to the SRNA, she "closed" Resident #1's door and left SRNA #9 caring for the resident. According to the report, interviews were conducted and SRNA #9 was suspended until the investigation was complete. Further review revealed no documented evidence that the facility reassigned SRNA #9 to duties that did not involve resident contact after the Medical Records personnel made an allegation of abuse to the Supervisor/LPN #3. Continued interview with RN #1, who was assigned to Resident #1 on 03/14/12, revealed SRNA #9 should not have continued to provide care to this resident after the allegation was made by the Medical Record personnel. She stated SRNA #9 should have been sent home immediately; however, she did not ensure SRNA #9 was reassigned or immediately suspended. Continued interview with the Supervisor/LPN #3, on 03/26/12 at 4:00 PM, revealed she allowed SRNA #9 to continue working with residents as it was near the end of her shift. She stated she "didn't see a problem with it" because both SRNA #9 and SRNA #10 denied the allegation occurred, even though she stated that it wasn't facility policy. Interview, on 03/23/12 at 2:47 PM with the Social Services (SS) Director, revealed she performed the investigation into the allegation made on 03/14/12 by the Medical Record personnel. When asked if SRNA #9 was reassigned after the allegation was made, the SS Director stated "no". She stated SRNA #9 should have been "sent home" immediately after the allegation was reported. The SS Director stated she did not talk to the Supervisor/LPN #3 about not following the facility's policy. She stated she performed abuse in-services on orientation and quarterly for all staff, including nursing, housekeeping, maintenance, kitchen and office staff. Interview, on 03/29/12 at 10:18 AM, with the Director of Nursing (DON) revealed the facility's policy was to remove staff involved in an abuse allegation from resident care. She stated the Supervisor/LPN #3 should have sent SRNA #9 home and not allowed her to continue performing resident care. Interview with the Administrator, on 03/29/12 at 11:00 AM, revealed the Supervisor/LPN #3 informed the DON of the allegation at 7:15 AM, but should have informed Administration immediately. He further stated the Supervisor/LPN #3 should have removed SRNA #9 from direct resident care first and then notified Administration per the facility's policy. Continued interview, on 04/26/12 at 3:30 PM, revealed he felt like the Supervisor/LPN #3 had investigated the allegation and determined no abuse had occurred because SRNA #9 and SRNA #10 both denied the allegation occurred, even though the policy indicated the alleged abuser would immediately be removed from direct resident care until the investigation was completed. The facility provided an acceptable credible Allegation of Compliance (AoC) on 04/27/12 that alleged removal of the Immediate Jeopardy (IJ) on 04/28/12, based on the following: 1. SRNA #9 was suspended on 03/14/12 after the DON and Administrator were notified of the allegation. 2. Resident #1 was assessed by the Supervisor on 03/14/12 and then moved to the day area on Unit 2 where he/she could be monitored. 3. The Supervisor and the Charge Nurse/RN #1 were re-educated on 03/26/12 on the facility policy of abuse and neglect, specifically the requirement that an employee be suspended immediately once an allegation of abuse or neglect is made against them. 4. SRNA #9 and SRNA #10 were re-educated on 03/15/12 and 03/26/12 by the Social Service Director on the facility's policy on abuse and neglect. 5. The Social Service Director began re-education of all facility staff on the Abuse Neglect Policy on 03/26/12 with 100% of staff completion (minus one employee on Family Medical Leave) which was completed by 04/25/12. Attendance was monitored and anyone that did not participate in the re-education training, was given 1:1 training by the Social Service Director until 100% of employees were reeducated by 04/25/12. 6. To ensure no other residents were affected, interviewable residents were asked by staff how they were treated in the facility of they had any complaints about their care. 7. Direct care staff observed residents for unexplained bruising and reddened areas while providing care. 8. On 04/27/12, all residents in the facility had a skin assessment for signs of abuse by the DON, ADON, QA Nurse, Staff Development Nurse, three (3) MDS Nurses, Unit Coordinators, Restorative Nurse, Wound Care Nurse and seven (7) Management Nurses. 9. No determination will be made in the outcome of an abuse investigation without the review and approval of the Administrator or designee. 10. The QA Nurse will monitor weekly, all allegations of abuse to ensure the proper procedure is followed by facility staff. 11. QA tools were created to monitor and assure that new hires are in-serviced on abuse and neglect, that quarterly mandatory in-services on abuse and neglect are scheduled and that proper roster attendance is kept. QA will also continue to interview ten (10) staff monthly including supervisors on knowledge of forms of abuse and what to do if you suspect or see abuse. QA will also use tool to review follow-up of allegations of abuse to ensure that the facility policy and procedure was followed. On 04/28/12, the State Agency verified the immediacy of the Immediate Jeopardy was removed and the facility implemented corrective actions as alleged in the AoC, effective 04/28/12 based on the following: Interview with the Supervisor/LPN #3 and RN #1, on 04/28/12 at 11:00 AM, revealed they received education on 03/26/12 on the facility policy of abuse and neglect, specifically the requirement that an employee be suspended immediately once an allegation of abuse or neglect was made against them. Interview with the Supervisor/LPN #3 further revealed she was instructed to immediately remove the alleged perpetrator from direct resident care. Review of the in-service education documentation revealed the education was conducted on 03/26/12. Interview with SRNA #9 and SRNA #10, on 04/28/12 at 11:15 AM, revealed they were re-educated on 03/15/12 and 03/26/12 by the Social Service Director on the facility's policy on abuse and neglect. Review of the education documentation revealed the education was conducted on 03/15/12 and 03/26/12. Interview with the Social Service Director, on 04/28/12 at 10:15 AM, revealed she began re-education of all facility staff on the Abuse Neglect Policy on 03/26/12 with 100% of staff completion (minus one employee on Family Medical Leave) which was completed by 04/25/12. Attendance was monitored and anyone that did not participate in the re-education training, was given 1:1 training by the Social Service Director until 100% of employees were re-educated by 04/25/12. Review of the facility's documentation revealed the facility provided education to all staff between 03/26/12 and 04/25/12 on the abuse and neglect policy. The education sign-in sheets were compared to the facility staff roster to ensure 100% of staff received the education. Interviews were conducted with the following staff to verify the facility had educated them and to ensure their knowledge of the facility's abuse and neglect policy: Dietary Manager on 04/28/12 at 11:00 AM, Assistant Dietary Manager, on 04/28/12 at 11:05 Am, Cook #17, on 04/28/12 at 11:15 AM, Dietary Aide #18, on 04/28/12 at 11:20 AM, Dietary Aide #19, on 04/2812 at 11:25 AM, Dietary Aide #11, on 04/28/12 at 11:30 AM, Housekeeper #12, on 04/28/12 at 11:35 AM, Cook #13 on 04/28/12 at 11:40 AM, Housekeeping #14 on 04/28/12 at 11:50 AM, Supervisor/LPN #3, on 04/28/12 at 11:00 AM, RN #4, on 04/28/12 at 11:55 AM, Restorative Nurse/LPN #14, on 04/28/12 at 11:45 AM, SRNA #17, on 04/28/12 at 11:00 AM, SRNA #6, on 04/28/12 at 11:05 AM, Unit Coordinator/LPN #11, on 04/28/12 at 11:25 AM, LPN #12, on 04/28/12 at 11:35 AM, SRNA #15, on 04/28/12 at 11:30 AM, Housekeeper #20, on 04/28/12 at 11:45 AM, ADON, on 04/28/12 at 11:40 AM and SRNA #16, on 04/28/12 at 11:55 AM. All of the above staff was knowledgeable of the facility's abuse and neglect policy and verified they had received re-education by the facility. Interview with the DON, on 04/28/12 at 10:20 AM, revealed the facility completed skin assessments on 100% of the resident population and identified no concerns with the skin assessments. Review of the resident census revealed the facility had one hundred-two (102) residents on 04/28/12. Review of the skin assessments revealed the facility completed 102 skin assessments on 04/28/12 and no concerns were identified. Interview with the Administrator, on 04/26/12 at 3:30 PM, revealed no determination will be made in the outcome of an abuse investigation without the review and approval of the Administrator or designee as per the facility's policy. Interview with the QA Nurse, on 04/28/12 at 1:00 PM revealed she will monitor weekly, all allegations of abuse to ensure the proper procedure is followed by facility staff. She further stated QA tools were created to monitor and assure that new hires were in-serviced on abuse and neglect, that quarterly mandatory in-services on abuse and neglect were scheduled and that proper roster attendance was kept. Further interview revealed QA will also continue to interview ten (10) staff monthly including supervisors on knowledge of forms of abuse and what to do if you suspect or see abuse. QA will also use tool to review follow-up of allegations of abuse to ensure that the facility policy and procedure was followed. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to protect residents from abuse. On 03/14/12, the facility received an allegation of abuse; however, the alleged perpetrator was not immediately removed from direct resident care and continued to provide resident care. Review of the facility's policy "Protection of Residents During Abuse Investigation" revealed employees accused of participating in an alleged abuse would be immediately reassigned to duties that did not involve resident contact until the findings of the investigation were reviewed by the Administrator. On 03/14/12, at approximately 5:30 AM, a Medical Records personnel witnessed State Registered Nursing Assistant (SRNA) #9 "slap" Resident #1 on the top of his/her left hand while providing care to the resident in the resident's room. Interview with the Medical Records personnel revealed she heard it "pop". She stated another aide, SRNA #10 was in the room at the time, exited the room, and closed the door after the incident, leaving SRNA #9 alone in the room with Resident #1. Per interview, the Medical Records personnel reported the incident to the Supervisor/Licensed Practical Nurse (LPN) #3 immediately. Interview with SRNA #9 revealed she was interviewed by the Supervisor/LPN #3 about the incident; however, she was allowed to continue to provide direct care to residents, for approximately one hour, until the end of her shift. Interview with the Supervisor/LPN #3 revealed she assessed Resident #1 for injuries and questioned SRNA #9 and SRNA #10. She stated she determined abuse had not occurred and therefore did not immediately remove SRNA #9 from resident care. Interview with the Administrator revealed the facility failed to protect residents from alleged abuse. The facility's failure to protect residents from abuse placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 04/25/12 and was determined to exist on 03/14/12. The facility was notified of the Immediate Jeopardy on 04/25/12. Substandard Quality of Care (SQC) was identified at 42 CFR 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable credible Allegation of Compliance (AoC) on 04/27/12 with the facility alleging removal of the Immediate Jeopardy on 04/28/12. Observations, staff interviews, and in-service record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable AoC on 04/28/12 prior to exiting the facility on 04/28/12. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents remain free from abuse. The findings include: Review of the facility's policy titled, "Reporting Abuse to Facility Management", updated 07/2001, revealed the facility would not condone resident abuse by anyone, including staff members. Further review of the policy revealed physical abuse was defined as hitting, slapping, pinching, kicking, etc. Review of the facility's policy titled, "Protection of Residents During Abuse Investigations", updated 10/99, revealed "employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by administrator". Review of Resident #1's medical record revealed the facility admitted the resident on 07/06/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was severely impaired cognitively. Further review of the MDS revealed the facility assessed the resident as requiring limited to extensive assistance with his/her Activities of Daily Living (ADLs), and was occasionally incontinent of urine. Review of the facility's "Self Reported Incident Form", (initial report) revealed there was an allegation of verbal and physical abuse on 03/14/12. Further review of the report revealed a Medical Record personnel reported to the Supervisor/LPN #3 that she witnessed SRNA #9 swat Resident #1 on the top of the hand while providing care as she walked past Resident #1's room at 5:30 AM. The report indicated the Medical Records personnel was walking past Resident #1's room where SRNA #9 and SRNA #10 were providing care to Resident #1's roommate when she heard Resident #1 asking for help. The report stated the Medical Records personnel heard SRNA #9 tell Resident #1, "you have to wait". The Medical Records personnel turned around and headed back towards the room watching through the door which was half open. The report stated as she watched the SRNA's giving care to the roommate, Resident #1 called out for help again and was getting out of the bed. SRNA #9 went over to Resident #1 and told the resident to sit down in a firm voice. Resident #1 put his/her hand down on the bed in the wet area and SRNA #9 swatted his/her hand away and told him/her not to put his/her hand in the wet area. Further review of the report revealed the Supervisor was immediately notified by the Medical Records personnel. The Supervisor initiated an investigation by having the SRNA's and the Medical Records personnel write statements and staff interviews were initiated. Review of the Medical Records personnel's written statement, attached to the report, revealed when Resident #1 put his/her hand in the wet area on the bed, SRNA #9 firmly said "No don't do that, look you've already made a mess, and I said keep you hand out". This is where SRNA #9 slapped Resident #1's hand and said "quit". The written statement further indicated when SRNA #9 saw the Medical Records personnel at the door she instructed SRNA #10 to shut the door. Her statement indicated she went immediately and told the Supervisor/LPN #3. Interview with the Medical Record personnel, on 03/23/12 at 3:38 PM, revealed she witnessed the above incident from the hallway, on 03/14/12 at 5:30 AM, and the door was half way open. She stated SRNA #9 slapped Resident #1's hand and she heard it "pop". She stated she went to the Supervisor/LPN #3 and reported what she saw and said she told the Supervisor that SRNA #9 was verbally rude to Resident #1 and slapped his/her hand. Interview with the Supervisor/LPN #3, on 03/26/12 at 4:00 PM, revealed on 03/14/12 when the Medical Records personnel reported the alleged abuse to her, she went to Resident #1's room and talked with SRNA #9 and SRNA #10 separately. She stated both SRNA's denied the abuse had occurred and she asked them both to write statements. She stated she assessed Resident #1, looking up to the resident's elbows and didn't see any redness or bruising. She stated she didn't see a problem with SRNA #9 continuing to work because it was almost the end of the shift and SRNA #9 was completing her paper work and writing her statement. Interview with SRNA #9, on 03/26/12 at 4:38 PM, revealed on 03/14/12 she went into the room with SRNA #10 to attend to Resident #1's roommate. She stated Resident #1 went to the bathroom and came back and sat on his/her bed. She stated Resident #1 said he/she was soaked so she went over to Resident #1 and the bed was soaked. She stated Resident #1 started to reach for the wet spot and she took the resident's hand and placed it on his/her lap. She said SRNA #10 was leaving the room so she asked her to close the door. She further stated she went on and cleaned the bed and assisted Resident #1 with getting dressed. She stated it was about 5:45 AM when the Supervisor/LPN #3 told her there had been an allegation that she had slapped Resident #1's hand. She said she told the Supervisor/LPN #3 she did not slap Resident #1's hand. She stated she finished with Resident #1's care and completed her shift. She stated she provided care for other residents because she had the residents on half of the 400 hall to care for before finishing her shift. Interview with SRNA #10, on 03/26/12 at 4:53 AM, revealed on 03/14/12 she asked SRNA #9 to help her with Resident #1's roommate. She stated Resident #1 got up and was almost naked so SRNA #9 went to help Resident #1 because he/she was soaked in urine. She stated she was concentrating on Resident #1's roommate and had her back to SRNA #9 and Resident #1. She stated she did not see anything. She stated when she left the room she closed the door and SRNA #9 continued to provide assistance to Resident #1. She said she was then interviewed by the Supervisor/LPN #3 and instructed to write a statement. Review of the facility's final investigation revealed after completing the interviews, Administrative staff determined there was no intent to harm the resident. It stated, SRNA #9 spoke in a loud voice and this may be misinterpreted. SRNA #9 would remain off the schedule until she attended additional education on communication techniques to use with people with Dementia. Interview with the DON, on 03/29/12 at 10:18 AM, revealed the Supervisor/LPN #3 notified her of the incident on 03/14/12 at 7:15 AM when she was on her way to the facility. She stated when she arrived at the facility, at 8:00 AM on 03/14/12, she reviewed the written statements. She stated the Medical Records personnel wrote two (2) statements and the first said SRNA #9 slapped the resident's hand and the second statement said she slapped the resident's wrist. She continued to state that both SRNA's in the room stated it didn't happen. Interview with the Administrator, on 03/29/12 at 10:30 AM, revealed according to the facility's policy, he should have been notified before 7:15 AM, SRNA #9 should have been removed from resident care first, and should have been sent home. The facility provided an acceptable credible Allegation of Compliance (AoC) on 04/27/12 that alleged removal of the Immediate Jeopardy (IJ) on 04/28/12, based on the following: 1. SRNA #9 was suspended on 03/14/12 after the DON and Administrator were notified of the allegation. 2. Resident #1 was assessed by the Supervisor on 03/14/12 and then moved to the day area on Unit 2 where he/she could be monitored. 3. The Supervisor and the Charge Nurse/RN #1 were reeducated on 03/26/12 on the facility policy of abuse and neglect, specifically the requirement that an employee be suspended immediately once an allegation of abuse or neglect is made against them. 4. SRNA #9 and SRNA #10 were reeducated on 03/15/12 and 03/26/12 by the Social Service Director on the facility's policy on abuse and neglect. 5. The Social Service Director began re-education of all facility staff on the Abuse Neglect Policy on 03/26/12 with 100% of staff completion (minus one employee on Family Medical Leave) which was completed by 04/25/12. Attendance was monitored and anyone that did not participate in the re-education training, was given 1:1 training by the Social Service Director until 100% of employees were reeducated by 04/25/12. 6. To ensure no other residents were affected, interviewable residents were asked by staff how they were treated in the facility of they had any complaints about their care. 7. Direct care staff observed residents for unexplained bruising and reddened areas while providing care. 8. On 04/27/12, all residents in the facility had a skin assessment for signs of abuse by the DON, ADON, QA Nurse, Staff Development Nurse, three (3) MDS Nurses, Unit Coordinators, Restorative Nurse, Wound Care Nurse and seven (7) Management Nurses. 9. No determination will be made in the outcome of an abuse investigation without the review and approval of the Administrator or designee. 10. The QA Nurse will monitor weekly, all allegations of abuse to ensure the proper procedure is followed by facility staff. 11. QA tools were created to monitor and assure that new hires are in-serviced on abuse and neglect, that quarterly mandatory in-services on abuse and neglect are scheduled and that proper roster attendance is kept. QA will also continue to interview ten (10) staff monthly including supervisors on knowledge of forms of abuse and what to do if you suspect or see abuse. QA will also use tool to review follow-up of allegations of abuse to ensure that the facility policy and procedure was followed. On 04/28/12, the State Agency verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective 04/28/12, based on the following: Interview with the Supervisor/LPN #3, on 04/28/12 at 11:00 AM and RN #1, on 04/28/12 at 11:15 AM, revealed they received education on 03/26/12 on the facility's policy of abuse and neglect, specifically the requirement that an employee be suspended immediately once an allegation of abuse or neglect was made against them. Interview with the Supervisor/LPN #3 further revealed she was instructed to immediately remove the alleged perpetrator from direct resident care. Review of the in-service education documentation revealed the education was conducted on 03/26/12. Interview with SRNA #9 and SRNA #10, on 04/28/12 at 11:15 AM, revealed they were re-educated on 03/15/12 and 03/26/12 by the Social Service Director on the facility's policy on abuse and neglect. Review of the education documentation revealed the education was conducted on 03/15/12 and 03/26/12. Interview with the Social Service Director, on 04/28/12 at 10:15 AM, revealed she began re-education of all facility staff on the Abuse Neglect Policy on 03/26/12 with 100% of staff completion (minus one employee on Family Medical Leave) which was completed by 04/25/12. Attendance was monitored and anyone that did not participate in the re-education training, was given 1:1 training by the Social Service Director until 100% of employees were re-educated by 04/25/12. Review of the facility's documentation revealed the facility provided education to all staff between 03/26/12 and 04/25/12 on the abuse and neglect policy. The education sign-in sheets were compared to the facility staff roster to ensure 100% of staff received the education. Interviews were conducted with the following staff to verify the facility had educated them and to ensure their knowledge of the facility's abuse and neglect policy: Dietary Manager on 04/28/12 at 11:00 AM, Assistant Dietary Manager, on 04/28/12 at 11:05 Am, Cook #17, on 04/28/12 at 11:15 AM, Dietary Aide #18, on 04/28/12 at 11:20 AM, Dietary Aide #19, on 04/2812 at 11:25 AM, Dietary Aide #11, on 04/28/12 at 11:30 AM, Housekeeper #12, on 04/28/12 at 11:35 AM, Cook #13 on 04/28/12 at 11:40 AM, Housekeeping #14 on 04/28/12 at 11:50 AM, Supervisor/LPN #3, on 04/28/12 at 11:00 AM, RN #4, on 04/28/12 at 11:55 AM, Restorative Nurse/LPN #14, on 04/28/12 at 11:45 AM, SRNA #17, on 04/28/12 at 11:00 AM, SRNA #6, on 04/28/12 at 11:05 AM, Unit Coordinator/LPN #11, on 04/28/12 at 11:25 AM, LPN #12, on 04/28/12 at 11:35 AM, SRNA #15, on 04/28/12 at 11:30 AM, Housekeeper #20, on 04/28/12 at 11:45 AM, ADON, on 04/28/12 at 11:40 AM and SRNA #16, on 04/28/12 at 11:55 AM. All of the above staff was knowledgeable of the facility's abuse and neglect policy and verified they had received re-education by the facility. Interview with the DON, on 04/28/12 at 10:20 AM, revealed the facility completed skin assessments on 100% of the resident population and identified no concerns with the skin assessments. Review of the resident census revealed the facility had one hundred-two (102) residents on 04/28/12. Review of the skin assessments revealed the facility completed 102 skin assessments on 04/28/12 and no concerns were identified. Interview with the Administrator, on 04/26/12 at 3:30 PM, revealed no determination will be made in the outcome of an abuse investigation without the review and approval of the Administrator or designee as per the facility's policy. Interview with the QA Nurse, on 04/28/12 at 1:00 PM revealed she will monitor weekly, all allegations of abuse to ensure the proper procedure is followed by facility staff. She further stated QA tools were created to monitor and assure that new hires were in-serviced on abuse and neglect, that quarterly mandatory in-services on abuse and neglect were scheduled and that proper roster attendance was kept. Further interview revealed QA will also continue to interview ten (10) staff monthly including supervisors on knowledge of forms of abuse and what to do if you suspect or see abuse. QA will also use tool to review follow-up of allegations of abuse to ensure that the facility policy and procedure was followed. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review, video review, and facility policy review, it was determined the facility failed to ensure each resident was free from neglect for one (1) of eleven (11) sampled residents (Resident #2). The facility failed to ensure necessary care and services were provided to Resident #2 immediately upon the identification of a change in condition. On [DATE], Licensed Practical Nurse (LPN) #1 noted Resident #2 was without respirations and pale; however, LPN #1 stated he did not attempt to physically assess the resident's vital signs or attempt to suction the resident after identifying the change in condition. Furthermore, the facility's video data for [DATE] revealed LPN #1 entered the resident's room and exited thirty (30) seconds later and returned to the room approximately six (6) minutes later with the Assistant Director of Nursing (ADON). The facility could provide no evidence that the staff attempted to physically assess the resident's observed change in condition immediately in an effort to provide necessary care and services. The resident was pronounced deceased at the facility on [DATE] at 9:00 AM. The facility's failure to protect residents from neglect placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Substandard Quality of Care (SQC) was identified at 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable Credible Allegation of Compliance (CAoC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Observations, staff interviews, and inservice record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable AoC on [DATE] prior to exiting the facility on [DATE]. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents remain free from neglect. The findings include: Review of the facility's "Emergency Care, General Guidelines For" policy undated, revealed the purpose was to provide emergency care to a resident in need of urgent service. Continued review revealed it was the basic responsibility of the Licensed Nurse to always take, report, and record vital signs when a resident's condition had changed and record the details and exact time of the condition change. In an interview with the Director of Nursing (DON), on [DATE] at 11:07 AM, revealed this was the facility's policy for providing emergency care to residents. The DON stated she would expect her licensed nurses to perform an assessment of a resident with a change in condition that would include obtaining vital signs. She stated nurses should ensure their documentation is accurate and should not "falsify" their documentation. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Nutrition, dated ,[DATE], revealed staff was to provide the resident with assistance if he/she started to choke. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely impaired with daily decision making and totally dependent on staff for all Activities of Daily Living (ADLs). Review of the State Registered Nursing Assistants' (SRNAs) care plan revealed the resident was on aspiration precautions. Interview, on [DATE] at 9:25 PM with SRNA #12, revealed he worked the 11:00 PM to 7:00 AM shift the night of [DATE]. He stated his shift was over at 7:00 AM on [DATE]. The SRNA stated he had been assigned to Resident #2's care that night. According to SRNA #12 every time he checked on the resident during that shift he/she was "okay". He stated Resident #2 was cleaned and dressed for breakfast prior to the end of his shift. SRNA #12 stated the last time he saw the resident was at approximately 6:15 AM to 6:30 AM on [DATE] and he/she was "okay" at that time. Observation, on [DATE] at 3:33 PM, of the video camera data for [DATE] revealed at 7:45:08 AM the Social Services Director entered Resident #2's room and exited at 7:45:32 AM. Interview, on [DATE] at 8:50 AM with the Social Services (SS) Director, revealed she went in to talk to Resident #2's roommate. The SS Director stated she couldn't remember if she "looked at" Resident #2. Video camera data review revealed at 7:48:22 AM State Registered Nursing Assistant (SRNA) #2 entered Resident #2's room and exited at 7:48:40. Interview, on [DATE] at 9:47 AM with SRNA #2, revealed she couldn't remember for sure why she went into Resident #2's room on [DATE]. She stated it may have been because Resident #2's roommate "cried out for help" as he/she "usually" did. SRNA #2 stated she thought Resident #2 was okay that morning; however, she could not "swear" that was the case. Review of the Nurse's Notes, dated [DATE] written by Licensed Practical Nurse (LPN) #1 revealed at 7:45 AM Resident #2 had been "cleaned up" and was in bed waiting to be "gotten up" for breakfast. Interview, on [DATE] at 2:07 PM with LPN #1, revealed he went into Resident #2's room to check on his/her roommate. He stated he noted Resident #2 was still in bed and should have been up, so he immediately left the room to check on why the resident was still in bed. Observation of the video camera data revealed at 8:02:33 AM LPN #1 entered and immediately exited Resident #2's room. Further interview with the LPN revealed he returned to Resident #2's room and observed that the resident's skin color was pale, "paler than usual" and he/she was not breathing. In an additional interview, on [DATE] at 11:10 AM with LPN #1, he stated Resident #2 had "mucous coming out of" his/her mouth when he found him/her pale and without respirations. Further interview, on [DATE] at 9:20 AM with LPN #1, revealed he performed a visual assessment of the resident when he found him/her pale and without respirations. The LPN stated he did not have a stethoscope with him. He stated he observed the resident having no respirations. LPN #1 stated his thoughts were "disorganized" when he found the resident in this condition. He stated twice that he did not "touch" the resident and stated that he made no attempts to suction the resident prior to going to find the ADON, despite having documented in the Nurse's Notes that when he walked into Resident #2's room to provide care to the resident's roommate, he noted Resident #2 had a "pale looking color" and had no respirations. The Note further detailed LPN #1 auscultated for lung sounds with none heard and "no pulse and B/P" (blood pressure) could be obtained. LPN #1 documented Resident #2's head was "inclined" at thirty (30) degrees and he/she was suctioned using the suction machine at the bedside. Review of the video camera data revealed the LPN was observed to return to Resident #2's room at 8:03:15 AM and exit the room at 8:03:45 AM, thirty (30) seconds later. Continued interview with LPN #1 revealed the ADON "rushed into the room", noted the resident had secretions in his/her mouth, and proceeded to suction him/her. He stated the secretions were "foamy". Additionally, he stated he and the ADON examined Resident #2 and found he/she did not have a pulse or respirations. Interview, on [DATE] at 3:25 PM with the ADON, revealed on [DATE] someone had informed her she needed to go "look" at Resident #2. She stated she could not remember if it was LPN #1 or not. She stated she went to Resident #2's room and noted the resident had "some secretions, not thick, kind of foamy" in his/her mouth. The ADON stated there was a suction machine at the bedside so she immediately started to suction the resident. When asked if LPN #1 had suctioned the resident prior to her coming to the room, she stated "I don't think so". She stated she put on gloves, "checked" the resident's mouth, and there was nothing there. The ADON stated vital signs were attempted; however, none were obtained. The ADON indicated Resident #2's skin was "warm the whole time". Further observation of the video camera data revealed LPN #1 returned to the resident's room with the ADON at 8:09:10 AM, approximately six (6) minutes later. Further review of the Nurse's Notes revealed the LPN documented at 7:50 AM the ADON was notified of the change in Resident #2's condition and she suctioned the resident. Further interview with the LPN revealed no assessment was performed until the ADON was present in Resident #2's room. Further review of the Nurse's Notes revealed a Note written by another nurse that stated Resident #2 was pronounced deceased at 9:00 AM. Interview, with the Director of Nursing (DON) on [DATE] at 11:07 AM, revealed if a resident needed to be suctioned she would expect the nurse to do so. She stated her expectations of the licensed nurses would be that if someone was not breathing, the nurse would check for a pulse and respirations. She stated if a resident had a change in condition the nurse should do a complete assessment that would include obtaining vital signs. Interview, on [DATE] at 5:40 PM, with the Medical Director revealed if a resident experienced a change in condition as in the case of Resident #2, he would expect the nurse to assess for signs of life. He stated the nurse should assess for respiration, pulse, pallor (paleness of the skin) and rigidity. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE], based on the following: 1. LPN #1 was suspended pending completion of an investigation into the allegations. 2. The DON conducted a review on [DATE] of all residents' medical records who had expired in the facility in the past six (6) months. All records were found in compliance. 3. Medical record reviews were completed on [DATE] of thirty-seven (37) individual charts of residents who had expired in the facility in the past six (6) months or who had been sent to the hospital due to a change in condition in the past six (6) months. 4. New policies and procedures were created and implemented immediately on [DATE]. A policy entitled "Assessment of Residents when found to have a Change in Condition" which addressed the immediate assessment of a resident exhibiting a change in condition. A revision of the policy, "Charting and Documentation" to emphasize the importance of timely and accurate charting in residents' medical records. Staff inservices were conducted on these policies. Re-inservices were conducted on the "General Guidelines for Emergency Care" and "Procedure for Nursing Report and Rounds" policies. All Registered Nurses and Licensed Practical Nurses were inserviced on all the above policies starting on [DATE], and completed on [DATE], with the exception of two (2) nurses. One nurse who was out of the country, and one currently on Family Medical Leave. These two (2) nurses will not be allowed to work on the floor with residents until they are inserviced on the policies as well. 5. The DON and ADON will audit medical records for any resident that expires in the facility. The audit will include review for compliance with the above cited policies and procedures. 6. Monitoring of nurse compliance with the existing and revised policies and procedures will be performed by including them in the nurse competency reviews. These reviews were started on [DATE], and were seventy-six (76) percent complete on [DATE]. 7. On [DATE], the facility also created and implemented a "Condition Change Documentation 24 Hour Report Follow-up" form that will be reviewed at the Interdisciplinary Team's (IDT) morning meeting. A new policy was implemented in regards to the new form. The form and policy revisions were implemented on [DATE] to utilize as tools for monitoring. 8. The facility will Quality Assurance (QA) condition change assessments by selecting five (5) resident medical records from the facility's two (2) units for a total of ten (10) records to review that accurate assessments were completed for the selected residents. If compliance is found during the initial six (6) month period, then five (5) records from the two (2) units will be reviewed on a quarterly basis. These QA audits will be completed by the QA nurse. On [DATE] it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective [DATE] based on the following: Observation, on [DATE] from 10:45 AM until 11:00 AM revealed the new or revised policies were present in the Policies and Procedures books located at the Nurse's Station on each of the two (2) units. Interviews with staff including Registered Nurse (RN) #3 on [DATE] at 11:05 AM, RN #2 on [DATE] at 4:30 PM, Licensed Practical Nurse (LPN) #8 at 10:22 AM, LPN #6 at 10:40 AM, LPN #7 at 10:50 AM, LPN #10 at 10:56 AM, LPN #4 at 3:05 PM and LPN #9 at 3:41 PM revealed they all were aware of the new policies and procedures that had been implemented or revised: "Assessment of Residents when found to have a Change in Condition", "Charting and Documentation", "General Guidelines for Emergency Care" and "Procedure for Nursing Report and Rounds". They all were aware of the "Condition Change Documentation 24 Hour Report Follow-up" form and new policy related to it. Review of the facility's inservices and interviews, on [DATE] at 9:25 AM, with the Staff Development Nurse and Director of Nursing (DON) revealed the facility had inserviced all licensed staff beginning [DATE] related to the new policies and procedures with the exception of two licensed staff who was out of the country or on medical leave and would not be allowed to return to work until inserviced. Further interview revealed to validate staff's competency related to the inservice, staff was given a change of condition scenario and they had to document a nurse's note describing their assessment of the change in condition, such as obtaining vital signs. Additionally, interview and review of the facility's chart audits revealed thirty-seven (37) individual charts of residents who had expired in the facility in the past six (6) months or who had been sent to the hospital due to a change in condition in the past six (6) months were reviewed to ensure there were no other residents effected related to not appropriately assessing a resident who had a change of condition. Interview on [DATE] at 4:10 PM with the Administrator revealed all but two (2) staff had been inserviced on the new or revised policies and procedures and new form. According to the Administrator, new employees will receive the information in orientation. He stated a new QA audit was in place to monitor residents' change of condition and ensure accurate assessments were completed by the licensed nursing staff. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review, and facility policy review it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility failed to protect residents from abuse, failed to implement its Abuse Policies by failing to immediately remove staff from direct resident care after staff reported an allegation of abuse to the Supervisor, and failed to ensure other residents were protected by allowing the alleged abusive staff to continue to provide resident care. In addition, the facility's Administration failed to ensure staff implemented its Abuse Policies and failed to ensure residents were protected during the investigation of the allegation by allowing the Supervisor to make the determination whether or not abuse had occurred. On 03/14/12, a Medical Records personnel reported to the Supervisor that she was walking down the hall and witnessed State Registered Nursing Assistant (SRNA) #9 "slap" Resident #1 on the top of his/her left hand at approximately 5:30 AM, while providing care to the resident in the resident's room. She stated she heard it "pop". Interview with the Medical Records personnel revealed she reported the incident to the Supervisor immediately. She stated another aide, SRNA #10 was in the room at the time and exited the room and closed the door after the incident, leaving SRNA #9 in the room with Resident #1. Review of the facility's policy "Protection of Residents During Abuse Investigation" revealed employees accused of participating in an alleged abuse will be immediately reassigned to duties that did not involve resident contact until the findings of the investigation were reviewed by the Administrator. Interview with SRNA #9 revealed she was interviewed by the Supervisor and was allowed to continue to work about an hour providing direct care to residents until the end of her shift. Interview with the Supervisor revealed she assessed Resident #1 for injuries and questioned SRNA #9 and SRNA #10, who was also in the room at the time of the allegation, and determined abuse, did not occur. The facility's failure to have an effective Administration related to the prevention of abuse and failure to ensure policy and procedures were implement to protect residents placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified at 42 CFR 483.13 Resident Behavior and Facility Practice, F-223 and F-226 at a Scope and Severity of a "J" and 42 CFR 483.75 Administration, F-490 at a Scope and Severity of a "J". An acceptable Credible Allegation of Compliance, related to the Immediate Jeopardy, was received on 04/27/12. On 04/28/12, the Immediate Jeopardy was verified removed on 04/28/12 as alleged. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, F-223 and F-226 and 42 CFR 483.75, Administration, F-490 with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained effective systems to ensure residents remain free from abuse, the facility implements their policy and Administration oversight is provided. The findings include: Review of the facility's policy titled, "Protection of Residents During Abuse Investigations", updated 10/99, revealed "employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by administrator". The facility failed to implement written policy to prohibit mistreatment, neglect and abuse of residents for one (1) of eleven (11) sampled residents (Resident #1). The facility failed to follow their "Protection of Residents During Abuse Investigations" policy. On 03/14/12, the facility received an allegation of abuse alleging that Medical Records personnel witnessed State Registered Nursing Assistant (SRNA) #9 "slap" Resident #1 on top of his/her hand at approximately 5:30 AM. The facility failed to protect residents by allowing SRNA #9 to continue to provide direct resident care for approximately one (1) hour after being made aware of an allegation of abuse. The Supervisor/Licensed Practical Nurse (LPN) #3 failed to re-assign SRNA #9 from providing resident contact or immediately suspending the staff. (Refer to F-223 and F-226) Interview, on 03/29/12 at 10:18 AM, with the Director of Nursing (DON) revealed the facility's policy was to remove staff involved in an abuse allegation from resident care. She stated the Supervisor/LPN #3 should have sent SRNA #9 home and not allowed her to continue performing resident care. Interview with the Administrator, on 03/29/12 at 11:00 AM, revealed the Supervisor/LPN #3 informed the DON of the allegation at 7:15 AM, but should have informed Administration immediately. He further stated the Supervisor/LPN #3 should have removed SRNA #9 from direct resident care first and then notify Administration per the facility's policy. Continued interview, on 04/26/12 at 3:30 PM, revealed he felt like the Supervisor/LPN #3 had investigated the allegation and determined no abuse had occurred because SRNA #9 and SRNA #10 both denied the allegation occurred, even though the policy indicated the alleged abuser would immediately be removed from direct resident care until the investigation was completed. The facility provided an acceptable credible Allegation of Compliance (AoC) on 04/27/12 that alleged removal of the Immediate Jeopardy (IJ) on 04/28/12, based on the following: 1. SRNA #9 was suspended on 03/14/12 after the DON and Administrator were notified of the allegation. 2. Resident #1 was assessed by the Supervisor on 03/14/12 and then moved to the day area on Unit 2 where he/she could be monitored. 3. The Supervisor and the Charge Nurse/RN #1 were re-educated on 03/26/12 on the facility policy of abuse and neglect, specifically the requirement that an employee be suspended immediately once an allegation of abuse or neglect is made against them. 4. SRNA #9 and SRNA #10 were re-educated on 03/15/12 and 03/26/12 by the Social Service Director on the facility's policy on abuse and neglect. 5. The Social Service Director began re-education of all facility staff on the Abuse Neglect Policy on 03/26/12 with 100% of staff completion (minus one employee on Family Medical Leave) which was completed by 04/25/12. Attendance was monitored and anyone that did not participate in the reeducation training, was given 1:1 training by the Social Service Director until 100% of employees were reeducated by 04/25/12. 6. To ensure no other residents were affected, interviewable residents were asked by staff how they were treated in the facility of they had any complaints about their care. 7. Direct care staff observed residents for unexplained bruising and reddened areas while providing care. 8. On 04/27/12, all residents in the facility had a skin assessment for signs of abuse by the DON, ADON, QA Nurse, Staff Development Nurse, three (3) MDS Nurses, Unit Coordinators, Restorative Nurse, Wound Care Nurse and seven (7) Management Nurses. 9. No determination will be made in the outcome of an abuse investigation without the review and approval of the Administrator or designee. 10. The QA Nurse will monitor weekly, all allegations of abuse to ensure the proper procedure is followed by facility staff. 11. QA tools were created to monitor and assure that new hires are in-serviced on abuse and neglect, that quarterly mandatory in-services on abuse and neglect are scheduled and that proper roster attendance is kept. QA will also continue to interview ten (10) staff monthly including supervisors on knowledge of forms of abuse and what to do if you suspect or see abuse. QA will also use tool to review follow-up of allegations of abuse to ensure that the facility policy and procedure was followed. On 04/28/12, the State Agency verified the immediacy of the Immediate Jeopardy was removed and the facility implemented corrective actions as alleged in the AoC, effective 04/28/12 based on the following: Interview with the Supervisor/LPN #3 and RN #1, on 04/28/12 at 11:00 AM, revealed they received education on 03/26/12 on the facility policy of abuse and neglect, specifically the requirement that an employee be suspended immediately once an allegation of abuse or neglect was made against them. Interview with the Supervisor/LPN #3 further revealed she was instructed to immediately remove the alleged perpetrator from direct resident care. Review of the in-service education documentation revealed the education was conducted on 03/26/12. Interview with SRNA #9 and SRNA #10, on 04/28/12 at 11:15 AM, revealed they were re-educated on 03/15/12 and 03/26/12 by the Social Service Director on the facility's policy on abuse and neglect. Review of the education documentation revealed the education was conducted on 03/15/12 and 03/26/12. Interview with the Social Service Director, on 04/28/12 at 10:15 AM, revealed she began re-education of all facility staff on the Abuse Neglect Policy on 03/26/12 with 100% of staff completion (minus one employee on Family Medical Leave) which was completed by 04/25/12. Attendance was monitored and anyone that did not participate in the re-education training, was given 1:1 training by the Social Service Director until 100% of employees were re-educated by 04/25/12. Review of the facility's documentation revealed the facility provided education to all staff between 03/26/12 and 04/25/12 on the abuse and neglect policy. The education sign-in sheets were compared to the facility staff roster to ensure 100% of staff received the education. Interviews were conducted with the following staff to verify the facility had educated them and to ensure their knowledge of the facility's abuse and neglect policy: Dietary Manager on 04/28/12 at 11:00 AM, Assistant Dietary Manager, on 04/28/12 at 11:05 Am, Cook #17, on 04/28/12 at 11:15 AM, Dietary Aide #18, on 04/28/12 at 11:20 AM, Dietary Aide #19, on 04/2812 at 11:25 AM, Dietary Aide #11, on 04/28/12 at 11:30 AM, Housekeeper #12, on 04/28/12 at 11:35 AM, Cook #13 on 04/28/12 at 11:40 AM, Housekeeping #14 on 04/28/12 at 11:50 AM, Supervisor/LPN #3, on 04/28/12 at 11:00 AM, RN #4, on 04/28/12 at 11:55 AM, Restorative Nurse/LPN #14, on 04/28/12 at 11:45 AM, SRNA #17, on 04/28/12 at 11:00 AM, SRNA #6, on 04/28/12 at 11:05 AM, Unit Coordinator/LPN #11, on 04/28/12 at 11:25 AM, LPN #12, on 04/28/12 at 11:35 AM, SRNA #15, on 04/28/12 at 11:30 AM, Housekeeper #20, on 04/28/12 at 11:45 AM, ADON, on 04/28/12 at 11:40 AM and SRNA #16, on 04/28/12 at 11:55 AM. All of the above staff was knowledgeable of the facility's abuse and neglect policy and verified they had received re-education by the facility. Interview with the DON, on 04/28/12 at 10:20 AM, revealed the facility completed skin assessments on 100% of the resident population and identified no concerns with the skin assessments. Review of the resident census revealed the facility had one hundred-two (102) residents on 04/28/12. Review of the skin assessments revealed the facility completed 102 skin assessments on 04/28/12 and no concerns were identified. Interview with the Administrator, on 04/26/12 at 3:30 PM, revealed no determination will be made in the outcome of an abuse investigation without the review and approval of the Administrator or designee as per the facility's policy. Interview with the QA Nurse, on 04/28/12 at 1:00 PM revealed she will monitor weekly, all allegations of abuse to ensure the proper procedure is followed by facility staff. She further stated QA tools were created to monitor and assure that new hires were in-serviced on abuse and neglect, that quarterly mandatory in-services on abuse and neglect were scheduled and that proper roster attendance was kept. Further interview revealed QA will also continue to interview ten (10) staff monthly including supervisors on knowledge of forms of abuse and what to do if you suspect or see abuse. QA will also use tool to review follow-up of allegations of abuse to ensure that the facility policy and procedure was followed. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review, video camera data review and facility policy review, it was determined the facility failed to ensure accurate clinical records were maintained for one (1) of eleven (11) sampled residents (Resident #2). The facility failed to ensure their "Emergency Care, General Guidelines For" policy was followed regarding ensuring the Licensed Nurse always take, report, and record vital signs when a resident's condition had changed and record the details and exact time of the condition change. On [DATE], LPN #1 identified a change in condition related to Resident #2 who was observed pale, having no respirations, and mucous in the his/her mouth. The LPN documented that he performed a physical assessment of Resident #2's change in condition, which included ausculating for lung sounds, attempting to obtain a blood pressure and pulse and suctioning the resident. However review of the facility's video data on [DATE] and LPN #1 interview revealed he did not personally perform a physical assessment as he had described in the Nurse's Notes. The facility did not conduct a physical assessment for approximately six (6) minutes after the LPN #1 had identified the change in condition and not until the Assistant Director of Nursing (ADON) initiated the assessment. The record revealed the resident was pronounced expired at 9:00 AM on [DATE]. The facility's failure to ensure staff followed their policy and procedure related to emergency care guidelines and standard of practice to ensure an accurate medical record to protect residents placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. Substandard Quality of Care (SQC) was identified at 42 CFR 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Observations, staff interviews, and inservice record reviews were conducted to verify removal of Immediate Jeopardy as alleged in the acceptable AoC on [DATE] prior to exiting the facility on [DATE]. However, non-compliance continued to exist at 42 CFR 483.75 Administration, with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents' medical record was maintained accurately. The findings include: Review of the facility's "Emergency Care, General Guidelines For" policy undated, revealed the purpose was to provide emergency care to a resident in need of urgent service. Continued review revealed it was the basic responsibility of the Licensed Nurse to always take, report, and record vital signs when a resident's condition had changed and record the details and exact time of the condition change. In an interview with the Director of Nursing (DON), on [DATE] at 11:07 AM, revealed this was the facility's policy for providing emergency care to residents. The DON stated she would expect her licensed nurses to perform an assessment of a resident with a change in condition that would include obtaining vital signs. She stated nurses should ensure their documentation is accurate. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Nutrition, dated ,[DATE], revealed staff was to provide the resident with assistance if he/she started to choke. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely impaired with daily decision making and totally dependent on staff for all Activities of Daily Living (ADLs). Review of the State Registered Nursing Assistants' (SRNAs) care plan revealed the resident was on aspiration precautions. Review of the Nurse's Notes, dated [DATE] written by Licensed Practical Nurse (LPN) #1 revealed at 7:45 AM Resident #2 had been "cleaned up" and was in bed waiting to be "gotten up" for breakfast. Interview, on [DATE] at 2:07 PM with LPN #1, revealed he went into Resident #2's room to check on his/her roommate. He stated he noted Resident #2 was still in bed and should have been up, so he immediately left the room to check on why the resident was still in bed. Observation of the video camera data revealed at 8:02:33 AM LPN #1 entered and immediately exited Resident #2's room. Further interview with the LPN revealed he returned to Resident #2's room and observed that the resident's skin color was pale, "paler than usual" and he/she was not breathing. In an additional interview, on [DATE] at 11:10 AM with LPN #1, he stated Resident #2 had "mucous coming out of" his/her mouth when he found him/her pale and without respirations. Further interview, on [DATE] at 9:20 AM with LPN #1, revealed he performed a visual assessment of the resident when he found him/her pale and without respirations. The LPN stated he did not have a stethoscope with him. He stated he observed the resident having no respirations. LPN #1 stated his thoughts were "disorganized" when he found the resident in this condition. He stated twice that he did not "touch" the resident and stated that he made no attempts to suction the resident prior to going to find the ADON despite having documented in the Nurse's Notes that he had performed a physical assessment of the resident's change in condition. Review of the Nurse's Note revealed LPN #1 noted Resident #2 had a "pale looking color" and had no respirations. The Note further detailed LPN #1 auscultated for lung sounds with none heard and "no pulse and B/P" (blood pressure) could be obtained. LPN #1 documented Resident #2's head was "inclined" at thirty (30) degrees and he/she was suctioned using the suction machine at the bedside. However, review of the video camera data revealed the LPN was observed to return to Resident #2's room at 8:03:15 AM and exit the room at 8:03:45 AM, thirty (30) seconds later. Continued interview with LPN #1 revealed the ADON "rushed into the room", noted the resident had secretions in his/her mouth, and proceeded to suction him/her. He stated the secretions were "foamy". Additionally, he stated he and the ADON examined Resident #2 and found he/she did not have a pulse or respirations. Interview, on [DATE] at 3:25 PM with the ADON, she stated she went to Resident #2's room and noted the resident had "some secretions, not thick, kind of foamy" in his/her mouth. The ADON stated there was a suction machine at the bedside so she immediately started to suction the resident. When asked if LPN #1 had suctioned the resident prior to her coming to the room, she stated "I don't think so". She stated she put on gloves, "checked" the resident's mouth, and there was nothing there. The ADON stated vital signs were attempted; however, none were obtained. The ADON indicated Resident #2's skin was "warm the whole time". Further observation of the video camera data revealed LPN #1 returned to the resident's room with the ADON at 8:09:10 AM, approximately six (6) minutes later. Further review of the Nurse's Notes revealed the LPN documented at 7:50 AM the Assistant Director of Nursing (ADON) was notified of the change in Resident #2's condition and she suctioned the resident. Further interview with the LPN revealed no assessment was performed until the ADON was present in Resident #2's room. Further review of the Nurse's Notes revealed a Note written by another nurse that stated Resident #2 was pronounced deceased at 9:00 AM. Continued interview with the DON, on [DATE] at 11:07 AM, revealed she would expect her licensed nurses to perform an assessment of a resident with a change in condition that would include obtaining vital signs and to ensure their documentation is accurate. She stated staff should not "falsify" their documentation. Interview with the Administrator, on [DATE] at 4:10 PM, revealed the facility held morning meetings with administrative staff (Administrator, Director of Nursing, Assistant Director of Nursing, Department and Unit Managers, Staff Development and Therapy staff) to discuss changes that had taken place with residents. The nurses discussed interventions, and put those into place. Then they follow up with education, in-services and competencies. However, the Administrator revealed they had not identified a problem with the staff's failure to conduct timely assessment of Resident #2 on [DATE] to ensure appropriate care and services were provided to the resident nor had they identified a problem with inaccurate documentation of the timing of when the assessment occurred and by whom. The facility could provide no evidence that they had identified a problem with inaccurate documentation of the medical record related to the incident of neglect which occurred involving Resident #2 on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE], based on the following: 1. LPN #1 was suspended pending completion of an investigation into the allegations. 2. The DON conducted a review on [DATE] of all residents' medical records who had expired in the facility in the past six (6) months. All records were found in compliance. 3. Medical record reviews were completed on [DATE] of thirty-seven (37) individual charts of residents who had expired in the facility in the past six (6) months or who had been sent to the hospital due to a change in condition in the past six (6) months. 4. New policies and procedures were created and implemented immediately on [DATE]. A policy entitled "Assessment of Residents when found to have a Change in Condition" which addressed the immediate assessment of a resident exhibiting a change in condition. A revision of the policy, "Charting and Documentation" to emphasize the importance of timely and accurate charting in residents' medical records. Staff inservices were conducted on these policies. Re-inservices were conducted on the "General Guidelines for Emergency Care" and "Procedure for Nursing Report and Rounds" policies. All Registered Nurses and Licensed Practical Nurses were inserviced on all the above policies starting on [DATE], and completed on [DATE], with the exception of two (2) nurses. One nurse who was out of the country, and one currently on Family Medical Leave. These two (2) nurses will not be allowed to work on the floor with residents until they are inserviced on the policies as well. 5. The DON and ADON will audit medical records for any resident that expires in the facility. The audit will include review for compliance with the above cited policies and procedures. 6. Monitoring of nurse compliance with the existing and revised policies and procedures will be performed by including them in the nurse competency reviews. These reviews were started on [DATE], and were seventy-six (76) percent complete on [DATE]. 7. On [DATE], the facility also created and implemented a "Condition Change Documentation 24 Hour Report Follow-up" form that will be reviewed at the Interdisciplinary Team's (IDT) morning meeting. A new policy was implemented in regards to the new form. The form and policy revisions were implemented on [DATE] to utilize as tools for monitoring. 8. The facility will Quality Assurance (QA) condition change assessments by selecting five (5) resident medical records from the facility's two (2) units for a total of ten (10) records to review that accurate assessments were completed for the selected residents. If compliance is found during the initial six (6) month period, then five (5) records from the two (2) units will be reviewed on a quarterly basis. These QA audits will be completed by the QA nurse. On [DATE] it was verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective [DATE] based on the following: Observation, on [DATE] from 10:45 AM until 11:00 AM revealed the new or revised policies were present in the Policies and Procedures books located at the Nurse's Station on each of the two (2) units. Interviews with staff including Registered Nurse (RN) #3 on [DATE] at 11:05 AM, RN #2 on [DATE] at 4:30 PM, Licensed Practical Nurse (LPN) #8 at 10:22 AM, LPN #6 at 10:40 AM, LPN #7 at 10:50 AM, LPN #10 at 10:56 AM, LPN #4 at 3:05 PM and LPN #9 at 3:41 PM revealed they all were aware of the new policies and procedures that had been implemented or revised: "Assessment of Residents when found to have a Change in Condition", "Charting and Documentation", "General Guidelines for Emergency Care" and "Procedure for Nursing Report and Rounds". They all were aware of the "Condition Change Documentation 24 Hour Report Follow-up" form and new policy related to it. Review of the facility's inservices and interviews, on [DATE] at 9:25 AM, with the Staff Development Nurse and Director of Nursing (DON) revealed the facility had inserviced all licensed staff beginning [DATE] related to the new policies and procedures with the exception of two licensed staff who was out of the country or on medical leave and would not be allowed to return to work until inserviced. Further interview revealed to validate staff's competency related to the inservice, staff was given a change of condition scenario and they had to document a nurse's note describing their assessment of the change in condition, such as obtaining vital signs. Additionally, interview and review of the facility's chart audits revealed thirty-seven (37) individual charts of residents who had expired in the facility in the past six (6) months or who had been sent to the hospital due to a change in condition in the past six (6) months were reviewed to ensure there were no other residents effected related to not appropriately assessing a resident who had a change of condition. Interview on [DATE] at 4:10 PM with the Administrator revealed all but two (2) staff had been inserviced on the new or revised policies and procedures and new form. According to the Administrator, new employees will receive the information in orientation. He stated a new QA audit was in place to monitor residents' change of condition and ensure accurate assessments were completed by the licensed nursing staff. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).