Every finding on record at Prestonsburg Health Care Center

Based on observation, interview, and record review, it was determined the facility failed to collaborate with the Hospice provider to ensure the development, implementation, and revision of the coordinated plan of care for one (1) of six (6) sampled residents (Resident #38). The facility failed to ensure Resident #38 had Physician's Orders to receive the Hospice services being provided for the resident. In addition, the facility failed to ensure Resident #38 had a Hospice Care Plan. The findings include: Review of the facility's, Hospice Services Agreement dated 12/31/2019, with the Hospice provider, revealed the facility and Hospice provider will jointly develop and agree upon a coordinated, interdisciplinary Plan of Care. Further review revealed the facility and Hospice provider were to periodically conduct joint reviews of each Plan of Care and modify the Plan of Care, if necessary for the involved Hospice residents. Review of the facility policy titled, Hospice Program, last reviewed 05/29/2018, revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON) or clinical designee would be responsible for the collaboration with the Hospice representatives and coordination of the facility staffs' participation in the Hospice care planning. Continued review revealed the DON, ADON or clinical designee were also responsible for communication with Hospice representatives and other healthcare providers participating in the provision of care for the terminal illness of the resident and related conditions to ensure quality of care for the resident and family. Continued review revealed for the resident receiving Hospice services the DON, ADON or clinical designee were to obtain information from the hospice provider to include: the most recent Hospice plan of care; Hospice election form; Physician certification and recertification of the terminal illness; names and contact information for Hospice personnel involved in the Hospice care for the resident Hospice medication information; Hospice Physician and applicable attending Physician Orders for the resident. Further review of the policy revealed the DON, ADON, or clinical designee were to additionally ensure the facility provided orientation of policies and procedures including resident rights, appropriate forms, and record documentation requirements to the Hospice staff providing care to the resident in the facility. Review of the Resident Face Sheet in Resident #38's medical record revealed the facility admitted the resident on 07/26/2022, with diagnoses of Parkinson's Disease and Unspecified Dementia without behavioral disturbance. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #38 to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #38 to require extensive assistance with all Activities of Daily Living (ADLs). Further review of the MDS revealed not documented evidence the facility identified Resident #38 had received Hospice care prior to his/her admission or while a resident residing in the facility. Review of the facility's Care Plan, dated 08/16/2022 for Resident #38, revealed no documented evidence Hospice care plan had been developed for the resident. Review of the Physician Note dated 07/28/2022, revealed Resident #38 had been on Hospice at home prior to admission to the facility for long-term care. Review of the current active Physician Orders in Resident #38's electronic medical health record revealed no order for Hospice care present in the medical record. Review of the Form CMS-802 Matrix for Providers, received on 08/23/2022, present in the Resident #38's record revealed it identified the resident as being on Hospice care. Interview on 08/25/2022 at 10:14 AM, with State Registered Nursing Assistant (SRNA) #4 revealed Resident #38 had been on Hospice since admission to the facility (admitted was 07/26/2022). Further interview revealed SRNA #4 indicated she was not aware of the reason for Resident #8's Hospice services however. Interview on 08/25/2022 at 2:15 PM, with Licensed Practical Nurse (LPN) #1 revealed Resident #38 had been admitted to the facility on Hospice. LPN #1 stated Hospice nurses visited Resident #38 weekly at the facility, and Hospice aides provided care for the resident three (3) times a week. Continued interview revealed LPN #1 indicated she was not aware of the Hospice diagnosis for Resident #38 however. LPN #1 further stated there was no order for Hospice services for the resident and the LPN was unsure how staff were made aware Hospice was being provided for the resident. Interview on 08/25/2022 at 2:22 PM, with the MDS Coordinator revealed she was not aware of Resident #38 receiving Hospice services and could not identify why the resident required Hospice services. The MDS Coordinator stated Hospice was a new service that the facility was providing. She revealed Hospice was not provided by the facility; the service was provided by the contracted Hospice company, so there would be no Physician's Order or care plan completed by the facility. Further interview revealed the MDS Coordinator stated the Hospice service was not placed on the MDS assessment either. Interview on 08/25/2022 at 3:03 PM, with the Medical Records Clerk revealed there was no written documentation exchanged between the Hospice provider and the facility. Interview on 08/25/2022 at 3:10 PM, with the Hospice Social Worker (SW) revealed Hospice service began about three (3) months ago at the facility. The Hospice SW stated Resident #38 was on Hospice services related to his/her diagnosis of Parkinson's Disease with related Dementia. The Hospice SW further revealed the Hospice's medical records should be sending written documentation to the facility regarding Resident #38. Interview on 08/25/2022 at 3:21 PM, with the Hospice Executive Director (ED) revealed the facility and the Hospice company, had a contract for an extended length of time; however, they only recently began providing Hospice services to the facility's residents. The Hospice ED further stated the Hospice company should have been providing the Hospice Order and Hospice care plan for the resident and be involved in the care planning process. Interview on 08/25/2022 at 4:09 PM, with the Hospice Registered Nurse (RN) revealed a verbal report was given to the floor nurse and the supervisor after the Hospice nurse visited Resident #38. The Hospice RN further stated the exchange of information had been verbal, but written documentation would start being coordinated with the facility staff and sent to the facility. Interview on 08/26/2022 at 9:30 AM, with the facility's Nurse Consultant revealed the facility and Hospice should be coordinating the care being provided for Resident #38. Further interview revealed there should also be an order for the Hospice care being provided and a care plan should also be in place. Interview on 08/25/2022 at 2:51 PM, with the Administrator revealed the facility just started taking Hospice residents within the last two (2) months and the process was new to everyone. The Administrator stated verbal communication was to occur to inform staff of the resident being on Hospice. She revealed she was unaware of any documents or care plans provided between the facility and the Hospice company. The Administrator further stated there should be a Physician's Order for Hospice and the MDS assessment should identify the Hospice services for the resident. An additional interview on 08/26/2022 at 11:49 AM, with the Administrator revealed her expectation was for Hospice services to be coordinated with the Hospice provider and facility staff. Further interview revealed the expectations were for an Physician's Order to be obtained, Hospice should be identified on the resident's MDS Assessment, and a Hospice care plan should be in place as required.

Based on observation, interview, record review, and policy review, it was determined that the facility failed to implement the care plan for one (1) of seventeen (17) residents. The facility developed a care plan for Resident #47 with an intervention to keep the catheter bag off the floor. However, observation revealed the resident's catheter was on the floor. The findings include: Review of facility policy titled, Comprehensive Care Plans, revised 07/19/18, revealed .The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Record review revealed the facility admitted Resident #47 on 06/19/19 with [DIAGNOSES REDACTED]. Review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating little or no cognitive impairment. Further review of the MDS revealed the resident had a catheter. Review of Resident #47's Care Plan, revised 09/27/19, revealed the resident had an indwelling urinary catheter related to a [DIAGNOSES REDACTED]. The facility developed a goal for the resident to have no signs of urinary tract infection, with an intervention to ensure the urinary drainage bag did not touch the floor. Observation on 09/26/19 at 3:33 PM of Resident #47 revealed the resident lying on his/her bed. Further observation revealed the resident's urinary catheter and tubing were lying on the floor. Interview on 09/27/19 at 12:38 PM with the Director of Nursing (DON)/Infection Control Nurse revealed catheter bags should not touch the floor. She further revealed that she conducted walking rounds twice a day and had not identified any concerns with urinary catheters being on the floor.

Based on observation, interview, and facility policy review, it was determined that the facility failed to conduct an accurate Minimum Data Assessment (MDS) assessment for one (1) of seventeen (17) sampled residents. Resident #36 was noted to have limited range of motion to both upper and lower extremities; however, the facility failed to document that the resident had limited range of motion on the resident's 08/24/19 MDS. The finding include: Review of the facility policy titled, Resident Assessment, review date 07/31/18, revealed, The facility must conduct initially and periodically a comprehesive, accurate, standardized reproducible assessment of each resident's functional capacity. Record review revealed the facility admitted Resident #36 on 06/13/18 with [DIAGNOSES REDACTED]. Observation of Resident #36 on 09/25/19 at 1:15 PM revealed the resident was sitting in a recliner. The resident's bilateral upper and lower extremities were contracted. Review of Resident #36 Care Plan, revised on 09/25/19, revealed the facility planned care for the resident to have assistance with activities of daily living related to contractures. However, a review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed no documented evidence that the resident had Functional Limitation in Range of Motion to the upper or lower extremities. Interview on 09/27/19 at 10:39 AM with the facility MDS Coordinator confirmed Resident #36 had limited range of motion to both upper and lower extremities. The MDS Coordinator stated the resident's previous MDS had been marked as having limited range of motion. She further stated that the resident's 08/24/19 MDS related to range of motion was an error.

Based on observation, interview, and policy review it was determined that the facility failed to ensure infection prevention was maintained for two (2) of seventeen (17) residents. Observation revealed Resident #37 and Resident #47's indwelling urinary catheter drainage bags and/or tubing were lying on the floor. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised (MONTH) (YEAR), revealed revealed, An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of facility policy titled, Catheterization, reviewed 05/23/19, revealed .avoid letting (the catheter) touch the floor. 1. Record review revealed the facility admitted Resident #37 on 07/26/16 with [DIAGNOSES REDACTED]. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed the resident had a catheter. Observation of Resident #37 on 09/25/19 at 2:02 PM and on 09/26/19 at 4:13 PM revealed the resident was in a low bed and the resident's urinary catheter bag and tubing were lying on the floor. Interview on 09/26/19 at 4:13 PM with State Registered Nursing Assistants #1 and #2 revealed they were aware that urinary drainage bags should not touch the floor and removed the drainage bag from the floor after the interview. 2. Record review revealed the facility admitted Resident #47 on 06/19/19 with [DIAGNOSES REDACTED]. Review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating little or no cognitive impairment. Further review of the MDS revealed the resident had a catheter. Review of Resident #47's Care Plan, revised 09/27/19, revealed the resident had a care plan that stated the resident had an indwelling urinary catheter related to a [DIAGNOSES REDACTED]. The resident had care-planned approaches to not allow the drainage bag to touch the floor. Observation on 09/26/19 at 3:33 PM of Resident #47 revealed the resident lying in bed and the catheter, as well as the tubing, were lying on the floor. Interview on 09/27/19 at 12:38 PM with the Director of Nursing (DON)/Infection Control Nurse revealed a resident's catheter drainage bag should not touch the floor. She further revealed that she conducted walking rounds twice a day and had not identified any concerns with catheters being on the floor.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments. Observation of the Ocean Side medication cart on 09/07/18, revealed the cart was observed in the hallway unlocked and unattended. The findings include: Review of the facility's policy titled, Medication Administration, dated (MONTH) (YEAR), revealed during medication administration staff were required to ensure the medication cart was kept locked when out of the eyesight of the medication nurse. Observation of the Ocean Side medication cart on 09/06/18 at 1:30 PM, revealed the medication cart was observed in the hallway unattended and unlocked. Interview conducted with RN #1 on 09/06/18 at 1:40 PM, revealed she had taken a drink to a resident and forgot to lock the medication cart. The RN stated she had been trained to lock the medication cart or keep the cart within eyesight. Interview with the Director of Nursing (DON) on 09/07/18 at 2:00 PM, revealed staff were required to keep their medication carts locked unless the cart was in direct eyesight. The DON stated RN #1 should have locked the cart when she went into the resident's room. The DON stated she made rounds several times daily and observed medication carts, but had not identified a concern with medication carts being unlocked.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure the medication error rate was less than five (5) percent. Observation of medication administration on 07/24/17 revealed Licensed Practical Nurse (LPN) #1 failed to administer the correct dose of [MEDICATION NAME] and [MEDICATION NAME] to unsampled Resident A. Observation of twenty-six (26) medication administration opportunities were observed with two (2) errors, resulting in a medication error rate of seven (7) percent. The findings include: Review of the facility's medication administration policy dated December 2001 revealed when administering suspensions and thick liquids that may coat calibrated measuring cups, staff were required to use water to rinse medication residue from the cup and administer to the resident to ensure the entire dose was given. Record review for Resident A revealed the resident's physician prescribed [MEDICATION NAME] 125 milligrams/5 milliliter (ml) suspension to be administered via tube (feeding tube) twice daily and [MEDICATION NAME] 10 grams/15 ml via tube twice daily. The physician's orders [REDACTED]. Review of the most recent [MEDICATION NAME] level conducted on 07/13/17 revealed the resident's level was 9.6 (normal range 10-20). Observation during medication pass on 07/24/17 with LPN #1 revealed the LPN failed to rinse the medication cup with water after administering [MEDICATION NAME] and [MEDICATION NAME] medications via the resident's gastrostomy tube. Interview with LPN #1 on 07/24/17 at 9:20 AM, revealed she was aware that she was required to rinse the medication cup after administering the medication to ensure the resident received the correct dose. LPN #1 stated she was nervous and was concentrating on administering the resident's medication in the correct order. LPN #1 acknowledged Resident A did not get the prescribed dose of [MEDICATION NAME] and [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 07/25/17 at 7:55 PM, revealed she intermittently monitored and observed staff administering medications, including gastrostomy tube medication. The DON stated the nurse should rinse the cup after administration of medication to ensure the correct dose was given. The DON stated she had not identified any problems with medication administration via gastrostomy tube.

Based on observation, interview, and facility policy review, it was determined the facility failed to label and store all drugs and biologicals in accordance with currently accepted professional principles. Observation of the medication storage room on the Memory Lane Unit on [DATE] revealed expired intravenous (IV) fluids and topical skin prep medications in the emergency storage box available for use. The findings include: Review of the facility's policy titled Medication Storage, dated [DATE], revealed that outdated, contaminated, discontinued, or deteriorated medications would immediately be removed from stock, and disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. Observation of the emergency drug storage box in the medication storage room on the Memory Lane Unit on [DATE] at 6:45 PM revealed the following medications were expired and available for use: 8.4% Na Bicarb (Sodium Bicarbonate - a medication used in emergencies) IV with an expiration date of [DATE]; 10% Dextrose 1000 cc (IV fluid) with an expiration date of [DATE]; D5 0.9% 1000 cc (IV fluid) with an expiration date of [DATE]; 5% Dextrose with 0.2% normal saline 1000 cc (IV fluid) with an expiration date of [DATE]; two (2) Imipenem 250 mg vials (IV antibiotic) with an expiration date of [DATE]; one (1) Imipenem 500 mg vial (IV antibiotic) with an expiration date of [DATE]; two (2) ChloraPrep applicators (used to cleanse skin) with an expiration date of [DATE]. Interview with Registered Nurse (RN) #2 revealed pharmacy personnel checked the emergency storage box monthly and replaced the emergency drug storage box with a new box. RN #2 stated she was not sure when pharmacy personnel last changed out the emergency drug storage box and was not aware there were medications that were expired in the emergency drug box. Interview with the Director of Nursing (DON) on [DATE] at 6:45 PM revealed it was the pharmacy's responsibility to check the emergency storage box weekly. The DON reported she had not identified any problems with changing out the emergency drug storage box.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to consult with the physician and notify the resident's responsible party for one (1) of three (3) sampled residents (Resident #1). Resident #1 was identified on 06/29/16 to have sustained a significant weight loss of twenty (20) pounds; however, the facility failed to notify Resident #1's physician of the weight loss until 07/22/16, and according to the responsible party the resident's family was not notified of the weight loss by the facility. The findings include: Review of the facility's policy and procedure titled, Change of Condition, not dated, revealed the facility would assess and document changes in a resident's health status and would relay assessment information to the physician. Further review revealed the facility would document actions in the medical record. Review of the Change of Condition policy and procedure revealed the facility would notify the resident's responsible party of the identified change and would document the notification in the medical record. Record review revealed the facility readmitted Resident #1 on 06/06/16 after a hospitalization , and the resident's weight upon readmission was 168 pounds. Review of Resident #1's weights revealed on 06/29/16, Resident #1's weight was documented as 150 pounds, a 20-pound weight loss in nine days. However, there was no evidence that Resident #1's physician was notified of the weight loss until 07/22/16, when the resident's physician was contacted and a new order received for staff to initiate the facility's Special Nutrition Program (SNP) which provided fortified foods for residents who are identified to be nutritionally at risk. Interview with Resident #1's family members on 10/18/16 at 6:56 PM revealed they were not notified of Resident #1's significant weight loss when it was identified on 06/29/16. Interview with the Medical Records Manager on 10/18/16 at 10:50 AM, and 10/19/16 at 2:32 PM, revealed she was responsible for notifying the Director of Nursing of any weight changes greater than five pounds. The Medical Records Manager stated she was responsible to notify the DON of weight changes greater than five pounds, who in turn made notifications to the physicians and responsible parties involved. Interview with the Director of Nursing on 10/18/16 at 3:28 PM, revealed the Medical Records Manager had not notified her of Resident #1's weight loss when it was identified on 06/29/16, and therefore did not make the physician and responsible party notifications as required.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure services were provided in accordance with each resident's plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 had a care plan intervention dated 06/20/16 that directed staff to weigh the resident weekly. However, record review revealed the resident's weights were not obtained as directed per the plan of care. The findings include: Review of the facility's policy and procedures titled, Comprehensive Care Plans, revised 06/01/15, revealed the facility would maintain a comprehensive care plan for each resident which identified the highest level of functioning the resident was expected to attain. Additional review of the policy revealed care plan interventions would be implemented to address any identified problems and their causes. Review of a Comprehensive Care Plan dated 06/20/16 revealed the facility had assessed Resident #1 to be at nutritional risk with interventions initiated for staff to weigh Resident #1 weekly and to monitor the results. Further review revealed the staff was to report to the physician any identified significant weight loss. Additionally, the care plan stated the staff would provide the responsible party with nutritional updates and discuss with the responsible party any concerns about nutritional impairment. Review of Resident #1's weight report revealed the resident weighed 170 pounds on 06/20/16 and 150 pounds on 06/29/16, a loss of 20 pounds in nine days. Additional review of the weight report revealed Resident #1 was not weighed by the facility again until 07/18/16, 19 days later when the resident was documented as weighing 149 pounds. Interview with the Director of Nursing on 10/18/16 at 3:28 PM revealed the Medical Records Manager was responsible for ensuring the resident's care plan was followed and weights were obtained per the resident's plan of care. The DON stated she expected the staff to follow the resident's care plan and had not identified a concern with care plans not being followed in the past.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure residents maintained acceptable parameters of nutrition for one (1) of three (3) sampled residents (Resident #1). Resident #1 was identified on 06/29/16 to have sustained a significant weight loss of twenty (20) pounds; however, the facility failed to address the weight loss and implement interventions to prevent further weight loss until 07/22/16, twenty-three (23) days after the identified weight loss. The findings include: Review of the facility's policy and procedure titled, Weight Monitoring, revised 06/01/15, revealed the facility would identify residents who were at nutritional risk. Further review revealed residents' weights would be monitored weekly upon admission/readmission for four weeks and monthly thereafter unless the weight remained unstable. Further review revealed if a weight loss was identified, a nurse would complete a Situation Background Assessment Recommendation (SBAR) and would notify the physician and responsible party of the weight loss. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's weight was 165 pounds, and he/she had not sustained a significant weight loss or gain. Resident #1's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. Record review revealed the facility readmitted Resident #1 on 06/06/16 from the hospital with [DIAGNOSES REDACTED]. Additional record review revealed Resident #1 was noted to weigh 168 pounds at readmission. The facility implemented weekly weights upon readmitting the resident per facility protocol. Review of Resident #1's weekly weights revealed Resident #1's weight was noted to be 170.8 pounds on 06/13/16 and 170 pounds on 06/20/16. However, on 06/29/16, Resident #1's weight was recorded to be 150 pounds, a 20-pound weight loss in nine days. Additional review of the weight report revealed Resident #1 was not weighed by the facility again until 07/18/16, 19 days later, at which time the resident's weight was recorded as 149 pounds. Additional record review revealed no documented evidence the facility addressed the resident's weight loss until 07/22/16, 21 days later. Review of a physician's telephone order dated 07/22/16 revealed a new order for Resident #1 to be placed on the Special Nutrition Program (SNP). The SNP was a facility program to provided fortified foods to residents who were underweight, experiencing significant weight loss, or with poor oral intake. The SNP also included providing the resident with a Multivitamin daily for decreased weight. Interview with Resident #1 on 10/18/16 at 5:30 PM, revealed he/she liked the food the facility served but stated, I just don't feel like eating sometimes. Interview with the Medical Records Manager on 10/18/16 at 10:50 AM, and 10/19/16 at 2:32 PM, revealed she was responsible for calculating resident weights to determine if a resident had sustained a significant change in weight. Further interview revealed that if a resident was identified to have had weight gain or loss of greater than five pounds she was responsible for notifying the Director of Nursing, who in turn notified the physician, the registered dietitian, and the resident's responsible party of the weight change. The Medical Records Manager stated she had failed to make the required notification to the DON when the resident's weight loss was identified. The Medical Records Manager stated she did not know why she failed to make the required notifications. Interview with the Director of Nursing revealed the Medical Records Manager was responsible for reporting to her any identified significant weight loss or gain. The DON stated she would then ensure an SBAR was completed and sent to the resident's physician. The DON stated she did not recall being notified by the Medical Records Manager of Resident #1's weight loss that was identified on 06/29/16.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a comprehensive plan of care was developed for three (3) of fourteen (14) sampled residents (Resident #7, Resident #9, and Resident #10) that had been identified by the facility to have a positive [MEDICATION NAME] (TB) skin test (PPD) history. Review of the comprehensive plan of care for Resident #7, Resident #9, and Resident #10, revealed the facility failed to develop a care plan related to the residents' positive TB skin test with interventions to monitor the resident for the development of [MEDICAL CONDITION] symptoms indicative of active [MEDICAL CONDITION]. The findings include: A review of the facility's policy titled Care Plans- Comprehensive, dated 06/01/15, revealed the facility would develop an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs for each resident. 1. A review of Resident #7's medical record revealed the facility admitted the resident on 11/30/12, with [DIAGNOSES REDACTED]. Further record review revealed the resident's chart was flagged Positive PPD (positive TB skin test, which indicates skin test with greater than 10 millimeters of induration). Review of Resident #7's care plan dated 04/28/16 revealed the facility had not developed a care plan related to the resident's positive PPD. In addition, there was no documentation the facility had monitored the resident for the development of [MEDICAL CONDITION] symptoms or signs/symptoms of active [MEDICAL CONDITION]. 2. A review of Resident #10's medical record revealed the facility admitted Resident #10 on 09/07/10, with [DIAGNOSES REDACTED]. Further record review revealed the resident's chart was flagged Positive PPD. Review of Resident #10's care plan dated 06/07/16 revealed the facility had not developed a care plan related to the resident's positive PPD. In addition, there was no documentation the facility had monitored the resident for the development of [MEDICAL CONDITION] symptoms or signs/symptoms of active [MEDICAL CONDITION]. 3. A review of Resident #9's medical record revealed the facility admitted the resident on 04/25/14, with [DIAGNOSES REDACTED]. Further record review revealed the resident's chart was flagged Positive PPD. Review of the care plan dated 02/27/15 revealed the facility had not developed a care plan related to the resident's positive PPD and there was no documentation the facility had monitored the resident for the development of [MEDICAL CONDITION] symptoms or signs/symptoms of active [MEDICAL CONDITION]. An interview conducted with the Minimum Data Set (MDS) Coordinator on 06/16/16, at 1:35 PM, revealed she was responsible for developing the residents' comprehensive care plans. The MDS Coordinator stated she was not aware she was required to develop a care plan related to residents that had a positive PPD. An interview conducted with the Director of Nursing (DON) on 06/16/16, at 1:45 PM, revealed she was not aware a resident was required to have a care plan for a positive TB skin test, but agreed they should have. The DON stated she reviewed residents' care plans at care plan meetings and had not identified any concerns with residents not having a care plan related to having a positive PPD.

Based on interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an effective infection control program to help prevent the development and transmission of [DIAGNOSES REDACTED] (TB) for three (3) of fourteen (14) sampled residents (Residents #7, #9, and #10) who had been identified to have a history of positive [MEDICATION NAME] (TB) skin test (PPD). The facility failed to monitor the residents for the development of pulmonary symptoms indicative of active [DIAGNOSES REDACTED]. The findings include: Review of the facility's policy titled TB Resident Administration/Interpretation, undated, revealed the facility would administer and interpret [MEDICATION NAME] skin tests in accordance with recognized guidelines and pertinent regulations using PPD (Purified Protein Derivative - a skin test for [DIAGNOSES REDACTED]). The policy failed to indicate what staff was required to do if a PPD skin test was positive. In addition, the policy did not indicate what interventions were required to monitor residents for signs and symptoms of active [DIAGNOSES REDACTED]. 1. A review of the medical record for Resident #7 revealed the facility admitted the resident on 11/30/12, with [DIAGNOSES REDACTED]. Further record review revealed the resident's chart contained a sticker that indicated Positive PPD. However, there was no documentation the facility had monitored the resident for the development of pulmonary symptoms or signs/symptoms of active [DIAGNOSES REDACTED]. 2. A review of the medical record for Resident #10 revealed the facility admitted the resident on 09/07/10, with [DIAGNOSES REDACTED]. Further record review revealed the resident's chart was flagged Positive PPD. However, there was no documentation the facility had monitored the resident for signs/symptoms of active pulmonary disease. Interview with the Director of Nursing (DON), who was also the Infection Control Nurse (ICN), on 06/16/16, at 1:45 PM, revealed a PPD skin test that measured greater than 15 millimeters in induration in a resident who was not immunosuppressed, and greater than 10 millimeters of induration in an immunosuppressed resident, would be considered positive. The DON stated if a resident was assessed to have a positive PPD skin test, a chest x-ray would be completed and repeated annually to assess the resident for signs and symptoms of active [DIAGNOSES REDACTED]. The DON stated the resident's chart would also be flagged to indicate the resident had a positive PPD skin test. The DON stated the facility did not develop a care plan to include interventions for monitoring for signs/symptoms of active [DIAGNOSES REDACTED] and only monitored for [DIAGNOSES REDACTED] with the PPD skin test and chest x-rays. 3. A review of the medical record for Resident #9 revealed the facility admitted the resident on 04/25/14, with [DIAGNOSES REDACTED]. Further record review revealed the resident's chart was flagged Positive PPD. However, the facility failed to document how they would monitor the resident for signs/symptoms of active pulmonary disease.

Based on interview, record review, and a review of the facility policy and investigations/incident reports, it was determined the facility failed to have an effective system in place to ensure residents' comprehensive care plans were reviewed and revised after falls occurred for one (1) of twenty-six (26) sampled residents (Resident #8). (Refer to F323.) Resident #8 sustained a fall on 03/05/15 when the resident leaned forward in his/her wheelchair and fell through the breakaway lap buddy onto the floor, hitting his/her head on the floor sustaining an injury. Facility staff determined the resident was trying to pick up a cup from the floor when the resident fell from the wheelchair. The facility educated staff on 03/05/15 to not leave cups (stuff from hydration) with the resident to prevent further falls from occurring. However, review of the comprehensive plan of care for Resident #8 provided no evidence that facility staff reviewed/revised the resident's plan of care to prevent further falls from occurring. Resident #8 sustained another fall on 04/12/15 when the resident leaned forward in his/her wheelchair and fell through the breakaway lap buddy onto the floor. As a result of the fall, the resident was diagnosed with [REDACTED]. The facility's failure to ensure residents' comprehensive plans of care were reviewed and revised to prevent accidents has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/23/15, and was determined to exist on 04/12/15. An acceptable Allegation of Compliance was received on 07/30/15, which alleged removal of the Immediate Jeopardy on 07/30/15. The State Survey Agency determined the Immediate Jeopardy was removed on 07/30/15, which lowered the scope and severity to D while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Care Plans, last revised October 2010, revealed the resident's comprehensive plan of care was designed to identify problem areas and incorporate risk factors associated with the problems identified by facility staff. Review of the closed medical record for Resident #8 revealed the facility admitted Resident #8 on 01/09/09, with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 required extensive assistance from staff with locomotion on and off the unit and the resident utilized a wheelchair as a mobility device. Review of Resident #8's comprehensive plan of care, dated 12/09/14 revealed staff had identified that the resident was at risk for fall related injury and required the use of a breakaway lap buddy (a cushion that fits on a wheelchair at the resident's lap. The middle of a breakaway cushion is held together with Velcro). A review of a fall investigation revealed Resident #8 sustained a fall on 03/05/15 when the resident leaned forward in a wheelchair and fell through the lap buddy onto the floor, hitting his/her head on the floor. Review of the resident's care plan revealed staff revised the resident's plan of care after the resident experienced the fall on 03/05/15 to include an intervention to not leave cups (stuff from hydration) with the resident. The care plan further revealed staff was in-serviced related to the intervention. However, review of the comprehensive plan of care provided no evidence that staff assessed the resident or the breakaway lap buddy to ensure the interventions that were implemented were effective to prevent further falls from occurring for the resident. Further review of fall investigations for Resident #8 revealed on 04/12/15, the resident sustained [REDACTED]. Resident #8 was transferred to the hospital and was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 07/23/15 at 6:25 PM revealed Resident #8's fall, including the care plan, was reviewed on 03/05/15. The DON stated staff was in-serviced to not leave cups/hydration items with the resident. However, the DON acknowledged staff had not assessed the resident to ensure the breakaway lap buddy was effective to prevent further falls from occurring for the resident. Interview with the MDS Coordinator on 07/30/15 at 2:17 PM revealed residents' care plans were reviewed and revised during daily clinical meetings. The MDS Coordinator stated care plans were a group effort and they had not identified any concerns with the revision of Resident #8's care plan on 03/05/15. **The facility provided an acceptable Allegation of Compliance (AOC) on 07/30/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #8 no longer resides at the facility. Resident #8's chart was audited and reviewed by the Regional Nurse Consultant on 07/23/15. 2) The facility has a current system to ensure residents' fall safety care needs are being met: -Floor staff process: a. Nurse notified of resident fall by State Registered Nurse Aide (SRNA), housekeeper, visitors, etc. b. Nurse to assess resident including neurological checks, pain, Range of Motion (ROM), skin, joints, extremities, vital signs. c. Nurse to provide immediate care as indicated by the assessment. d. Notify physician and Power of Attorney (POA) of the fall. e. Document assessment and pertinent facts related to the fall. f. Begin investigation of the fall. g. Complete Incident/Accident in event manager system. h. Determine root cause of fall if possible. 1. Nurse utilizes root cause questionnaire to assist with root cause. 2. SRNAs draw out a picture of the scene. i. Update care plan with appropriate intervention. j. Enter resident's name on Nursing communication log for 72 hour follow-up charting. k. Notify the Director of Nursing (DON) if the resident is sent out; otherwise, the Administrator and the DON are notified by event manager system. -Clinical administration/IDT team process: The facility Administrator, DON, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Social Services Director (SSD), Therapy Services Manager, Central Supply, and Quality of Life (QOL) Director review event data, which includes falls, weight loss, skin integrity, etc. in the event manager system daily during morning clinical meeting. a. Daily clinical/PI meeting conducted and all Accident/Incidents, care plans, SRNA care plans, and pertinent resident data is reviewed. b. Resident is logged on the fall tracker log and resident tracker log for tracking and trending. c. Root cause is completed utilizing the five (5) why template. d. The resident chart is reviewed during the meeting. e. Tracking/trending, root cause, and info from resident chart review are all taken into consideration for appropriate intervention. f. Care plan and SRNA care plan is updated with new interventions. g. Follow up for 72 hours to assess resident's status and intervention appropriateness. 3) All facility residents were assessed by completing a falls risk assessment on each resident and then comparing falls risk identified to current care plan interventions by the DON, ADON, SDC, Nursing Supervisor, or Regional Nurse Consultant on 07/24/15 and then all resident care plans were re-audited, by comparing current resident care plans with current resident ADLs assist level with latest MDS, starting on 07/28/15 and completed on 07/29/15 to determine if safety needs were being met as outlined by resident's care plan, to include wheelchair (w/c) safety devices. Noted concerns from re-audit on 07/28 - 07/29 were five (5) residents whose ADL care plan did not reflect the residents' current level of ADL assistance required. 4) All accident/incident reports, for the past 90 days, have been reviewed, to include not just the individual incident/accident but a more global approach by reviewing the tracking/trending of individual resident falls to include day, shift, time, location on 07/24/15 by the DON, ADON, SDC, Nursing Supervisor, or Signature Care Consultant to identify any safety concerns, ensure thorough investigation of all Accidents/Incidents was completed, and implemented interventions on care plan that address root cause. No concerns identified by the facility. 5) Once resident assessments and accident/incident reviews along with tracking/trending reviews were completed by 07/24/15, then all resident care plans and SRNA care plans were audited, utilizing a census board audit tool, by 07/24/15, reviewed and updated as needed, to include wheelchair safety devices, by the DON, ADON, Nursing Supervisor, MDS Coordinator, or Regional Nurse Consultant to ensure that each resident's care plan/SRNA care plan reflects current resident safety care needs. The DON, ADONs, Nursing supervisor, or MDS Coordinator will audit all residents, with any changes noted, care plan/SRNA care plan for any updates, revisions, and/or new interventions, during the morning clinical meeting with IDT present, daily starting on 07/24/15, and continuing until immediacy is lifted, then 10 different resident care plans/SRNA care plans will be audited weekly for 4 weeks to ensure resident safety care needs are being met. Results will be reviewed in weekly (Quality Assurance Performance Improvement) QAPI meeting. QAPI committee will determine ongoing frequency of resident care plan audit at that time 6) The DON, ADONs, SDC, MDS or Nursing Supervisor will review all A/I daily to ensure thorough (individual incident along with tracking/trending for that specific resident) investigation initiated, root cause analysis conducted and appropriate intervention, to meet root cause, implemented, along with care plan updated to reflect new intervention starting on 07/24/15. Compliance will be reviewed in weekly QAPI meeting. 7) The DON, ADONs, Nursing Supervisor, or MDS Coordinator will audit all residents, with any changes noted, care plan/SRNA care plan for any updates, revisions, and/or new interventions, during the morning clinical meeting with IDT present, daily starting on 07/24/15, and continuing until immediacy is lifted, then 10 different resident care plans/SRNA care plans will be audited weekly for 4 weeks to ensure resident safety care needs are being met. Results will be reviewed in weekly QAPI meeting. QAPI committee will determine ongoing frequency of resident care plan audit at that time 8) The facility Administrator, DON, ADON, SDC, RN Supervisor, MDS Coordinator, Business Office Manager (BOM), Rehabilitation Service Manager (RSM), Dietary Manager, QOL Director, Human Resources (HR) Director, Environmental Services Director, SSD, Admissions Director, Medical Records, and Chaplain were educated on 07/23/15 by the Signature Care Consultant on the fall program process/system noted in #2, care plan policy, to include revising and updating the care plan along with interventions that meet not only the individual accident/incident but also patterns identified from tracking and trending, accident/incident policy, and falls policy and procedure, to include tracking and trending procedure. This training was performed face-to-face in order to facilitate discussion and question. Department Administrative Managers could not return to work until the above education was provided, post-test administered, and 100% score obtained; if Manager did not score 100% on post-test, then Manager was immediately re-educated and post-test re-administered. This process continued until all Managers obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Signature Care Consultant. 9) Once facility Administrator, DON, ADON, SDC, RN Supervisor, MDS, BOM, RSM, Dietary Manager, QOL Director, HR, Environmental Services Director, SSD, Admissions Director, Medical Records, and Chaplain were re-educated on the process in #2, care plan policy, to include revising and updating the care plan along with interventions that meet not only the individual accident/incident but also patterns identified from tracking and trending, accidents/incidents policy, and falls policy and procedure, to include tracking and trending procedure, they were then assigned to assist the SDC in providing education to the staff on the above policies and procedures, which started on 07/23/15. No employee will be allowed to work until education is provided. The facility has 88 employees. Seventy employees received the education by 07/24/15, six employees were scheduled to receive education by 07/26/15, and twelve employees had certified letter sent out on 07/24/15. Employees could not return to work until the above education was provided, post-test administered and 100% score obtained; if employee did not score 100% on post-test, then employee was immediately re-educated and post-test re-administered. This process continued until all employees obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Signature Care Consultant. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained; if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. No agency staff is utilized by the facility. 10) A nurse from the Regional Team or Corporate Office has been onsite since 07/23/15 and will remain in the facility daily until jeopardy has been lifted. The nurses from the Regional Team or home office will be validating compliance with all audits and reviews completed daily until immediacy is lifted, then will validate compliance weekly for 4 weeks. The Regional Nurse Consultants will also be assisting with completion of investigations, root cause analysis, updating and/or revising care plans, performing chart audits, and providing oversight and consultation. The Vice-President of Operations, Special Projects Administrator, or Director of Clinical Programs will be in daily contact with the Signature Care Consultant and will review compliance daily until immediacy is lifted, then weekly for 4 weeks. 11) Administrative oversight of the facility will be completed by the Vice President of Operations, Signature Care Consultant, or Special Projects Administrator daily until the removal of immediacy beginning 07/23/15, then weekly for 4 weeks, then monthly. 12) Results of all audit and reviews will be discussed daily for compliance and action plan implemented immediately to address any identified concerns. Any identified concerns will be discussed during weekly QAPI meeting. A Quality Assurance meeting will be held weekly for 4 weeks beginning 07/23/15, then monthly for recommendations and further follow-up regarding the above stated plan. At that time based upon evaluation the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Record review revealed the Regional Nurse Consultant audited Resident #8's chart on 07/23/15. 2) Interviews on 07/30/15 with Housekeeping Staff #1 at 10:58 AM, Dietary Staff #1 at 1:50 PM, SRNA #8 at 9:57 AM, SRNA #9 at 10:08 AM, SRNA #10 at 10:14 AM, SRNA #3 at 10:22 AM, SRNA #6 at 10:30 AM, Licensed Practical Nurse (LPN) #4 at 10:38 AM, and Registered Nurse (RN) #4 at 10:50 AM revealed the staff had been trained and were familiar with the facility's fall protocol. Interviews on 07/30/15 with the Administrator at 2:37 PM, DON at 11:21 AM, ADON at 2:08 PM, MDS Coordinator at 2:17 PM, SDC at 12:15 PM, SSD at 12:01 PM, Central Supply at 12:07 PM, and QOL at 11:03 AM revealed the staff was familiar with the review process for falls and accidents/incidents. 3) Record review of fall assessment and audits of care plans and CNA care plans revealed any issues identified were corrected by facility staff beginning on 07/24/15 and completed on 07/29/15. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:15 PM, and the Regional Nurse Consultant at 1:57 PM revealed there were some issues identified with ADL assistance requirements with the care plans, MDS assessments, and the CNA care plans but the issues were corrected. 4) Review of facility audits and tracking logs revealed facility administrative staff had reviewed all accident/incident reports related to falls for the past 90 days and did not identify any concerns. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:01 PM, and Signature Care Consultant at 1:57 PM revealed all falls for the past 90 days had been reviewed and no concerns were identified. 5) Review of audits completed by administrative staff on 07/24/15 revealed no issues were identified related to safety devices on care plans and CNA care plans and no safety concerns were identified with residents. The reviews continued in the daily morning clinical meeting. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, and MDS Coordinator at 2:17 PM revealed the audits were done for all residents and continued in the daily morning clinical meeting. 6) Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:15 PM, and MDS Coordinator at 2:17 PM revealed all accident and incident reports were reviewed daily and any concerns identified would be corrected immediately. The interviews revealed no concerns had been identified. 7) Review of audits conducted of all resident charts, care plans, and CNA care plans for changes noted revealed the reviews were done daily during the morning clinical meeting. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, and MDS Coordinator at 2:17 PM revealed resident charts were audited daily for changes to ensure care plans and CNA care plans were updated with changes. 8) Review of education provided on 07/23/15 to the facility Administrator, DON, ADON, SDC, RN Supervisor, MDS Coordinator, BOM, RSM, Dietary Manager, QOL Director, HR, Environmental Services Director, SSD, Admissions Director, Medical Records, and Chaplain included information on the fall process/program, care plan policy including revising and updating care plans, appropriate interventions implemented, tracking and trending of falls, the fall policy and procedure, and environmental hazards. A Review of the POS [REDACTED]. Interviews on 07/30/15 with the Administrator at 2:37 PM, DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:15 PM, MDS Coordinator at 2:17 PM, RSM at 2:26 PM, Dietary Manager at 1:15 PM, QOL Director at 11:03 AM, Environmental Services Director at 9:45 AM, SSD at 12:01 PM, Admissions Director at 12:01 PM, and Medical Records at 12:07 PM revealed they were educated face to face on the fall policy and procedures, tracking and trending of falls, care plan revision and updating, ensuring appropriate interventions are implemented after falls and environmental hazards. 9) Review of education provided to direct care staff revealed the staff was educated on the fall policy and procedure, care plan revision and updates, ensuring appropriate interventions are implemented after a fall and environmental hazards. Interviews on 07/30/15 with Housekeeping Staff #1 at 10:58 AM, Dietary Staff #1 at 1:50 PM, SRNA #8 at 9:57 AM, SRNA #9 at 10:08 AM, SRNA #10 at 10:14 AM, SRNA #3 at 10:22 AM, SRNA #6 at 10:30 AM, Licensed Practical Nurse (LPN) #4 at 10:38 AM, and Registered Nurse (RN) #4 at 10:50 AM revealed the staff was knowledgeable about the fall policy/procedures, environmental hazards, care plan revision and updates, and ensuring interventions implemented after a fall were appropriate and related to the root cause of the fall. 10) Interview on 07/30/15 at 1:57 PM with the Regional Nurse Consultant revealed he had been in the facility daily since the Immediate Jeopardy was identified and had been conducting audits to validate compliance daily. The Regional Nurse Consultant further revealed he had assisted with fall investigations, chart audits, and care plan audits. 11) Interview on 07/30/15 at 1:57 PM with the Regional Nurse Consultant revealed administrative oversight had been provided by the VP of Operations, Special Projects Administrator, and the Signature Care Consultant daily since the beginning of the immediate jeopardy and would continue weekly for 4 weeks and then monthly. 12) Interviews on 07/30/15 with the DON at 11:21 AM, Administrator at 2:37 PM, and the Regional Nurse Consultant at 1:57 PM revealed all audits and reviews were discussed daily and any identified concerns were corrected immediately. The interview further revealed all identified concerns were discussed weekly in the QAPI meeting and the weekly QAPI meetings would be weekly for 4 weeks, then monthly, and then the frequency would be evaluated and determined for meeting and audits.

Based on observation, interview, record review, and a review of the facility's policy and investigations/incident reports, it was determined the facility failed to have an effective system in place to assess residents' falls to determine if other risk factors for falls were present or if interventions were implemented and/or revised to prevent falls for two (2) of twenty-six (26) sampled residents (Residents #8 and #20). On 03/05/15, Resident #8 leaned forward in the wheelchair and fell through a breakaway lap buddy onto the floor, hitting his/her head on the floor. The facility determined the resident was trying to pick up a cup from the floor, but failed to assess the resident to determine if other risk factors for falls were present or if interventions that were in place to prevent falls were effective. Facility staff continued to utilize the breakaway lap buddy as a fall prevention for the resident. On 04/12/15, Resident #8 leaned forward again and fell through the lap buddy onto the floor. The resident sustained [REDACTED]. Resident #20 required the assistance of two (2) staff persons with transfers; however, on 04/16/15, one (1) staff person assisted the resident and the resident fell . The facility failed to identify that the assessed level of assistance was not being provided when the resident fell . The failure of the facility to assess residents' falls to determine if other risk factors for falls were present or if interventions were implemented and/or revised to prevent falls has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/23/15, and was determined to exist on 04/12/15. An acceptable Allegation of Compliance was received on 07/30/15, which alleged removal of the Immediate Jeopardy on 07/30/15. An extended survey was conducted on 07/30/15. The State Survey Agency determined the Immediate Jeopardy was removed on 07/30/15, which lowered the scope and severity to D while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Falls Policy, dated April 2012, revealed staff was to initiate an investigation and determine the root cause of the fall if possible. Staff was to update the resident's care plan, and the resident's falls and care plans were to be reviewed during the daily clinical meeting for a minimum of three (3) days. The policy further stated staff was required to continue root cause analysis during the daily clinical meeting and take appropriate action as indicated. 1. Review of the closed medical record for Resident #8 revealed the facility admitted Resident #8 on 01/09/09, with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 required extensive assistance from staff with locomotion on and off the unit and the resident utilized a wheelchair as a mobility device. The resident had no Brief Interview for Mental Status (BIMS) score coded on the MDS, therefore was not interviewable. Review of Resident #8's care plan dated 12/09/14 revealed the facility identified the resident was at risk for a fall related injury and required the use of a breakaway lap buddy (a cushion that fits on a wheelchair at the resident's lap with the middle held together with Velcro). Review of an incident report dated 03/05/15 revealed Resident #8 leaned forward in his/her wheelchair and fell through the lap buddy onto the floor, hitting his/her head on the floor. As a result of the fall, Resident #8 was assessed to have a 3-centimeter (cm) laceration to the left side of his/her forehead and was transferred to a local hospital, where the resident required eight (8) sutures for the laceration. A Computerized Tomography (CT) scan of the resident's head was also obtained and no brain injury was noted. Facility staff determined the resident was trying to pick up a cup from the floor when the resident fell from the wheelchair, but failed to assess the resident to determine if other risk factors for falls were present or if interventions to prevent falls that were in place were effective. Facility staff continued to utilize the breakaway lap buddy as a fall prevention for the resident. Review of an incident report dated 04/12/15, revealed Resident #8 sustained another fall from the wheelchair when the resident leaned forward and fell through the breakaway lap buddy a second time. Record review revealed Resident #8's lap buddy came undone and the resident sustained [REDACTED]. Facility staff assessed the resident to have a 2 cm long laceration, with a large amount of blood observed to the left side of the resident's forehead. The resident was also assessed to have an abrasion to his/her left knee that was 2 cm long. The resident was transferred to a local hospital. Review of the resident's hospital record revealed the resident was diagnosed with [REDACTED]. Review of Resident #8's CT scan results, documented 04/13/15, revealed the resident had a brain contusion, a 6.4 by 4.4 millimeter (mm) area in the brain that was either a small hematoma (a collection of blood that has leaked into tissue where it does not belong) or an aneurysm (an enlargement of an artery caused by a weakening of the artery wall). The CT further revealed blood was observed in the resident's right lateral ventricle of the brain. Interview with State Registered Nurse Aide (SRNA) #1 on 07/23/15 at 6:00 PM revealed that on 04/12/15 she was assigned to care for Resident #8. The SRNA stated the resident appeared weaker and was leaning forward in the wheelchair more than usual. The SRNA stated she had to readjust the resident a few times on 04/12/15. The SRNA stated she did not notify the nurse that Resident #8 appeared weaker and was leaning forward in his/her wheelchair and further stated no action was taken to assess the resident to determine if interventions continued to be appropriate for the resident. Interview with Resident #8's physician on 07/23/15 at 3:15 PM revealed the resident was observed to always be leaning forward when he evaluated the resident in the facility. The physician stated the resident had Dementia, had a history of [REDACTED]. He stated the injuries the resident sustained [REDACTED]. was probably related to the injuries sustained from the fall in the facility on 04/12/15. Interview with the Director of Nursing (DON) on 07/23/15 at 6:25 PM revealed when a resident sustained [REDACTED]. The DON stated the interdisciplinary team met each morning Monday through Friday to review incident reports and fall investigations. She stated the team also reviewed the interventions that the nurse had put in place and implemented other interventions as they saw fit. The DON stated Resident #8's fall that occurred on 03/05/15 had been reviewed in the daily clinical meetings as required. The DON stated an intervention was implemented to ensure staff kept hydration items away from the resident to prevent cups from being on the floor. However, the DON acknowledged staff had not assessed the resident or the breakaway lap buddy to determine if further interventions were required to prevent the resident from falling. 2. Observation of Resident #20 on 07/29/15 at 4:15 PM revealed the resident was propelling him/herself in a wheelchair. Observation of the resident's room revealed the resident utilized a low bed. Review of the medical record revealed the facility admitted Resident #20 on 10/29/09 with [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment completed on 02/06/15 revealed the facility assessed Resident #20 to require extensive physical assistance of two (2) or more persons with bed mobility, transfers, and locomotion on and off the unit. The resident utilized a wheelchair as a mobility device. Further review of the MDS revealed the resident's BIMS score was 12. Review of a Fall Risk Evaluation dated 02/13/15 revealed the facility assessed Resident #20 to be at high risk for falls, and the resident utilized a low bed for a fall intervention. Review of the comprehensive care plan dated 02/06/15 revealed the resident had an ADL (activities of daily living) self-care deficit and was at risk for complications related to difficulty walking and lack of coordination. The approach to address the problem was to transfer the resident with the assistance of one (1) staff member and the use of a gait belt. The care plan did not address Resident #20's need for two (2) persons to assist with transfers as assessed by the MDS. Review of the Certified Nursing Assistant (CNA) care plan for April 2015 revealed that prior to 04/20/15, the care plan stated Resident #20 required the assistance of one (1) person for transfer with a gait belt. Review of the facility's fall investigation for Resident #20 revealed the resident sustained [REDACTED]. According to the fall investigation, the resident's knee gave out, and the resident went down to the floor on both knees. The investigation revealed the resident's bed was in a low position and the resident did not sustain injury from the fall. According to the facility's investigation, the SRNA who assisted the resident reported she was helping the resident out of bed and the resident was unable to support his/her own weight. The resident became very weak and fell to the floor. Review of the Fall Investigation revealed the facility identified the factors contributing to the fall were the resident's poor balance, difficulty maintaining sitting balance, impaired balance during transitions, unsteady gait, and change or increase in ADL assistance. There was no evidence the facility identified that staff failed to provide the assessed level of assistance required to transfer Resident #20 as a factor that contributed to the resident's fall. Further review of the facility's investigation of Resident #20's fall revealed the facility referred the resident to Therapy to evaluate the need for the assistance of two (2) staff persons instead of one (1), even though the facility had already assessed Resident #20 to require extensive physical assistance of two (2) or more persons with transfers. The SRNA involved in the incident no longer worked at the facility and was not available for interview. Interview with the DON at 11:00 AM on 07/30/15 revealed the clinical team which included the DON reviewed Resident #20's fall during the morning clinical meeting and did not identify that Resident #20 was already assessed to need two (2) persons to assist with transfers when the fall occurred on 04/16/15. The DON stated if the resident had two (2) persons assisting with the transfer on 04/16/15 as assessed on the MDS, the fall probably would have been prevented. **The facility provided an acceptable Allegation of Compliance (AOC) on 07/30/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #8 no longer resides at the facility. Resident #8's chart was audited and reviewed by the Regional Nurse Consultant on 07/23/15. 2) The facility has a current system to ensure residents' fall safety care needs are being met: -Floor staff process: a. Nurse notified of resident fall by State Registered Nurse Aide (SRNA), housekeeper, visitors, etc. b. Nurse to assess resident including neurological checks, pain, Range of Motion (ROM), skin, joints, extremities, vital signs. c. Nurse to provide immediate care as indicated by the assessment. d. Notify physician and Power of Attorney (POA) of the fall. e. Document assessment and pertinent facts related to the fall. f. Begin investigation of the fall. g. Complete Incident/Accident in event manager system. h. Determine root cause of fall if possible. 1. Nurse utilizes root cause questionnaire to assist with root cause. 2. SRNAs draw out a picture of the scene. i. Update care plan with appropriate intervention. j. Enter resident's name on Nursing communication log for 72 hour follow-up charting. k. Notify the Director of Nursing (DON) if the resident is sent out; otherwise, the Administrator and the DON are notified by event manager system. -Clinical administration/IDT team process: The facility Administrator, DON, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Social Services Director (SSD), Therapy Services Manager, Central Supply, and Quality of Life (QOL) Director review event data, which includes falls, weight loss, skin integrity, etc. in the event manager system daily during morning clinical meeting. a. Daily clinical/PI meeting conducted and all Accident/Incidents, care plans, SRNA care plans, and pertinent resident data is reviewed. b. Resident is logged on the fall tracker log and resident tracker log for tracking and trending. c. Root cause is completed utilizing the five (5) why template. d. The resident chart is reviewed during the meeting. e. Tracking/trending, root cause, and info from resident chart review are all taken into consideration for appropriate intervention. f. Care plan and SRNA care plan is updated with new interventions. g. Follow up for 72 hours to assess resident's status and intervention appropriateness. 3) All facility residents were assessed by completing a falls risk assessment on each resident and then comparing falls risk identified to current care plan interventions by the DON, ADON, SDC, Nursing Supervisor, or Regional Nurse Consultant on 07/24/15 and then all resident care plans were re-audited, by comparing current resident care plans with current resident ADLs assist level with latest MDS, starting on 07/28/15 and completed on 07/29/15 to determine if safety needs were being met as outlined by resident's care plan, to include wheelchair (w/c) safety devices. Noted concerns from re-audit on 07/28 - 07/29 were five (5) residents whose ADL care plan did not reflect the residents' current level of ADL assistance required. 4) All accident/incident reports, for the past 90 days, have been reviewed, to include not just the individual incident/accident but a more global approach by reviewing the tracking/trending of individual resident falls to include day, shift, time, location on 07/24/15 by the DON, ADON, SDC, Nursing Supervisor, or Signature Care Consultant to identify any safety concerns, ensure thorough investigation of all Accidents/Incidents was completed, and implemented interventions on care plan that address root cause. No concerns identified by the facility. 5) Once resident assessments and accident/incident reviews along with tracking/trending reviews were completed by 07/24/15, then all resident care plans and SRNA care plans were audited, utilizing a census board audit tool, by 07/24/15, reviewed and updated as needed, to include wheelchair safety devices, by the DON, ADON, Nursing Supervisor, MDS Coordinator, or Regional Nurse Consultant to ensure that each resident's care plan/SRNA care plan reflects current resident safety care needs. The DON, ADONs, Nursing supervisor, or MDS Coordinator will audit all residents, with any changes noted, care plan/SRNA care plan for any updates, revisions, and/or new interventions, during the morning clinical meeting with IDT present, daily starting on 07/24/15, and continuing until immediacy is lifted, then 10 different resident care plans/SRNA care plans will be audited weekly for 4 weeks to ensure resident safety care needs are being met. Results will be reviewed in weekly (Quality Assurance Performance Improvement) QAPI meeting. QAPI committee will determine ongoing frequency of resident care plan audit at that time 6) The DON, ADONs, SDC, MDS or Nursing Supervisor will review all A/I daily to ensure thorough (individual incident along with tracking/trending for that specific resident) investigation initiated, root cause analysis conducted and appropriate intervention, to meet root cause, implemented, along with care plan updated to reflect new intervention starting on 07/24/15. Compliance will be reviewed in weekly QAPI meeting. 7) The DON, ADONs, Nursing Supervisor, or MDS Coordinator will audit all residents, with any changes noted, care plan/SRNA care plan for any updates, revisions, and/or new interventions, during the morning clinical meeting with IDT present, daily starting on 07/24/15, and continuing until immediacy is lifted, then 10 different resident care plans/SRNA care plans will be audited weekly for 4 weeks to ensure resident safety care needs are being met. Results will be reviewed in weekly QAPI meeting. QAPI committee will determine ongoing frequency of resident care plan audit at that time 8) The facility Administrator, DON, ADON, SDC, RN Supervisor, MDS Coordinator, Business Office Manager (BOM), Rehabilitation Service Manager (RSM), Dietary Manager, QOL Director, Human Resources (HR) Director, Environmental Services Director, SSD, Admissions Director, Medical Records, and Chaplain were educated on 07/23/15 by the Signature Care Consultant on the fall program process/system noted in #2, care plan policy, to include revising and updating the care plan along with interventions that meet not only the individual accident/incident but also patterns identified from tracking and trending, accident/incident policy, and falls policy and procedure, to include tracking and trending procedure. This training was performed face-to-face in order to facilitate discussion and question. Department Administrative Managers could not return to work until the above education was provided, post-test administered, and 100% score obtained; if Manager did not score 100% on post-test, then Manager was immediately re-educated and post-test re-administered. This process continued until all Managers obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Signature Care Consultant. 9) Once facility Administrator, DON, ADON, SDC, RN Supervisor, MDS, BOM, RSM, Dietary Manager, QOL Director, HR, Environmental Services Director, SSD, Admissions Director, Medical Records, and Chaplain were re-educated on the process in #2, care plan policy, to include revising and updating the care plan along with interventions that meet not only the individual accident/incident but also patterns identified from tracking and trending, accidents/incidents policy, and falls policy and procedure, to include tracking and trending procedure, they were then assigned to assist the SDC in providing education to the staff on the above policies and procedures, which started on 07/23/15. No employee will be allowed to work until education is provided. The facility has 88 employees. Seventy employees received the education by 07/24/15, six employees were scheduled to receive education by 07/26/15, and twelve employees had certified letter sent out on 07/24/15. Employees could not return to work until the above education was provided, post-test administered and 100% score obtained; if employee did not score 100% on post-test, then employee was immediately re-educated and post-test re-administered. This process continued until all employees obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Signature Care Consultant. This education will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until education is provided, post-test administered and 100% score obtained; if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. No agency staff is utilized by the facility. 10) A nurse from the Regional Team or Corporate Office has been onsite since 07/23/15 and will remain in the facility daily until jeopardy has been lifted. The nurses from the Regional Team or home office will be validating compliance with all audits and reviews completed daily until immediacy is lifted, then will validate compliance weekly for 4 weeks. The Regional Nurse Consultants will also be assisting with completion of investigations, root cause analysis, updating and/or revising care plans, performing chart audits, and providing oversight and consultation. The Vice-President of Operations, Special Projects Administrator, or Director of Clinical Programs will be in daily contact with the Signature Care Consultant and will review compliance daily until immediacy is lifted, then weekly for 4 weeks. 11) Administrative oversight of the facility will be completed by the Vice President of Operations, Signature Care Consultant, or Special Projects Administrator daily until the removal of immediacy beginning 07/23/15, then weekly for 4 weeks, then monthly. 12) Results of all audit and reviews will be discussed daily for compliance and action plan implemented immediately to address any identified concerns. Any identified concerns will be discussed during weekly QAPI meeting. A Quality Assurance meeting will be held weekly for 4 weeks beginning 07/23/15, then monthly for recommendations and further follow-up regarding the above stated plan. At that time based upon evaluation the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Record review revealed the Regional Nurse Consultant audited Resident #8's chart on 07/23/15. 2) Interviews on 07/30/15 with Housekeeping Staff #1 at 10:58 AM, Dietary Staff #1 at 1:50 PM, SRNA #8 at 9:57 AM, SRNA #9 at 10:08 AM, SRNA #10 at 10:14 AM, SRNA #3 at 10:22 AM, SRNA #6 at 10:30 AM, Licensed Practical Nurse (LPN) #4 at 10:38 AM, and Registered Nurse (RN) #4 at 10:50 AM revealed the staff had been trained and were familiar with the facility's fall protocol. Interviews on 07/30/15 with the Administrator at 2:37 PM, DON at 11:21 AM, ADON at 2:08 PM, MDS Coordinator at 2:17 PM, SDC at 12:15 PM, SSD at 12:01 PM, Central Supply at 12:07 PM, and QOL at 11:03 AM revealed the staff was familiar with the review process for falls and accidents/incidents. 3) Record review of fall assessment and audits of care plans and CNA care plans revealed any issues identified were corrected by facility staff beginning on 07/24/15 and completed on 07/29/15. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:15 PM, and the Regional Nurse Consultant at 1:57 PM revealed there were some issues identified with ADL assistance requirements with the care plans, MDS assessments, and the CNA care plans but the issues were corrected. 4) Review of facility audits and tracking logs revealed facility administrative staff had reviewed all accident/incident reports related to falls for the past 90 days and did not identify any concerns. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:01 PM, and Signature Care Consultant at 1:57 PM revealed all falls for the past 90 days had been reviewed and no concerns were identified. 5) Review of audits completed by administrative staff on 07/24/15 revealed no issues were identified related to safety devices on care plans and CNA care plans and no safety concerns were identified with residents. The reviews continued in the daily morning clinical meeting. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, and MDS Coordinator at 2:17 PM revealed the audits were done for all residents and continued in the daily morning clinical meeting. 6) Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:15 PM, and MDS Coordinator at 2:17 PM revealed all accident and incident reports were reviewed daily and any concerns identified would be corrected immediately. The interviews revealed no concerns had been identified. 7) Review of audits conducted of all resident charts, care plans, and CNA care plans for changes noted revealed the reviews were done daily during the morning clinical meeting. Interviews on 07/30/15 with the DON at 11:21 AM, ADON at 2:08 PM, and MDS Coordinator at 2:17 PM revealed resident charts were audited daily for changes to ensure care plans and CNA care plans were updated with changes. 8) Review of education provided on 07/23/15 to the facility Administrator, DON, ADON, SDC, RN Supervisor, MDS Coordinator, BOM, RSM, Dietary Manager, QOL Director, HR, Environmental Services Director, SSD, Admissions Director, Medical Records, and Chaplain included information on the fall process/program, care plan policy including revising and updating care plans, appropriate interventions implemented, tracking and trending of falls, the fall policy and procedure, and environmental hazards. A review of the post-test revealed no issues were identified. Interviews on 07/30/15 with the Administrator at 2:37 PM, DON at 11:21 AM, ADON at 2:08 PM, SDC at 12:15 PM, MDS Coordinator at 2:17 PM, RSM at 2:26 PM, Dietary Manager at 1:15 PM, QOL Director at 11:03 AM, Environmental Services Director at 9:45 AM, SSD at 12:01 PM, Admissions Director at 12:01 PM, and Medical Records at 12:07 PM revealed they were educated face to face on the fall policy and procedures, tracking and trending of falls, care plan revision and updating, ensuring appropriate interventions are implemented after falls and environmental hazards. 9) Review of education provided to direct care staff revealed the staff was educated on the fall policy and procedure, care plan revision and updates, ensuring appropriate interventions are implemented after a fall and environmental hazards. Interviews on 07/30/15 with Housekeeping Staff #1 at 10:58 AM, Dietary Staff #1 at 1:50 PM, SRNA #8 at 9:57 AM, SRNA #9 at 10:08 AM, SRNA #10 at 10:14 AM, SRNA #3 at 10:22 AM, SRNA #6 at 10:30 AM, Licensed Practical Nurse (LPN) #4 at 10:38 AM, and Registered Nurse (RN) #4 at 10:50 AM revealed the staff was knowledgeable about the fall policy/procedures, environmental hazards, care plan revision and updates, and ensuring interventions implemented after a fall were appropriate and related to the root cause of the fall. 10) Interview on 07/30/15 at 1:57 PM with the Regional Nurse Consultant revealed he had been in the facility daily since the Immediate Jeopardy was identified and had been conducting audits to validate compliance daily. The Regional Nurse Consultant further revealed he had assisted with fall investigations, chart audits, and care plan audits. 11) Interview on 07/30/15 at 1:57 PM with the Regional Nurse Consultant revealed administrative oversight had been provided by the VP of Operations, Special Projects Administrator, and the Signature Care Consultant daily since the beginning of the immediate jeopardy and would continue weekly for 4 weeks and then monthly. 12) Interviews on 07/30/15 with the DON at 11:21 AM, Administrator at 2:37 PM, and the Regional Nurse Consultant at 1:57 PM revealed all audits and reviews were discussed daily and any identified concerns were corrected immediately. The interview further revealed all identified concerns were discussed weekly in the QAPI meeting and the weekly QAPI meetings would be weekly for 4 weeks, then monthly, and then the frequency would be evaluated and determined for meeting and audits.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received an accurate assessment by staff regarding relevant care areas about the residents' status, needs, strengths, and areas of decline for four (4) of twenty-six (26) sampled residents (Residents #17, #18, #22, and #23). Residents #17, #18, #22, and #23 were assessed by facility staff on the most recent Minimum Data Set (MDS) Assessments to require extensive assistance from staff for various areas of activities of daily living (ADLs). However, observations and interviews with facility staff and residents, conducted on 07/30/15, revealed the assessments were not accurate and the residents did not require the amount of assistance that was coded by the facility on the MDS. The findings include: Interview with the Minimum Data Set (MDS) Assessment Coordinator on 07/30/15 at 2:17 PM revealed the facility had no policy related to MDS assessments; however, she stated she utilized the MDS manual in completing assessments for facility residents. A review of the MDS 3.0 manual revealed when completing the ADL section of the MDS, staff should review the documentation in the medical record for the last seven days; talk with direct care staff from each shift that has cared for the resident to learn what the resident does for himself during each episode of each ADL activity during the seven day look-back period; and when reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition. 1. Review of Resident #17's medical record revealed facility staff admitted the resident on 04/02/15 with [DIAGNOSES REDACTED]. Review of a significant change MDS assessment for the resident, dated 07/03/15, revealed the resident required extensive assistance of two (2) staff members with bed mobility and transferring. Staff had also assessed Resident #17 to require extensive assistance of one (1) staff member for walking in his/her room and for locomotion on and off the unit. However, review of Resident #17's physician's orders [REDACTED]. Further review revealed the order for the resident to transfer independently was initiated on 05/25/15. Observations conducted of Resident #17 on 07/30/15 at 9:00 AM revealed the resident transferred from bed to a standing position and ambulated in the room and to the facility dining room with no assistance required from staff. Interview with State Registered Nurse Aide (SRNA) #6 on 07/30/15 at 11:00 AM revealed she had provided care to Resident #17 within the past 30 days. The SRNA stated she had never had to provide assistance to the resident with transferring out of bed, and stated the resident turned and repositioned independently when in bed. The SRNA stated Resident #17 ambulated in and out of his/her room independently, and required no assistance with ambulation. 2. Review of Resident #22's medical record revealed facility staff admitted the resident on 07/01/15 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], revealed staff assessed the resident to require extensive assistance of two (2) staff members with bed mobility, transferring, and walking in his/her room. Staff had also assessed that the resident required extensive assistance of one (1) staff member for locomotion on and off the unit. Observations of Resident #22 on 07/30/15 at 12:00 PM revealed the resident rose from the bed and ambulated to his/her sink with no assistance required. Continued observations revealed the resident ambulated in the facility hallway and to the dining room, with no assistance required from staff. Interview with SRNA #6 on 07/30/15 at 11:00 AM revealed she had provided care to Resident #22 often within the past 30 days. The SRNA stated she had never had to provide assistance to Resident #22 with transferring out of bed, and the resident was able to turn and reposition independently when in bed. The SRNA stated the resident ambulated in and out of the room independently, and required no assistance with ambulation. 3. Review of Resident #18's medical record revealed the facility admitted the resident on 07/06/15 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed staff assessed the resident to require extensive assistance of two (2) staff members with transfers and ambulation. Resident #18's Brief Interview for Mental Status (BIMS) score was 15, which revealed the resident was interviewable. However, review of Resident #18's physician's orders [REDACTED]. Observations of Resident #18 on 07/30/15 at 9:45 AM revealed the resident up in the facility hall ambulating with the assistance of one (1) staff member and the use of a walker and a gait belt. Interview on 07/30/15 at 9:45 AM with Resident #18 revealed the resident required the assistance of one (1) staff member and the use of a walker and a gait belt for transfers and ambulation. Interview on 07/30/15 at 10:05 AM with SRNA #6 revealed Resident #18 required assistance of one (1) staff member and the use of a gait belt for ambulation and transfers. The interview further revealed the SRNA had worked with Resident #18 often since his/her admission to the facility and the resident had always ambulated with the assistance of one (1) staff member and the use of a gait belt and a walker. 4. Review of Resident #23's medical record revealed the facility readmitted the resident on 07/13/15 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed staff assessed the resident to require extensive assistance of two (2) staff members for transfers and toileting. Resident #23's BIMS score was 13, which revealed the resident was interviewable. Observation on 07/30/15 at 10:05 AM of Resident #23 revealed the resident transferred independently from the resident's wheelchair to the toilet. Interview on 07/30/15 at 10:15 AM with Resident #23 revealed the resident was independent for all activities of daily living except the resident required assistance with showers. Interview on 07/30/15 at 2:25 PM with SRNA #8 revealed Resident #23 was independent for activities of daily living except the resident required assistance with showers. The interview further revealed the SRNA had worked with Resident #23 multiple times since the resident's admission to the facility and the resident had always been able to transfer and toilet independently. Interview with the MDS Coordinator on 07/30/15 at 2:17 PM revealed she was responsible to code the Functional Status portion of MDS assessments for facility residents. The MDS Coordinator stated she coded the MDS from information obtained from the tracking forms completed by the facility SRNAs, and she also reviewed physician's orders [REDACTED]. highest level of assistance documented by the SRNAs. The MDS Coordinator stated when she had identified discrepancies in the ADL tracking information related to a resident's functional status, she should have clarified the SRNA's fluctuations in documentation related to the assistance the resident was documented to require, prior to coding information on the resident's MDS assessment. The MDS Coordinator acknowledged Residents #17 and #22 ambulated independently in the facility daily, Resident #18 transferred independently and ambulated with one (1) staff member's assistance and the use of a gait belt, and Resident #23 was independent with transfers and toileting. However, she had not identified that the MDS information she had coded was inaccurate related to the residents' functional status. Interview with the facility Clinical Resource Specialist on 07/30/15 at 2:26 PM revealed she conducted quarterly audits in the facility to ensure MDS assessment information had been coded accurately. She stated she had conducted an audit a few months ago at the facility and had not identified any major concerns.

Based on interview, record review, and a review of the facility policy it was determined the facility failed to use the results of the assessment to develop the residents' comprehensive plans of care for three (3) of twenty-six (26) sampled residents (Residents #11, #20, and #21). Review of the Minimum Data Set (MDS) Assessments for Residents #11, #20, and #21 revealed the residents were assessed using the MDS for the level of assistance required to be provided by staff. However, review of the Comprehensive Care Plans for the residents revealed the information in the plan of care was not consistent with the assessment. Interview with the MDS Coordinator revealed she had not utilized information from the residents' MDS assessments to develop, review, and/or revise the residents' comprehensive plans of care. The findings include: Review of the facility policy titled Care Plans, last revised October 2010, revealed the residents' comprehensive care plans were based on a thorough assessment which included, but was not limited to, the MDS Assessment. 1. Review of Resident #21's medical record revealed the facility admitted the resident on 07/09/15 with [DIAGNOSES REDACTED]. Review of an Admission MDS assessment dated [DATE] revealed staff assessed the resident to require extensive assistance of two (2) staff members with transferring and ambulation in his/her room. The resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident was not interviewable. Review of Resident #21's comprehensive care plan dated 07/16/15, revealed the resident required assistance of one (1) staff person and use of a gait belt, instead of two (2) person assist per the MDS assessment when he/she was transferred. Further review of the care plan revealed the care plan failed to direct staff on what level of assistance was required to assist the resident with ambulation. The Certified Nurse Aide (CNA) care plan directed staff to provide assistance with mobility to the resident; however, the number of staff required to safely assist the resident was not included on the resident's plan of care. Interview with State Registered Nurse Aide (SRNA) #6 on 07/28/15 at 10:05 AM, revealed she had provided care to Resident #21 a couple of times since the resident's admission to the facility. She stated the resident required assistance of one (1) staff member for transfers and ambulation, and had never required assistance of two (2). 2. Review of the medical record revealed the facility admitted Resident #20 on 10/29/09 with [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment completed on 02/06/15 revealed the facility assessed Resident #20 to require extensive physical assistance of two (2) or more persons with transfers. Review of the Fall Risk assessment for Resident #20 dated 02/13/15 revealed Resident #20 was assessed to be at high risk for falls. Further review of the medical record revealed the comprehensive care plan for Resident #20 dated 02/06/15 did not address Resident #20's need for two (2) persons to assist with transfers as assessed on the MDS. Review of the facility's fall investigation for Resident #20 revealed the resident sustained [REDACTED]. The nursing fall intervention that was implemented on 04/16/15 was to refer Resident #20 to Therapy to evaluate for transfer with the assistance of two (2) persons instead of one (1) person. However, the resident had already been assessed on the annual MDS assessment dated [DATE] to require the assistance of two (2) persons with transfers but the information was not on the plan of care. 3. Review of the medical record for Resident #11 revealed the facility admitted the resident on 02/22/10 with [DIAGNOSES REDACTED]. Review of Resident #11's Annual MDS dated [DATE] and Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #11 to require the extensive assistance of two persons to transfer. The MDS also revealed Resident #11 had been assessed to have a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Review of the comprehensive plan of care for Resident #11 dated 11/17/14 with a revision date of 04/16/15 revealed the facility developed a care plan that stated the resident required the assistance of one person with a gait belt for transfers. Review of the CNA care plan dated July 2015 revealed the facility developed a CNA care plan that stated the resident required the assistance of one person with a gait belt. Interview with the MDS Coordinator on 07/30/15 at 2:17 PM revealed she had not utilized information from the resident's MDS to develop, review, or revise the resident's comprehensive plan of care. The MDS Coordinator stated she had not been trained to develop, review, or revise a resident's comprehensive plan of care from information contained in the MDS. Interview with the Director of Nursing (DON) on 07/30/15 at 11:45 AM revealed she did not compare the MDS to the comprehensive care plan to make sure they coincide. The DON further stated she reviewed care plans, but not MDS assessments. Interview with the Administrator on 07/30/15 at 2:35 PM revealed she was not aware that the interventions on the resident's care plan did not address the resident's assessed needs as identified in the comprehensive assessment. She also stated she was not aware that the MDS Coordinator did not follow the MDS to formulate the resident's care plans. The Administrator further stated that the previous MDS Coordinator trained the current MDS Coordinator, but she did not think the current MDS Coordinator gets it related to developing the care plan according to the assessment.

Based on observation, interview, record review, and a review of the facility's policy it was determined the facility failed to establish and maintain an effective infection control program related to incontinence care provided to facility residents for one (1) unsampled resident (Resident A). Observations revealed staff failed to change their gloves when the gloves became contaminated, while providing incontinence care to Resident A. The findings include: Review of the facility policy titled Perineal Care, dated December 2010, revealed staff was to cleanse the resident's perineum to prevent infections and odors. The policy directed staff to wear disposable gloves. The policy did not address staff changing or discarding gloves if they became contaminated with urine or stool. Review of Resident A's medical record revealed the facility admitted the resident on 08/08/14 with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was incontinent of bowel and bladder and required extensive assistance of two (2) staff members for toileting needs. Observations conducted of incontinence care for Resident A on 07/22/15 at 1:20 PM revealed staff provided perineal care, cleaned urine and stool from the resident, and discarded the resident's soiled brief. Staff was observed to apply a clean brief and touch the resident's clothing, linen, and bed railing without discarding the contaminated gloves. Interview with State Registered Nurse Aide (SRNA) #2 on 07/22/15 at 4:20 PM revealed she had provided incontinence care to Resident A. The SRNA acknowledged she had failed to change her gloves after they became contaminated with urine and stool. SRNA #2 stated she had been trained to change her gloves after they were contaminated, but forgot to do so. Interview with the Director of Nursing on 07/23/15 at 6:25 PM confirmed staff had been trained to change their gloves when they became contaminated with urine or stool, when incontinence care was provided to facility residents. The DON acknowledged the failure of staff to change their gloves after they became contaminated was an infection control concern for facility residents.

Based on interview and record review it was determined the facility failed to ensure one of three sampled residents (Resident #2) received adequate supervision and assistance devices to prevent accidents. On 10/21/14 at 11:00 PM, Resident #2 was found on the floor by facility staff. There was no evidence that the facility initiated an investigation of the fall or implemented interventions to prevent further falls until Resident #2's family questioned facility staff about the resident's fall the next day, 10/22/14. The findings include: A review of the facility's fall policy dated April 2012, revealed if a fall occurred staff was required to complete an incident/accident occurrence form, determine the root cause of the fall if possible, update the resident's plan of care, and enter the resident's name on the 24-hour report for follow-up assessments and charting. A review of the medical record for Resident #2 revealed the resident was admitted by the facility on 09/23/14 with [DIAGNOSES REDACTED]. A review of a nurse's note dated 10/21/14 at 11:00 PM revealed Resident #2 had sustained a fall but denied pain, was moving all extremities, and no changes were noted to the resident's level of consciousness. There was no evidence the root cause of the fall was assessed or that the resident's care plan was revised after the fall. An interview conducted with Resident #2's responsible party (RP) on 11/19/14 at 2:20 PM, revealed Resident #2's roommate told the RP on 10/22/14 that Resident #2 had fallen out of bed. The RP questioned facility staff about the fall, but staff was not aware the resident had sustained a fall on 10/21/14. An interview conducted on 11/19/14 at 4:25 PM, with State Registered Nurse Aide (SRNA) #1 revealed when the SRNA was making rounds on 10/21/14 at approximately 11:00 PM, Resident #2 was lying on the floor. According to SRNA #1, she notified the nurse assigned to Resident #2 that the resident had fallen from bed. An interview conducted with Licensed Practical Nurse (LPN) #1 on 11/19/14 at 5:35 PM, revealed she was notified that Resident #2 was on the floor. She stated she went to the resident's room and assessed the resident and found no injuries to the resident. The LPN stated she documented that the resident had fallen in the nurse's notes in the resident's chart. According to LPN #1, she was training another nurse, had gotten busy, and forgot to complete an incident report, notify the resident's physician and responsible party, and update the resident's plan of care. An interview conducted with the facility Administrator on 11/19/14 at 6:10 PM, revealed when a resident sustained [REDACTED]. regarding the fall. Further interview revealed the fall and the interventions were reviewed in the morning meeting for appropriate interventions.

Based on interview and record review it was determined the facility failed to review/revise the plan of care for one of three sampled residents. Resident #2 sustained a fall on 10/21/14 at 11:00 PM. The resident's plan of care was not revised with interventions to prevent/attempt to prevent other falls until 10/23/14. The findings include: A review of the facility's fall policy dated April 2012, revealed if a resident sustained [REDACTED]. A review of Resident #2's medical record revealed the resident sustained [REDACTED]. An interview conducted with Licensed Practical Nurse (LPN) #1 on 11/19/14 at 5:35 PM, revealed LPN #1 assessed Resident #2 after the fall on 10/21/14 and observed a problem with the resident's positioning being too low at the head of the bed, but was busy training a new employee and forgot to review and revise the resident's plan of care or communicate the problem with positioning to the next shift. A review of Resident #2's plan of care revealed no evidence the resident's plan of care was revised until 10/23/14, when the facility initiated the use of a fall mat on the floor beside the resident's bed and the resident's bed in the lowest position. An interview conducted with the Director of Nursing (DON) on 11/19/14 at 6:00 PM, revealed the fall mat and bed in the lowest position interventions were implemented for Resident #2 on 10/22/14; however, the resident's care plan was not updated to include the interventions until the morning meeting on 10/23/14. Further interview revealed the DON was not aware that LPN #1 had identified any concerns regarding the resident's positioning.

Based on interview and record review it was determined the facility failed to immediately inform the resident's physician and responsible party for one of three sampled residents (Resident #2) of a fall that required physician intervention. Resident #2 sustained a fall from bed on 10/21/14 at 11:00 PM and required x-rays. The findings include: A review of the facility's fall policy dated April 2012, revealed if a fall occurred staff was required to notify the resident's attending physician and responsible party. A review of the medical record for Resident #2 revealed the resident was admitted by the facility on 09/23/14 with [DIAGNOSES REDACTED]. An interview conducted with Resident #2's responsible party (RP) on 11/19/14 at 2:20 PM, revealed when the RP was visiting Resident #2 on 10/22/14, the resident's roommate notified the RP that Resident #2 had fallen out of bed on 10/21/14. When the RP questioned facility staff, staff was not aware the resident had sustained a fall on 10/21/14. An interview conducted with Registered Nurse (RN) #1 on 11/19/14 at 3:35 PM revealed on 10/22/14, Resident #2's RP asked her about a fall the resident had sustained. According to RN #1, she interviewed the resident's roommate and she suspected the resident had fallen from bed on 10/21/14. Further interview with RN #1 revealed she contacted the resident's physician on 10/22/14, and orders were received for x-rays. A review of Resident #2's medical record revealed no evidence that the resident's physician or responsible party was notified on 10/21/14 that Resident #2 had sustained a fall. An interview conducted with the Director of Nursing (DON) on 11/19/14 at 6:00 PM, revealed Resident #2 sustained a fall from bed on 10/21/14. The Nurse assigned to the resident that day did not fill out an incident report and had not notified the resident's attending physician or responsible party that the resident had fallen as required by the facility's policy.

Based on observation, interview, record review, and a review of facility policy, it was determined the facility failed to provide the necessary treatment and services to prevent new pressure sores from developing for two of sixteen sampled residents (residents #3 and #7). The facility failed to ensure policies related to Skin Management and Prevention, Pressure Sore Management, and Measures for Preventing Pressure Sores were implemented to prevent pressure sore management. The facility identified residents #3 and #7 as at risk for pressure sores. The facility failed to identify the development of pressure sores for residents #3 and #7. On June 16, 2011, residents #3 and #7 were identified as having unidentified pressure sores. Staff interviews revealed resident #3 was noncompliant with repositioning while sitting and was resistant with incontinence care. Resident #3 was observed sitting up in a wheelchair for extensive periods of time on June 14, 2011, June 15, 2011, and June 16, 2011. There was no evidence the facility had assessed the resident's noncompliance as a risk factor for the development of pressure sores. Additionally, interview revealed staff failed to provide incontinence care for resident #3 during two scheduled shifts as required by the comprehensive plan of care. On June 15, 2011, resident #3 was observed to have a new open area to the coccyx, which had not been identified by staff. In addition, resident #7, who was identified to be at risk for the development of pressure sores, was observed to have two unidentified open areas to the left buttock. The findings include: A review of the facility's policy Skin Management and Prevention (no date noted) revealed staff would complete total body skin observations on resident shower/bath days, and notify the resident's physician and family of new skin conditions. In addition, review of the facility's policy Pressure Sore Management (dated December 2010) revealed staff was to develop an effective care plan consistent with the resident's goals and wishes. The policy stated staff was to implement a program to prevent additional new areas from developing which included weekly skin assessments, the utilization of pressure-relieving devices for residents identified at risk for the development of pressure sores, reposition residents identified at risk every two hours while seated in the chair, cleanse the resident's skin after every incontinence episode, and apply an ointment-based product to protect the skin. The policy further required staff to complete a Braden Scale pressure risk assessment for each resident upon admission, quarterly, and as needed. The policy stated the presence of one pressure sore would indicate the resident was at risk for developing additional sores, and staff was to implement a program to prevent additional new areas from occurring. Review of the facility policy entitled Measures for Preventing Pressure Sores (dated December 2003) revealed pressure sores were unavoidable if the facility properly assessed, care planned, implemented the care plan, evaluated the resident outcome, and revised the care plan as needed. 1. Resident #3 was admitted to the facility on [DATE]. The Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was frequently incontinent of bowel and bladder, and required one staff person for physical assistance with transfers, bed mobility, toilet use, and personal hygiene. A review of the Pressure Sore Care Area Assessment Summary (CAAS) dated December 14, 2010, revealed resident #3 was identified as high risk for the development of pressure ulcers due to incontinence and impaired mobility. Record review revealed the last Braden Scale Risk Assessment was completed on February 24, 2011, with the resident's score documented as 16, indicating the resident was at risk for pressure sore development. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #3 had a Stage II pressure ulcer to the coccyx. A review of resident #3's current comprehensive care plan with a review date of February 24, 2011, revealed the facility had identified that resident #3 was at risk for the development of pressure sores due to immobility and incontinence. Interventions to prevent the development of pressure sores for this resident included incontinence care after each incontinence episode, completion of the Braden Scale Risk Assessment quarterly, turning/repositioning the resident every two hours, and to conduct weekly skin assessments and report changes in the skin assessment to the nurse and physician. However, there was no evidence the Braden Scale Risk Assessment had been conducted when the quarterly MDS assessment was completed on May 27, 2011. Observations on June 14, 2011, at 3:00 p.m. and 4:00 p.m., revealed resident #3 was seated in a wheelchair, was not assisted by staff with repositioning, and no incontinence care was observed to be provided. On June 15, 2011, at 8:45 a.m., 10:40 a.m., 12:00 p.m., 2:50 p.m., and 3:50 p.m., the resident was again observed seated in a wheelchair without being repositioned by staff and no incontinence care was observed to be provided. Interview on June 15, 2011, at 4:20 p.m., with CNA #1 revealed the CNA was assigned to provide care for resident #3 and was aware incontinence care was to be provided for resident #3 every two hours per the CNA care plan. However, the CNA stated she had not provided resident #3 with perineal care since reporting to work at 6:00 a.m., and as a result had not identified the open area to the resident's coccyx. CNA #1 stated resident #3 was incontinent at times, wore incontinence briefs, had a long-term history of noncompliance with incontinence care, and the CNA had not assessed the resident during her shift to ensure the resident was clean and dry. CNA #1 stated resident #3 had remained seated in a wheelchair since 6:00 a.m. on June 15, 2011, and had refused to go back to bed. CNA #1 stated resident #3, "sits up in the wheelchair every day, and refuses to change positions." The CNA failed to report the resident's noncompliance with care to the nurse. A review of a "total body skin observation" completed by CNA #6 on June 15, 2011, during the shower provided for resident #3, revealed no new open areas were identified in the resident's skin. Interview on June 15, 2011, at 4:10 p.m., with CNA #6 revealed she had bathed resident #3 and had completed a "total body skin observation" of the resident; however, the CNA did not identify the open area to the resident's coccyx. Observation of a skin assessment completed by LPN #1 on June 15, 2011, at 2:40 p.m., after the shower was provided for resident #3, revealed an unidentified open area to the resident's coccyx. LPN #1 measured the new open area during the skin assessment and the pressure sore was identified to measure 0.5 cm by 0.5 cm. The open area was red in color and no drainage was observed. Interview with LPN #1 revealed the newly identified open area to resident #3's coccyx had not been reported. The LPN stated resident #3 had just returned from the shower and staff should have completed a "total body skin observation" of the resident at that time. Interview on June 15, 2011, at 4:10 p.m., with CNA #6 revealed the CNA had just bathed resident #3 and had completed a total body skin observation; however, the CNA did not identify the new open area to the resident's coccyx area. On June 16, 2011, at 8:35 a.m., 9:30 a.m., 10:40 a.m., 11:35 a.m., 1:00 p.m., 2:35 p.m., and 3:45 p.m., resident #3 was again observed seated in a wheelchair, was not assisted by staff with repositioning, and no incontinence care was observed to be provided. Interviews with CNA #3 and CNA #4 on June 16, 2011, at 5:30 p.m., revealed the CNAs had been assigned to care for resident #3 on the 6:00 p.m. to 6:00 a.m. shift beginning on June 14, 2011. CNA #4 stated resident #3 had "accidents" at times, often refused incontinence care, and the resident would frequently change his/her own brief without requesting staff assistance. CNA #4 stated the CNA had not provided perineal care to the resident during the entire shift on June 14-15, 2011, and therefore had not noted the new open area to resident #3's coccyx. CNA #3 stated resident #3 was incontinent at times, would change his/her own wet incontinence briefs, and refused staff assistance to remove wet briefs. CNA #4 had not provided incontinence care for resident #3 during the shift. Interview with the Director of Nursing (DON) on June 16, 2011, at 5:40 p.m., revealed resident #3 should receive incontinence care after each incontinence episode. The DON was not aware staff failed to provide the incontinence care. The DON was aware that resident #3 did sit in a wheelchair for long periods of time and refused to go back to bed. However, no care plan interventions had been developed/implemented regarding the resident's noncompliance with care. The DON was not aware resident #3 had developed a new open area until the area was identified by the surveyor on June 15, 2011. The DON also stated resident #3 should have been assessed using the Braden Scale for Pressure Sore Risk, during the completion of the May 2011 quarterly MDS assessment. 2. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Comprehensive Minimum Data Set (MDS) dated [DATE], and the CAAS dated January 26, 2011, revealed the facility assessed the resident as having an indwelling urinary catheter, bowel incontinence, and to be at high risk for the development of pressure sores. The assessment revealed resident #7 required extensive assistance from staff with bed mobility, toilet use, and bathing. A review of the CAAS revealed the care team would care plan and focus on assuring signs and symptoms of skin breakdown would be recognized and treated promptly. Review of resident #7's comprehensive care plan dated April 13, 2011, revealed the resident was at risk for the development of pressure ulcers due to immobility and incontinence. Staff was required to complete a weekly skin assessment, provide incontinence care after each incontinence episode, inspect the resident's skin during bathing, and notify the physician of any changes in the resident's skin condition. Review of the most recent skin assessment completed on June 13, 2011, revealed there were no open areas to the resident's skin. Observation during a skin assessment performed by LPN #1 on June 15, 2011, at 3:55 p.m., revealed resident #7 had two open areas to the resident's left buttock that were red in color with no drainage noted. The LPN was observed to measure the open areas and measurements revealed one open area was 1 cm by 1 cm with the other open area measuring 0.5 cm by 0.5 cm. Interview with LPN #1 during the skin assessment revealed these open areas had not been identified by facility staff. Interview with CNA #1 on June 15, 2011, at 4:20 p.m., revealed she was assigned to provide care for resident #7 on the 6:00 a.m. to 6:00 p.m. shift on June 15, 2011. However, the CNA had not looked at the resident's "bottom" during the shift and had not identified the open area to the resident's buttock. Interview with CNA #2 on June 15, 2011, at 4:25 p.m., revealed she had identified redness to resident #7's buttock the last day she worked (unable to remember when), and did not report the redness to anyone. Interview with the DON on June 16, 2011, at 5:40 p.m., revealed the DON was unaware resident #7 had two open areas to the buttocks.

Based on observation, record review, and interview, the facility failed to conduct a thorough assessment utilizing the Resident Assessment Instrument (RAI) process for one of sixteen sampled residents. The facility failed to comprehensively assess, identify risks and causative factors, and develop individualized interventions regarding the development of pressure sores for resident #3. Resident #3 was observed to be sitting in a wheelchair for extensive periods of time on June 14, 2011, June 15, 2011, and June 16, 2011. Interviews with staff revealed resident #3 was noncompliant with taking rest periods from the wheelchair, changing positions while sitting, and notifying staff of incontinence episodes so that incontinence care could be provided. However, there was no evidence the facility had assessed the resident's noncompliance with care as a risk factor for pressure sores. On June 15, 2011, resident #3 was observed to have a Stage II open area to the coccyx that had not been identified by the facility. The findings include: A review of the facility policy entitled Pressure Ulcer Management (dated December 2010) revealed that an assessment is the beginning of pressure ulcer treatment and the entire resident must be assessed by health care professionals to include the Physical Therapist and Registered Dietitian. Based on the assessment, the policy stated an effective plan of care would be developed consistent with the resident's goals/wishes and a preventative program would be implemented to prevent the development of pressure sores. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to usually make his/her self understood and to usually understand others. Further review of the assessment revealed the resident was assessed to be at risk for developing pressure ulcers and was frequently incontinent of bowel and bladder. Resident #3 was also assessed to require one staff person for physical assistance with transfers, bed mobility, toilet use, and personal hygiene. Resident #3 was not assessed to be resistant to care. Review of the Care Area Assessment Summary (CAAS) dated December 13, 2010, revealed resident #3 had impaired daily decision-making skills, required cues and supervision at times, and staff was to anticipate the resident's needs and assist with meeting them daily. The CAAS also revealed resident #3 was at high risk for developing pressure ulcers due to incontinence and impaired mobility, and staff was to provide peri-care to the resident after each incontinence episode. Further review of the CAAS revealed no evidence that resident #3 was assessed to be resistive to care. A review of the quarterly Minimum Data Set (MDS) assessment, with a completion date of May 27, 2011, revealed the facility assessed resident #3 to usually make his/her self understood and to usually understand others. The assessment revealed resident #3 was continent of bowel and bladder and required the assistance of one staff person with transfers, bed mobility, toilet use, and personal hygiene. The quarterly assessment further revealed the resident had a Stage II pressure ulcer and was at risk for developing new pressure ulcers; however, the resident was not assessed to refuse or be resistant to care. A review of resident #3's most recent skin assessment dated [DATE], that was conducted by CNA #6 during the resident's shower revealed the resident had one Stage II pressure sore to the coccyx and had no new open areas. Observation of a skin assessment of resident #3 conducted by LPN #1 on June 15, 2011, at 2:40 p.m., after the resident returned from the shower, revealed an additional open area to the resident's coccyx which had not been identified by facility staff during the resident's shower. The unidentified open area measured .5 centimeters (cm) by .5 cm. Observations on June 14, 2011, at 3:00 p.m. and 4:00 p.m.; on June 15, 2011, at 8:45 a.m., 10:40 a.m., 12:00 p.m., 2:50 p.m., and 3:50 p.m.; on June 16, 2011, at 8:35 a.m., 9:30 a.m., 10:40 a.m., 11:35 a.m., 1:00 p.m., 2:35 p.m., and 3:45 p.m., revealed resident #3 was sitting in a wheelchair in the same position and was not assisted to bed or to reposition in the chair. Interviews with CNA #1 on June 15, 2011, at 4:20 p.m., with CNA #4 on June 16, 2011, at 5:30 p.m., and with CNA #3 on June 16, 2011, at 5:35 p.m., revealed resident #3 was incontinent at times, wore incontinence briefs, and had a long history of noncompliance with incontinence care and repositioning when up in a chair. CNA #1 stated resident #3 "sits up in a wheelchair every day and refuses to change positions." CNA #4 stated resident #3 "likes to take care of herself." CNA #3 stated the resident would change the wet incontinence briefs without staff assistance, refused to allow staff assistance with removing the wet briefs, and frequently refused staff assistance with personal care. Interview with the Director of Nursing (DON) on June 16, 2011, at 5:40 p.m., revealed resident #3 should receive incontinence care after each incontinence episode and the DON was not aware staff had failed to provide the incontinence care. The DON was aware resident #3 sat in a wheelchair for long periods of time and refused to go back to bed. The DON stated the facility should have identified the resident's resistance to care as a causative factor for the development of pressure sores and interventions should have been developed/implemented regarding the resident's refusal of care due to the resident's risk for the development of new pressure sores and the presence of the Stage II pressure sore to the resident's coccyx area. The DON was unaware of the second open area to resident #3's coccyx until it was identified by the surveyor on June 15, 2011. The DON stated the facility's newly hired MDS nurse was still in training and the DON was responsible for the completion of all MDS assessments.