Every finding on record at Princeton Nursing & Rehabilitation

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation on 09/08/2024 of the reach-in cooler revealed multiple food items which had been opened; however, were not labeled and undated. The facility's failure had the potential to affect 96 of the facility's 98 residents who consumed food from the kitchen. The findings include: Review of the facility documents titled,Safe Standards and Procedures, Food Handling, dated 03/08/2024, from the facility's contracted kitchen services provider, revealed, foods, intended for storage beyond 24 hours, must be labeled. Further review revealed the food labels were to include: the item name; the preparation date and a use by date within seven days of preparation or opening; and the employees initials. Review of the facility policy, Food Storage - Cold, dated 10/2019, revealed it was the facility's policy to ensure all time and temperature control for safety (TCS), frozen and refrigerated food items be appropriately stored in accordance with the guidelines of the FDA Food Code. Further review revealed the Dining Services Director or cook were to ensure all food items were stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the United States Department of Agricultural Food Safety and Inspection Services for Food Safety Information Basics for Handling Food Safely, revealed safe steps in food handling, cooking, and storage were essential to prevent food borne illness. Continued review revealed leftover food was to be used within four days. Observation, with the Dietary Manager (DM), during the initial tour of the kitchen on 09/08/2024 at 11:30 AM, of the reach-in cooler, revealed a large container of breakfast gravy 3/4 full not labeled or dated; 2 large containers of sausage patties dated 09/09/2024; a plastic bag containing 5 dinner rolls dated 9/05/2024. Continued observation of the reach-in cooler revealed a small bowl of yogurt, not labeled or dated; 17 prepared sandwiches of various types, dated 09/06-09/13; a small bowl of chicken soup, not labeled or dated; and packaged flour tortillas with an expiration date of 08/10/2024. Further observation revealed packaged ham slices containing six slices dated 08/26/2024. In addition, observation of the walk-in freezer contained 1 pint of ice cream with an expiration date of 06/30/2024. In an interview with the Dietary Manager on 09/08/2024 at 11:47 AM, during the initial kitchen tour, she stated food products were good for seven days after being opened. She stated she expected dietary staff to label and date all items as required. The Dietary Manager further stated food items should contain two dates, the date the item was placed in the cooler and the date it should be removed. In an interview with the Director of Nursing (DON) on 09/12/2024 at 10:15 AM, she stated she would expect the kitchen staff, from a contracted company, to follow their polices and procedures related to food storage. During an interview with the Administrator on 09/13/2024 at 10:35 AM, she stated the dietary department was a contract company and had their own policies. She stated she expected the dietary staff to follow their policies and ensure all items placed in the coolers were labeled and dated.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, with measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for two (2) of three (3) sampled residents. (Resident (R)38), and R26. The facility care planned R38 for alteration in nutritional status related to receiving enteral (tube) feedings, with interventions that included elevating the head of bed (HOB) during feedings, and maintaining the resident in an upright posture to decrease aspiration risk. However, observation on 09/10/24 at 5:00 PM, revealed R38 lying on the bed with the HOB flat and the bed elevated while the resident's enteral tube feeding was hanging and infusing. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 02/01/2024 revealed it was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident to meet their medical, physical, mental, and psychosocial needs. Review of the facility policy titled, Resident Rights, revised 03/22/2022, revealed residents had the right to receive the items and/or services included in their plan of care. Review of the facility policy titled, Nursing Services and Sufficient Staff , revised 02/20/2024, revealed the facility must ensure the nursing assistants were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through their assessments and as described in the plan of care. Review of the facility's Face Sheet for R38 revealed the resident was admitted on [DATE], with diagnoses which included Malignant Neoplasm of the bladder, Alzheimer's Disease, Stage 3 Chronic Kidney Disease and a history of gastrostomy tube (g-tube) placement with enteral feedings. Review of R38's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/08/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) of zero (00) out of fifteen (15), which indicated she was severely cognitively impaired. Review of R38's Comprehensive Care Plan dated 11/23/2022, revealed the facility care planned the resident for alterations with nutritional status related to protein calorie malnutrition, requiring feeding tube with oral food intake diet, and failure to thrive. Continued review revealed the goal was for lessening potential signs of complications from bolus feedings or enteral feeding solution. Review further revealed interventions that included maintaining R38 in an upright posture and elevating the head of bed (HOB) 30-45 degrees during feedings to decrease the risk for aspiration. Observation on 09/10/2024 at 5:00 PM, of R38 revealed the resident's tube feeding was hanging and infusing. Continued observation revealed R38 was lying flat on the bed and the bed was elevated. In interview on 09/12/2024 at 10:42 AM, Certified Nursing Assistant (CNA) 16 stated she typically got information on the residents in her care from the night shift CNA's. She said depending on who's working, they would update them with information. CNA 16 stated if nightshift staff did not tell them they just usually had to figure it out. She said she could access residents' care plan in Matrix (facility's electronic charting system) to get the information on how to care for her residents if she needed to do that. The CNA stated however, most times she got information in report from the off-going shift. She further stated after assisting CNA 17 with R38's care she had left the resident's room where CNA 17 was still with the resident. CNA 16 also stated she assumed CNA 17 was going to raise the head of R38's bed back up. In interview on 09/12/2024 at 3:31 PM, CNA 5 stated she got residents' care information from the care plan on the computer. She further stated if she could not find information on the resident in the computer she would look at the Kardex or Binder. In interview on 09/10/2024 at 5:00 PM, Licensed Practical Nurse (LPN) 1 stated R38 needed to have the head of her bed raised and bed lowered for her safety. The LPN stated R38 could potentially aspirate if left in a lying flat position. She stated she had two new CNA's working that had provided care for R38 and they must have forgotten to place the resident back into the appropriate position. LPN 1 said she had last checked on R38 around 3:00 PM or so and the resident had been sitting in the correct position at that time. She additionally stated she did not know why the CNA's had not implemented R38's care plan interventions; however, would educate the two CNA's on the proper positioning for R38. In interview on 09/12/2024 at 3:32 PM, Registered Nurse (RN) 1 stated nurses had books they could go to for reference if needed. She stated when she was working she had morning huddles with her nursing staff and discussed care expectations and tasks. The RN said she had the staff members sign off that they attended huddle, and she did walking rounds and checked on residents on the hall to ensure they were being cared for (as per their care plan). In interview on 09/12/2024 at 3:24 PM, RN 2 stated she looked at a resident's care plan and admit information to find out what care staff needed to provide for the resident. She stated she checked up on the CNA's by looking over their charting and different things to ensure they were providing resident care according to the residents' care plans. The RN further stated the MDS Nurse, and Social Services Director (SSD) were responsible for updating residents' care plans. She additionally stated facility staff should implement residents' care plan interventions as ordered. In interview on 09/12/2024 at 2:13 PM, the MDS Coordinator stated care plans were updated after an MDS Assessment had been performed. She stated she also updated residents' care plans daily as she got new orders. The MDS Coordinator stated usually information was attached to the care profile (CNA Care Plan/Kardex) and nurses' care plan. She stated they verified residents' care plan were implemented by staff by visually observing resident care and confirmed staff were following the residents' care profile or were implementing residents' care plans. The MDS Coordinator also stated floor nurses could update residents' care plans when they got a new order for something. She further stated she went back over residents' care plans and checked them to make sure that it had been updated. In interview on 09/12/2024 at 3:15 PM, the Director of Nursing (DON) stated her expectations was for her staff to follow R38's care plan interventions. In interview on 09/13/2024 at 10:19 AM, the Administrator stated she was a member of the facility's Interdisciplinary Team (IDT) team, who confirmed interventions were in place by going to check after the IDT meeting to make sure interventions were done. She stated she expected staff to follow residents' care plans, and a potential outcome for not following the care plan was a resident might not receive the care they were supposed to be getting. The Administrator further stated, regarding R38, that staff should have followed the resident's care plan interventions.

Based on observation, interview, record review, and review of the facility policies, the facility failed to ensure the comprehensive care plan was reviewed and revised by its Interdisciplinary Team (IDT following a fall with major injury for 1 of 22 sampled residents, Resident (R)26. On 06/23/2024 a perimeter defining mattress (PDM) was recommended as an intervention by the IDT for R26, and a PDM was placed on the resident's bed. The PDM was removed at R26's request; however, was not added to the resident's falls care plan to accurately reflect the resident's plan of care. In addition, R26's falls care plan noted a high rise mattress r/t fall from bed remained as an active intervention, but was not observed to be in use. The findings include: Review of the facility policy titled, Comprehensive Care Plans revised 02/2024, revealed it was the policy of the facility to develop and implement a comprehensive, patient-centered care plan for each resident to meet the resident's medical, physical, mental, and psychosocial needs. Further policy review revealed the care plan was to include resident specific interventions that reflected the resident's needs and preferences and was to include factors identified by the IDT. Review of the facility policy titled, Falls revised 03/22/2022, revealed care plan interventions should be implemented that address the resident's risk factors. Continued review revealed the care plan interventions were to reduce risk of repeat episode. Further review revealed any orders received from the Physician were to be noted and the resident care plan should be updated to reflect any new or change in interventions. Review of the facility's medical record for R26 revealed the facility admitted the resident on 05/31/2016, with diagnoses of history of malignant neoplasm of the breast, primary generalized (osteo)arthritis, and hypertensive chronic kidney disease (CKD). Review of R26's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognition was intact. Per MDS review, the facility assessed R26's functional abilities as requiring substantial to maximal assistance for rolling left to right. Further review revealed the facility further assessed R26 as dependent for all transfers and wheelchair mobility. Review of R26's Significant Change in Status MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of 6/15, which indicated severe cognitive impairment. Per MDS review, the facility also assessed R26 to be dependent for rolling left and right; and dependent for chair/bed and bed/chair transfers and wheelchair mobility. Review of the facility's comprehensive care plan developed for R26 revealed a falls care plan with start date of 11/15/2022, for the resident's risk for falls due to incontinence of bowel and bladder, psychoactive drug use, and impaired functional status and mobility. Continued review revealed the falls care plan goal was to lessen R26's potential for falls/injury through the review date, and a target goal date of 10/18/2024. Per care plan review, there were three discontinued interventions that included an intervention for an x-ray of R26's right leg and send out to the emergency room (ER) for evaluation which had a start and end date of 06/25/2024. Review also revealed a discontinued intervention for a body pillow to provide R26 an extra reminder of bed edges with a start date of 6/24/2024 and end date of 7/02/2024. Care plan review revealed an additional discontinued intervention for a urinalysis (U/A) to be obtained due to R26's confusion related to fall and for therapy to evaluate and treat that had a start and end date of 6/24/2024. Further review of the falls care plan revealed it included active interventions for assuring R26's glasses were clean and in good repair and making sure she wore the glasses; encouraging use of 1/2 side rails for bed mobility and transfers dated 6/28/2023; and keeping personal and frequently used items in reach. Additionally, review of the falls care plan revealed however, no current or historical/resolved interventions related to a specialized mattress or for the resident's bed to be in a low position. Review of R26's comprehensive care plan additionally revealed a care plan for pressure ulcer/injury related to the resident being at risk for skin integrity alterations due to impaired mobility. Further review revealed interventions which included a pressure reduction high rise mattress with a start date of 06/28/2023, which had not been discontinued and was still an active intervention. Review of the Physician's orders dated 03/29/2023, revealed a high rise mattress related to falls from bed, which had a discontinued date of 09/11/2024. Review of the facility's investigation titled, Incident Fall with Major Injury with a date of 06/23/2024, for R26's fall which revealed a brief review of the incident. Continued review revealed the investigation noted What was the new intervention placed on the care plan/Kardex at time of incident? with a response for R26's bed to be in low position, perimeter defined mattress. Review of the IDT's review in the progress notes dated 06/27/2024 at 12:22 PM, revealed, Care plan revision perimeter defined mattress. Observation on 09/10/2024 at 5:04 PM ,and on 09/11/2024 at 10:51 AM and at 11:05 AM, of R26's mattress, revealed a standard pressure reduction mattress in place on the resident's bed. In interview on 09/11/2024 at 2:03 PM, Certified Nursing Assistant (CNA) 11 stated the CNA's accessed residents' care plans on Matrix (facility's electronic health record) all day every day. She stated that was where the CNA knew to find information on residents' transfer status; whether they were continent or incontinent; their behaviors; and how to bathe the resident. CNA 11 stated sometimes it did say if a resident had an intervention like bed low to the ground. She said she was not able to see the full nursing care plan in Matrix, but received report from the previous shift CNA and got any new information that report. In interview on 09/11/2024 at 2:20 PM, the CCN stated the CNA care plan in Matrix showed the level of assistance a resident required. In interview on 09/11/2024 at 10:51 AM, Registered Nurse (RN) 2 stated she did not participate in residents' care plan meetings. She further stated however, she had been asked for updates on residents for their care plans. In interview on 09/12/2024 at 2:14 PM, MDS Coordinator 10 stated the MDS Coordinators were responsible to update residents' care plans when doing their MDS Assessment and daily with any new orders. MDS Coordinator 10 stated the floor nurses were supposed to assist in updating residents' care plans. She stated she checked the care plans to make sure interventions were there (on the care plan). The MDS Coordinator stated once the care plan was updated staff could see the updates. She said interventions were attached to the care profile for the CNA's and everyone could see residents' care plans. The MDS Coordinator stated she was not really sure what a high rise mattress but thought it was like a perimeter mattress that was used to keep the body in the bed. In interview on 9/12/2024 at 9:31 AM, the Director of Nursing (DON) stated the nurses should put interventions on residents' care plans that they came up with, and the IDT added something else which the MDS Coordinator usually made the changes to on the care plan. She stated the IDT reviewed falls in the morning meetings where the fall event was discussed, and the care plan reviewed and updated. In an additional interview on 09/13/2024 at 10:18 AM, the DON stated she expected residents' care plans to be up to date and reflect the care being provided to the resident. When the State Survey Agency (SSA) Surveyor asked the DON if audits were completed to ensure the care plan interventions were in use, she stated audits were completed periodically; however, did not specify a frequency of the auditing. She stated she did not know when the last audit was completed and would have to look, then she stated maintenance did bed audits. The DON she told us it got done and the nurse and CNA would know in regards to care plan intervention implementation. She stated residents' care plan were reviewed in the IDT meetings to see if additional interventions needed to be added, with the additions usually made by the MDS Coordinator. In interview on 09/13/2024 at 10:20 AM, the Administrator stated she led a daily morning meeting with facility managers where incidents were discussed with the IDT at that time to review the incident report and resident's care plan. She stated it was her expectation for the care plan to be changed when an intervention was added or removed and, a progress note documented if needed to reflect the current care to be provided for a resident. The Administrator further stated, in regards to the PDM for R26, she expected the care plan intervention to be removed if it was discontinued.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure medical provider orders were entered upon receipt for 1 of 22 sampled residents, Resident (R)26. On 06/25/2024 at 11:11 AM, Registered Nurse (RN) 3 contacted the Advanced Practice Registered Nurse (APRN) 1 to report R26 had right leg pain, scattered bruising of the right leg and swelling of the right knee. RN 3 said APRN 1 ordered an x-ray of R26's right leg the previous night. Review of the medical record revealed no documented evidence of an x-ray order or documentation of the nurse's communication with APRN 1 on 06/24/2024. The findings include: Review of the facility policy titled, Verbal Orders, with a revision date of 03/23/2020 revealed Physician orders might be received by a licensed nurse or registered health care specialist who was legally authorized to do so. Per review, verbal orders were given to the nurse by the Physician or extender in person or by telephone. Further review of the policy revealed the orders were to be entered into the resident's medical record and were to be followed through with by making appropriate contact or notification (eg. lab or pharmacy). Review of R26's electronic health record (EHR), revealed the facility admitted the resident on 05/31/2016 with primary diagnoses of Hypertensive Chronic Kidney Disease (CKD), Unspecified Convulsions, personal history of malignant neoplasm of the breast, and primary generalized (osteo)arthritis. Review of R26's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six out of 15 indicating the resident had severe cognitive impairment. Review of R26's comprehensive care plan revealed the facility developed a problem for Falls, with a start date of 11/15/2022. Review of the Falls care plan revealed R26 was at risk for falling related impaired mobility and functional status, incontinent of bowel and bladder (B&B), and psychoactive drug use. Per review, the target goal date was 10/18/2024, with the goal noted as to lessen potential for falls/injury through the review date. Review of the care plan approaches/interventions revealed three interventions had been discontinued that included one on 06/25/2024, with the same date as the end date, to x-ray R26's right leg, and send out to the emergency room (ER) for evaluation. Continued review revealed the second discontinued approach, with a start date of 06/24/2024 and an end date of 07/02/2024, which noted, Body pillow to provide resident extra reminder of bed edges. Care plan review revealed the third discontinued approach, with a start date of 06/24/2024, with the same end date, revealed therapy was to evaluate and treat, and a urinanalysis (U/A) was to be obtained related to confusion from a fall. Review of the nursing progress note dated 06/23/2024 at 12:55 AM, revealed R26 experienced a fall from the bed on that date at 12:15 AM, with an abrasion identified at the time but no other injury identified. Per review of the note, the Physician was notified and no new orders were received at that time. Review of the nursing progress notes from 06/24/2024 through early on 06/25/2024, revealed the resident was monitored; however, there was no documented evidence of R26 reporting pain or other abnormalities. Review of a progress note 06/25/2024 at 9:30 AM, revealed RN 3 had contacted APRN 1 due to R26 having, Right leg pain and scattered bruising and Right knee Swollen. In addition, revealed APRN 1 ordered an x-ray of R26's right leg and foot. Review of the progress notes further revealed the x-ray was obtained and results reported to the APRN (APRN 2) on 06/25/2024 at 1:30 PM, with a new order received to send out the resident. Review of the x-ray report results received on 06/25/2024 revealed R26 had a Fracture of the distal femur. In an phone interview with RN 3 on 09/11/2024 at 2:52 PM, she stated she had received report and was told about R26 sustaining a fall. She stated she assessed R26 on 06/25/2024, during incontinence care and found bruising to the resident's leg down to her foot and the resident complained of pain in the right leg. RN 3 stated she contacted APRN 1 who said she gave an order the previous night to obtain an x-ray of R26's right lower extremity. She said however, no order had been entered for R26's x-ray and so she contacted the Unit Manager (UM) who had worked the day prior (06/24/2024) to ask about the order. The RN stated the UM reported an order was received the night before but the UM had not had a chance to enter the order into the computer yet. RN 3 stated she entered the x-ray order on 06/25/2024 at 9:30 AM, and the x-ray was completed at 11:11 AM. She stated the x-ray results were received at 1:30 PM, and reported to APRN 2 who gave an order to send the resident out to the ER for evaluation. In an interview with APRN 1 on 09/11/2024 at 3:12 PM, she stated she recalled the situation involving R26 and the x-ray. She said she gave an order for the x-ray the night before RN 3 contacted her (06/24/2024). APRN 1 stated the UM had contacted her on 06/24/2024, to report redness of R26's leg and so she gave the order for the x-ray. Per continued interview, APRN did not indicate the x-ray order was a stat (immediate) order. She stated she worked on Monday, Wednesday, and Friday and she had not examined the resident. APRN 1 stated staff probably entered the order into the Trident System, (a computerized order entry system used to enter Physician/provider orders for x-rays) and they don't come until the next day. In a phone interview with the UM on 09/12/2024 at 10:20 AM, she stated she recalled that R26 had experienced a fall. She said she recalled contacting APRN 1 due to the resident having complaints of pain, but did not recall if the UM reported whether the pain was constant or intermittent. The UM stated APRN 1 gave an order for an x-ray; however, she could not recall if she entered the order into the system or not. She stated the x-ray order was received at shift change, and she might have passed it on in report to the next nurse to enter the order. The UM said she would have to look at R26's record to see. The UM further stated there was no guarantee the mobile x-ray provider would come and do the x-ray on the same day if the order had been entered on 06/24/2024. In an interview with a Representative from the mobile x-ray provider on 09/12/2024 at 10:49 AM, she stated if an order was entered at 7:00 PM, and was entered as a stat order, the mobile x-ray provider's policy was to complete the order within four to six hours from the time the order was received. She stated the policy was to include a report of the results of the x-ray within the required timeframe. The mobile x-ray Representative said if the x-ray order was entered as a routine order, the provider had eight to 24 hours to complete and result the x-ray. She stated depending upon the volume of x-rays to be completed, the test might be done the following day. The Representative said a call was to be placed to the facility to notify them the x-ray would not be completed the same day. In addition, she said she had been unable to locate an order in their electronic system requesting an x-ray for R26 on 06/24/2024. She further stated the only x-ray that had been obtained was on 06/25/2024, with the results reported on 06/25/2024. In an interview with the Director of Nursing (DON) on 09/12/2024 at 9:31 AM, she stated it was her expectation that orders were entered into the facility's system before the nurse left their shift. The DON stated she did not think the mobile x-ray provider would have completed the x-ray until probably the next morning, unless it was a stat order. She further stated if there was any delay in receiving the x-ray, she would expect the delay to only be one to two at most to get the x-ray In an interview with the Administrator on 09/13/2024 at 10:20 AM, she stated an order was to be noted in the system when it was obtained. She stated any negative outcomes for a resident would depend on what the order was for, in determining the negative outcome. The Administrator stated that had the x-ray order been entered as a stat order, she did not think it still would have been completed on the same day by the mobile x-ray provider. She further stated if we thought a resident needed a stat order we would send that resident to the ER for evaluation.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the use of assistive devices to prevent injury for 1 of 3 sampled residents, Resident (R)26. Review of the Physician's Order History revealed an order with a start date of 03/29/2023 and a discontinue date of 9/11/2024 for High rise mattress as intervention r/t falls from bed. However, observation of R26's bed mattress revealed a standard mattress was in place, not the ordered high rise mattress. Therefore, on 6/23/2024 R26 sustained a fall from the bed that resulted in a comminuted impacted extra-articular (bone broken into multiple pieces with the ends driven into each other) right distal femur fracture with lateral displacement that required surgical repair. The findings include: Review of the facility policy titled, Falls with a revised date of 03/22/2022, revealed the purpose of the policy was to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Per review, care plan interventions were to be implemented that addressed the resident's risk factors with interventions to reduce risk of repeated episodes. Continued review revealed any orders received from the Physician should be noted and carried out. Further review revealed the resident's care plan should be updated to reflect any new or change in interventions. Review of the facility policy titled, Accidents and Supervision, revised 02/21/2024, revealed each resident was to receive adequate supervision and assistive devices to prevent accidents. Continued review of the policy revealed Fall as a potential accident with a definition of a fall. Further review revealed a section titled, Policy Explanation and Compliance Guidelines which noted ensuring interventions are put into action. Review of R26's record revealed the facility admitted the resident on 05/31/2016 with primary diagnoses of primary generalized (osteo)arthritis, hypertensive chronic kidney disease (CKD), unspecified convulsions, and history of malignant neoplasm of the breast. Review of the Quarterly Minimum Data Set (MDS) Assessment for R26 dated 04/04/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Continued review of the MDS revealed for R26's functional abilities and goals, the facility assessed the resident to require substantial/maximal assistance for rolling left to right; as dependent for all transfers; and as dependent for wheelchair mobility. Review of the Significant Change in Status MDS Assessment for R26 dated 07/05/2024, revealed the resident with a BIMS score of six out of 15, indicating the resident had severe cognitive impairment. Further review of the MDS revealed for R26's functional abilities and goals, the facility assessed the resident as: dependent for rolling left and right; dependent for chair to bed and bed to chair transfers; and dependent for wheelchair mobility. Review of the Physician's Order History for R26 revealed an order with a start date of 03/29/2023 and a discontinue date of 9/11/2024, for a high rise mattress as an intervention related to falls from bed. Review of R26's comprehensive care plan revealed the facility developed a care plan for falls with a problem start date of 11/15/2022, related to the resident being at risk for falls due to impaired functional status and mobility, incontinence of bowel and bladder (B&B), and psychoactive drug use. Per review, the falls care plan target goal date was 10/18/2024, and the goal was to lessen potential for falls/injury through the review date. Continued review revealed the interventions included three discontinued interventions which x-ray of right leg and send out to the emergency room (ER) for evaluation with a start and end date of 6/25/2024. The falls care plan review also revealed a second discontinued intervention with a start date of 6/24/2024 and end date of 7/02/2024, for R26 to have a body pillow to provide the resident extra reminder of bed edges. Further review revealed a third discontinued approach with a start and end date of 6/24/2024, noting therapy was to evaluate and treat R26 and for a urinalysis (U/A) to be obtained due to confusion related to fall. Additionally, review revealed active intervention included: keeping personal and frequently used items in reach dated 3/10/2024; assuring R26 wore her glasses, and ensuring the glasses were clean and in good repair; and encouraging use of 1/2 side rails for bed mobility and transfers dated 6/28/2023. Further review of R26's comprehensive care plan revealed the facility developed a care plan titled, Category: Pressure Ulcer/Injury related to the resident being at risk for alterations in skin integrity due to impaired mobility. Per care plan review, the interventions included an approach for a pressure reduction high rise mattress with a start date of 6/28/2023, that was still an active intervention and had not been discontinued. Review of the Matrix Care (an electronic medical records [EMR] system used for charting) Resident Profile (the care guide utilized for the Certified Nursing Assistants [CNA's] with no print date), provided after request on 09/11/2024, revealed a Last Updated Date of 08/27/2024 at 8:53 AM. Further review revealed no documentation noting a mattress specified for R26's use. Review of the facility's progress note dated 06/23/2024 at 12:55 AM, revealed R26 had been found lying on the floor at 12:15 AM. Per review, R26 was assessed and found to have an abrasion to the right lower extremity with wound care provided. Ongoing review of the progress note revealed documentation noting R26's range of motion (ROM on the bilateral lower extremities (BLE) was decreased per norm. Review of the facility's progress notes dated 06/23/2024 through 06/25/2024, revealed documentation noting R26 was being monitored, had no complaints of pain, and indicated no problems until the resident was assessed by Registered Nurse (RN) 3 on 06/25/2024 at 11:11 AM. Review of the 06/25/2024 at 11:11 AM, progress note documented by RN 2, revealed R26 had right leg pain and scattered bruising, with a swollen right knee. Per review, RN 3 contacted Advanced Practice Registered Nurse (APRN) 1 who ordered an x-ray of R26's right leg and foot. Further review of the progress notes revealed the x-ray was obtained and resulted on 06/25/2024 at 1:30 PM, and was shown to APRN 2 with a new order received to send R26 out to the ER. Additionally progress note review revealed R26 left the facility at 1:55 PM. Review of the x-ray report results dated 06/25/2024, revealed R26 had a fracture of the distal femur. Review of the After Visit Summary from the hospital revealed R26 was hospitalized on [DATE] related to injury sustained from a fall from her bed. Review of the After Visit Summary with dates of 06/25/2024 through 06/29/2024, revealed R26 had been hospitalized with a comminuted impacted extra-articular right distal femur fracture with lateral displacement. Further review revealed R26 underwent surgery for repair of the fracture. Review of the facility's Interdisciplinary Team (IDT) documentation for review of R26's fall dated 06/27/2024 at 12:12 PM, revealed the possible root cause of the resident's fall was poor safety awareness and thinks she can walk. Continued review revealed the IDT referral section noted the team would look at after R26's return from the hospital. Further review revealed the IDT's recommended interventions included a care plan revision for R26 to have a perimeter defined mattress and noted the resident's care plan was reviewed and updated. Review of the facility's monthly bed audits dated May 2024; June 2024; July, 2024; and August 16, 2024, revealed R26's mattress was documented as a regular mattress in May 2024, June 2024, July 2024 and August 2024. In an interview with RN 2 on 09/11/2024 at 10:51 AM, the RN stated a high rise mattress was higher on the edges which was the same as a perimeter mattress. In additional interview on 09/11/2024 at 11:05 AM, RN 2 stated that neither a high rise mattress or perimeter mattress was on R26's bed. The RN further stated maintenance was responsible to change out residents' mattresses and maintenance would be notified by a phone call or a work order. In an interview with the Director of Maintenance (DOM) on 09/11/2024 at 2:51 PM, he stated he was responsible for replacing mattresses. He stated a high rise mattress had bolsters built into an overlay that was zipped over the mattress. The DOM said staff placed work orders for maintenance requests/issues into the facility's, TELS, electronic system (used for communicating day-to-day maintenance requests). He stated if staff verbally reported a request for a resident's mattress change, that request was verified with the Director of Nursing (DON) to ensure the request was valid and had been care planned before placement of the mattress. The DOM stated there was a record of completed work orders through the facility's TELS system. The DOM provided a work order requesting placement of a perimeter mattress for R26, with a created date of 06/27/2024 and completion date of 6/28/2024. No further work orders regarding R26 were provided by the facility. In an interview with the MDS Coordinator on 09/12/2024 at 2:13 PM, she stated she and two other MDS Nurses were responsible for updating residents' care plans with all new Physician's orders from the previous day. She said they also updated residents' care plans when reviewing the MDS. The State Survey Agency (SSA) Surveyor asked the MDS Coordinator to define the high rise mattress intervention on R26's care plan. The MDS Coordinator stated she was not really sure, but thought a high rise mattress was like a perimeter mattress, to keep the resident's body in the bed. She stated if there was a Physician's order a specialty mattress would be noted on the resident's care plan, and if there was not an order the specialty mattress wound not be on the care plan. The MDS Coordinator further stated to ensure staff were following a resident's care plan, visualization, observation and review of what was checked off were all items reviewed. In an interview with the DON on 09/12/2024 at 9:31 AM, she stated the nurse on duty at the time of a resident's fall was to look for root cause of the fall and put an immediate intervention in place. She said the fall would then be reviewed in the morning meeting that was attended by the IDT members which included: herself, the Administrator, Assistant Director of Nursing (ADON), Unit Manager (UM), MDS Coordinator, Therapy Manager, Business Office Manager (BOM), Social Services Director (SSD), Housekeeping Manager, and Dietary Manager. The DON also stated at that time of a fall care plans were reviewed and revised based on discussion of the fall and the MDS Coordinator usually made the changes needed in the resident's care plan. In continued interview on 09/12/2024 at 9:31 AM, the DON stated a high rise mattress was raised up on the sides a little, but was not full sides, like a perimeter mattress. She stated she was not sure why the Physician's order for the high rise mattress was discontinued on 9/11/2024, but would wonder if it was not on the bed. The DON stated periodic audits were done to ensure the residents' interventions in place matched their care plans. She stated however, she did not know when the last time that audit occurred. The DON said maintenance audited residents' beds for the type of bed, type of mattress, type of rail, gap assessment of the side rails, and a general safety assessment to ensure the appropriate bed and mattress were in use for the weight of the resident, the mattress was affixed to the bed, bed rails were firmly attached, and the bed rails latched appropriately. She further stated if an intervention was added to a resident's care plan and was implemented, the nurses and CNA's would know and would tell us it had gotten done. In addition, the DON said maintenance would notify staff when a request was completed. In an interview with the Administrator on 09/13/2024 at 10:20 AM, she stated that a morning meeting was held daily and falls and interventions were reviewed. She stated if changes were needed it was her expectation that the care plan was changed (updated) during the morning meeting and a note made in the resident's record if needed. The Administrator stated she was trying to put in the work orders because verbal requests got forgotten and there was no record that a request had been completed. She stated after the morning meeting we check to ensure (necessary) interventions were in place and maintenance will let her know a task had been completed. The Administrator additionally stated they would follow up. In continued interview on 09/13/2024 at 10:20 AM, the Administrator stated a high rise mattress could be an overlay or perimeter mattress. Per interview, the Administrator described the edges of the high rise or perimeter mattress as raised. She stated she recalled at some point after the perimeter mattress was placed on R26's bed, following the resident's fall in June 2024, R26 complained she did not like the mattress and did not want it on her bed anymore, so the mattress was changed out. The Administrator stated however, no work order was entered but she knew it was changed out and said it just was not in black and white that they had done that. She further stated if an intervention was discontinued, she expected it to be removed from the resident's care plan.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure a resident who was fed by enteral (tube) feedings, received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia for 1 of ?? sampled residents, Resident (R)38. 1. Review of the manufacturer's instruction manual for R38's feeding system revealed the feeding set should be replaced after 24 hours from initiation of the feeding to prevent bacterial growth that could be a hazard to the patient. However, observation on 09/09/2024 at 12:49 PM, revealed R38's enteral (tube) feeding bottle had been hanging for greater than 24 hours, and included a 4 hour holding of the feeding solution. 2. Review of R38's care plan revealed the head of the resident's bed was to be elevated during enteral feedings. Observation on 09/10/2024 at 5:00 PM and on 09/11/2024 at 5:00 PM, revealed R38 lying flat on the bed while her enteral feeding was infusing. The findings include: Review of the facility policy titled, Assisted Nutrition and Hydration, revised 02/21/2024, revealed the facility was to ensure each resident fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding. Further review revealed the complications included, but were not limited to, aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Review of the facility policy titled, Appropriate Use of Feeding Tubes, revised 05/31/2023, revealed feeding tubes were to be utilized in accordance with current clinical standards of practice with interventions to prevent complications to the extent possible. 1. Review of the manufacturer's instruction manual titled, Kangaroo OMNI Enteral Feeding Pump, revealed the feeding set should be replaced after 24 hours from initiation of the feeding. Continued review revealed replacing the feeding set ensured the enteral feeding pump was operating within the specified parameters and prevented bacterial growth that could be a hazard to the patient. Review of the facility's Face Sheet for R38, revealed the facility admitted the resident on 05/07/2021, with diagnoses to include Alzheimer's Disease, Stage 3 Chronic Kidney Disease, and Malignant Neoplasm of the bladder. Review of R38's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero (00) out of 15, indicating R38 had severe cognitive impairment. Review of Resident 38's Comprehensive Care Plan dated 11/23/2022, revealed the facility care planned the resident for alteration with nutritional status related to failure to thrive and protein calorie malnutrition. Continued review revealed R38 required a feeding tube along with an oral food intake diet with a goal of lessening potential signs of complications from bolus feedings or enteral feeding solution. Further review revealed interventions which included elevating the head of bed (HOB) 30-45 degrees during (tube) feedings, and maintaining an upright posture to decrease aspiration risk. Observation on 09/09/2024 at 12:49 PM, of R38's enteral feeding bottle revealed it was dated 09/08/2024 at 8:18 AM, indicating the feeding had been hanging for 27 hours, and contained a 4 hour holding of the feeding solution. In an interview with Licensed Practical Nurse (LPN) 1 on 09/09/2024 at 1:00 PM, she stated enteral tube feeding was good for 48 hours. She further stated to her knowledge that was the facility's standard of practice. In an interview with Registered Nurse (RN) 1 on 09/12/2024 at 3:32 PM, she stated tube feeding systems should be changed every 24 hours. In an interview with the Director of Nursing (DON) on 09/09/2024 at 5:36 PM, she stated she thought tube feedings were good for 24 hours, but she was going to check on the facility's policy. In an additional interview on 09/12/2024 at 9:31 AM, the DON stated the (standard of) practice was to change the entire enteral feeding system every 24 hours. She additionally stated that was the protocol she expected all the nurses to follow. In an interview with the Administrator on 09/13/2024 at 10:19 AM, she stated the tube feeding systems needed to be changed every 24 hours. She stated it used to be changed every 48 hours, but with the new feeding system they had been using for the last few months it was to be done every 24 hours. The Administrator further stated they were starting to educate staff on that information now. 2. Review of the facility policy titled, Nursing Services and Sufficient Staff, revised 02/20/2024, revealed the facility must ensure nursing assistants were able to demonstrate competency in skills and techniques necessary to care for residents needs as identified through resident assessments and as described in the plan of care. Observation on 09/11/2024 at 5:00 PM revealed Resident 38 lying on her bed with her head of bed (HOB) flat while the resident's enteral tube feeding was hanging and infusing. In an interview with Certified Nursing Assistant (CNA) 16 on 09/12/2024 at 10:42 AM, she stated she helped CNA 17 change Resident 38's brief earlier, but did not recall what position the resident was in when being changed. She stated she left R38's room where CNA 17 remained and assumed they had left the resident lying flat. CNA 16 said she assumed that because afterwards the nurse came and got her and talked to both her and CNA 17 about how R38 had been lying and she assumed there must have been an issue with how the resident had been left lying. She stated they were both educated about positioning of R38, but were never told anything specifically about the resident's need for sitting up. The CNA stated she was taught how to clean the feeding tube, but not much else. She further stated now, if she saw a resident on tube feeding, she would raise the HOB to make sure the resident did not aspirate. In additional interview on 09/10/2024 at 5:00 PM, LPN 1 stated R38 needed to have her HOB raised as the resident could potentially aspirate if left in the lying flat position. She stated she last checked on R38 around 3:00 PM or so, and the resident had been sitting up in the correct position. LPN 1 stated she had two new CNA's caring for residents, that came in and provided care for R38 and they must have forgotten to put the resident back into the appropriate position. She further stated she would educate the CNA's on the proper positioning for R38. In an interview with Registered Nurse (RN) 1 on 09/12/2024 at 3:32 PM, she stated R38 should have had the head of her bed elevated to prevent aspiration, pneumonia, or an anxiety attack. In a follow-up interview on 09/12/2024 at 9:31 AM, the DON stated a potential negative outcome that could occur for R38 being left lying flat would be that the feeding could back up and the resident could aspirate it. In additional interview on 09/13/2024 at 10:19 AM, the Administrator stated a resident on tube feeding should have the head of their bed elevated, because they could potentially aspirate the feeding solution.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 sampled residents, Resident (R)2. Observation revealed staff failed to follow infection control guidelines related to catheter care, clean linen placement, and hand hygiene for R2. Additionally, staff failed to perform proper hand hygiene while passing residents' meal trays. The findings include: Review of the facility policy titled, Hand Hygiene, revised 03/22/2024, revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to residents, other personnel, and visitors. Per policy review, that applied to all staff working in all locations within the facility. Continued review revealed hand hygiene was a term for cleaning your hands by handwashing with soap and water or through use of an antiseptic hand rub. Review revealed hand hygiene was indicated and was to be performed under the following conditions: when hands were visibly dirty; soiled with blood or other body fluids; before and after eating; after using a restroom; and between resident contacts. Further policy review revealed hand hygiene was additionally to be performed: after handling contaminated objects; before and after applying personal protective equipment (PPE) including use of gloves; before performing resident care procedures; and when during resident care, moving from a contaminated body site to a clean body site. 1. Review of the facility policy titled, Catheter Care revised 02/20/2024, revealed it was the policy of the facility to ensure residents with indwelling catheters received appropriate catheter care and their dignity and privacy was maintained when indwelling catheters were in use. The policy review revealed for catheter care of a female resident, the cleansing was to include gently separating the labia to expose the urinary meatus, using a new part of the cloth or different cloth for each side. Further review revealed the process for female residents' catheter care also included cleansing of the catheter included using a new moistened cloth and starting at the urinary meatus moving out and making sure to hold the catheter in place so the catheter would not pull on the meatus. Review of R2's medical record revealed the facility admitted the resident on 03/08/2022, with diagnoses which included obstructive and reflux uropathy, retention of urine, and neuromuscular dysfunction of bladder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R2 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Observation on 09/11/2024 at 10:42 AM, of Certified Nursing Assistant (CNA) 11 and CNA 12 conducting indwelling catheter care for R2, revealed clean linens sitting at end of the roommate's bed. Per observation, CNA 12 pulled the overbed table with R2's belongings on it over, pushing the belongings to one side and placing a towel over the table without cleaning the table first. Observation revealed CNA 12 obtained a bath basin, ran water in it and placed it on the overbed table, and then picked up washcloths from the roommate's bed and placed them in the water. Continued observation revealed the two CNA's washed their hands, donned gloves and removed R2's soiled brief then initiated the resident's catheter care. Observation revealed neither CNA washed their hands after removing the soiled brief and prior to beginning the catheter care. In continued observation on 09/11/2024 at 10:42 AM, of CNA 11 and CNA 12 providing R2's catheter care, revealed during the cleansing of the catheter tubing the CNA's started at the resident's pubis and cleaned down; however, the CNA did not reposition the cloth to clean areas. Per observation, the CNA did the separate the labia to cleanse the meatus, and only cleaned down the catheter tubing approximately four inches from meatus. Continued observation revealed when R2 was turned to the side, stool was observed at the anus, and the CNA's started cleaning the stool off the resident. Observation revealed the CNA did not have cleansing wipes, so she used wash cloths and began cleaning R2's anal area contaminating the sleeve of her barrier/gown with stool. Further observation revealed after completing the catheter care and cleansing R2, the CNA's did not remove their dirty gloves prior to placing a clean brief on the resident. In addition, they were observed to reposition R2 up in the bed, touching the resident's bed clothes and overbed table with their contaminated gloves. Observation further revealed after ensuring R2 was comfortable, the CNA's placed the soiled laundry in bags, removed their gloves, washed their hands, picked up the dirty laundry and trash and left the room. During an interview on 09/11/2024 at 9:48 AM, CNA 12 stated she should have done a better job of cleaning R2, but since the resident had stool, it had caused some issues. CNA 12 stated she should have used a different technique when cleaning R2's catheter tubing by changing the site of the wash cloth to ensure it was clean each time. She further stated she should have washed her hands and changed gloves more frequently during the catheter care and when cleaning the stool from R2. During an interview with the Director of Nursing (DON) on 09/12/2024 at 10:05 AM, she stated she expected staff to use a clean technique procedure when providing catheter care. She also stated she expected staff to follow the facility's policy as written for indwelling catheter care and hand washing. The DON further stated the CNA was a new CNA who had just passed her test, who would need more education which was an ongoing process. During an interview on 09/11/2024 at 11:18 AM with the facility's Infection Preventionist, she stated there were skills fair during which certain areas were taught and check offs were completed for competency. She stated education was ongoing with staff. The IP also stated she made rounds to ensure staff were washing their hands appropriately and using proper infection control practices. She further stated she expected staff to follow the facility policy. 45914 2. Observation of meal tray pass on Wing 100, on 09/08/2024 at 12:50 PM, revealed CNA 1 serving meal trays to residents. CNA 1 was observed to exit room [ROOM NUMBER] and retrieve a meal tray from the food cart without using hand sanitizer or washing her hands. Per observation, CNA 1 then re-entered room [ROOM NUMBER] with another meal tray, returning to the food cart and pulled another meal tray again without sanitizing her hands prior to removing the tray and entering room [ROOM NUMBER] to serve the next tray. Further observation revealed CNA 1 delivered the tray, exited room [ROOM NUMBER] and went into room [ROOM NUMBER] to assist another CNA with readjusting a resident in the bed for dining without using hand sanitizer or washing her hands to prevent the spread of germs. In an interview with CNA 1 on 09/08/2024 at 1:10 PM, she stated she had worked in the facility for about 2-3 weeks. She stated she was aware she was required to sanitize her hands in between each resident's room when delivering meal trays and was to wash her hands after after every third resident room. CNA 1 further stated she was aware she was not practicing proper hand hygiene when going in and out of residents' rooms without following the guidelines which could be potentially harmful to residents. In an interview with CNA 6 working on Wing 200, on 09/13/2024 at 9:00 AM, she stated the facility's policy on hand hygiene required handwashing with soap and water before serving meal trays. She stated hand sanitizing was to occur between residents' rooms and handwashing required after entering every third room. CNA 6 further stated if staff had not followed the facility's policy and procedures for hand hygiene there was potential for harm of a resident if germs were carried into other residents' rooms. In an interview with CNA 16, working on Wing 300, on 09/13/2024 at 9:15 AM, she stated when passing meal trays staff were to use hand sanitizer between residents; rooms, and wash their hands with soap and water after entering the third room. She further stated there was always a potential to spread germs from resident to resident if staff did not followed the facility's policy and procedures for proper hand hygiene to prevent harm to residents. In an interview with Licensed Practical Nurse (LPN) 1 on 09/08/2024 at 1:20 PM, she stated she was Unit Manager (UM) of Wing 100, and had worked in the facility for [AGE] years. She stated she had not observed CNA 1 not using proper hand hygiene. LPN 1 stated CNA 1 was a good worker and new to her position, but she would use the incident as a teachable moment to re-educate CNA 1 on infection control procedures. In an interview with the Assistant Director of Nursing (ADON) on 09/08/2024 at 1:25 PM, she stated expectations were that all staff were to practice proper hand hygiene by sanitizing between residents' rooms and residents. She further stated staff should practice proper hand hygiene whenever a situation required it. During an interview with the DON on 09/12/2024 at 10:06 AM, she stated expectations for direct care staff were for them to follow facility policy and procedures when assisting with distribution of meal trays in resident rooms. She further stated all staff should be sanitizing their hands in between residents' rooms and handwashing after the third room to prevent the spread of germs. In interview with the Administrator on 09/12/2024 at 11:20 AM, she stated she expected all staff to follow the facility policies regarding hand washing and indwelling catheter care.

Based on interview, record review, Hospital Behavioral Unit Discharge Summary, and review of facility policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents was free from sexual abuse (Resident #2). Resident #1 displayed sexually inappropriate behavior toward other residents on 01/23/2021 and 0124/2021. Resident #1 was sent to a behavioral unit and returned on 01/28/2021; however, the facility failed to protect other residents from abuse when the facility failed to ensure staff were aware of the resident's behaviors and need for increased monitoring/supervision to ensure the resident would not sexually abuse another resident; per facility policy. On 02/02/2021, Resident #1 was observed by staff to forcibly kiss Resident #2 on the mouth by holding his/her head with both his/her hands on both side of face. The findings include: Review of facility policy, titled Abuse, Neglect and Exploitation, last revised October 2020, revealed it was the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Continued review revealed Sexual Abuse was defined as non-consensual sexual contact of any type with a resident. Further review revealed the facility should identify, correct, and intervene, in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property was more likely to occur with trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned had knowledge of individual residents' care needs and behavioral symptoms. Closed record review revealed the facility admitted Resident #1 on 01/19/2021 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/2021, revealed the facility assessed Resident #1's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Further review of the MDS revealed the resident had delusions and verbal and physical behaviors that were directed toward others. Record review revealed the facility admitted Resident #2 on 01/25/2021 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 02/01/2021, revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Resident #2 has a dual Power of Attorney (POA). Review of Progress Notes, dated 01/23/2021 at 6:19 PM, revealed Resident #1 was observed by staff kissing Resident #3 in front of his/her spouse (who is also a resident), and allowing Resident #3 to put his/her hand up Resident #1's shirt. The LPN and previous shift staff redirected Resident #1 to the table with his/her spouse. Review of Progress Notes, dated 01/24/2021 at 10:31 AM, revealed Resident #1 was in the dining room arguing with his/her spouse using very foul language and talking to self. The resident was noted going in and out of Resident #3's room being hyper-sexual. The Physician was called and an order was received to send the resident and spouse out to a behavioral unit. However, review of Resident #1's Baseline Care Plan, dated 01/21/2021 revealed the care plan was not revised to address the resident's sexually inappropriate behavior towards other residents so that staff assigned were aware of the resident's behaviors, and to monitor/provide supervision related to this behavior towards other residents; per facility policy. Review of the Hospital Behavioral Unit Discharge Summary, dated 01/28/2021, revealed there was no evidence of sexually inappropriate behavior and felt that Resident #1 was at his/her baseline and ready to return to his/her nursing home. Further review revealed the resident was not suicidal, homicidal or psychotic at discharge; and did not present danger to self or others. The resident was discharged back to the facility on [DATE]. Review of the facility Progress Notes, dated 02/02/2021 at 4:03 PM, revealed Resident #1 was kissing Resident #2 with force, and holding the resident's face so he/she could not move. The Physician, Administrator, and resident's son was contacted; and EMS was called to transport the resident to the emergency room for evaluation. Interview with a Medical Records Staff, on 02/23/2021 at 3:10 PM, revealed she was going to clock out on 02/02/2021 sometime between 3:30 PM and 4:00 PM, and she could see the back of Resident #1, with one hand on each side of Resident #2's face, kissing the resident on the lips, at the end of the hall across from the Medical Records Staff office. Resident #1 had Resident #2's head turned sideways. The Medical Record Staff stated she had never seen Resident #1 display this type of behavior in the past. She revealed she told Resident #1 that he/she could not do that and escorted Resident #2 to the nurse and informed her of what happened. Resident #1 was left in the supervision of RN #1 and was on 1:1 supervision by either RN #1 or the Administrator until the resident left the building with EMS. She then reported it to Social Services and then they both reported it to the Administrator. She stated she felt like it was inappropriate behavior and thought it was sexual abuse. Interview (Post Survey) with SRNA #2, on 03/11/2021 at 8:07 AM, revealed she was told by her charge nurse prior to 02/02/2021, that Resident #1 had sexually inappropriate behaviors and she should redirect the resident but the resident was hard to redirect. She revealed she witnessed Resident #1 kissing Resident #2 on 02/02/2021. Interview (Post Survey) with SRNA #3 who also was working on 02/02/2021, on 03/11/2021 at 8:14 AM, revealed she was not told Resident #1 had sexually inappropriate behaviors. She stated the resident was difficult to redirect and was mad a lot. She stated she never personally witnessed the resident have a sexually inappropriate behavior. Interview with Registered Nurse (RN) #1, on 02/24/2021 at 11:43 AM, revealed she was working the day of the incident between Resident #1 and Resident #2. She stated the two (2) residents were immediately separated and Resident #1 was placed on 1:1 observation which was done by the RN and the Administrator. The resident was transported to an acute care hospital and admitted to Behavioral Health. She revealed staff would have to constantly watch the resident related to his/her behaviors. The RN was aware of sexually inappropriate behaviors prior to 02/02/2021 by Resident #1 and considered kissing a person of the same sex as abuse. Interviews with the Social Services Director (SSD), on 02/24/2021 at 10:48 AM and 11:30 AM, and interview (Post Survey) on 03/11/2021 at 10:37 AM, revealed she did not think that the incident between Resident #1 and Resident #2 was abuse. She stated staff should know that anytime a resident was sent out for behaviors they should be watched more closely when they return. She further stated, We are not set up to do 1:1 here Interview with the facility Administrator, on 02/23/2021 at 4:36 PM and on 02/24/2021 at 1:51 PM, revealed she expected staff to use communication tools such a report book that was located on the desk and through use of verbal communication to ensure all staff were aware of resident behaviors. She stated a baseline care plan was developed on admission and the facility had fourteen (14) days to develop comprehensive care plan.

Based on interview, record review and facility policy review, it was determined the facility failed to revise the care plan for one (1) of three (3) sampled residents (Resident #1), related to sexually inappropriate behaviors. On 01/23/2021 and 01/24/2021, Resident #1 displayed hyper-sexual behavior toward other residents; however, the facility failed to revise the care plan to address the resident's sexually inappropriate behavior, per facility policy. On 02/02/21, the resident was observed by staff to forcibly kiss Resident #2 on the mouth. There were staff working that were not aware of the resident's behaviors or the need to provide supervision/monitoring of resident. The findings include: Review of the facility policy, titled Goals and Objectives, Care Plans, not dated, revealed goals and objectives that lead to the resident's highest obtainable level of independence should be incorporated into the resident's care plan. Care plan goals and objectives were defined as the desired outcome for a specific resident problem. Staff should document in the resident's clinical record why the goals and objectives were not achieved if occurred, and what new goals and objectives were established; and modify the care plans accordingly. Goals and objectives should be entered on the resident's care plan so all disciplines would have access to such information and were able to report whether or not the desired outcomes were being achieved. Goals and objectives should be reviewed and/or revised: when there has been a significant change in the resident's condition; when the desired outcome has not been achieved; and when the resident has been readmitted to the facility from a hospital/rehabilitation stay. Closed record review revealed the facility admitted Resident #1 on 01/19/2021 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/2021, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Further review of the MDS revealed the resident had delusions and verbal and physical behaviors that were directed toward others. Review of the Nursing Progress Notes, dated 01/23/21 at 6:19 PM, and 01/24/2021 at 10:31 AM, revealed Resident #1 had behaviors of kissing another resident, and going in and out of male resident rooms being hyper-sexual. However, review of the Baseline Care Plan, dated 01/21/2021, revealed there was no revision of the care plan to address the resident's behaviors to include being sexually inappropriate; and, no interventions to address monitoring/supervision related to these behaviors; per facility policy. Interview (Post Survey) with SRNA #3 who also was working on 02/02/2021, on 03/11/2021 at 8:14 AM, revealed she was not told Resident #1 had sexually inappropriate behaviors. She stated the resident was difficult to redirect and was mad a lot. She stated she never personally witnessed the resident have a sexually inappropriate behavior. Interview with Registered Nurse (RN) #1, who was the nurse during the 01/24/2021 and 02/02/2021 incidents, on 02/24/2021 at 11:43 AM and 3:38 PM, and interview (Post Survey) on 03/11/2021 at 11:15 AM, revealed nurses can enter care plan interventions on the care plan but she did not. She stated she reported Resident #1's behaviors to her supervisor to take to the care plan team for any changes, but did not make any care plan revisions herself. Interview with the facility Administrator, on 02/24/2021 at 11:13 AM, revealed if an intervention was needed when Social Services or MDS staff were off, the nurses on the floor had the ability to update the care plan with any new intervention. She stated falls and behaviors were discussed during the morning meetings and care plans updated as needed. Continued interview revealed staff were expected to use communication tools such a report book that was located on the desk and verbal communication to ensure staff were aware of resident behaviors.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality for one (1) of four (4) sampled residents, (Resident #3). On 04/01/202. Licensed Practical Nurse (LPN) #2 failed to administer medication according to professional standards of quality when she left Resident #4's 9:00 PM medication on the resident's bedside table unsupervised. Resident #3, the roommate, was able to get the medications and take them. The findings include: Review of the facility's policy titled, Administering Medications, dated December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Record review revealed the facility admitted Resident #3 on 02/26/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Review of the Facility's Investigation dated 04/01/2020, and interview with Registered Nurse (RN) #2 on ??? at ??? revealed LPN #2 was administering Resident #4's 9:00 PM medications when she (LPN #2) became nauseated and left the room quickly, leaving the resident's medication on the bedside table. Resident #3 (Resident's roommate) was able to get the medication and swallowed the medication. The medications were [MEDICATION(S)] 20 milligrams (mg) for high cholesterol; [MEDICATION(S)] Extended Release (ER) 250 mg for seizures; [MEDICATION(S)] 67 mg for high cholesterol; [MEDICATION(S)] (Seroquel) 200 mg for Schizophrenia; Tamsulosin 0.4 mg for urine retention; [MEDICATION(S)] 10 mg for anxiety, and [MEDICATION(S)] 100 mg for leg pain. Review of Resident #3's Hospital Discharge Summary, dated 04/02/2020, revealed the resident was evaluated and treated with cardiac and neurological status monitoring subsequent to ingestion of the medications. On 04/02/2020 at 7:15 AM, Resident #3 was without concerns, felt to be stable, and discharged back to the facility. Interview with LPN #2 was attempted on 04/14/2020 at 2:00 PM; on 04/15/2020 at 3:48 PM; 04/16/2020 at 7:26 AM, and 04/17/2020 at 8:39 AM was unsuccessful. LPN #2 was terminated and not available to interview. Interviews with Certified Medication Technician (CMT) #1, on 04/13/2020 at 4:25 AM, RN #2, on 04/17/2020 at 8:10 AM; and the Staff Development Coordinator (SDC), on 04/17/2020 at 2:35 PM revealed during medication administration, no medications are left at the bedside. Staff administering the medication should witness the resident take their medications. Interview with the Director of Nursing (DON), on 04/14/2020 at 10:50 AM, revealed she expected the nurse to stay and ensure the residents take their medications. She stated LPN #2 had three (3) occasions she failed to ensure residents took their medication. She further revealed LPN #2 had been counseled and re-educated on medication administration; and the final result was termination. **The facility implemented the following actions to correct the deficient practice: 1. Nurse involved in medication error to be terminated from her position due this being the second time in ten (10) days this type of medication error occurred when the nurse was on duty. 2. All nurses and CMT's will be educated on the need to watch a resident take their medications and to not leave medication unattended. 3. Floor nurse will begin filling out a Hall Round sheet during their shift and look for medications being left unattended in resident rooms and anywhere else. **The State Survey Agency validated the corrective action taken by the facility as follows 1. Review of the Termination Agreement, dated 04/10/2020, revealed the reason LPN #2 was terminated was medication error and performance. 2. Review of In-service sign in sheets revealed all facility staff were educated from 04/10/2020 through 04/12/2020 on the facility's medication administration policy. Interviews on 04/13/2020 with LPN #1 at 4:30 PM, and CMT #1 at 4:25 PM; on 04/14/2020 with CMT #2 at 8:40 AM; on 04//16/2020 with RN #1 at 7:29 AM; and, on 04/17/2020 with RN #2 at 8:10 AM; RN #3 at 8:10 AM, and LPN #3 at 9:15 AM; revealed they received education on the facility medication administration policy. 3. Review of Hall Round Sheets revealed they were implemented on 04/12/2020 and continue to be ongoing. The Hall Round Sheets are turned in to the DON. Interview with the DON on 04/14/2020 at 10:50 AM revealed she reviews the Hall Round Sheet for any follow up, if needed.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the environment was free from accident hazards for one (1) of four (4) sampled residents (Resident #3). On 04/01/2020, Licensed Practical Nurse (LPN) #2 left Resident #4's 9:00 PM medications on the resident's bedside table unsupervised. Resident #3, the roommate, who was known for wandering and taking other resident's snacks was able to get the medications and take them. The findings include: Review of the facility's policy titled, Safety and Supervision of Residents, last revised July 2017, revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Review of the facility's policy titled, Administering Medications dated December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. Record review revealed the facility admitted Resident #3 on 02/26/2020 with diagnoses which included Adult Failure To Thrive, Severe Intellectual Disabilities, and Altered Mental Status, Unspecified. Review of the Initial Minimum Data Set (MDS) assessment, dated 03/02/2020, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Review of Resident #3's Comprehensive Care Plan, Dependent on staff for meeting emotional, intellectual, physical, and social needs related to Cognitive deficits, dated 03/09/2020, revealed the resident wanders and takes snacks from other residents. Review of a Situation Background Assessment Response (SBAR) document, dated 04/01/2020, revealed Resident #3 had taken his/her roommate medications that was left on the bedside table. Interview with Registered Nurse (RN) #2, on 04/17/2020 at 2:35 PM, revealed on 04/01/2020, Resident #4 yelled out to staff that Resident #3 had taken his/her medication that was left on the bedside. Certified Nursing Assistant (CNA) #6 entered the room but was unable to stop Resident #3 from taking the medication. Review of a Facility's Investigation revealed, on 04/01/2020, Licensed Practical Nurse (LPN) #2 was administering Resident #4's 9:00 PM medications when she (LPN #2) became nauseated and left the room quickly leaving Resident #4's medication on the bedside table. Resident #3 who was the resident's roommate took Resident #4's medication. The medications were [MEDICATION(S)] 20 milligrams (mg) for high cholesterol; [MEDICATION(S)] Extended Release (ER) 250 mg for seizures; [MEDICATION(S)] 67 mg for high cholesterol; [MEDICATION(S)] (Seroquel) 200 mg for Schizophrenia; Tamsulosin 0.4 mg for urine retention; [MEDICATION(S)] 10 mg for anxiety, and [MEDICATION(S)] 100 mg for leg pain. Review of Resident #3's Hospital Discharge Summary, dated 04/02/2020, revealed the resident was evaluated and treated with cardiac and neurological status monitoring subsequent to ingestion of the medications. Further review revealed Resident #3 was completely somnolent, arousable, and had no acute distress. Poison control was contacted and recommended six (6) hours of observation to make certain there was no [CONDITION(S)]. On 04/02/2020 at 7:15 AM, Resident #3 was felt to be stable, and discharged back to the facility. Interview with LPN #2 was attempted on 04/14/2020 at 2:00 PM; 04/15/2020 at 3:48 PM; 04/16/2020 at 7:26 AM, and 04/17/2020 at 8:39 AM without success. LPN #2 was terminated by the facility and not available to interview. Interview with Certified Medication Technician (CMT) #1, on 04/13/2020 at 4:25 PM, revealed during medication administration, no medications are left at the bedside. CMT #1 stated it is the responsibility of the staff administering the medication to witness the resident take their medications. She revealed revealed staff are not allowed to prepare a resident's medications and leave at the resident's bedside. Interview with RN #2, on 04/17/2020 at 8:10 AM, revealed residents are not allowed to self administer medications. RN #2 stated it is the responsibility of the staff administering medication to ensure each resident takes their prescribed medications and medications should never be left at a resident's bedside. Interview with the Staff Development Coordinator (SDC), on 04/17/2020 at 2:35 PM, revealed all staff administering medications were responsible to ensure medications are given to each resident as ordered. The SDC stated medications should not be left unattended and she would expect each staff to observe the resident take their medications. Interview with the Director of Nursing (DON), on 04/14/2020 at 10:50 AM, revealed she would expect staff to follow the facility policy when administering medications and staff to follow rights to medication administration. The DON stated, I would have expected the nurse to stay and ensure the residents take their medications. She (LPN #2) had three (3) occasions she failed to ensure residents took their medication. LPN #2 had been counseled and re-educated on medication administration; final result was termination. **The facility implemented the following actions to correct the deficient practice: 1. Nurse involved in medication error to be terminated from her position due this being the second time in ten (10) days this type of medication error occurred when the nurse was on duty. 2. All nurses and CMT's will be educated on the need to watch a resident take their medications and to not leave medication unattended. 3. Floor nurse will begin filling out a Hall Round sheet during their shift and look for medications being left unattended in resident rooms and anywhere else. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the Termination Agreement, dated 04/10/2020, revealed the reason LPN #2 was terminated was medication error and performance. 2. Review of In-service sign in sheets revealed all facility staff were educated from 04/10/2020 through 04/12/2020 on the facility's medication administration policy. Interviews on 04/13/2020 with LPN #1 at 4:30 PM, and CMT #1 at 4:25 PM; on 04/14/2020 with CMT #2 at 8:40 AM; on 04//16/2020 with RN #1 at 7:29 AM; and, on 04/17/2020 with RN #2 at 8:10 AM; RN #3 at 8:10 AM, and LPN #3 at 9:15 AM; revealed they received education on the facility medication administration policy. 3. Review of Hall Round Sheets revealed they were implemented on 04/12/2020 and continue to be ongoing. The Hall Round Sheets are turned in to the DON. Interview with the DON on 04/14/2020 at 10:50 AM revealed she reviews the Hall Round Sheet for any follow up, if needed.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure an advance directive care plan was revised to ensure resident wishes were followed for one (1) of one (1) sampled resident. Resident #1's code status had changed from a full code to a DNR (Do Not Resuscitate) on [DATE]; however, the facility failed to revise the care plan to a DNR. The findings include: Review of the facility policy titled, Care Plan, last revised [DATE], revealed it is the facility policy that residents will have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. The plan of care will be reviewed and revised when requested by the resident and/or indicated, based on resident's response to the plan of care. The facility will honor the resident's rights regarding the development and implementation of the plan of care. Record review revealed the facility readmitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of twelve (12) twelve which indicated the resident was interviewable. Review of a Physician's Order dated [DATE] revealed the resident was a DNR. However, review of advance directive care plan dated [DATE] with closed out date of [DATE] revealed Resident #1 was still documented as a full code with interventions of Code Status: CPR Full Code and not revised to address the resident's DNR status. Interview with Licensed Practical Nurse (LPN) #1 on 10 ,[DATE] at 2:06 PM revealed the care plan should be updated if the advance directive changes. Interview with the Social Service Director (SSD), on [DATE] at 3:42 PM revealed Resident #1 had discussed with the SSD of desire to be DNR and a physician order was written. Interview with Director of Nursing (DON) on [DATE] at 10:23 PM revealed she would have expected the care plan to be updated if code status changed.

Based on interview and review of the facility policy, it was determined the facility failed to ensure residents received mail delivery on the weekends. The findings include: Review of the facility policy, Resident Rights, not dated, revealed the resident has the right to send and receive mail, and to receive letters, packages, and other materials delivered to the Center for the resident through a means other than the postal service. The resident has a right to privacy of such communications and access to stationary, postage, and writing implements at the resident's own expense. Interview with Resident Council members during a Resident Council meeting, on 09/11/19 at 2:00 PM, revealed the facility had not delivered mail to the residents on the weekends for some time. Interview with the Activities Director on 09/11/19 at 2:30 PM, revealed she was made aware the residents had not been receiving their mail on the weekends since (MONTH) 2019 and had failed to assign someone to do so. She stated she would now ensure one of the Restorative Aides would be responsible for passing resident mail to them on the weekends. Interview with the Administrator on 09/12/19 at, revealed she was not aware of the issue of the residents not receiving mail on the weekends, until the Activities Director made her aware. The Administrator stated she knew it was a regulation and would ensure the issue was addressed.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to develop and/or implement a comprehensive person-centered care plan for three (3) of eighteen (18) sampled residents (Resident #61, #38, and #31). Resident #61 was care planned for staff to check the resident's Arteriovenous (AV) Fistula, however, further review of the record revealed there was no documented evidence staff conducted assessments of the AV fistula. Resident #38 was assessed for behaviors, favorite activities, etc; however, the facility failed to develop a Person Centered Comprehensive Care Plan to include the resident's choices and goals. Resident #31 was care planned for shower twice a week; however, the resident was provided bed baths instead of a shower/full bath for eight (8) days. The findings include: Review of the facility policy titled, Nursing Care Plan, last revised 11/20/17, revealed it is the facility policy that residents will have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. Further review of the policy revealed the facility will honor the resident's rights regarding the development and implementation of the plan of care. Record review revealed the facility admitted Resident #61 on 06/12/19 with [DIAGNOSES REDACTED]. Review of the 5-day Medicare Minimum Data Assessment (MDS) assessment, dated 09/02/19 revealed the facility assessed Resident #61's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of Resident #61's [MEDICAL TREATMENT] Comprehensive Care Plan, dated 08/23/19, revealed to check the AV fistula; palpate gently over area with fingertips or palm of hand and feel for bruit (a rumbling sound that you can hear) or thrill (a rumbling sensation that you can feel). Auscultate over fistula with stethoscope to detect bruit. Assess for signs of infection, bleeding or sensation impairment around fistula/entire extremity. However, review of the July, (MONTH) and (MONTH) 2019 Medication Administration Records (MARS) and Treatment Administration Records (TAR's) revealed there was no documented evidence staff assessed the resident's AV fistula per care plan. Interview with Resident #61, on 09/11/19 at 1:52 PM revealed he/she did not understand what it meant to check the site but felt it was not being done. Interview with Registered Nurse (RN) #2 on 09/12/19 at 3:05 PM, and RN #1 on 09/13/19 at 10:29 AM revealed the AV assessment should also be on a Physician's Order so it would be added to the MAR. The RN's stated this would be a reminder to nurses to complete the assessment every shift, and a place to document the assessment was completed. RN #1 stated she knows she completed an assessment of the AV fistula site when the resident returned from [MEDICAL TREATMENT]. Interview with the Director of Nursing (DON) on 09/12/19 at 2:45 PM revealed she expected the nurses to check the site every shift and if no thrill or bruit, to notify the physician. She stated they should document the assessment was performed, and also, follow the resident's care plan. 2. Record review revealed the facility admitted Resident #38 on 08/29/18 with [DIAGNOSES REDACTED].#38's cognition as moderately impaired with a BIMS score of nine (9) which indicated the resident was interviewable. Further review of the last full MDS on 07/18/19 revealed Section F for Preference for Customary and Routine Activities revealed an interview was not completed due to resident was rarely/never understood. Further review of Section F revealed staff assessed resident's daily activities of snacks between meals, staying up past 8:00 PM, use of private phone, listening to music, being around pets, and taking part in favorite activity. However, review of the Activities Care Plan dated 07/22/19 revealed an intervention to offer snacks but did not specify the resident's favorite snacks, and an intervention to invite the resident to scheduled activities with no listed documentation of residents' favorite activities. In addition, there was an intervention to turn on TV, or music in room to provide sensory stimulation; however, there was no documented evidence of resident's favorite music or TV programs. Review of 60 day MDS dated [DATE] revealed Resident #38 had behaviors of hitting, scratching self, verbal vocal behaviors, likes to scream, disruptive sounds, and rejects care. However, review of the resident's care plan for resident has [DIAGNOSES REDACTED]. In addition, further review of these care plans revealed there were no measurable goals and timeframe's to meet the resident's medical, nursing, mental and psychosocial needs in these areas. Review of the Nurse Aide Data Sheet for Resident #38, not dated revealed no directions for caring for the resident with Dementia and no documented evidence the resident had any special preferences or choices. Observation and interview with Resident #38 on 09/10/19 at 11:03 AM revealed the resident lying on back. Resident #38 stated he/she liked music; however there was no music playing and TV was off. Interview with the MDS Coordinator on 09/12/19 at 10:27 AM revealed Social Services developed the Comprehensive Care Plan for residents with dementia and the care plan was usually based on [DIAGNOSES REDACTED]. She stated she made sure the medications were correct with diagnosis. Interview with the Social Services Director (SSD) on 09/12/19 at 11:49 AM revealed she did not initiate the Comprehensive Care Plan for residents with Dementia. The SSD stated the care plans were completed by MDS. Further interview with the MDS Coordinator on 09/12/19 at 12:05 revealed she initiated the Comprehensive Care Plans for residents with Dementia; however, most all updates were completed by the SSD. Interview with MDS Coordinator on 09/12/19 at 3:19 PM revealed she does develop the dementia care plans; however, reviewing residents' care plans revealed these was not a person centered care plan. She stated the care plan should have measurable goals and timeframes to meet the resident's medical, nursing, mental and psychosocial needs. She also revealed likes and dislikes should always be on the Care Plan. Interview with the Charge Nurse on 09/12/19 at 1:14 PM revealed the nurses initiate the CNA care plan. She stated if changes are made, it is usually when a CNA comes to the nurses with information that a resident needs less assistance or more assistance. Also if special needs are needed, the information is added by the nurse. Interview with DON, on 09/12/19 at 2:47 PM revealed she expected dementia care plans to be person-centered and reflect the resident's goals and to maximize the resident's dignity, autonomy, privacy, socialization, independence and choice. When she reviewed this resident's Dementia Care Plan, she stated it was not person centered. She further revealed she expected the CNA care plans to reflect care for dementia. 3. Record review revealed the facility admitted Resident #31 on 07/22/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 07/29/19 revealed the facility assessed Resident #31's cognition as intact with a BIMS score of ten (10) which indicated the resident was interviewable. Review of the Interdisciplinary Care Plan for Activity of Daily Living (ADL's) dated 07/22/19 revealed an intervention for one (1) staff to assist Resident #31 for bathing; and review of the Nurse Aide Data Sheet, not dated, revealed the resident required Physical Assistance of one (1) for bathing and will receive two (2) full baths/showers per week. However, review of Resident #31's ADL Tracking Log for (MONTH) 2019 revealed the resident did not receive a full bath/shower from 09/01/19 through 09/09/19; he/she received bed baths. Interview with Resident #31 on 09/10/19 at 9:13 AM revealed the resident appeared to have clean clothing in place; however, his/her hair appeared very dirty and oily. The resident stated, Look at me, I haven't had a shower in over a week. The resident revealed he/she preferred to have a shower or whirlpool bath instead of a bed bath. Interview with Certified Nurse Aide (CNA) #6 on 09/11/19 at 2:06 PM revealed she had worked on Resident #31's hall last week and she recorded the resident had bed baths and no showers. She stated the resident refused showers for several days and wanted bed baths instead; however, there was no documented evidence the resident refused showers/baths. Interview with CNA #7 on 09/11/19 at 2:15 PM revealed she had given Resident #31 a whirlpool bath and shave on 09/10/19. CNA #7 stated the resident had never refused a shower or bath with her. She revealed when a resident refuses a shower, bath, or bed bath, she documents the refusal in the ADL CNA charting book and tells the charge nurse. Interview with Licensed Practical Nurse (LPN)/Charge Nurse for Hall one and two, on 09/11/19 at 2:22 PM revealed the CNA did not tell her the resident refused his/her showers. She stated if she was told a resident refused, she would go speak with resident to confirm, then record in nurses notes. Further interview with the DON, on 09/11/19 at 2:55 PM revealed she expected all nursing staff to follow the Comprehensive Care Plans and CNA care plans as written.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of eighteen (18) sampled residents who were unable to carry out activities of daily living received the necessary services related to weekly showers (Residents #31, 36, 62, #6, and #24). Residents #31, 36, 62, #6, and #24 were assessed and care planned for staff to assist with showers two (2) times a week; however, the facility failed to ensure the residents received the showers. The findings include: Interview with the Director of Nursing (DON) on 09/11/19 at 3:00 PM revealed the facility did not have a policy regarding Activities of Daily Living or Bathing. She revealed the staff used the Eighth Edition of Clinical Nursing Skills Basic to Advanced Skills for procedures regarding hygienic care. Review of the Eight Edition of Clinical Nursing Skills (no date noted) regarding bathing revealed routine bathing is an essential component of daily care. Its is essential to prevent body odor, because excessive perspiration interacts with bacteria to cause odor. Dead skin cells can lead to infection if impaired skin integrity occurs. Bathing promotes a feeling of self-worth by improving the person's appearance. Relaxation and improved circulation are benefits of bathing and play a therapeutic role in the care of residents' bedrest. In addition to the therapeutic effects, the bath affords the nurse time to communicate with and assess the client. Assessment of skin conditions, mobility, and self-care deficits can be detected while bathing the client. Record review revealed the facility admitted Resident #31 on 07/22/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 07/29/19 revealed the facility assessed Resident #31's cognition as intact with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive assist of one staff for bathing. Review of the Interdisciplinary Care Plan for Activity of Daily Living (ADL's) dated 07/22/19 revealed the Resident #31 required assist with ADL's secondary to [DIAGNOSES REDACTED]. The resident required one (1) staff assist for bathing; however, the level of care was not circled. Review of the Nurse Aide Data Sheet, not dated, revealed the resident required Physical Assistance of one (1) for bathing and will receive two (2) full baths/showers per week. Review of Resident #31's ADL Tracking Log for (MONTH) 2019 revealed there was no documented evidence the resident had a shower or bath from 09/01/19 through 09/09/19; however, there was documentation the resident received bed baths during this time. There was documentation the resident was assisted with a shower on 09/10/19. Interview with Resident #31 on 09/10/19 at 9:13 AM revealed he/she had not had a shower in over a week. The resident appeared to have clean clothing in place; however, his/her hair appeared very dirty and oily. The resident stated he/she always wanted a shower or whirlpool bath instead of a bed bath. Interview with Certified Nurse Aide (CNA) #6 on 09/11/19 at 2:06 PM revealed she had worked on Resident #31's hall last week and she recorded the resident had bed baths and no showers. She stated the resident refused showers for several days and wanted bed baths instead; however, there was no documented evidence the resident refused showers during this time. Further interview revealed she was not able to provide an explanation as to why there was no documentation that the resident had refused a shower/bath. Interview with CNA #7 on 09/11/19 at 2:15 PM revealed she had given Resident #31 a whirlpool bath and shave on 09/10/19. She stated when a resident refuses a shower or bed bath, she tells the charge nurse. She further revealed the nurse charts the refusal and she would chart in the ADL CNA charting book if the resident refused (ADL tracking log). Interview with Licensed Practical Nurse (LPN)/Charge Nurse for Hall one and two, on 09/11/19 at 2:22 PM revealed the CNA did not tell her Resident #31 was refusing showers. She stated if she was told a resident refused, she would go speak with resident to confirm, then record in nurses notes. 2. Record review, revealed the facility admitted Resident #36 on 05/24/17 Review of Quarterly MDS assessment, dated 07/31/19, revealed the facility assessed Resident #36's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #36 was scheduled to receive showers on Monday and Friday of each week. However, further review revealed there was only documented evidence Resident #36 received two (2) showers in a twelve (12) day period. 3. Record review, revealed the facility admitted Resident #62 on 08/09/19. Review of Quarterly MDS assessment, dated 07/31/19, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #62 was scheduled to receive showers on Monday and Friday of each week. However, further review revealed there was no documented evidence Resident #36 received a shower in a twelve (12) day period. 4. Record review, revealed the facility admitted Resident #6 on 06/16/19 Review of Quarterly MDS assessment, dated 07/31/19, revealed the facility assessed Resident #6's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #6 was scheduled to receive showers on Monday and Friday of each week. However, further review revealed there was only documented evidence Resident #6 received one (1) shower in a twelve (12) day period. Interview with Resident #6 on 09/10/19 at approximately 9:21 AM revealed he/she was concerned that he/she was not receiving her showers every week like she was supposed to. Resident #6 stated she has not had a shower in a while. 5. Record review, revealed the facility admitted Resident #24 on 10/13/17 Review of Quarterly MDS assessment, dated 07/22/19, revealed the facility assessed this resident's BIMS score as a fifteen (15), which indicated the resident was interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #24 was scheduled to receive showers on Monday and Wednesday of each week. However, further review revealed there was only documented evidence the resident received two (2) showers in a twelve (12) day period. Interview with Resident #24 on 09/10/19 at approximately 10:02 AM revealed she is not receiving her showers every week like she is supposed to. Resident #24 stated she has only had one (1) shower in the last week. Interview with CNA #2 on 09/12/19 at approximately 10:45 AM revealed the only reason that a resident should not receive a shower on their scheduled days is if they refuse. CNA #2 stated most times the facility is short staffed and staff are unable to make sure the residents get their showers on their scheduled days. CNA #2 revealed if a resident refuses the CNA's are supposed to report it to the charge nurse, and the resident should be asked again by another staff member. CNA #2 further stated each day at the end of the shift, staff are supposed to report to the charge nurse how many showers were given and how many were not. Interview with CNA #3 on 09/12/19 at approximately 11:20 AM revealed each resident has scheduled days their supposed to receive a shower. CNA #3 stated not all residents get their showers on the day scheduled because there is not always enough staff to give showers and sometimes staff are not doing their jobs. CNA #3 revealed if a resident does not get a shower and they did not refuse, then the CNA is supposed to report it to the charge nurse and the nurse is supposed to talk with the resident and see if they will take their shower. CNA #3 stated these issues have been reported to nursing staff but the issue does not get fixed because there is no organization. Interview with CNA #4 on 09/12/19 at approximately 1:45 PM revealed if staff on their shift do not give showers to all the residents scheduled they should report it to the next shift so they can try to get their shower done for that day. CNA #4 stated if a resident refuses a shower then staff should notify the nurse so they can talk with the resident and offer them another opportunity to take a shower. CNA #4 revealed the facility has a lot of call-ins and a lot of times there is not enough staff to get everything done. CNA #4 revealed there used to be a Unit Manager who oversaw things but there was not currently anyone in that position. Interview with CNA #5 on 09/12/19 at approximately 2:00 PM revealed if a resident refuses their shower the CNA is supposed to tell the nurse and staff are supposed to ask more than one time. CNA #5 stated at the end of the shift staff are supposed to inform the nurse if any residents did not get their scheduled showers during that shift. CNA #5 revealed there was an issue with call-ins and being short staffed a lot was usually the reason residents were not receiving their showers. Interview with RN #2 Charge Nurse on 09/13/19 at approximately 10:10 AM revealed the facility use to have a unit coordinator but there is no longer anyone in that position who would oversee the shower schedule. RN #2 stated that CNA staff update the shower schedule and the charge nurses are responsible for checking that it is completed. RN #2 revealed she was not aware that showers were not being given to residents and that the shower schedules were not being checked daily like they were supposed to be. RN #2 stated if a resident refuses a shower the CNA's were supposed to tell a nurse and the nurse was supposed to talk with the resident and try to see if they will take their shower. If after several attempts by staff the resident still refuses then the CNA is supposed to document the refusal on the shower logs. RN #2 revealed in addition to the log, CNA's were supposed to report to the charge nurse any residents that did not receive their showers for that shift. RN #2 stated the charge nurse (herself included) were supposed to look at the shower log book documentation every shift and report to the ADON if showers were not given. RN #2 stated she was unaware that so many residents were not receiving their showers because the shower logs are not being checked regularly like they were supposed to be. Interview with the Assistant Director of Nursing (ADON) on 09/12/19 at approximately 3:00 PM revealed CNA staff were responsible for updating the shower log and ensuring its accuracy. The ADON stated that nursing staff were supposed to be checking the shower logs and making sure they were current and reflected the residents shower schedule, type, and preference. The ADON revealed there was not any administrative staff overseeing the nursing staff to ensure that this was being done. The ADON further stated there was not any type of check and balance system in place to ensure that shower logs were being tracked and that residents were receiving their showers as scheduled. The ADON revealed she believed a big part of the reason was the CNA staff were charting incorrectly but the ADON did state that a part of the issue was the facility being short staffed. Interview with the DON on 09/13/19 at approximately 11:55 AM revealed she just became aware that the showers were not being given and that she had already spoken with the ADON. She stated she expected the showers to be provided according to the Comprehensive Care Plans, CNA care plans and shower logs. 2. Record review, revealed the facility admitted Resident #36 on 05/24/17 Review of Quarterly MDS assessment, dated 07/31/19, revealed the facility assessed Resident #36's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #36 was scheduled to receive showers on Monday and Friday of each week. However, further review revealed there was only documented evidence Resident #36 received two (2) showers in a twelve (12) day period. 3. Record review, revealed the facility admitted Resident #62 on 08/09/19. Review of Quarterly MDS assessment, dated 07/31/19, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #62 was scheduled to receive showers on Monday and Friday of each week. However, further review revealed there was no documented evidence Resident #36 received a shower in a twelve (12) day period. 4. Record review, revealed the facility admitted Resident #6 on 06/16/19 Review of Quarterly MDS assessment, dated 07/31/19, revealed the facility assessed Resident #6's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #6 was scheduled to receive showers on Monday and Friday of each week. However, further review revealed there was only documented evidence Resident #6 received one (1) shower in a twelve (12) day period. Interview with Resident #6 on 09/10/19 at approximately 9:21 AM revealed he/she was concerned that he/she was not receiving her showers every week like she was supposed to. Resident #6 stated she has not had a shower in a while. 5. Record review, revealed the facility admitted Resident #24 on 10/13/17 Review of Quarterly MDS assessment, dated 07/22/19, revealed the facility assessed this resident's BIMS score as a fifteen (15), which indicated the resident was interviewable. Review of the Monthly Shower Log for (MONTH) 2019 revealed Resident #24 was scheduled to receive showers on Monday and Wednesday of each week. However, further review revealed there was only documented evidence the resident received two (2) showers in a twelve (12) day period. Interview with Resident #24 on 09/10/19 at approximately 10:02 AM revealed she is not receiving her showers every week like she is supposed to. Resident #24 stated she has only had one (1) shower in the last week. Interview with CNA #2 on 09/12/19 at approximately 10:45 AM revealed the only reason that a resident should not receive a shower on their scheduled days is if they refuse. CNA #2 stated most times the facility is short staffed and staff are unable to make sure the residents get their showers on their scheduled days. CNA #2 revealed if a resident refuses the CNA's are supposed to report it to the charge nurse, and the resident should be asked again by another staff member. CNA #2 further stated each day at the end of the shift, staff are supposed to report to the charge nurse how many showers were given and how many were not. Interview with CNA #3 on 09/12/19 at approximately 11:20 AM revealed each resident has scheduled days their supposed to receive a shower. CNA #3 stated not all residents get their showers on the day scheduled because there is not always enough staff to give showers and sometimes staff are not doing their jobs. CNA #3 revealed if a resident does not get a shower and they did not refuse, then the CNA is supposed to report it to the charge nurse and the nurse is supposed to talk with the resident and see if they will take their shower. CNA #3 stated these issues have been reported to nursing staff but the issue does not get fixed because there is no organization. Interview with CNA #4 on 09/12/19 at approximately 1:45 PM revealed if staff on their shift do not give showers to all the residents scheduled they should report it to the next shift so they can try to get their shower done for that day. CNA #4 stated if a resident refuses a shower then staff should notify the nurse so they can talk with the resident and offer them another opportunity to take a shower. CNA #4 revealed the facility has a lot of call-ins and a lot of times there is not enough staff to get everything done. CNA #4 revealed there used to be a Unit Manager who oversaw things but there was not currently anyone in that position. Interview with CNA #5 on 09/12/19 at approximately 2:00 PM revealed if a resident refuses their shower the CNA is supposed to tell the nurse and staff are supposed to ask more than one time. CNA #5 stated at the end of the shift staff are supposed to inform the nurse if any residents did not get their scheduled showers during that shift. CNA #5 revealed there was an issue with call-ins and being short staffed a lot was usually the reason residents were not receiving their showers. Interview with RN #2 Charge Nurse on 09/13/19 at approximately 10:10 AM revealed the facility use to have a unit coordinator but there is no longer anyone in that position who would oversee the shower schedule. RN #2 stated that CNA staff update the shower schedule and the charge nurses are responsible for checking that it is completed. RN #2 revealed she was not aware that showers were not being given to residents and that the shower schedules were not being checked daily like they were supposed to be. RN #2 stated if a resident refuses a shower the CNA's were supposed to tell a nurse and the nurse was supposed to talk with the resident and try to see if they will take their shower. If after several attempts by staff the resident still refuses then the CNA is supposed to document the refusal on the shower logs. RN #2 revealed in addition to the log, CNA's were supposed to report to the charge nurse any residents that did not receive their showers for that shift. RN #2 stated the charge nurse (herself included) were supposed to look at the shower log book documentation every shift and report to the ADON if showers were not given. RN #2 stated she was unaware that so many residents were not receiving their showers because the shower logs are not being checked regularly like they were supposed to be. Interview with the Assistant Director of Nursing (ADON) on 09/12/19 at approximately 3:00 PM revealed CNA staff were responsible for updating the shower log and ensuring its accuracy. The ADON stated that nursing staff were supposed to be checking the shower logs and making sure they were current and reflected the residents shower schedule, type, and preference. The ADON revealed there was not any administrative staff overseeing the nursing staff to ensure that this was being done. The ADON further stated there was not any type of check and balance system in place to ensure that shower logs were being tracked and that residents were receiving their showers as scheduled. The ADON revealed she believed a big part of the reason was the CNA staff were charting incorrectly but the ADON did state that a part of the issue was the facility being short staffed. Interview with the DON on 09/13/19 at approximately 11:55 AM revealed she just became aware that the showers were not being given and that she had already spoken with the ADON. She stated she expected the showers to be provided according to the Comprehensive Care Plans, CNA care plans and shower logs.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of eighteen (18) sampled residents were free from abuse (Residents #42 and #4). Certified Nurse Aide (CNA) #1 and #2 stated they witnessed Certified Medication Technician (CMT) #1 state, You're acting like a f****** child. to Resident #42, and lunge at Resident #4 stating, Shut up. The findings include: Review of the facility policy titled, Alleged Abuse/Potential Neglect/Exploitation/Investigation, revealed the definition of abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish/injury. It includes deprivation by an individual including a care taker, of goods or services necessary to attain or maintain physical, mental, and psycho-social wellbeing. Also verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology. An intentional act that could reasonably be expected to result in physical or psychological injury to an elderly person or disabled adult. Willful as used in this definition of abuse, means an individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse of oral, written, or gestured language that is intended to be disparaging to a resident regardless of their age, ability to comprehend, or disability. Record review revealed the facility readmitted Resident #42 on 09/06/18 with diagnoses, which included [MEDICAL CONDITION]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 04/13/19, revealed the facility assessed Resident #42's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Record review revealed the facility readmitted Resident #4 on 08/14/19 with diagnoses, which included [MEDICAL CONDITION]. Review of a Entry MDS assessment, dated 08/14/19, revealed the facility assessed Resident #4 cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of Facility Investigation dated 07/26/19 revealed on 07/25/19, CNA #1 and CNA #2 reported they observed CMT #1 in Resident #42's room giving medication to him/her. Both staff heard CMT #1 say to resident You're acting like a f***** two (2) year old as CMT #1 left Resident #42's room. CNA #2 stated when CMT #1 walked out of Resident #42's room she asked CMT #1 who she was talking to and she stated Resident #42. When CNA #2 was interviewed later by facility staff she stated that she felt like CMT #1's remark was abusive. Interview with CNA #1 on 09/12/19 at approximately 8:35 AM revealed on 07/25/19 she along with CNA #2 were standing in the hallway by the showers when she heard CMT #1 say from inside Resident #42's room You're acting like a f****** child. CNA #1 stated she believed Resident #42 spit out his/her medication after CMT #1 gave them to him/her because he/she had a habit of doing that. CNA #1 revealed she was standing with CNA #2 at the time and both her and CNA #2 were upset by the remark and decided they would report it to the Social Services Director (SSD) before their shift was over. CNA #1 stated a few hours later she and CNA #2 were both in Resident #4's room providing care to him/her and Resident #4 was being verbally aggressive and yelling at them which was normal for him/her. CNA #1 revealed at some point CMT #1 came into the room and told Resident #4 to Shut up. CNA #1 stated when she and CNA #2 wheeled Resident #4 out of his/her room into the hallway, CMT #1 was in the hallway and told Resident #4 if he/she did not shut up the yelling, staff would not be taking him/her anywhere. CNA #1 revealed she was not aware of any other incidents in which CMT #1 was rude or said something inappropriate to a resident. CNA #1 stated they reported it that day. Interview with CNA #2 on 09/12/19 at approximately 10:40 AM revealed she was in the hallway up a few doors from Resident #42's room with CNA #1 and she observed CMT #1 in Resident #42's room and heard CMT #1 say you're acting like a f******two (2) year old as CMT #1 was coming out of Resident #42's room. CNA #2 stated she looked at CNA #1 and they both decided that the incident needed to be reported to the Social Services Director before their shifts ended that day. CNA #2 revealed a little later in the day, she was in Resident #4's room along with CNA #1 providing care. CNA #2 stated Resident #4 was yelling and complaining which was common behavior for Resident #4 when CMT #1 came into the room and lunged at Resident #4 and stated Shut up and to stop yelling. CNA #2 stated it happened so fast that it scared her, so she was certain that it had to scare Resident #4 too. CNA #2 stated that she does not usually work with CMT #1 but those were the only incidents that she has ever observed CMT #1 being abusive towards a resident. Interview with CMT #1 on 09/12/19 at approximately 2:20 PM revealed on the day before the incident occurred 07/24/19 when some aides were giving Resident #42 a shower she observed the aides were having issues with the resident. CMT #1 said she told CNA #1 that Resident #42 reminded her of a two (2) year old. CMT #1 revealed Resident #42 did not hear this statement and there were no other residents around that could have heard. CMT #1 stated on the day of the alleged incident on 07/25/19 she was in a good mood and did not get frustrated with any of the residents that day. CMT #1 stated when the incident occurred later that day with Resident #4 she heard Resident #4 cussing and screaming at the aides when they were trying to provide care while she was standing in the hallway. The CMT stated she stuck her head into Resident #4's room and explained to Resident #4 that she needed to quiet down since staff and other residents could hear her. CMT #1 denied ever approaching the resident or being intimidating towards the resident. Interview with CNA #3 on 09/12/19 at approximately 11:20 AM revealed based on her experience of working with CMT #1 that she feels like CMT #1 was hostile with staff during working hours. CNA #3 stated that MT #1 was mouthy and has a very bad attitude. CNA #3 revealed she has never observed CMT #1 being directly hostile to residents but CNA #3 stated there have been times when CMT #1 was hostile with staff and residents observed and witnessed these inappropriate interactions. Interview with CNA #5 on 09/13/19 at approximately 10:00 AM revealed he was providing care to Resident #35 a while ago when he observed CMT #1 giving medication to Resident #35 and Resident #35 spit out the medication. CNA #5 stated CMT #1 said to Resident #35, I don't know why I even give you the medicine. CNA #5 revealed a family member was in the process of approaching him and was about to ask something when CMT #1 made the remark and CNA #5 stated he could tell in the family member's face that they heard the remark too and were bothered by it. CNA #5 stated the family member's facial expression completely changed and they turned around and walked away. CNA #5 stated he reported that incident to the charge nurse at the time. Interview with Director of Nursing (DON) on 09/13/19 at approximately 11:55 AM revealed the facility conducted an investigation and determined CMT #1's behavior was inappropriate but did not rise to the level of abuse. She stated she expected staff to treat every resident with respect and dignity.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS) User's Manual, it was determined the facility failed to accurately assess one (1) of eighteen (18) sampled residents to reflect his/her status (Resident #43). The findings include: Review of the RAI MDS 3.0 Manual revealed steps for assessment of weight: upon admission, weigh the resident and record results. For subsequent assessments, check the medical record and enter the weight taken within thirty (30) days of the Assessment Reference Date (ARD) of the assessment. Record review revealed the facility admitted Resident #43 on 05/06/19, with [DIAGNOSES REDACTED]. Review of Section K-Swallowing/Nutritional Status of the Admission MDS assessment, dated 05/13/19 , revealed a weight of one-hundred and forty-nine (149) pounds. Review of the Quarterly MDS assessment dated [DATE], revealed a weight of one-hundred and eighty-six (186) pounds which indicated the resident had a thirty-seven pound weight gain. However, further review of the Quarterly MDS assessment dated [DATE], box K0300 revealed weight loss was checked, indicating the resident had a weight loss during this assessment period. Interview with the MDS Coordinator on 09/12/19 at 3:05 PM, revealed she did not complete section K of the MDS assessment for Resident #43. She stated the Dietary Manager had completed the section. The MDS Coordinator stated the residents' weights are reviewed and the section should have reflected no weight loss for Resident #43. Interview with the Dietary Manager on 09/12/19 at 3:34 PM, revealed she answered the question in Section K of the MDS assessment incorrectly, as Resident #43 actually had a weight gain and not a weight loss. Interview with the Director of Nursing (DON) on 09/13/19 at 11:53 AM, revealed she would expect staff to review the resident's weights when completing resident MDS assessments to ensure it was completed accurately.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of one (1) sampled resident who required [MEDICAL TREATMENT] in a sampled of eighteen residents received services consistent with professional standards of practice (Resident #61). Resident #61 was a [MEDICAL TREATMENT] patient and had a Arteriovenous (artery connected to a vein in the arm, to create a fistula) Fistula (a blood vessel made wider and stronger by a surgeon to handle the needles that allow blood to flow out to and return from a [MEDICAL TREATMENT] machine). Review of the original Physician's Orders revealed to check the shunt to the left upper extremity for a thrill (a rumbling sound that you can feel) and bruit (a rumbling sound you can hear) every shift; however, the order was not carried over to the July, August, and (MONTH) 2019 Physician's Orders. This caused the order not to be carried over to the July, August. and (MONTH) Medication Administration Records (MAR) or Treatment Administration Record (TAR) which resulted in no validation or reminder for the nurse to check the site every shift as ordered. The findings include: Review of the facility policy titled, [MEDICAL TREATMENT], last revised 04/17/13 revealed it is the policy of the facility to analyze and monitor the condition of the residents receiving [MEDICAL TREATMENT]. The procedure revealed orders will be obtained from the attending physician for resident receiving [MEDICAL TREATMENT], and residents receiving [MEDICAL TREATMENT] will be monitored pre and post [MEDICAL TREATMENT] services. Record review revealed the facility admitted Resident #61 on 06/12/19 with [DIAGNOSES REDACTED]. Review of the 5-day Medicare Minimum Data Assessment ((MDS) dated [DATE] revealed the facility assessed Resident #61's cognition was intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of the original Admission Physician Orders, dated 06/12/19 revealed to check for thrill and bruit every shift. Review of Resident #61's [MEDICAL TREATMENT] Comprehensive Care Plan, dated 08/23/19, revealed to check the AV (Arteriovenous) fistula; palpate gently over area with fingertips or palm of hand and feel for bruit or thrill. Auscultate over fistula with stethoscope to detect bruit. Assess for signs of infection, bleeding or sensation impairment around fistula/entire extremity. Review of the (MONTH) 2019 MAR/TAR and Physician Orders revealed there was no order to check the site for a thrill and bruit every shift and no documented evidence the assessment was completed. Interview with Resident #61, on 09/11/19 at 1:52 PM revealed he/she goes to [MEDICAL TREATMENT] on Monday, Wednesday and Friday; and, he/she did not have any concerns with the care he/she was receiving at the facility. The resident stated he/she did not understand what it meant to check the site but felt it was not being done, especially two (2) times a day. Interview with Registered Nurse (RN) #2 on 09/12/19 at 3:05 PM, revealed with her background she knew to check the AV site for thrill and bruit, but there was no where to document it. She stated the order being added to the MAR as a reminder, is very helpful and it does need to be on the MAR/TAR for a reminder and documentation. Interview with RN #1 on 09/13/19 at 10:29 AM revealed the order to check the AV site every shift should have been on the MAR or TAR, and she knew it was originally because she had taken off the orders. She stated it was a helpful reminder to check the site as ordered. Interview with the Director of Nursing (DON) on 09/12/19 at 2:45 PM revealed she investigated the omission on the MAR to check the site and feels the pharmacy failed to carry the order to the next month (from (MONTH) to (MONTH) 2019) orders, which caused it not to be documented on the MAR. She stated she expected the nurses to check the site every shift and if no thrill or bruit, to notify the physician, document it was performed, and also, to follow the resident's care plan.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. Observation on 09/19/19 revealed staff failed to ensure medications on two (2) of four (4) medication carts on Wing 1 and Wing 2, were dated when opened. The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, revised 07/23/19, revealed facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. Observation of the Wing 2 medication cart, on 09/10/19 at 10:36 AM, revealed an opened bottle of [MEDICATION NAME] Acid not dated, with approximately one-fourth (1/4) of liquid remaining. Observation of the Wing 1 medication care on 09/10/19 at 10:50 AM, revealed a bottle of Milk of Magnesia, not dated, with approximately one-half (1/2) of liquid remaining. Interview with Licensed Certified Medication Aide (CMA) #1, on 09/10/19 at 11:00 AM, revealed all liquid medications should be dated when opened. Interview with the Director of Nursing (DON), on 09/13/19 at 11:53 AM, revealed she expected the nurses and medication aides to date liquid medications when opened to ensure it is not used beyond the expiration date.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to serve food in accordance with professional standards for food service safety. Observation on 09/10/19 revealed a Certified Nurse Aide (CNA) handled a residents' bread with her bare hands. The findings include: Review of the facility policy, Dietary: Responsibilities for Meal Services, revealed both Nursing and Dietary personnel with assistance of other designated staff as assigned were responsible for meal service. Nursing and/or Dietary personnel pass trays, maintaining proper infection control and food handling practices. Areas of utensils, glasses, cups, etc. that come in contact with the resident's mouth should not be touched by the server. Observation of a lunch meal pass on 09/10/19 at 12:06 revealed CNA #8 removed the resident's bread from the package and touched the bread slices with her bare hands. She then removed the paper covering of the drinking straw and touched it with her bare hands. CNA #8 was not interviewed due to her starting leave on 09/10/19. Interview with CNA #2, on 09/12/19 at 2:25 PM revealed staff should not touch the residents' food with their bare hands. She stated if touched, the food should be discarded and the food should be replaced for the resident. Interview with the Assistant Director of Nursing (ADON) on 09/12/19 at 2:27 PM revealed she expected staff to open foods, drinks and utensils without touching with their bare hands. She stated staff should also use good hand washing technique.

Based on interview, record review, review of the facility's policy/procedure, review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14 and the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group, S&C:13-02-NH, dated 11/02/12; standards of practice, Section II item B, it was determined the facility failed to have an effective system to ensure medication was administered according to the professional standards of quality for eight (8) of twenty-one (21) sampled residents (Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10). The facility failed to have an effective system in place to ensure medications were transcribed correctly on the Medication Administration Record (MAR) for Resident #2 and Resident #3, failed to ensure a Physician's Telephone Order to discontinue a medication for Resident #5 was carried out, and failed to ensure narcotic pain patches were disposed of by two (2) nurses per facility policy for Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10. On 03/16/14, Resident #2's Physician ordered [MEDICATION NAME] 40 milligrams (mg) daily for Hypertension, and on 03/21/14, an order was received for [MEDICATION NAME] 20 mg twice daily. LPN #2 documented on the March and April 2014 MAR that the resident's [MEDICATION NAME] 40 mg daily had been "changed", with the initiation of the [MEDICATION NAME] 20 mg twice daily even though the physician's order did not indicate to discontinue the 40 mg order. During the May 2014 review of the MARs for accuracy, Resident #2's [MEDICATION NAME] 20 mg twice daily was transcribed onto Resident #3's MAR, in error. From 05/01/14 through 05/17/14, Resident #2 received [MEDICATION NAME] 40 mg daily, and Resident #3 received thirty-three (33) doses of [MEDICATION NAME] 20 mg twice a day without a physician's order. LPN #1 identified the medication error on 05/17/14; however, she failed to clarify the order for Resident #2's [MEDICATION NAME], leaving both orders, [MEDICATION NAME] 40 mg daily and [MEDICATION NAME] 20 mg twice daily, on the resident's MAR. The resident received 80 mg daily from 05/18/14 through 05/30/14. Refer to F333, F309, F514. On 05/02/14, the facility received orders to discontinue Resident #5's [MEDICATION NAME] 10 mg every day order; however, the facility failed to ensure the medication was discontinued on the June, July, August and September 2014 MAR during the checking of MARs for the new month which resulted in the resident receiving ninety-five (95) doses of [MEDICATION NAME] between 06/01/14-09/03/14. Refer to F333. The facility's failure to ensure medication was administered according to the nursing standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/30/14, and was determined to exist on 05/01/14. The facility was notified of the Immediate Jeopardy on 07/30/14. An acceptable Allegation of Compliance (AoC) was received on 08/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/06/14, as alleged. The Scope and Severity was lowered to a "E" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Even though 100% resident MAR to physician orders audits were conducted on 07/29/14 and 08/04/14 to ensure accurate reflection of the current physician's orders per the AoC, the facility failed to identify another example (Resident #5). This error was identified by the State Survey Agency. Therefore, it was determined the Immediate Jeopardy was not removed on 08/06/14, as alleged. The facility conducted additional audits and training related to ensuring the residents' MARs were an accurate reflection of the current physician's orders. After validation of the facility's actions, the State Survey Agency determined the Immediate Jeopardy was removed on 09/09/14. The findings include: Review of the facility's policy titled, "General Dose Preparation and Medication Administration", last revised 01/01/13, revealed facility staff should verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Confirm that the MAR reflected the most recent medication order. Review of the facility's policy titled, "Documentation Standards", last revised 01/02/14, revealed documentation standards would follow established professional ethics and practices. Prior to documenting, always check the identifying information to verify and authenticate it was the correct medical record for charting. Review of the facility's "Protocol for Checking MARs for the New Month", dated 07/30/14, revealed to check the new physician's orders and update with any telephone orders since the last physician's orders were checked. Check the new physician's orders against the new MARs, check the new MARs against the current month's MARs, and check new physician's orders against the previous month's physician's orders. Review of the KBN Advisory Opinion, AOS #14, last revised 10/2010, revealed Registered Nurses (RN) and Licensed Practical Nurses (LPN) were required to administer medications and treatments prescribed by the physician, physician assistant, dentist and advanced practice registered nurse. Components of medication administration included preparing and giving medication in the prescribed dosage, route, and frequency. 1. Record review revealed the facility admitted Resident #2 on 07/02/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 as cognitively intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Review of the Physician's Orders, dated 03/16/14, revealed an order for [REDACTED]. Further review revealed a Physician's Order, dated 03/21/14, for [MEDICATION NAME] 20 mg twice daily for Hypertension. Review of Resident #2's March 2014 MARs revealed the order for [MEDICATION NAME] 40 mg daily had been marked as "changed", with the last dose initialed as being administered on 03/21/14 at 8:00 AM. Further review revealed the [MEDICATION NAME] 20 mg twice daily had been transcribed onto the MAR with the first dose initialed indicating it had been administered on 03/21/14 at 8:00 PM. Review of Resident #2's April 2014 MAR revealed an order for [REDACTED]. However, review of the May 2014 MAR revealed the [MEDICATION NAME] 40 mg once daily was not marked as changed; it was initialed indicating it had been administered from 05/01/14 through 05/31/14. In addition, the [MEDICATION NAME] 20 mg twice daily was also initialed as been administered 05/18/14 through 05/30/14 Phone interview with LPN #2, on 07/28/14 at 3:10 PM; and, on 07/29/14 at 10:40 AM, revealed she received a telephone order from Physician #1 for [MEDICATION NAME] 20 mg twice daily on 03/21/14. She stated Resident #2 had been having an increase in his/her blood pressure in the evening or the morning (she could not remember which one). She stated Physician #1 ordered the divided dose of [MEDICATION NAME] so the medication would be evenly distributed throughout the day. LPN #2 further stated if the previous order of [MEDICATION NAME] had been replaced, it should have been documented as "discontinued' on the telephone order. Interview with LPN #1, on 07/28/14 at 3:30 PM, revealed she had identified, on 05/17/14, that the order for [MEDICATION NAME] 20 mg twice daily order had been transcribed onto the wrong MAR (Resident #3's May 2014 MAR). LPN #1 stated after the error was found, she added the medication to Resident #2's MAR; however, she did not discontinue the order for the [MEDICATION NAME] 40 mg daily which resulted in the resident receiving 80 milligrams of [MEDICATION NAME] daily from 05/18/14 through 05/30/14. LPN #1 stated she did not notify the physician to verify the order. She stated she "assumed" the resident was supposed to have both orders, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 20 mg twice daily. Interview with Physician #1, on 07/28/14 at 3:45 PM; and, on 07/29/14 at 10:15 AM, revealed if he gave an order for [REDACTED]. Physician #1 verified the maximum dose of [MEDICATION NAME] for an elderly resident was 40 mg daily. He stated if a resident received 80 mg daily, there was a potential to lower the resident's blood pressure too much, causing fatigue, dizziness, lightheadedness when standing, weakness, and an increased risk for falling. 2. Record review revealed the facility admitted Resident #3 on 11/28/05 with [DIAGNOSES REDACTED].#3 as cognitively intact with a BIMS score of fifteen (15). Review of the May 2014 MAR revealed an entry for [MEDICATION NAME] 20 mg twice daily. The [MEDICATION NAME] was initialed indicating it was administered thirty-three (33) times from 05/01/14 through 05/17/14. Review of the May 2014 Physician's Orders revealed an order for [REDACTED]. When the nurse reconciled the physician's orders to the May 2014 MARs, the nurse documented the [MEDICATION NAME] order on Resident #3's May 2014 MAR instead of Resident #2's May 2014 MAR. Interview with the Director of Nursing (DON), on 07/29/14 at 10:55 AM, 12:00 PM, 2:30 PM; and, on 07/30/14 at 10:30 AM, revealed it was expected for licensed staff to discontinue the previous order if an order change was received. She stated staff should have received clarification for the two (2) [MEDICATION NAME] orders written for Resident #2, as common practice for licensed staff. The process for verifying accuracy of a resident's MAR each month included comparison of the resident's current physician's orders with the resident's new MAR. The DON verified LPN #2 was most likely the nurse reviewing the May 2014 MAR for Resident #3. She stated they were reviewed by one licensed staff, but not double checked by a second licensed staff member. 3. Record review revealed the facility admitted Resident #5 on 02/05/13 with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated 02/05/13, revealed an order for [REDACTED]. Review of a Physician's Order, dated 05/02/14 at 5:35 PM, revealed an order to discontinue the [MEDICATION NAME]. Review of the May 2014 MAR revealed the [MEDICATION NAME] was discontinued on 05/02/14; however review of the June, July, August, and and September 2014 MARs revealed ninety-five (95) doses were administered between 06/01/14 and 09/03/14. The 02/05/13 order for [MEDICATION NAME] 10 mg daily remained on the MARs. Interview with the DON, on 09/02/14 at 11:15 AM, revealed she was unaware of another significant medication error involving [MEDICATION NAME]. She stated the month end change-over of 08/31/14 and the September 2014 MAR to medication cart audit conducted as part of the AoC did not reveal any discrepancies. Interview with the Clinical Care Coordinator, on 09/12/14 at 8:25 AM, revealed an audit was conducted on all resident MARs on 07/29/14 and a second audit was conducted on 08/04/14 as part of the facility's AoC to ensure accurate reflection of the physician's orders; however, staff failed to identify that Resident #5's [MEDICATION NAME] 10 mg daily order remained on the MARs with no physician's order. She stated Resident #5 received [MEDICATION NAME] 10 mg daily from 06/01/14 through 09/03/14 in error. Interview on 09/02/14 at 1:55 PM with the Medical Director, who was also Resident #5's Primary Care Provider, revealed she knew Resident #5 well and had stopped the [MEDICATION NAME] 10 mg daily on 05/02/14 probably due to his/her B/P being low and [MEDICAL CONDITION]. Further interview revealed she would have expected the resident's B/P to remain low when the medication was continued, and due to the resident's [MEDICAL CONDITION] she would not have restarted the medication at all as that could cause further renal compromise. 4. Record review revealed the facility admitted Resident #11 on 08/20/13 with [DIAGNOSES REDACTED]. Review of the Physician's Orders, dated 08/25/14, revealed an order for [REDACTED]. Review of the September 2014 MAR revealed the [MEDICATION NAME] administration time was 7:00 AM. Observation of the medication pass, on 09/05/14 at 7:53 AM, revealed Resident #11 was administered his/her [MEDICATION NAME] after breakfast at 7:53 AM. The resident was noted to have his/her breakfast tray in front of him/her with most of the food eaten. The [MEDICATION NAME] was given by Certified Medication Aide (CMA) #12 with the resident's morning medications. Interview with CMA #12 on 09/05/14 at 10:35 AM, revealed she was forty-five (45) minutes late giving the resident his/her [MEDICATION NAME] and was aware the medication was for brittle bones and was to be given on an empty stomach at least thirty (30) minutes before the first food or drink of the day. 5. Record review revealed the facility admitted Resident #12 on 05/24/12 with [DIAGNOSES REDACTED]. Review of the September 2014 MAR revealed an order for [REDACTED]. Observation of a medication pass, on 09/05/14 at 8:05 AM, revealed CMA #11 administered the [MEDICATION NAME] by sprinkling the medication on applesauce. The medication was administered after breakfast. Interview with CMA #11, on 09/05/14 at 10:35 AM, revealed she was not aware that she had given the medication after the resident's breakfast. Interview with the DON, on 09/05/14 at 3:35 PM, revealed she expected staff to contact the physician prior to administering a late medication and get instructions. 6. Review of the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group, S&C:13-02-NH, dated 11/02/12, standards of practice, Section II item B, revealed staff should dispose of [MEDICATION NAME]es in the same manner as wasting of any other controlled substance. Wasting involved a secure and safe method so diversion and/or accidental exposure were minimized. Review of the facility's policy entitled "LTC Facilities Receiving Pharmacy Products and Services from Pharmacy", last revised 01/01/13, revealed wasting of controlled medications should be destroyed by two (2) licensed nurses employed by the facility, and the disposal should be documented on the accountability record on the line representing that dose. Record review revealed the facility admitted Resident #6 on 03/31/13 with [DIAGNOSES REDACTED]. Review of the Physician's Order, dated 07/29/14, revealed an order for [REDACTED].) patch apply one (1) patch every seventy-two (72) hours. Review of the August 2014 Medication Administration Record (MAR) revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on ten (10) out of 10 days the patch was changed between 08/01/14 through 08/31/14. Review of the September 2014 MAR revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal destruction of the patch two (2) days between 09/01/14 and 09/05/14. 7. Record review revealed the facility admitted Resident #7 on 10/01/13 with [DIAGNOSES REDACTED]. Review of the Physician's Order, dated 07/29/14, revealed an order for [REDACTED]. Review of the August 2014 Medication Administration Record (MAR) revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on ten (10) out of 10 days between 08/01/14 through 08/31/14. Review of the September 2014 MAR revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on two (2) days between 09/01/14 and 09/05/14. 8. Record review revealed the facility admitted Resident #8 on 08/04/11 with [DIAGNOSES REDACTED]. Review of the Physician's Order, dated 07/22/14, revealed an order for [REDACTED]. Review of the August 2014 Medication Administration Record (MAR) revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on five (5) out of fifteen (15) days between 08/01/14 through 08/15/14; and, six (6) out of 6 days between 08/15/14 and 08/31/14 . Review of the September 2014 MAR revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on two (2) days between 09/01/14 and 09/05/14. 9. Record review revealed the facility admitted Resident #9 on 05/22/13 with [DIAGNOSES REDACTED]. Review of the Physician's Order, dated 07/10/14, revealed an order for [REDACTED]. Review of the August 2014 Medication Administration Record (MAR) revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on ten (10) out of 10 days between 08/01/14 through 08/31/14. Review of the September 2014 MAR revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch two (2) days between 09/01/14 and 09/05/14. 10. Record review revealed the facility admitted Resident #10 on 02/07/13 with [DIAGNOSES REDACTED]. Review of the Physician's Order, dated 07/10/14, revealed an order for [REDACTED]. Review of the August 2014 Medication Administration Record (MAR) revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on ten (10) out of 10 days between 08/01/14 through 08/31/14. Review of the September 2014 MAR revealed there was no documented evidence indicating two (2) licensed nurses had verified the removal and destruction of the patch on two (2) days between 09/01/14 and 09/05/14. Interview with Certified Medication Aide (CMA) #1, on 09/05/14 at 1:06 PM, revealed she would apply the patch, and label it with the date and her initials. She stated when she removed a patch she would take off the old patch and discard it in the sharps' container. She was not aware that two (2) licensed nurses were supposed to dispose of the used patches. Interview with CMA #7, on 09/05/14 at 3:00 PM, revealed she would follow the MAR for putting the pain patches on a resident and then label the patches with her initials and the date. She stated when she removed a patch, she folded it together and put it in the sharps' container in the resident's room. She was not aware that two (2) licensed nurses were supposed to dispose of the used patches. Interview with CMA #9, on 09/05/14 at 3:18 PM, revealed she would follow the MAR when she applied a pain patch to a resident. She stated when she removed a patch she would fold the patch up in her glove and place it in the sharps' container in the resident's room. She was not aware that two (2) licensed nurses were supposed to dispose of the used patches. Interview with Unit Manager #1 on 09/07/14 at 5:07 PM; Registered Nurse (RN) #1 on 09/12/14 at 3:00 PM, and RN #2 on 09/05/14 at 12:25 PM revealed they were aware the CMAs had applied, removed and disposed of the pain patches. They were not aware of the facility's policy that two (2) nurses were supposed to witness the disposal of the patch. Interview with the DON, on 09/05/14 at 3:35 PM, revealed she was not aware that two (2) licensed nurses were supposed to dispose of used pain patches and she thought there was no medication left in the patch when the CMAs removed it. Interview with the Pharmacist in Charge from the contracted facility pharmacy vendor, on 09/05/14 at 2:00 PM, revealed a [MEDICATION NAME] or [MEDICATION NAME] patch was a controlled substance and when the used patch was removed from a resident it should be wasted "just like any other controlled substance". ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #3's blood pressure was monitored three (3) times on 05/17/14, two (2) times on 05/18/14 and then daily for the next five (5) days. The Nurse Practitioner assessed the resident on 06/18/14 and an RN assessed the resident on 07/30/14 with no indications of any adverse effect. On 07/29/14, all resident Medication Administration Records (MARs) were audited to ensure accurate reflection of the current physician's orders. A second audit was conducted, on 08/04/14, by the DON and the Regional Quality Management Nurse. After the audit, the facility implemented a revised process for faxing telephone orders to the pharmacy. Education was provided to licensed staff of the new process, which included the attachment of the fax verification to the telephone order. The Clinical Care Coordinator (CCC) or the weekend monitor would verify the fax confirmation was present for all new orders. The end of the month procedure for reviewing MARs was modified to designate one specific nurse to be removed from additional duties other than MAR revision at the end of the month. The nurse was designated as the "Order Validation Nurse". That nurse was trained by the Staff Development Coordinator (SDC) on 07/31/14, on the process which included comparing the previous month's orders and subsequent telephone orders to ensure new orders contained all changes that occurred since the previous month began. The new orders would be utilized to verify that the MARs accurately reflected those orders. On the last day of the month, prior to utilization, the night nurse would compare the new MAR which had been checked against the new orders to the MAR currently being utilized. The process for reviewing new orders was revised to include the CCC validating accurate transcription of new orders on the correct MAR on weekdays. The night shift nurse would validate on the weekends and holidays. The DON would assign responsibility or complete the reviews in the absence of the CCC. The process included implementation of a task list to utilize when reviewing orders to guide the reviewer through the process. 2. Education was provided, on 07/30/14 to the Administrator, DON, CCC, SDC, Unit Managers, and MDS Nurses by the Regional Resource Team Nurse regarding proper administration techniques utilizing the "rights" of medication administration to prevent errors, accuracy of transcribing medications, correct process for month end transcription and validation of physician's orders and MARs, administration of medication, and transcription of orders. On 07/31/14, the Regional Resource Nurse educated the Administrative Team on root cause analysis. On 07/31/14, education was provided by the SDC to licensed staff and CMAs regarding accurate medication administration, obtaining vital signs as indicated by medication and as directed on the MAR, and the prohibition of borrowing medication from another resident. If a medication was not available, the pharmacy should be contacted regarding the medication. The physician should be notified for clarification if there were any discrepancies. Education was provided to licensed nurses by the SDC on 07/31/14 regarding accurate transcription of telephone orders onto the MAR. The education included to read back the order to the prescriber to ensure the initial order reflects his/her verbal order correctly, transcribe the order onto the correct MAR, clearly discontinue existing orders that may be stopped or modified due to the new order. Nurses were educated on 07/31/14 by the SDC that a resident was to have a complete assessment each shift for a minimum of twenty-four hours after identification of a medication error. The assessment would be documented in the clinical record. Education was provided to licensed nurses by the SDC on 07/31/14 regarding accurate transcription of telephone orders onto the MAR. The education included to read back the order to the prescriber to ensure the initial order reflected his/her verbal order correctly, transcribe the order onto the correct MAR, clearly discontinue existing orders that may be stopped or modified due to the new order. Nurses were educated on 07/31/14 by the SDC that a resident was to have a complete assessment each shift for a minimum of twenty-four hours after identification of a medication error. The assessment would be documented in the clinical record. On 07/31/14, the Regional Director of Operations educated the Administrator on utilizing the Abbreviated Quality Assurance processes, a review of the previous day's events, with focus on unusual events or deviation from normal. The process included audits of documents and departmental reports of activities and findings that may prompt the need for additional review, identify any weaknesses in processes as they relate to medication or other facility operations and systems. 3. Training would be provided to all staff currently working and would continue with oncoming staff, prior to beginning duty, until completed by the SDC. After the State Survey Agency identified the facility failed to remove the Jeopardy on 08/06/14, the facility implemented the following actions: 4. Resident #5's physician was notified and an order was obtained to discontinue the medication. The resident was assessed by the nurse, with her findings noted in the clinical record. The assessment was repeated each shift for the next twenty-four (24) hours then daily for the next two (2) days. No adverse effects were identified. All the resident's blood pressure obtained during the time the resident was receiving the medication were within the physician's parameters for administration. 5. The facility revised the process for the handling of medication discontinue orders to include the placement of a "Discontinue" sticker on the medication cards containing the remainder of the medication and remove that medication from the medication cart at that time. The facility conducted an additional one-hundred percent (100%) resident record review audit on 09/05/14 through 09/07/14; which included Physician Telephone Orders and MAR/TAR from 04/01/14 through 09/07/14 which revealed no errors related to transcription, communication with the pharmacy or removal of discontinued medications and no further medication order to MAR discrepancies. A re-audit was conducted by the Director of Nursing (DON), Clinical Care Coordinator (CCC), Staff Development Coordinator (SDC), Unit Managers (UM), Regional Quality Control Specialist (RQMS), and Minimum Data Set (MDS) Coordinator, utilizing the services of outside Registered Nurses (RNs) with known performance credentials, on 09/05/14 through 09/07/14 of all the residents' records which included; the Physician Orders, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) and Telephone Physician Orders dating from 04/01/14 to 09/07/14 to identify problems associated with order transcription and/or communication with the Pharmacy. 6. The facility conducted re-education and in-servicing on 09/04/14 with all licensed staff related to the discontinuation of medications. The education included; write the order for the discontinued medication,make the correction on the MAR, pull medication from medication cart, scan the barcode for return, place "discontinued" stickers on each of the discontinued medication cards, and place the medication in the tote to be returned to the Pharmacy or if the medication was a controlled substance secure for destruction. 7. The Regional Resource Team Nurse and the DON educated and in-serviced the licensed nurses and CMAs on 09/05/14 related to the facility's policy for the removal and disposal of narcotic patches by two (2) licensed nurses and that the CMAs should not dispose of the narcotic patches. 8. The facility reviewed and revised the medication administration schedule on the MAR for all residents; a revised administration time schedule was noted for daily routine medications and the special administration times (before breakfast, before meals, after meals, or with food) were noted and located on the MAR in a specific group for each type, the as needed (PRN) medications will be kept separated from the routine and special schedule medications. Nurses were monitored during medication administration on 09/07/14 and is ongoing; the DON, SDC, UM and CCC ensured the observations will continue to include; observations of appropriate technique, including securing medications when the cart is unattended, proper storage of supplies, administering medications as ordered and scheduled in the appropriate time frame, and is an ongoing Quality Control process. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility's documentation revealed each resident's August MAR was reviewed for accuracy, reflecting the resident's current orders 07/31/14, with all blood pressure parameters listed on the MARs. 2. Review of the in-service form, dated 07/30/14, revealed administrative staff was in-serviced on the rights of medication, receiving new orders/transcription, end of the month MAR review, medication administration, and medication errors. Review of the in-service form, dated 07/31/14, revealed the administrative team was educated on root cause analysis. Review of the in-service form dated 07/31/14, revealed licensed nurses and CMAs were in-serviced on the "rights" of medication administration, unavailable medications, borrowing medication, medication errors/assessment of the resident, blood pressures obtained prior to administration of anti-hypertensive medications, what to do if the blood pressure was outside the written parameters, and care plans. Interviews with RN #1, LPN #2, LPN #3, and LPN #4, on 08/06/14 at 3:40 PM, 5:05 PM, 4:55 PM, and 5:30 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, receiving new orders/transcription of new orders, end of the month MAR review, obtaining blood pressures before administering anti-hypertensive medications, identification of medication errors and assessment of the resident afterwards, and care plans. Interviews with CMA #10, CMA #4, and CMA #3 on 08/06/14 at 4:25 PM, 5:15 PM, and 5:45 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, not borrowing medication for a resident, obtaining blood pressures before administering anti-hypertensive medications, and care plans. 3. Verified with the SDC all medication observations and in-servicing of staff was completed with the exception of 2-3 weekend staff who would receive their training/testing prior to starting their shift. 4. Review on 09/12/14 of Resident #5's September MAR and Physician's Orders revealed the [MEDICATION NAME] order was discontinued. Review of a Nursing Assessments revealed the resident was assessed each shift for twenty-fou

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure services were provided by qualified persons in accordance with the resident's written plan of care for two (2) of five (5) sampled residents (Resident #2 and Resident #3). The facility failed to administer anti-hypertensive medications as ordered and evaluate the resident's blood pressure, per the care plan for Resident #2 and Resident #3. Resident #2's Care Plan for Hypertension revealed staff should administer anti-hypertensive medications as ordered and evaluate the resident's blood pressure per the physician's orders [REDACTED].#2 received and transcribed an order for [REDACTED]. On the March and April 2014 MAR, [MEDICATION NAME] 40 mg daily had been changed to [MEDICATION NAME] 20 mg twice daily, and blood pressures were to be obtained when administered. Upon verification of the May 2014 MARs, Resident #2's [MEDICATION NAME] 20 mg twice daily was transcribed onto Resident #3's May 2014 MAR, resulting in Resident #2 receiving [MEDICATION NAME] 40 mg daily from 05/01/14 through 05/17/14 instead of [MEDICATION NAME] 20 mg twice a day as ordered by the physician. Review of Resident #2's MAR revealed thirteen (13) doses of [MEDICATION NAME] were administered without obtaining the resident's blood pressure. On 05/17/14, LPN #1 identified the medication error; however, she failed to clarify the order. This resulted in the resident receiving [MEDICATION NAME] 80 mg from 05/18/14 through 05/30/14. Resident #3's Care Plan for Hypertension revealed staff should administer anti-hypertensive medications as ordered and evaluate the blood pressure per the physician's orders [REDACTED]. However, there was no order for [MEDICATION NAME]. The facility determined Resident #2's order for [MEDICATION NAME] 20 mg twice a day was transcribed to Resident #3's May 2014 MAR. It was determined Resident #3 received thirty-three (33) doses of anti-hypertensive medication not ordered for him/her from 05/01/14 to 05/17/14 with staff stating they borrowed the medication from other residents. In addition the resident received twelve (12) doses of medication without his/her blood pressure being obtained. The facility's failure to ensure services were provided in accordance with the resident's care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/30/14, and was determined to exist on 05/01/14. The facility was notified of the Immediate Jeopardy on 07/30/14. An acceptable Allegation of Compliance (AoC) was received on 08/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/06/14, as alleged. The Scope and Severity was lowered to a "E" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. However, the survey was reopened and it was determined the IJ was removed on 09/09/14. The findings include: Review of the facility's "Comprehensive Care Plans" policy/procedure, last revised 04/03/13, revealed a care plan would be developed based on assessed needs. Care plan approaches would be communicated to staff for use in providing direction for care. Review of the facility's "General Dose Preparation and Medication Administration" policy/procedure, last revised 01/01/13, revealed prior to administration of medication, facility staff should obtain vital signs, if necessary. 1. Record review revealed the facility admitted Resident #2 on 07/02/13 with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Care Plan for Hypertension, dated 01/16/14, revealed to administer anti-hypertensive medications as ordered and evaluate blood pressure per the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed a physician's orders [REDACTED]. Review of the MAR, dated March 2014, revealed the order for [MEDICATION NAME] 40 mg daily was marked on the MAR as "changed", with the last dose initialed as administered on 03/21/14 at 8:00 AM. [MEDICATION NAME] 20 mg twice daily was transcribed onto the MAR with the first dose initialed as administered on 03/21/14 at 8:00 PM. Review of the MAR, dated April 2014, revealed an order for [REDACTED]. However, review of the MAR, dated May 2014, revealed the [MEDICATION NAME] 40 mg once daily was initialed as administered from 05/01/14 through 05/31/14 with [MEDICATION NAME] 20 mg twice daily initialed as administered starting on 05/18/14 through 05/30/14. After the medication was initiated on 05/18/14, thirteen (13) doses were documented in (May 2014) as administered without obtaining the resident's blood pressure. Phone interview with LPN #2, on 07/28/14 at 3:10 PM; and, on 07/29/14 at 10:40 AM, revealed she received the telephone order from Physician #1 for [MEDICATION NAME] 20 mg twice daily on 03/21/14. She stated if the previous order was replaced, it should have been discontinued on the telephone order. Interview with Physician #1, on 07/28/14 at 3:45 PM and on 07/29/14 at 10:15 AM, revealed if he gave an order for [REDACTED]. Physician #1 stated there was a potential to lower the resident's blood pressure too much, causing fatigue, dizziness, lightheadedness when standing, weakness, and an increased risk for falling. Interview with LPN #1, on 07/28/14 at 3:30 PM, revealed she identified the medication error involving Resident #2, on 05/17/14. She stated the resident's [MEDICATION NAME] 20 mg twice daily order was transcribed onto the wrong MAR (Resident #3's May 2014 MAR). After the error was found, [MEDICATION NAME] 20 mg twice daily was transcribed onto Resident #2's MAR; however, there had been no discontinue order for the [MEDICATION NAME] 40 mg daily. She "assumed" the resident was supposed to have both orders ([MEDICATION NAME] 40 mg and [MEDICATION NAME] 20 mg twice daily). 2. Record review revealed the facility admitted Resident #3 on 11/28/05 with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Care Plan for Hypertension, dated 02/18/14, revealed to administer anti-hypertensive medications as ordered and evaluate the blood pressure per the physician's orders [REDACTED]. Review of the MAR, dated May 2014, revealed an entry for [MEDICATION NAME] 20 mg twice daily. The [MEDICATION NAME] was initialed as being administered thirty-three (33) times from 05/01/14 through 05/17/14 with twelve (12) doses administered to Resident #3 without obtaining the resident's blood pressure. Review of the physician's orders [REDACTED]. Orders also included [MEDICATION NAME] 25 mg tablet every morning for Hypertension and [MEDICATION NAME] 10 mg tablet once daily; however, there was no order for [MEDICATION NAME]. Phone interview with Certified Medication Aide (CMA) #6, on 07/29/14 at 3:00 PM, revealed she was supposed to obtain and document a resident's blood pressure before administering anti-hypertensive medication. However, when she was busy, she did not always document the blood pressures. She stated the care plans were not utilized, as she administered medications per the MAR. Interview with CMA #9, on 07/30/14 at 10:00 AM, revealed she was trained to obtain a resident's blood pressure prior to administering anti-hypertensive medications. However, the blood pressure reading did not have to be documented if it was "normal." She stated she was not aware of a specific care plan to monitor blood pressures or medications. Interview with the Director of Nursing (DON), on 07/30/14 at 10:30 AM, revealed the CMAs, who were responsible for administering medications, were not expected to utilize the resident's care plan, they administered medications per the MAR. She stated licensed staff updated the care plans with new physician's orders [REDACTED]. She stated staff was expected to obtain and document a resident's blood pressure on the MAR prior to administration of an anti-hypertensive medication. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #3's blood pressure was monitored three (3) times on 05/17/14, two (2) times on 05/18/14 and then daily for the next five (5) days. The Nurse Practitioner assessed the resident on 06/18/14 and an RN assessed the resident on 07/30/14 with no indications of any adverse effect. On 07/31/14, care plan interventions, relating to medication administration, were placed with each specific resident's MAR. 2. Education was provided, on 07/30/14 to the Administrator, DON, CCC, SDC, Unit Managers, and MDS Nurses by the Regional Resource Team Nurse regarding the need to ensure staff administering medications were aware of care plan interventions for hypertension. On 07/31/14, education was provided that the interventions for residents receiving anti-hypertension medications would be located in the MAR and were to be followed. 3. Training would be provided to all staff currently working and would continue with oncoming staff, prior to beginning duty, until completed by the SDC. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of each hall's MAR book revealed Hypertension care plans on all resident's receiving anti-hypertensive medications. They were with each specific resident's MAR, on "green" paper for easy detection. Medication related care plans, other than Hypertension, were located in a book on the medication cart. 2. Review of the in-service form, dated 07/31/14, revealed licensed nurses and CMAs were in-serviced on following the care plans. Interviews with RN #1, LPN #2, LPN #3, and LPN #4, on 08/06/14 at 3:40 PM, 5:05 PM, 4:55 PM, and 5:30 PM, respectively, revealed they were in-serviced related to care plans. Interviews with CMA #10, CMA #4, and CMA #3, on 08/06/14 at 4:25 PM, 5:15 PM, and 5:45 PM, respectively, revealed they were in-serviced related to care plans. There were Hypertension care plans in front of each resident's specific MAR, if they had the diagnosis. They were on "green" paper, making it easily accessible. Other medical care plans for residents were in a book on the medicine cart, for reference. 3. Verified with the SDC all medication observations and in-servicing of staff was completed with the exception of 2-3 weekend staff who would receive their training/testing prior to starting their shift.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of five (5) sampled residents (Resident #2 and Resident #3). The facility failed to ensure appropriate monitoring of a resident's blood pressure before administration of anti-hypertensive medications and failed to conduct an assessment of Residents #2 and #3's for twenty-four hours after the identification of a significant medication error, per the facility policy. Licensed Practical Nurse (LPN) #1 identified a significant medication error for both residents on 05/17/14. Resident #2 did not receive an anti-hypertensive medication as ordered from 05/01/14 through 05/30/14; and thirteen (13) of the doses were administered without obtaining a blood pressure. Resident #3 received thirty-three (33) doses of the wrong anti-hypertensive medication from 05/01/14 through 05/17/14. Twelve (12) of the doses were administered to Resident #3 without obtaining the resident's blood pressure. In addition, there was no evidence of an assessment for either resident following the medication error with follow-up assessment for a minimum of twenty-four (24) hours, per the facility's policy. Refer to F333, F514, F281 The facility's failure to ensure appropriate monitoring of a resident's blood pressure while on anti-hypertensive medications and failure to conduct on-going assessments of the residents' for twenty-four (24) hours after a significant medication error was identified has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/30/14, and was determined to exist on 05/01/14. An acceptable Allegation of Compliance (AoC) was received on 08/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/06/14, as alleged. The Scope and Severity was lowered to a "E" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. However, after supervisory review, the survey was reopened and it was determined the IJ was removed on 09/09/14. The findings include: Review of the facility's "Medication Error" policy/procedure, last revised 05/19/14, revealed the licensed staff member would conduct an assessment of the resident where appropriate and document follow-up assessments in the Nurse's Notes for a minimum of twenty-four (24) hours. Review of the facility's "General Dose Preparation and Medication Administration" policy/procedure, last revised 01/01/13, revealed prior to administration of medication, facility staff should obtain vital signs if necessary. 1. Record review revealed the facility admitted Resident #2 on 07/02/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/18/14, revealed the facility assessed the resident as cognitively intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15). Review of a physician's orders [REDACTED]. Further review revealed when the medication was added on 05/17/14 after the medication error was identified, thirteen (13) doses were documented as being administered without obtaining the resident's blood pressure. Review of the Nurse's Notes for Resident #2, dated 05/17/14 at 5:00 PM, revealed a blood pressure reading of 166/78 mm/hg when the medication error was identified; and, review of the Nurse's Notes, dated 05/18/14 at 9:00 AM, revealed a blood pressure reading of 136/78 mm/hg sixteen hours after the medication error was identified; however, there was no documented evidence of further assessments for twenty-four hours after the medication error per the facility's policy. 2. Record review revealed the facility admitted Resident #3 on 11/28/05 with [DIAGNOSES REDACTED]. Review of the May 2014 MAR indicated [REDACTED]. The orders revealed to check the resident's blood pressure every shift. Review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of Resident #3's Nurse's Notes dated 05/17/14 at 5:00 PM, revealed a blood pressure reading of 135/76 mm/hg at the time the medication error was identified; and on 05/19/14 at 8:00 AM, the resident's B/P was 118/72 mm/hg fifteen (15) hours after the medication was identified. However, there was no documented evidence of further assessments conducted for twenty-four hours (24) after the medication error was identified per the facility's policy. Phone interview with Certified Medication Aide (CMA) #7, on 07/29/14 at 3:10 PM, revealed she was a previous employee of the facility, her last day working at the facility was on 05/12/14. She stated she had administered medication to Resident #3 during May 2014. CMA #7 stated she "probably borrowed" the [MEDICATION NAME] from another resident and did not report it to the nurse. She stated staff was supposed to report missing medication to the nurse, who would then notify the pharmacy. Interview with the Director of Nursing (DON), on 07/29/14 at 3:40 PM, revealed a medication error report was initiated on 05/17/14 at approximately 9:00 AM, involving Residents #2 and #3. She stated the [MEDICATION NAME] 20 mg twice daily ordered for Resident #2 had been transcribed on the MAR for Resident #3, it was a "human error." Interview with LPN #1, on 07/29/14 at 2:35 PM, revealed she identified the medication error on 05/17/14. She stated it was the first time she had identified an error and was not sure what the facility's policy specified as far as assessment of the resident. Review of the "Medication Error" policy revealed the licensed staff member was to conduct an assessment of the resident and document any follow-up assessments in the Nurse's Notes for a minimum of twenty-four (24) hours. She stated her assessment of each resident included a blood pressure reading; however, it was not documented. Further interview with the DON revealed no increased monitoring of either resident was initiated after the medication error. Interview with Physician #2, on 07/29/14 at 2:15 PM, revealed he was the primary physician for Resident #3. Further interview revealed he had been made aware Resident #3 received [MEDICATION NAME] 20 mg twice daily without an order. He stated there was a potential for the resident to have a "lower" blood pressure than usual, [MEDICAL CONDITION], and an increased risk of falls. He expected facility staff to monitor the resident's blood pressure 2-3 times daily for 5-7 days after the error was identified. Phone interview with Certified Medication Aide (CMA) #6, on 07/29/14 at 3:00 PM, revealed she was supposed to obtain and document a resident's blood pressure before administering anti-hypertensive medication; however, she was busy in the evening and "did not always document". Phone interview with CMA #8, on 07/30/14 at 11:45 AM, revealed she did not document "normal" blood pressure readings on the MAR. Interview with CMA #9, on 07/30/14 at 10:00 AM, revealed she was trained to obtain a resident's blood pressure prior to administering anti-hypertensive medications; however, the reading did not have to be documented if "normal." She stated some of the resident's blood pressure parameters were indicated on the MAR. Further interview with the DON, on 07/29/14 at 3:40 PM and on 07/30/14 at 10:30 AM, revealed she expected staff to obtain a blood pressure reading for each resident following the medication error. She stated staff obtained a blood pressure reading on the next 12-hour shift which covered the twenty-four (24) period per the facility's policy and procedure. She stated she felt that was an adequate assessment of each resident as the error involved anti-hypertensive medications. She revealed staff was expected to obtain and document a resident's blood pressure on the MAR prior to administration of an anti-hypertensive medication; however, there was no system in place to ensure compliance. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 07/31/14, the August MARs were audited to verify that residents who have medications for which vital signs should be obtained, have parameters listed and that the appropriate vital signs were being obtained. The August MARs were revised to clearly connect vital signs with medication administration. 2. Education was provided, on 07/30/14 to the Administrator, DON, CCC, SDC, Unit Managers, and MDS Nurses by the Regional Resource Team Nurse regarding proper administration techniques utilizing the "rights" of medication administration to prevent errors, need for obtaining blood pressure prior to administration of anti-hypertensive medication, need for assessment following identification of a medication error, need for accurate and consistent documentation of blood pressure reading prior to administration of anti-hypertensive medication. Licensed nurses and CMAs were educated on 07/30/14 by the SDC regarding obtaining a blood pressure before an anti-hypertensive medication was administered. If the blood pressure was outside the established parameters on the MAR, the CMA would notify the nurse, who would notify the physician. On 07/31/14, education was provided by the SDC to licensed staff and CMAs regarding accurate medication administration and obtaining vital signs as indicated by medication and as directed on the MAR. Nurses were educated on 07/31/14 by the SDC that a resident was to have a complete assessment each shift for a minimum of twenty-four hours after identification of a medication error. The assessment would be documented in the clinical record. 3. Training would be provided to all staff currently working and would continue with oncoming staff, prior to beginning duty, until completed by the SDC. 4. The MARs would be audited to verify vital signs that were indicated prior to medication administration have been recorded. The audits would be completed daily for four weeks, then three times per week for four weeks, then one week for four weeks, then every other week for four weeks, then monthly for three months. When a medication error was identified, the record would be reviewed to validate that the root cause of the error was identified and an assessment of the condition impacted by the involved error was conducted. The monitoring would continue for three months. If no concerns, medication errors would be reviewed by the DON or CCC and reported to the QAA monthly. The Regional Director of Operations would review the quality assurance records of medication errors monthly for three months. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility documentation revealed each resident's August MAR indicated [REDACTED]. 2. Review of the in-service form, dated 07/30/14, revealed administrative staff was in-serviced on the rights of medication, anti-hypertensive medications, and medication errors/resident assessment. Review of the in-service form, dated 07/31/14, revealed the administrative team was educated on root cause analysis. Review of the in-service form dated 07/31/14, revealed licensed nurses and CMAs were in-serviced on the "rights" of medication administration, medication errors/assessment of the resident, blood pressures obtained prior to administration of anti-hypertensive medications, and what to do if the blood pressure was outside the written parameters. Interviews with RN #1, LPN #2, LPN #3, and LPN #4, on 08/06/14 at 3:40 PM, 5:05 PM, 4:55 PM, and 5:30 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, obtaining blood pressures before administering anti-hypertensive medications, identification of medication errors and assessment of the resident afterwards. Interviews with CMA #10, CMA #4, and CMA #3 on 08/06/14 at 4:25 PM, 5:15 PM, and 5:45 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, obtaining blood pressures before administering anti-hypertensive medications, and documenting them on the MAR. 3. Verified with the SDC all medication observations and in-servicing of staff was completed with the exception of 2-3 weekend staff who would receive their training/testing prior to starting their shift. 4. Interview with the DON, on 08/06/14 at 7:27 PM, revealed daily audits were being conducted to ensure vital signs were obtained and documented correctly. She stated the audits would be conducted daily times four (4) weeks, then three (3) a week times four (4) weeks, then one (1) time a week times four (4) weeks, then every other week times four (4) weeks, then monthly times three (3). She revealed when a medication error was identified staff would conduct a root cause analysis. The DON stated they had audit tool to use to ensure all aspects were covered (MD notification, assessment of resident, immediate corrective action, systemic problems, etc.) She revealed it would be taken through the next QA meeting and talked about as a group.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure three (3) of twenty-one (21) sampled residents (Resident #2, Resident #3 and Resident #5) were free of significant medication errors. The facility failed to have an effective system in place to ensure medications were transcribed correctly on the Medication Administration Record (MAR) for Resident #2 and Resident #3 and failed to ensure a medication was discontinued on the MAR for Resident #5. On 03/21/14, Licensed Practical Nurse (LPN) #2 received an order for [REDACTED].#2, and transcribed the order on the March MAR leaving a previous order for [MEDICATION NAME] (anti-hypertensive) 40 milligrams (mg) daily on the MAR. When the May 2014 MARs were verified for accuracy; Resident #2's [MEDICATION NAME] 20 mg twice daily was transcribed onto Resident #3's MAR. This resulted in Resident #2 receiving [MEDICATION NAME] 40 mg daily from 05/01/14 through 05/17/14, and Resident #3 incorrectly received thirty-three (33) doses of [MEDICATION NAME] 20 mg from 05/01/14 to 05/17/14, resulting in a significant medication error. LPN #1 identified the significant medication error on 05/17/14; however, she failed to clarify the order for Resident #2's [MEDICATION NAME] with the physician which resulted in Resident #2 receiving 80 mg of [MEDICATION NAME] from 05/18/14 through 05/30/14. Additionally, the facility failed to conduct an investigation to determine how the [MEDICATION NAME] was obtained for Resident #3 when he did not have an order. Refer to F281, F309, F514 On 05/02/14, the facility received orders to discontinue Resident #5's [MEDICATION NAME] 10 mg every day order; however, the facility failed to ensure the medication was discontinued on the June, July, August and September 2014 MAR during the monthly checks. This resulted in Resident #5 receiving ninety-five doses of [MEDICATION NAME] between 06/01/14-09/03/14 which resulted in a significant medication error. Refer to F281. The facility's failure to ensure that residents were free from significant medication errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/30/14, and was determined to exist on 05/01/14. The facility was notified of the Immediate Jeopardy on 07/30/14. An acceptable Allegation of Compliance (AoC) was received on 08/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/06/14, as alleged. The Scope and Severity was lowered to a "E" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Even though 100% resident MAR to physician orders [REDACTED].#5) was found. Therefore, it was determined the Immediate Jeopardy was not removed on 08/06/14, as alleged. The facility conducted additional audits and training related to ensuring the residents' MARs were an accurate reflection of the current physician's orders [REDACTED]. The findings include: Review of the facility's "General Dose Preparation and Medication Administration" policy, last revised 01/01/13, revealed facility staff should verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Confirm that the MAR reflected the most recent medication order. Review of the facility's "Protocol for Checking MARs for the New Month", dated 07/30/14, revealed to check the new physician's orders [REDACTED]. [REDACTED]. [REDACTED]. 1. Record review revealed the facility admitted Resident #2 on 07/02/13 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the MAR, dated March 2014, revealed the order for [MEDICATION NAME] 40 mg daily was marked on the MAR as "changed", with the last dose initialed as administered on 03/21/14 at 8:00 AM. [MEDICATION NAME] 20 mg twice daily was transcribed on the MAR with the first dose initialed as administered on 03/21/14 at 8:00 PM. Review of the MAR, dated April 2014, revealed an order for [REDACTED]. Review of the MAR, dated (May 2014), revealed the [MEDICATION NAME] 40 mg once daily was not marked as changed but was initialed as administered from 05/01/14 through 05/31/14 and [MEDICATION NAME] 20 mg twice daily initialed as administered from 05/18/14 through 05/30/14. Phone interview with LPN #2, on 07/28/14 at 3:10 PM and on 07/29/14 at 10:40 AM, revealed she received the order from Physician #1 for [MEDICATION NAME] 20 mg twice daily on 03/21/14. She stated Resident #2 had been having an increase of blood pressure in the evening or the morning (she could not remember which one). Physician #1 ordered the divided dose of [MEDICATION NAME] as it would evenly distribute the medication throughout the day, as best she could remember. She stated if the previous order was replaced, it should have been discontinued. Interview with Physician #1, on 07/28/14 at 3:45 PM, and on 07/29/14 at 10:15 AM, revealed if he gave an order for [REDACTED]. He verified the maximum dose of [MEDICATION NAME] for an elderly resident was forty (40) mg daily. Physician #1 stated if a resident received eighty (80) mg daily, there was a potential to lower the resident's blood pressure too much, causing fatigue, dizziness, lightheadedness when standing, weakness, and an increased risk for falling. Interview with LPN #1, on 07/28/14 at 3:30 PM, revealed she identified the medication error involving Resident #2, on 05/17/14. She stated the resident's [MEDICATION NAME] 20 mg twice daily order was transcribed onto the wrong MAR. After the error was found, [MEDICATION NAME] 20 mg twice daily was transcribed to Resident #2's MAR; however, there had been no discontinue order for the [MEDICATION NAME] 40 mg daily. LPN #1 stated she "assumed" the resident was supposed to have both orders, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 20 mg twice daily. 2. Review of the "Medication Error" policy, revised 05/19/11, revealed the Director of Nursing (DON) would follow-up on all medication errors that have occurred. Review of the facility's "Medication Shortages/ Unavailable Medications" policy/procedure, revised 01/13/13, revealed if upon delivery the facility had an inadequate supply of medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from the pharmacy. Record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The [MEDICATION NAME] was initialed indicating it had been administered thirty-three (33) times from 05/01/14 through 05/17/14. Review of the physician's orders [REDACTED]. Further record review revealed there was no documented evidence the facility conducted a thorough investigation to identify how Resident #3 received thirty-three (33) doses of a medication without an order, and pharmacy did not deliver the medications. Phone interview with Certified Medication Aide (CMA) #7, on 07/29/14 at 3:10 PM, revealed she was a previous employee of the facility, her last day working at the facility was on 05/12/14. She stated she had administered medication to Resident #3 during May 2014. CMA #7 stated she "probably borrowed" the [MEDICATION NAME] from another resident and did not report it to the nurse. She stated staff was supposed to report missing medication to the nurse, who would then notify the pharmacy. Observation of the Facility's Emergency Drug Kit (EDK), on 09/02/14 at 3:00 PM revealed [MEDICATION NAME] 5 mg. times four (4) tablets was kept in the EDK. Review of the EDK Logs revealed the [MEDICATION NAME] tablets were not used during the timeframe Resident #2 and #3 were receiving the [MEDICATION NAME]. Interview with the Pharmacist in Charge, on 09/05/14 at 2:00 PM, revealed when monthly pharmacy reviews conducted they compare MARs to MARs. He stated they did not compare physician's orders [REDACTED]. He revealed the Pharmacy did not do a medication cart count until 08/04/14 and found no discrepancies at that time. He stated Resident #2's [MEDICATION NAME] 40 mg tablets were delivered but the pharmacy had never received the order for the [MEDICATION NAME] 20 mg. tablets. Phone interview with Physician #2, on 07/29/14 at 2:15 PM, revealed he was made aware Resident #3 received [MEDICATION NAME] 20 mg twice daily without an order. Physician #2 stated there was a potential for the resident to have a "lower" blood pressure than usual, [MEDICAL CONDITION], and an increased risk of falls. Interview with the Director of Nursing (DON), on 07/29/14 at 10:55 AM, 12:00 PM, 2:30 PM and, on 07/30/14 at 10:30 AM, revealed she was not aware Resident #2 had two (2)different [MEDICATION NAME] orders until 07/28/14. She stated it was expected for licensed staff to discontinue the previous order if an order change was received. The DON stated staff should have received clarification for the two (2) [MEDICATION NAME] orders, as common practice. The process for verifying accuracy of a resident's MAR each month included comparison from the resident's current physician's orders [REDACTED]. She verified the MARs were reviewed by one licensed staff, but not double checked. The DON verified LPN #2 was most likely the nurse reviewing the (May 2014) MAR for Resident #3. She stated the investigation of the medication error concluded that the order for [MEDICATION NAME] 20 mg twice daily was written on the wrong resident's MAR; she stated it was "human error". The DON stated both residents' physicians were notified. The DON's follow-up to the error included review of both resident's blood pressures later in the shift, which were normal. She stated there was no in-servicing conducted directly related to the medication error. She further stated the CMAs were not questioned about the [MEDICATION NAME] for Resident #3 until 07/30/14, at which time the CMAs verified they "borrowed" the medication from one (1) resident for another resident. She revealed staff was expected to check for the medication in the Emergency Drug Kit (EDK) and have the nurse call the pharmacy for timely delivery. Further interview with the Administrator, on 07/30/14 at 2:00 PM, revealed the medication error involving Resident #2 and Resident #3 was discussed in the Quality Assurance meeting, where it was determined LPN #2 had written an order on the wrong MAR. She stated it was discussed to have licensed staff "double check" the MAR for the right resident's name when reviewing at the end of the month. She stated there was no need for follow-up after the meeting on 05/20/14, as there was no change in either resident's condition. She revealed it was not discussed how Resident #3 received the [MEDICATION NAME], as "borrowing" medication had not happened in years. 3. Record review revealed the facility admitted Resident #5 on 02/05/13 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the May 2014 MAR revealed a [MEDICATION NAME] 10 mg every day order, dated 02/05/13, which was discontinued on 05/02/14. However, review of the June, July, August, and September 2014 MARs revealed the 02/05/13 [MEDICATION NAME] order remained on the MARS and the resident received [MEDICATION NAME] 10 mg for ninety-five (95) doses between 06/01/14 and 09/03/14 which resulted in a significant medication error. Interview, on 09/02/14 at 1:55 PM with the Medical Director/Resident #5's Primary Care Provider, revealed she discontinued the [MEDICATION NAME] 10 mg daily on 05/02/14 probably due to the resident's blood pressure being low and [MEDICAL CONDITION]. She stated she would have expected the resident's blood pressure to remain low if the medication continued and due to the resident's [MEDICAL CONDITION] she would not have restarted the medication as that could cause further renal compromise. Interview with the DON, on 09/02/14 at 11:15 AM, revealed she was aware the month end change-over of 08/31/14 and the MAR to medication cart audit conducted as part of the AoC did not reveal any discrepancies. Interview with the Clinical Care Coordinator (CCC), on 09/12/14 at 8:25 AM, revealed an audit was conducted on all resident MARs on 07/29/14 and a second audit was conducted on 08/04/14 as part of the facility's AoC to ensure accurate reflection of the physician's orders [REDACTED].#5's [MEDICATION NAME] 10 mg daily order remained on the MARs after the medication was discontinued. She stated Resident #5 received [MEDICATION NAME] 10 mg daily from 06/01/14 through 09/03/14 in error. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 07/31/14, the August MARs were audited to verify that residents who have medications for which vital signs should be obtained, have parameters listed and that the appropriate vital signs were being obtained. The August MARs were revised to clearly connect vital signs with medication administration. 2. Education was provided, on 07/30/14 to the Administrator, DON, CCC, SDC, Unit Managers, and MDS Nurses by the Regional Resource Team Nurse regarding proper administration techniques utilizing the "rights" of medication administration to prevent errors, need for obtaining blood pressure prior to administration of anti-hypertensive medication, need for assessment following identification of a medication error, need for accurate and consistent documentation of blood pressure reading prior to administration of anti-hypertensive medication. Licensed nurses and CMAs were educated on 07/30/14 by the SDC regarding obtaining a blood pressure before an anti-hypertensive medication was administered. If the blood pressure was outside the established parameters on the MAR, the CMA would notify the nurse, who would notify the physician. On 07/31/14, education was provided by the SDC to licensed staff and CMAs regarding accurate medication administration and obtaining vital signs as indicated by medication and as directed on the MAR. Nurses were educated on 07/31/14 by the SDC that a resident was to have a complete assessment each shift for a minimum of twenty-four hours after identification of a medication error. The assessment would be documented in the clinical record. 3. Training would be provided to all staff currently working and would continue with oncoming staff, prior to beginning duty, until completed by the SDC. 4. The MARs would be audited to verify vital signs that were indicated prior to medication administration have been recorded. The audits would be completed daily for four weeks, then three times per week for four weeks, then one week for four weeks, then every other week for four weeks, then monthly for three months. When a medication error was identified, the record would be reviewed to validate that the root cause of the error was identified and an assessment of the condition impacted by the involved error was conducted. The monitoring would continue for three months. If no concerns, medication errors would be reviewed by the DON or CCC and reported to the QAA monthly. The Regional Director of Operations would review the quality assurance records of medication errors monthly for three months. After the State Survey Agency identified the facility failed to remove the Jeopardy on 08/06/14, the facility implemented the following actions: 5. Resident #5's physician was notified and an order was obtained to discontinue the medication. The resident was assessed by the nurse, with her findings noted in the clinical record. The assessment was repeated each shift for the next twenty-four (24) hours then daily for the next two (2) days. No adverse effects were identified. All the resident's blood pressure obtained during the time the resident was receiving the medication were within the physician's parameters for administration. 6. The facility revised the process for the handling of medication discontinue orders to include the placement of a "Discontinue" sticker on the medication cards containing the remainder of the medication and remove that medication from the medication cart at that time. The facility conducted an additional one-hundred percent (100%) resident record review audit on 09/05/14 through 09/07/14; which included Physician Telephone Orders and MAR/TAR from 04/01/14 through 09/07/14 which revealed no errors related to transcription, communication with the pharmacy or removal of discontinued medications and no further medication order to MAR discrepancies. A re-audit was conducted by the Director of Nursing (DON), Clinical Care Coordinator (CCC), Staff Development Coordinator (SDC), Unit Managers (UM), Regional Quality Control Specialist (RQMS), and Minimum Data Set (MDS) Coordinator, utilizing the services of outside Registered Nurses (RNs) with known performance credentials, on 09/05/14 through 09/07/14 of all the residents' records which included; the Physician Orders, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) and Telephone Physician order [REDACTED]. 7. The facility conducted re-education and in-servicing on 09/04/14 with all licensed staff related to the discontinuation of medications. The education included; write the order for the discontinued medication,make the correction on the MAR, pull medication from medication cart, scan the barcode for return, place "discontinued" stickers on each of the discontinued medication cards, and place the medication in the tote to be returned to the Pharmacy or if the medication was a controlled substance secure for destruction. 8. The Regional Resource Team Nurse and the DON educated and in-serviced the licensed nurses and CMAs on 09/05/14 related to the facility's policy for the removal and disposal of narcotic patches by two (2) licensed nurses and that the CMAs should not dispose of the narcotic patches. 9. The facility reviewed and revised the medication administration schedule on the MAR for all residents; a revised administration time schedule was noted for daily routine medications and the special administration times (before breakfast, before meals, after meals, or with food) were noted and located on the MAR in a specific group for each type, the as needed (PRN) medications will be kept separated from the routine and special schedule medications. Nurses were monitored during medication administration on 09/07/14 and is ongoing; the DON, SDC, UM and CCC ensured the observations will continue to include; observations of appropriate technique, including securing medications when the cart is unattended, proper storage of supplies, administering medications as ordered and scheduled in the appropriate time frame, and is an ongoing Quality Control process. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility documentation revealed each resident's August MAR was reviewed for accuracy, reflecting the resident's current orders 07/31/14, with all blood pressure parameters listed on the MARs. 2. Review of the in-service form, dated 07/30/14, revealed administrative staff was in-serviced on the rights of medication, anti-hypertensive medications, and medication errors/resident assessment. Review of the in-service form, dated 07/31/14, revealed the administrative team was educated on root cause analysis. Review of the in-service form dated 07/31/14, revealed licensed nurses and CMAs were in-serviced on the "rights" of medication administration, medication errors/assessment of the resident, blood pressures obtained prior to administration of anti-hypertensive medications, and what to do if the blood pressure was outside the written parameters. Interviews with RN #1, LPN #2, LPN #3, and LPN #4, on 08/06/14 at 3:40 PM, 5:05 PM, 4:55 PM, and 5:30 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, obtaining blood pressures before administering anti-hypertensive medications, identification of medication errors and assessment of the resident afterwards. Interviews with CMA #10, CMA #4, and CMA #3 on 08/06/14 at 4:25 PM, 5:15 PM, and 5:45 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, obtaining blood pressures before administering anti-hypertensive medications, and documenting them on the MAR. 3. Verified with the SDC all medication observations and in-servicing of staff was completed with the exception of 2-3 weekend staff who would receive their training/testing prior to starting their shift. 4. Interview with the DON, on 08/06/14 at 7:27 PM, revealed daily audits were being conducted to ensure vital signs were obtained and documented correctly. She stated the audits would be conducted daily times four (4) weeks, then three (3) a week times four (4) weeks, then one (1) time a week times four (4) weeks, then every other week times four (4) weeks, then monthly times three (3). She revealed when a medication error was identified staff would conduct a root cause analysis. The DON stated they had audit tool to use to ensure all aspects were covered (MD notification, assessment of resident, immediate corrective action, systemic problems, etc.) She revealed it would be taken through the next QA meeting and talked about as a group. 5. Review on 09/12/14 of Resident #5's September MAR and physician's orders [REDACTED]. Review of a Nursing Assessments revealed the resident was assessed each shift for twenty-four hours then daily for two days. 6. Observation of the medication room, on 09/12/14 at 8:15 AM, revealed a medication box designated for medications to be sent back to the pharmacy containing a medication card with a "Discontinued" sticker attached below the resident's identifying information, a roll of stickers imprinted "Discontinued", and a copy of the Staff Development Attendance Record dated 09/04/14 for education on writing medication orders, affixing the sticker to discontinued medications, removal of discontinued medications from the medication carts, and the designated location to place the medications for return to the pharmacy. Review of facility audit reports, dated 09/05-07/14, revealed audits were conducted to ensure the MARs only contained current physician orders [REDACTED]. 7. Observation of a medication pass conducted on 09/12/14 beginning at 8:25 AM, on halls one-hundred (100), two-hundred (200) and three-hundred (300) respectively revealed no medication errors. Review of the in-service records, dated 09/04/14 and signed by all licensed staff and CMAs, education was provided related to discontinuation of medications. Interviews on 09/12/14 with RN #1 at 9:35 AM, RN #2 at 1:00 PM, LPN #1 at 2:30 PM, LPN #2 2:45 PM, and UM #1 at 3:00 PM, revealed they were in-serviced related to the actions to take when a medication was discontinued. 8. Review of inservice records dated 09/05/14, revealed the RQMS and the DON provided all licensed staff and CMAs education on "Destroying Narcotics including [MEDICATION NAME] Patches". Interviews on 09/12/14 with RN #1 at 9:35 AM, RN #2 at 1:00 PM, LPN #1 at 2:30 PM, LPN #2 2:45 PM, and UM #1 at 3:00 PM revealed the CMAs no longer removed or disposed of the pain patches only the licensed nurses do that now, that they were provided education related to the policy of two (2) licensed nurses witnessing the removal and disposal of the pain patches. Review of the MARs of Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10 revealed two (2) licensed nurses initials as witnesses to the removal and disposal of the pain patches. Interview with the DON and Administrator, on 09/12/14 at 9:00 AM revealed both were provided education by the Regional Resource Team Nurse on 09/05/14 and they in turn provided re-education and testing for all licensed nurses and CMA's starting on 09/06/14 related to the confirmation that two (2) licensed nurses removed patches and signed as witnesses of disposal. 9. Observation of a medication pass on all three halls, on 09/12/14 at 7:12 AM, which included the administration of oral, inhaled, topical eye drops, and insulin injection which no medication errors identified.

Based on interview and review of the facility's Administrator's Job Description, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to investigate to determine how medication was obtained to administer without a physician's orders [REDACTED].#2, Resident #3 and Resident #5). On 05/17/14, the facility identified an order for [REDACTED]. The facility determined that during the May 2014 review of the Medication Administration Records (MARs) for accuracy, Resident #2's order for [MEDICATION NAME] 20 mg twice daily was transcribed onto the MAR for Resident #3. The order was discontinued; however, the facility failed to investigate and determine how the staff obtained the medication for administration. Resident #3 received thirty-three (33) doses of [MEDICATION NAME] 20 mg, in error, without a physician's orders [REDACTED]. (Refer to F333). On 05/02/14, the facility received a physician's orders [REDACTED].#5's [MEDICATION NAME] 10 mg every day order. The medication was discontinued on the May 2014 MAR, however, the facility failed to ensure the medication was discontinued on the June, July, August and September 2014 MAR. Resident #5 received ninety-five (95) doses of [MEDICATION NAME] 10 mg, in error, without a physician's orders [REDACTED]. The facility's failure to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/30/14, and was determined to exist on 05/01/14. The facility was notified of the Immediate Jeopardy on 07/30/14. An acceptable Allegation of Compliance (AoC) was received on 08/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/06/14, as alleged. The Scope and Severity was lowered to a "E" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The facility conducted 100% resident MAR to physician orders [REDACTED].#5 was receiving hypertension medication that had been discontinued in May 2014. Therefore, it was determined the Immediate Jeopardy was not removed on 08/06/14, as alleged. The facility conducted additional audits and training related to ensuring the residents' MARs were an accurate reflection of the current physician's orders [REDACTED]. The findings include: Review of the Facility Administrator's Job Description, undated, revealed the job summary included the oversight of patient/resident care, managing overall operation, employee management, fiscal management, and ensuring compliance with State and Federal regulations. Job responsibilities included to review, monitor, and follow-up on incident reports, adverse incidents, resident grievances, and deficiencies cited by the agency. Develop plans of action to correct and respond to identified quality and risk issues. 1. Interview and record review revealed during the May 2014 MAR review staff transcribed Resident #2's [MEDICATION NAME] 20 mg order onto Resident #3's MAR. Resident #3 received thirty-three (33) doses of [MEDICATION NAME] 20 mg without a physician's orders [REDACTED]. 2. Interview and record review revealed the facility received an order to discontinue Resident #5's [MEDICATION NAME] 10 mg every day order on 05/02/14. The facility failed to ensure the order was discontinued on the June, July, August and September MARs which resulted in Resident #5 receiving ninety-five (95) doses between 06/01/14 through 09/03/14. The facility conducted audits on 07/29/14 and 08/04/14 to ensure accurate reflection of the current physician's orders [REDACTED]. Interview with the Administrator, on 07/30/14 at 2:00 PM, revealed the medication error involving Resident #2 and Resident #3 was discussed in the Quality Assurance meeting, on 05/20/14, where it was determined LPN #2 had written an order on the wrong MAR. She revealed it was discussed to have licensed staff "double check" the MAR for the right resident name when reviewing at the end of the month. She revealed there was no need for follow-up after the meeting on 05/20/14, as there was no change in either resident's condition. She stated it was not discussed how Resident #3 received the [MEDICATION NAME], as "borrowing" medication had not happened in years. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 07/31/14, the Regional Director of Operations educated the Administrator on utilizing the Abbreviated Quality Assurance processes, a review of the previous day's events, with focus on unusual events or deviation from normal. The process included audits of documents and departmental reports of activities and findings that may prompt the need for additional review, identify any weaknesses in processes as they relate to medication or other facility operations and systems. 2. The Administrator reviewed survey findings, identified medication error, findings of root cause analysis, and corrective measures to be implemented to remove immediate jeopardy and sustain compliance. A meeting with the Medical Director occurred 07/31/14. 3. The Regional Director of Operations would review the quality assurance records of medication errors monthly for three months. 4. Resident #5's physician was notified and an order was obtained to discontinue the medication. The resident was assessed by the nurse, with her findings noted in the clinical record. The assessment was repeated each shift for the next twenty-four (24) hours then daily for the next two (2) days. No adverse effects were identified. All the resident's blood pressure obtained during the time the resident was receiving the medication were within the physician's parameters for administration. 5. The facility revised the process for the handling of medication discontinue orders to include the placement of a "Discontinue" sticker on the medication cards containing the remainder of the medication and remove that medication from the medication cart at that time. The facility conducted an additional one-hundred percent (100%) resident record review audit on 09/05/14 through 09/07/14; which included Physician Telephone Orders and MAR/TAR from 04/01/14 through 09/07/14 which revealed no errors related to transcription, communication with the pharmacy or removal of discontinued medications and no further medication order to MAR discrepancies. A re-audit was conducted by the Director of Nursing (DON), Clinical Care Coordinator (CCC), Staff Development Coordinator (SDC), Unit Managers (UM), Regional Quality Control Specialist (RQMS), and Minimum Data Set (MDS) Coordinator, utilizing the services of outside Registered Nurses (RNs) with known performance credentials, on 09/05/14 through 09/07/14 of all the residents' records which included; the Physician Orders, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) and Telephone Physician order [REDACTED]. 6. The facility conducted re-education and in-servicing on 09/04/14 with all licensed staff related to the discontinuation of medications. The education included; write the order for the discontinued medication,make the correction on the MAR, pull medication from medication cart, scan the barcode for return, place "discontinued" stickers on each of the discontinued medication cards, and place the medication in the tote to be returned to the Pharmacy or if the medication was a controlled substance secure for destruction. 7. The Regional Resource Team Nurse and the DON educated and in-serviced the licensed nurses and CMAs on 09/05/14 related to the facility's policy for the removal and disposal of narcotic patches by two (2) licensed nurses and that the CMAs should not dispose of the narcotic patches. 8. The facility reviewed and revised the medication administration schedule on the MAR for all residents; a revised administration time schedule was noted for daily routine medications and the special administration times (before breakfast, before meals, after meals, or with food) were noted and located on the MAR in a specific group for each type, the as needed (PRN) medications will be kept separated from the routine and special schedule medications. Nurses were monitored during medication administration on 09/07/14 and is ongoing; the DON, SDC, UM and CCC ensured the observations will continue to include; observations of appropriate technique, including securing medications when the cart is unattended, proper storage of supplies, administering medications as ordered and scheduled in the appropriate time frame, and is an ongoing Quality Control process. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with the Administrator, on 08/06/14 at 7:45 PM, revealed she was in-serviced by the Risk Manager on the root cause analysis process of investigation, different quality issues, how to ensure the well-being of residents, training on medications, the "rights" of medications, monitoring through the QAA, and discussing medication errors in the daily QA meeting. Interview with the Regional Director of Operations, on 08/06/14 at 7:50 PM, revealed she inserviced the Administrator about how to utilize internal systems on how to monitor system errors, problems that were identified- to use the root cause analysis, how to utilize the audits integrated into our QA process, red flags that might need follow up, putting systems in place and monitoring. Review of the QA Committee Minutes, dated 07/31/14 revealed the Medical Director was present for the QA committee meeting and the IJ was explained and the process to remove IJ was discussed. 2. Interview with the Administrator, on 08/06/14 at 7:45 PM, revealed the MAR/TARs were to be audited every month times three months until 100% compliance was achieved. Vital sign audits will be conducted by the DON and CCC daily for four (4) weeks, then less often per schedule. If any problems are identified it will be addressed in QA. He stated medication errors will be reviewed in daily QA meetings and they will look at what caused it, who was involved, then ask the "why" questions. 3. Interview with the Regional Director of Operations, on 08/06/14 at 7:50 PM, revealed she will monitor medication error reports for three (3) months and tools we use to gather information (to look for potential things that may have been missed). 4. Review on 09/12/14 of Resident #5's September MAR and physician's orders [REDACTED]. Review of a Nursing Assessments revealed the resident was assessed each shift for twenty-four hours then daily for two days. 5. Observation of the medication room, on 09/12/14 at 8:15 AM, revealed a medication box designated for medications to be sent back to the pharmacy containing a medication card with a "Discontinued" sticker attached below the resident's identifying information, a roll of stickers imprinted "Discontinued", and a copy of the Staff Development Attendance Record dated 09/04/14 for education on writing medication orders, affixing the sticker to discontinued medications, removal of discontinued medications from the medication carts, and the designated location to place the medications for return to the pharmacy. Review of facility audit reports, dated 09/05-07/14, revealed audits were conducted to ensure the MARs only contained current physician orders [REDACTED]. 6. Observation of a medication pass conducted on 09/12/14 beginning at 8:25 AM, on halls one-hundred (100), two-hundred (200) and three-hundred (300) respectively revealed no medication errors. Review of the in-service records, dated 09/04/14 and signed by all licensed staff and CMAs, education was provided related to discontinuation of medications. Interviews on 09/12/14 with RN #1 at 9:35 AM, RN #2 at 1:00 PM, LPN #1 at 2:30 PM, LPN #2 2:45 PM, and UM #1 at 3:00 PM, revealed they were in-serviced related to the actions to take when a medication was discontinued. 7. Review of inservice records dated 09/05/14, revealed the RQMS and the DON provided all licensed staff and CMAs education on "Destroying Narcotics including [MEDICATION NAME] Patches". Interviews on 09/12/14 with RN #1 at 9:35 AM, RN #2 at 1:00 PM, LPN #1 at 2:30 PM, LPN #2 2:45 PM, and UM #1 at 3:00 PM revealed the CMAs no longer removed or disposed of the pain patches only the licensed nurses do that now, that they were provided education related to the policy of two (2) licensed nurses witnessing the removal and disposal of the pain patches. Review of the MARs of Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10 revealed two (2) licensed nurses initials as witnesses to the removal and disposal of the pain patches. Interview with the DON and Administrator, on 09/12/14 at 9:00 AM revealed both were provided education by the Regional Resource Team Nurse on 09/05/14 and they in turn provided re-education and testing for all licensed nurses and CMA's starting on 09/06/14 related to the confirmation that two (2) licensed nurses removed patches and signed as witnesses of disposal. 8. Observation of a medication pass on all three halls, on 09/12/14 at 7:12 AM, which included the administration of oral, inhaled, topical eye drops, and insulin injection which no medication errors identified.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure clinical records were maintained on each resident in accordance with accepted professional standards and practices that were accurately documented for three (2) of five (5) sampled residents (Resident #2, Resident #3 and Resident #5). The facility failed to have an effective system in place to ensure medications were transcribed correctly on the Medication Administration Records (MARs). On 03/16/14, Resident #2 received an order for [REDACTED]. On 03/21/14, Licensed Practical Nurse (LPN) #2 transcribed a telephone order for Resident #2 for [MEDICATION NAME] 20 mg twice daily; the order did not include to discontinue the [MEDICATION NAME] 40 mg daily. However, LPN #2 indicated on the March 2014 MAR that the resident's [MEDICATION NAME] 40 mg daily had been changed, with the initiation of the [MEDICATION NAME] 20 mg twice daily. The same changes were made on the resident's April 2014 MAR. When the residents' MARs for May 2014 were verified for accuracy, Resident #2's [MEDICATION NAME] 20 mg twice daily was transcribed onto the MAR for Resident #3 in error. Resident #3 received thirty-three (33) doses of [MEDICATION NAME] 20 mg twice daily without a physician's order from 05/01/14 to 05/17/14. Resident #2 received [MEDICATION NAME] 40 mg daily from 05/01/14 through 05/17/14, since LPN #1 had placed the 20 mg [MEDICATION NAME] order on Resident #3's MAR. When LPN #1 identified the medication error on 05/17/14 she failed to clarify the order for Resident #2's [MEDICATION NAME], leaving both of the orders ([MEDICATION NAME] 40 mg daily and [MEDICATION NAME] 20 mg twice daily) on the resident's MAR which resulted in the resident receiving 80 mg of [MEDICATION NAME] from 05/18/14 through 05/30/14. (Refer to F281, F309, F333) On 05/02/14, Resident #5 received an order to discontinue his/her [MEDICATION NAME] 10 mg. every day order. The facility discontinued the order on the May 2014 MAR; however, failed to discontinue the order on the June, July, August and September 2014 MARs. Resident #5 received ninety-five doses of the [MEDICATION NAME] without a physician's order from 06/01/14 through 09/03/14. (Refer to F281, F333) The facility's failure to ensure that clinical records were maintained on each resident in accordance with accepted professional standards and practices that were accurately documented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/30/14, and was determined to exist on 05/01/14. The facility was notified of the Immediate Jeopardy on 07/30/14. An acceptable Allegation of Compliance (AoC) was received on 08/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/06/14, as alleged. The Scope and Severity was lowered to a "E" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Even though 100% resident MAR to physician orders audits were conducted on 07/29/14 and 08/04/14 to ensure accurate reflection of the current physician's orders as part of the facility's AoC; another example (Resident #5) was found. Therefore, it was determined the Immediate Jeopardy was not removed on 08/06/14, as alleged. The facility conducted additional audits and training related to ensuring the residents' MARs were an accurate reflection of the current physician's orders. After validation of the facility's actions, the State Survey Agency determined the Immediate Jeopardy was removed on 09/09/14. The findings include: Review of the facility's "Documentation Standards" policy/procedure, last revised 01/02/14, revealed prior to documenting, always check the identifying information to verify and authenticate it as the correct medical record for charting. Review of the facility's "Physician's Orders" policy/procedure, last revised 06/28/11, revealed physician's orders would be transcribed, noted, and implemented in a timely manner. 1. Record review revealed the facility admitted Resident #2 on 07/02/13 with [DIAGNOSES REDACTED]. Review of the Physician's Orders, dated 03/16/14, revealed an order for [REDACTED]. Further review revealed a Physician's Order, dated 03/21/14, for [MEDICATION NAME] 20 mg twice daily for Hypertension. Review of the MAR, dated March 2014, revealed the order for [MEDICATION NAME] 40 mg daily was marked on the MAR as "changed", with the last dose initialed as administered on 03/21/14 at 8:00 AM. [MEDICATION NAME] 20 mg twice daily was transcribed on the MAR with the first dose initialed as administered on 03/21/14 at 8:00 PM. Review of the MAR, dated April 2014, revealed an order for [REDACTED]. However, review of the MAR, dated May 2014, revealed the [MEDICATION NAME] 40 mg once daily was initialed as administered from 05/01/14 through 05/31/14 with [MEDICATION NAME] 20 mg twice daily initialed as administered, starting 05/18/14 through 05/30/14. Phone interview with LPN #2, on 07/28/14 at 3:10 PM; and, on 07/29/14 at 10:40 AM, revealed she received the order from Physician #1 for [MEDICATION NAME] 20 mg twice daily on 03/21/14. She revealed if the previous order was replaced, it should have been discontinued. Interview with Physician #1, on 07/28/14 at 3:45 PM and on 07/29/14 at 10:15 AM, revealed if he gave an order for [REDACTED]. Interview with LPN #1, on 07/28/14 at 3:30 PM, revealed she identified the medication error involving Resident #2, on 05/17/14. She stated the resident's [MEDICATION NAME] 20 mg twice daily order was transcribed on the wrong MAR (Resident #3's). After the error was found, [MEDICATION NAME] 20 mg twice daily was transcribed onto Resident #2's MAR; however, there had been no discontinue order for the [MEDICATION NAME] 40 mg daily. She "assumed" the resident was supposed to have both orders ([MEDICATION NAME] 40 mg and [MEDICATION NAME] 20 mg twice daily). 2. Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [MEDICATION NAME] was initialed as administered thirty-three (33) times from 05/01/14 through 05/17/14; however, review of the Physician's Orders, dated May 2014, revealed no order for [MEDICATION NAME]. Interview with the Director of Nursing (DON), on 07/29/14 at 10:55 AM, 12:00 PM, and 2:30 PM; and, on 07/30/14 at 10:30 AM, revealed it was expected for licensed staff to discontinue the previous order if an order change was received. She stated staff should have received clarification for the two (2) [MEDICATION NAME] orders for Resident #2, as common practice. The process for verifying accuracy of a resident's MAR each month included comparison from the resident's current Physician's Orders with the resident's new MAR. The DON stated the MARs were reviewed by one licensed staff, but not double checked by another licensed staff member. The DON verified LPN #2 was most likely the nurse reviewing the May 2014 MAR for Resident #3. Further interview with the DON revealed the investigation of the medication error involving both Resident #2 and Resident #3 concluded the order for [MEDICATION NAME] 20 mg twice daily was written on the wrong resident's MAR, it was "human error." 3. Record review revealed the facility admitted Resident #5 on 02/05/13 with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated 05/02/14 at 5:35 PM, revealed an order to discontinue the [MEDICATION NAME]. Review of the May 2014 MAR revealed the order was discontinued. However, review of the June, July, August, and September 2014 MARs revealed the [MEDICATION NAME] 10 mg. order remained on the MARs and had not been discontinued. Resident #5 received ninety-five (95) doses of [MEDICATION NAME] without a physician's order from 06/01/14 and 09/03/14. Interview with the Clinical Care Coordinator, on 09/12/14 at 8:25 AM, revealed an audit was conducted on all resident MARs on 07/29/14 and a second audit was conducted on 08/04/14 as part of the facility's AoC to ensure accurate reflection of the physician's orders on the MAR; however, staff failed to identify Resident #5's [MEDICATION NAME] 10 mg daily order remained on the MARs with no physician's order. She stated Resident #5 received [MEDICATION NAME] 10 mg daily from 06/01/14 through 09/03/14 in error. Interview on 09/02/14 at 1:55 PM with the Medical Director, who was also Resident #5's Primary Care Provider, revealed she stopped the [MEDICATION NAME] 10 mg daily on 05/02/14 probably due to his/her B/P being low and [MEDICAL CONDITION]. Further interview revealed she would have expected the resident's B/P to remain low when the medication was continued, and due to the resident's [MEDICAL CONDITION] she would not have restarted the medication at all as that could cause further renal compromise. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 07/29/14, all resident Medication Administration Records (MARs) were audited by the Director of Nursing (DON) Clinical Care Coordinator (CCC), Staff Development Coordinator (SDC), Regional Quality Management Nurse, Unit Managers and Minimum Data Set (MDS) Coordinators to ensure accurate reflection of the current physician's orders. A second audit was conducted, on 08/04/14, by the DON and the Regional Quality Management Nurse. After the audit, the facility implemented a revised process for faxing telephone orders to the pharmacy. Education was provided to licensed staff beginning on 08/04/14 by the SDC of the new process, which included the attachment of the fax verification to the telephone order. The Clinical Care Coordinator (CCC) or the weekend monitor would verify the fax confirmation was present for all new orders. 2. The end of the month procedure for reviewing MARs was modified to designate one specific nurse to be removed from additional duties other than MAR revision at the end of the month. The nurse was designated as the "Order Validation Nurse." That nurse was trained by the SDC, on 07/31/14, on the process of comparing the previous month's orders and subsequent telephone orders to ensure new orders contained all changes that occurred since the previous month began. The new orders would be utilized to verify that the MARs accurately reflected those orders. On the last day of the month, prior to utilization, the night nurse would compare the new MAR which had been checked against the new orders to the MAR currently being utilized. 3. The process for reviewing new orders was revised to include the CCC validating accurate transcription of new orders on the correct MAR on weekdays. The night shift nurse would validate on the weekends and holidays. The DON would assign responsibility or complete the reviews in the absence of the CCC. The process included implementation of a task list to utilize when reviewing orders to guide the reviewer through the process. 4. On 07/31/14, the August MARs were audited by the DON, CCC and Unit Managers to verify that residents who have medications for which vital signs should be obtained, have parameters listed and that the appropriate vital signs were being obtained. The August MARs were revised to clearly connect vital signs with medication administration. 5. Education was provided, on 07/30/14 to the Administrator, DON, CCC, SDC, Unit Managers, and MDS Nurses by the Regional Resource Team Nurse regarding proper administration techniques utilizing the "rights" of medication administration to prevent errors, accuracy of transcribing medications, correct process for month end transcription and validation of physician's orders and MARs, need for obtaining blood pressure prior to administration of anti-hypertensive medication, need for assessment following identification of a medication error, need for accurate and consistent documentation of blood pressure reading prior to administration of anti-hypertensive medication, administration of medication, transcription of orders and assessment findings. 6. Licensed nurses and Certified Medication Aides (CMAs) were educated on 07/30/14 by the SDC regarding obtaining a blood pressure before an anti-hypertensive medication was administered. If the blood pressure was outside the established parameters on the MAR, the CMA would notify the nurse, who would notify the physician. On 07/31/14, education was provided to the Licensed Nurses and CMTs by the SDC that the interventions for residents receiving anti-hypertension medications would be located in the MAR and were to be followed. Training would be provided to all staff currently working and would continue with oncoming staff, prior to beginning duty, until completed by the SDC. 7. On 07/31/14, education was provided by the SDC to licensed staff and CMAs regarding accurate medication administration, obtaining vital signs as indicated by medication and as directed on the MAR, and the prohibition of borrowing medication from another resident. If a medication was not available, the pharmacy should be contacted regarding the medication. The physician should be notified for clarification if there were any discrepancies. Education was provided to licensed nurses by the SDC on 07/31/14 regarding accurate transcription of telephone orders onto the MAR. The education included to read back the order to the prescriber to ensure the initial order reflects his/her verbal order correctly, transcribe the order onto the correct MAR, clearly discontinue existing orders that may be stopped or modified due to the new order. Training would be provided to all staff currently working and would continue with oncoming staff, prior to beginning duty, until completed by the SDC. 8. Audits would be initiated to verify accuracy of transcription to new month's orders and MARs. One-hundred percent (100%) would be reviewed for three months. Findings would be reviewed by the Quality Assurance and Assessment Committee (QAA). If no significant transcription error was identified, the committee may reduce the sample size to fifty percent (50%) for the next three months. 9. The MARs would be audited by the Unit Charge Nurse, CCC, MDS Coordinator or the DON to verify vital signs that were indicated prior to medication administration have been recorded. The audits would be completed daily for four weeks, then three times per week for four weeks, then one week for four weeks, then every other week for four weeks, then monthly for three months. When a medication error was identified, the record would be reviewed to validate that the root cause of the error was identified and an assessment of the condition impacted by the involved error was conducted. The monitoring would continue for three months. If no concerns, medication errors would be reviewed by the DON or CCC and reported to the QAA monthly. 10. Resident #5's physician was notified and an order was obtained to discontinue the medication. The resident was assessed by the nurse, with her findings noted in the clinical record. The assessment was repeated each shift for the next twenty-four (24) hours then daily for the next two (2) days. No adverse effects were identified. All the resident's blood pressure obtained during the time the resident was receiving the medication were within the physician's parameters for administration. 11. The facility revised the process for the handling of medication discontinue orders to include the placement of a "Discontinue" sticker on the medication cards containing the remainder of the medication and remove that medication from the medication cart at that time. The facility conducted an additional one-hundred percent (100%) resident record review audit on 09/05/14 through 09/07/14; which included Physician Telephone Orders and MAR/TAR from 04/01/14 through 09/07/14 which revealed no errors related to transcription, communication with the pharmacy or removal of discontinued medications and no further medication order to MAR discrepancies. A re-audit was conducted by the Director of Nursing (DON), Clinical Care Coordinator (CCC), Staff Development Coordinator (SDC), Unit Managers (UM), Regional Quality Control Specialist (RQMS), and Minimum Data Set (MDS) Coordinator, utilizing the services of outside Registered Nurses (RNs) with known performance credentials, on 09/05/14 through 09/07/14 of all the residents' records which included; the Physician Orders, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) and Telephone Physician Orders dating from 04/01/14 to 09/07/14 to identify problems associated with order transcription and/or communication with the Pharmacy. 12. The facility conducted re-education and in-servicing on 09/04/14 with all licensed staff related to the discontinuation of medications. The education included; write the order for the discontinued medication,make the correction on the MAR, pull medication from medication cart, scan the barcode for return, place "discontinued" stickers on each of the discontinued medication cards, and place the medication in the tote to be returned to the Pharmacy or if the medication was a controlled substance secure for destruction. 13. The Regional Resource Team Nurse and the DON educated and in-serviced the licensed nurses and CMAs on 09/05/14 related to the facility's policy for the removal and disposal of narcotic patches by two (2) licensed nurses and that the CMAs should not dispose of the narcotic patches. 14. The facility reviewed and revised the medication administration schedule on the MAR for all residents; a revised administration time schedule was noted for daily routine medications and the special administration times (before breakfast, before meals, after meals, or with food) were noted and located on the MAR in a specific group for each type, the as needed (PRN) medications will be kept separated from the routine and special schedule medications. Nurses were monitored during medication administration on 09/07/14 and is ongoing; the DON, SDC, UM and CCC ensured the observations will continue to include; observations of appropriate technique, including securing medications when the cart is unattended, proper storage of supplies, administering medications as ordered and scheduled in the appropriate time frame, and is an ongoing Quality Control process. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility documentation revealed each resident's August MAR was reviewed for accuracy, reflecting the resident's current orders 07/31/14, with all blood pressure parameters listed on the MARs. Review of an inservice record, dated 08/04/14, revealed licensed staff was inserviced on the new process related to attaching a copy of fax confirmation to the physician's order. 2. Interview with the Order Validation Nurse, on 08/06/14 at 4:55 PM, revealed she was the "order validation nurse". She stated she checked the MARs the last month and the SDC in-serviced her on checking the new physician orders against the old ones, any telephone orders brought forward (ensure on the new orders), check the new orders against the new MAR/TAR, then compare them to the old MAR/TAR. She revealed if she identifies a discrepancy, she checked the chart to see how the order was written. If there is a med error, she assessed the resident, and called the Physician and the DON. She stated she conducts a full head to toe assessment, fills out the error report, documents on the twenty-four (24) hour report to follow up assessment with vitals a minimum every twenty-four (24) hours (document assessments in the chart). She stated if she has a question about a medication she clarifies it with the physician. 3. Interview with the CCC, on 08/06/14 at 6:45 PM, revealed she receives the written orders Monday-Friday, then sorts them out by Wings. She stated she ensures all orders are written on the MAR correctly. She revealed she has a form to type out each resident's name with the new order and there was a check list to ensure all criteria was met and the orders were transcribed accurately. She stated the new order checklist had been in effect, but now she initials the orders after she has checked them. She stated the night nurse on the weekends checks to ensure accurate transcription on the weekends, then on Monday, she checks behind them to make sure nothing was missed. 4. Interviews conducted on 08/06/14 with Unit Manager (UM) #1 at 2:40 PM, UM #2 at 5:20 PM and the DON at 7:27 PM revealed they conducted audits of MARs to physician orders on 07/31/14. They stated they compared the newest physician orders to the old ones (July/August). In addition, they compared the new physician orders with the new MAR, then July MAR to August MAR. They stated they made sure the blood pressure and pulse parameters were in place. 5. Review of the in-service form, dated 07/30/14, revealed administrative staff was in-serviced on the rights of medication, receiving new orders/transcription, end of the month MAR review, medication administration, anti-hypertensive medications, and medication errors. Review of the in-service form, dated 07/31/14, revealed the administrative team was educated on root cause analysis. 6. Review of the in-service forms dated 07/30/14 and 07/31/14, revealed licensed nurses and CMAs were in-serviced on the "rights" of medication administration, unavailable medications, borrowing medication, medication errors/assessment of the resident, blood pressures obtained prior to administration of anti-hypertensive medications, what to do if the blood pressure was outside the written parameters, and care plans. Licensed Nurses were also educated on the accurate transcription of telephone orders on the MAR. 7. Review of the in-service forms dated 07/30/14 and 07/31/14, revealed licensed nurses and CMAs were in-serviced on the "rights" of medication administration, unavailable medications, borrowing medication, medication errors/assessment of the resident, blood pressures obtained prior to administration of anti-hypertensive medications, what to do if the blood pressure was outside the written parameters, and care plans. Licensed Nurses were also educated on the accurate transcription of telephone orders on the MAR. Interviews with RN #1, LPN #2, LPN #3, and LPN #4, on 08/06/14 at 3:40 PM, 5:05 PM, 4:55 PM, and 5:30 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, receiving new orders/transcription of new orders, end of the month MAR review, obtaining blood pressures before administering anti-hypertensive medications, identification of medication errors and assessment of the resident afterwards, and care plans. Interviews with CMA #10, CMA #4, and CMA #3 on 08/06/14 at 4:25 PM, 5:15 PM, and 5:45 PM, respectively, revealed they were in-serviced related to the "rights" of medication administration, not borrowing medication for a resident, obtaining blood pressures before administering anti-hypertensive medications, and care plans. Verified with the SDC all medication observations and in-servicing of staff were completed with the exception of 2-3 weekend staff who would receive their training/testing prior to starting their shift. 8./9. Interview with the DON, on 08/06/14 at 7:27 PM, revealed daily audits were being conducted to ensure vital signs were obtained and documented correctly. She stated the audits will be conducted daily times four (4) weeks, then three (3) a week times four (4) weeks, then one (1) time a week times four (4) weeks, then every other week times four (4) weeks, then monthly times three (3). She revealed when a medication error was identified staff would conduct a root cause analysis. We have audit tool to use to ensure all aspects are covered (MD notification, assessment of resident, immediate corrective action, systemic problems, etc.) She revealed it would be taken through the next QA meeting and talked about as a group. 10. Review on 09/12/14 of Resident #5's September MAR and Physician's Orders revealed the [MEDICATION NAME] order was discontinued. Review of a Nursing Assessments revealed the resident was assessed each shift for twenty-four hours then daily for two days. 11. Observation of the medication room, on 09/12/14 at 8:15 AM, revealed a medication box designated for medications to be sent back to the pharmacy containing a medication card with a "Discontinued" sticker attached below the resident's identifying information, a roll of stickers imprinted "Discontinued", and a copy of the Staff Development Attendance Record dated 09/04/14 for education on writing medication orders, affixing the sticker to discontinued medications, removal of discontinued medications from the medication carts, and the designated location to place the medications for return to the pharmacy. Review of facility audit reports, dated 09/05-07/14, revealed audits were conducted to ensure the MARs only contained current physician orders and discontinued medications were removed from the cart. 12. Observation of a medication pass conducted on 09/12/14 beginning at 8:25 AM, on halls one-hundred (100), two-hundred (200) and three-hundred (300) respectively revealed no medication errors. Review of the in-service records, dated 09/04/14 and signed by all licensed staff and CMAs, education was provided related to discontinuation of medications. Interviews on 09/12/14 with RN #1 at 9:35 AM, RN #2 at 1:00 PM, LPN #1 at 2:30 PM, LPN #2 2:45 PM, and UM #1 at 3:00 PM, revealed they were in-serviced related to the actions to take when a medication was discontinued. 13. Review of inservice records dated 09/05/14, revealed the Regional Quality Supervisor (QMS) and the DON provided all licensed staff and CMAs education on "Destroying Narcotics including [MEDICATION NAME] Patches". Interviews on 09/12/14 with RN #1 at 9:35 AM, RN #2 at 1:00 PM, LPN #1 at 2:30 PM, LPN #2 2:45 PM, and UM #1 at 3:00 PM revealed the CMAs no longer removed or disposed of the pain patches only the licensed nurses do that now, that they were provided education related to the policy of two (2) licensed nurses witnessing the removal and disposal of the pain patches. Review of the MARs of Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10 revealed two (2) licensed nurses initials as witnesses to the removal and disposal of the pain patches. Interview with the DON and Administrator, on 09/12/14 at 9:00 AM revealed both were provided education by the Regional Resource Team Nurse on 09/05/14 and they in turn provided re-education and testing for all licensed nurses and CMA's starting on 09/06/14 related to the confirmation that two (2) licensed nurses removed patches and signed as witnesses of disposal. 14. Observation of a medication pass on all three halls, on 09/12/14 at 7:12 AM, which included the administration of oral, inhaled, topical eye drops, and insulin injection which no medication errors identified.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to implement their policy and procedure to prevent neglect for one resident (#1), in the selected sample of four residents. The facility assessed Resident #1 as at risk for falls and placed the resident on the Falling Star Program. Interviews with staff revealed the resident required extensive assistance, having poor sitting balance, stating the resident should not be left unattended. On [DATE], at approximately 2:00 AM, a PRN (as needed) dose of [MEDICATION NAME] (pain medication) was administered to Resident #1. At 4:00 AM, the staff assisted Resident #1 up to the side of the bed to a sitting position, then left him/her alone in the room, which resulted in Resident #1's fall from the bed to the floor. The resident sustained [REDACTED]. [MEDICAL CONDITION] was listed as the underlying cause of death on a certified copy of Resident #1's death certificate. Furthermore, the facility's investigation failed to identify neglect occurred which prevented the facility from initiating action to prevent future neglect. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F279, F323, F490, and F520) Findings include: A review of the facility's policy/procedure,"Alleged Abuse Reporting/Investigation," revised [DATE], revealed the facility defined neglect as a failure or omission on the part of the care giver to provide the care, supervision, and services necessary to maintain the physical and mental health of the disabled adult or elderly person, including, but not limited to providing food, clothing, medicine, shelter, supervision and medical services that a prudent person would consider essential for the well being of the disabled adult or elderly person. Neglect can also mean the failure of care givers to make a reasonable effort to protect a disabled adult or elderly person from abuse, neglect or exploitation by others. Neglect can be either repeated conduct or a single incident of carelessness which produces or could be reasonably expected to result in serious physical or psychological injury or a substantial risk of death. A review of the document, "Falling Star Program," undated, revealed the purpose was to promote recognition of residents who have been identified as being at risk for falls. Residents who were identified through the Falls Risk Analysis as being at risk for falls would be included in the Falling Star Program. Falling Star residents would have a large star placed beside their name plate outside their room. Upon a resident's transfer or room change, the designated staff member would remove or move the star to the appropriate room and the resident Falling Star Program would be reviewed quarterly. Staff was alerted to a resident being on the Falling Star Program with a green star by the resident's name outside their door. Residents on the Falling Star Program had alarms, floor mats, required assistance with bed mobility, transfer, ambulation and required two staff assistance at all times. A record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident also received [MEDICATION NAME] Therapy (a blood thinner). A review of the Falls Risk Analysis, dated [DATE], revealed the facility assessed the resident as high risk for falls related to having three or more falls in the past three months prior to admission to the facility. The document detailed the resident had balance problems, decreased muscular coordination, and was on four medications (Antihypertensive, Diuretic, Hypoglycemic, and a Narcotic), with side effects to include dizziness and unsteadiness. Predisposing factors for Resident #1 included Stroke, Fractures, Diabetes, and [MEDICAL CONDITION]. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as cognitively intact. He/she required extensive assistance of two staff for bed mobility, transfers, ambulation and toileting. A review of the Comprehensive Care Plan for "Falls," dated [DATE], revealed Resident #1 was at risk for falls related to weakness, clavicle fracture, and impaired mobility; however, there was no evidence the facility addressed the resident's condition related to balance, or the potential for dizziness and unsteadiness associated with his/her medication. An interview with the Unit Nurse (UN), Registered Nurse (RN) #1, on [DATE] at 10:20 AM, revealed, on [DATE], she completed Resident #1's admission assessment. She recalled the resident required much assistance. She stated the resident was weak and it was not safe for the resident to sit up alone on the side of his/her bed. Interviews with State Registered Nurse Aide (SRNA) #2, on [DATE] at 12:10 PM, SRNA#3, on [DATE] at 11:55 AM, SRNA #4, on [DATE] at 10:43 AM, SRNA #5, on [DATE] at 12:45 PM, SRNA #6, on [DATE] at 10:55 AM, and SRNA #7 on [DATE] at 10:00 AM, revealed Resident #1 had periods of weakness and was only able to maintain balance while sitting on the side of the bed for a maximum of ten minutes with assistance because the resident swayed and was "wobbly." Each of the SRNA interviews revealed it was not safe to leave Resident#1 alone sitting on the side of the bed. An interview with SRNA #1, on [DATE] at 10:30 AM, revealed, on the morning of [DATE], at approximately 4:00 AM, Resident #1 requested to sit up on the side of his/her bed. She stated the resident was restless during the the night and was up and down. Often, he/she sat up on the side of the bed to dangle his/her legs when having leg cramps. She stated she assisted the resident to sit up in the bed, propped a pillow under his/her left arm, then left the room to go answer other call lights. She stated Resident #1 was able to brace himself/herself with the right hand while sitting on the side of the bed. There was a personal clip alarm attached to the right side of the resident's gown when she left the room. She stated she was in a room down the hall when she heard a loud noise, like a chair moving, and ran back down the hall to Resident #1's room to find the resident on the floor mat. Resident #1 was bleeding from his/her knees and from an area on his/her head. She stated the alarm did not sound. When she entered the room, the alarm was not attached to Resident #1. The alarm was on the left side of the bed attached to the alarm box. She stated the resident could have taken the alarm off. Further interview with SRNA #1, on [DATE] at 1:00 PM, revealed she was aware Resident #1 was on the Falling Star Program, which meant the resident was at high falls risk. She revealed she was alone while providing care for Resident #1 because SRNA #4, who was working with her that night, was down the hall answering lights. She stated she was aware Resident #1 was paralyzed on the left side, and required extensive assistance with all care. She stated Resident #1 would only want to sit up ,[DATE] minutes at a time, then would ask to lay back down. She stated she should not have left the resident alone sitting on the side of the bed, but it was a busy night and she "had to do what she had to do." Additional interview with SRNA #1, on [DATE] at 9:27 AM, revealed Resident #1 constantly asked for pain medication. She stated she let the nurse know that the resident requested medication for leg pain and the nurse gave pain medication to Resident #1 an hour prior to the fall. An interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:40 AM, revealed Resident #1 complained of leg cramps and [MEDICATION NAME] was administered for pain. She stated that the resident had frequent leg cramps, and the request was not unusual. She stated Resident #1 requested to sit up on the side of the bed due to his/her leg cramps, as he/she had requested to do so in the past. She stated the SRNA assisted the resident up on the side of the bed, then left the room to go check on another resident. The SRNA returned to Resident #1's room after hearing a noise and found the resident on the floor. LPN #1 stated she went back to the room and observed Resident #1 face down on the floor mat at the bedside. Resident #1 told LPN #1 that he/she lost his/her balance and fell forward onto the floor mat. She stated [MEDICATION NAME] was administered prior to the resident's fall and may have caused the resident to be "light-headed." She stated they should not have left the resident alone sitting up on the side of the bed. An interview with the attending Physician, on [DATE] at 9:10 AM, whose signature appeared on the certified copy of Resident #1's death certificate, revealed the [MEDICAL CONDITION] listed as the underlying cause of death on Resident #1's death certificate was the result of the fall the resident sustained [REDACTED].#1's death. An interview with the Administrator and the Director of Nursing (DON), on [DATE] at 3:00 PM, revealed Resident #1 was on the Falling Star Program which meant the resident was a high risk for falls and it should have been "common knowledge" that the resident should not be left sitting on the side of the bed. On [DATE], the Administrator stated no further investigation was conducted related to the resident's fall from the bed because the resident said he/she lost his/her balance and fell ; therefore, that was thought to be the cause of the fall. Any further investigation would only be completed if abuse, neglect or exploitation were involved. Thus the facility did not identify through their investigation that neglect had occurred as staff left a resident unsupervised who the facility assessed as requiring extensive assistance due to a "wobbly" balance, and at high risk for falls. This failure prevented the facility from taking action to prevent neglect recurrence. An acceptable Allegation of Compliance was received on [DATE] and detailed the following: All facility staff including the Nursing Assistants, Medication Aides, Administrative and Licensed Nurses, Administrator, Social Services, Activities, Dietary, Environmental Service, Housekeeping, and Laundry have been or will be re-educated on the facility's Abuse /Neglect policy by the Staff Development Coordinator and the Quality Management Specialist starting [DATE] and will continue with each oncoming shift until completed. Verification of removal of Immediate Jeopardy was completed as follows: The Quality Management Nurse trained the DON, Assistant Director of Nursing (ADON), and Staff Development, who educated licensed nurses in the process related to falls, falls prevention, supervision, conducting an investigation, interventions, implementing and updating the care plans, was initiated on [DATE] and verified by a sign-in sheet. Interview with RN #2, on [DATE] at 9:20 AM, revealed she was inserviced on falls and fall prevention, supervision, investigation, updating the care plan and abuse/neglect. Interviews with LPN #1 on [DATE] at 9:50 AM, LPN #2 on [DATE] at 9:10 AM, LPN #3 on [DATE] at 3:00 PM, and LPN #4 on [DATE] at 1:40 PM, revealed they were inserviced on falls and fall prevention, supervision, investigation, updating the care plan and abuse/neglect. Training on supervision was initiated on [DATE] by the Staff Development and verified by a sign-in sheet. Interviews with SRNA #7 on [DATE] at 1:15 PM, SRNA #8 on [DATE] at 2:07 PM, SRNA #9 on [DATE] at 1:35 PM, and SRNA #10 on [DATE] at 9:30 AM, revealed they were inserviced about not leaving the residents sitting on bed or toilet alone, unless they were independent. They were to keep dependent residents within arms' reach and to ensure all alarms were in place and in working order. Housekeeping, laundry and dietary staff was educated on [DATE], and was verified on [DATE], by a sign-in sheet and by interviews with Housekeeper #1, Dietary staff #1 and Dietary staff #2 on [DATE] at 1:50 PM, as well as the Beautician on [DATE] at 2:05 PM. A Falls Risk Analysis will be completed for all current residents by the Unit Managers, or other Licensed Nurse designee, and was verified by observation, on [DATE]. The analysis completed on all current residents, care plans and nurse aide data sheets were updated as indicated and verified. A Quality assurance and Assessment meeting was conducted, on [DATE], to validate that the analyses were complete and that the interventions based on the scores were added to the Interdisciplinary Care plans and the corresponding Nurse Aide Data Sheet. Verified by a sign-in sheet and observation of the updated Falls Analysis Forms and Care Plans on all residents in the facility on [DATE] . Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed , effective [DATE] , as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on interview, record review and review of the facility's policy and procedure, it was determined the facility failed to provide services to meet professional standards of quality for one resident (#1), in the selected sample of four residents, in accordance with care planning. The facility assessed Resident #1 as a falls risk, upon admission on [DATE], related to balance problems, decreased muscular coordination, receiving four medications (Antihypertensive, Diuretic, Hypoglycemic, and a Narcotic), which have side effects, to include dizziness and unsteadiness; however, these risk factors were not addressed in Resident #1's "Falls" Plan of Care. On [DATE], at approximately 2:00 AM, the facility administered a PRN (as needed) dose of [MEDICATION NAME] (pain medication) to Resident #1. At 4:00 AM, the staff assisted Resident #1 up to a sitting position on the side of the bed and left him/her alone without supervision. Resident #1 fell forward from the bed and sustained an [MEDICAL CONDITION] (bleeding within the skull). Resident #1 subsequently expired on [DATE]. [MEDICAL CONDITION] was listed as the underlying cause of death on a certified copy of Resident #1's death certificate. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F224, F323, F490, and F520) Findings include: A review of the facility's policy and procedure, "Comprehensive Care Plans," revised [DATE], revealed it was the facility's policy that residents would have a plan of care for assessed needs. A written plan of care would be initiated at the time of admission and would be incorporated into a comprehensive plan of care following the comprehensive assessment and Minimum Data Set (MDS) process. The care plan established would be individualized to the resident and their identified risk factors and problems. The care plan would be easily followed by designated staff members. The care plan would be accessible to staff and some interventions would be provided through methods such as the Nurse Aide Data Sheet, assignment sheet or other communication tools. An interview with Unit Nurse (UN), Registered Nurse (RN) #1, on [DATE] at 10:20 AM, revealed the admission assessment was completed within 24 hours of admission and the MDS staff formulated a care plan after the assessment was completed. An interview with Unit Manager #1, on [DATE] at 12:00 PM, revealed she signed off on the comprehensive admission assessment and the MDS staff formulated the initial care plan within 24 hours of a resident's admission. The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident also received [MEDICATION NAME] Therapy (a blood thinner). On [DATE], the facility completed a Falls Risk Analysis which determined the resident was at high risk for falls related to three or more falls in the past three months prior to admission to the facility,balance problems, decreased muscular coordination, receiving four medications (Antihypertensive, Diuretic, Hypoglycemic, and a Narcotic) which have side effects to include dizziness and unsteadiness. The document detailed Resident #1 had three or more predisposing conditions to include Stroke, Fractures, Diabetes and [MEDICAL CONDITION]. The admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as intact. He/she required extensive assistance of two staff for bed mobility, transfers, ambulation and toileting. The Comprehensive Care Plan for "Falls," dated [DATE], detailed Resident #1 was at risk for falls related to weakness, clavicle fracture, impaired mobility; however, there was no documented evidence the facility addressed the resident's problems with balance or the potential for dizziness and unsteadiness associated with his/her medications. On [DATE] the resident was administer [MEDICATION NAME] at 2:00 AM and at 4:00 AM sustained a fall when he/she was left alone sitting on the side of the bed. An interview with Unit Nurse (UN), Registered Nurse (RN) #1, on [DATE] at 10:20 AM, revealed, on [DATE], she completed the admission comprehensive assessment on Resident #1 and recalled the resident required much assistance. She stated the resident was weak and would not be safe to be left alone sitting on the side of the bed. An interview with the MDS Coordinator, on [DATE] at 1:35 PM, revealed she was ultimately responsible for the accuracy of the individual care plans. Further interview, on [DATE] at 4:40 PM, revealed she did not address the issue of dizziness or unsteadiness on the falls care plan, She stated side effects from narcotic use were addressed on the care plan for pain, and included monitoring for signs and symptoms of dizziness, unsteadiness, blurred vision and oversedation, however review of the care plan for "Pain" did not monitor for the side effects. She offered no explanation as to why no interventions, that addressed Resident #1 having balance problems, decreased muscular coordination, being on four medications (Antihypertensive, Diuretic, Hypoglycemic, and a Narcotic) with side effects to include dizziness and unsteadiness, were noted on the initial or the comprehensive care plans. An interview with the Administrator, on [DATE] at 3:00 PM, revealed Resident #1 was on the falling star program which designated a resident was at high risk for falls, and a green star was placed outside the resident's door to alert the staff. She stated if a resident was at risk for falls, it should be common knowledge that a resident should not be left sitting on the side of the bed unsupervised, and it was not not necessary to document all the risk factors related to balance. An acceptable Allegation of Compliance was received on [DATE] and detailed the following: The facility's system for screening was reviewed to establish the amount of supervision a resident required to avoid preventable falls. The process was modified to provide a consistent methodical process for determining whether or not a resident may sit on the bed or the toilet unsupervised. The modification enhanced the communication of this information to the facility staff. The revised process required a resident be evaluated for his/her fall risk using the facility's fall risk analysis tool. The falls analysis will be completed by the MDS Coordinator, Unit Charge Nurses and Licensed Nurses. This will be completed on admission, re-admission, quarterly, significant change, and after each fall. Upon completion of this screening tool, a resident who scored a ten or higher on the analysis should not be seated on the side of the bed or toilet by staff and left unsupervised. Supervision means the resident must be within arms' reach of the staff member. Even if a resident scored less than ten, there may be instances where the interdisciplinary team determined that a resident should be supervised. The determination as to whether or not the resident may be unattended on the bedside or toilet, based on the Falls Risk Analysis, will be placed on the resident's interdisciplinary plan of care by the Unit Charge Nurse/Licensed Nurse and updated after admission and readmission, quarterly, annually, significant change, and after each fall. It will be recorded on the resident's Nurse Aide Data Sheet, which is the instruction guide Nursing Assistants utilize to provide care to assigned residents. The Quality Management Nurse trained the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Staff Development in the process, on [DATE], and they were responsible for providing training to all other nursing staff to include Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses (LN), MDS/Care Plan Coordinators, Administrative Nurses and the Administrator, and to continue with nurses and nurses assistants on each oncoming shift until training is completed. A Falls Risk Analysis will be completed for all current residents by the Unit Managers, or other Licensed Nurse designee. The nurse who completed the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised, if indicated, on [DATE] and [DATE]. The Care Plans and Nurse Aide Data Sheets for those residents were reviewed and/or revised to reflect their need for supervision while sitting unattended on the bedside or toilet. A Quality Assurance and Assessment meeting was conducted, on [DATE], to validate that the analysis were completed and the interventions based on the scores were added to the Interdisciplinary Care plans and the corresponding Nurse Aide Data Sheet. The nurse who completed the the falls risk analysis will be responsible for the revision of the care plan and the nurse aide data sheet. The DON or her designee will review for completion of this task through the admission audit process. The UM and/or DON or designee will review for completion after a fall through the Daily AQA process. The Quarterly Fall Risk Analysis will be checked by the designated MDS nurse responsible for the quarterly MDS. On weekends, the CN will be responsible to validate that all falls risk analysis were completed and the care plan and nurse aide data sheet are revise with the proper information. Verification of removal of Immediate Jeopardy was completed as follows: The Quality Management Nurse trained the DON, ADON, and the Staff Development on the process on [DATE], and they were responsible for providing training to all other nursing staff including Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses (LN), MDS/Care Plan Coordinators, and Administrative Nurses and the Administrator, and to continue with nurses and nurses assistants on each oncoming shift until training was completed, and verified by sign-in sheets initiated on [DATE]. A Falls Risk Analysis will be completed by the Unit Managers or other Licensed Nurse designee for all current residents verified as completed on each unit. The nurse completing the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised, if indicated, on [DATE] and [DATE], and was verified by the care plan and the nurse aide data sheet for each resident on each unit. The Care Plans and Nurse Aide Data Sheets for those residents were reviewed and/or revised to refect the need for supervision with sitting unattended when placed on the bedside or toilet by staff, was verified as completed by review of the care plan and the nurse aide data sheet for each resident on each unit. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed , effective [DATE] , as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure the comprehensive care plan is periodically reviewed and revised by a team of qualified persons after each assessment for one resident (#4), in the selected sample of four residents. A review of the resident's care plan, dated 11/17/11, revealed no documented evidence the facility updated the falls care plan to reflect the padding added to the resident's bedside table. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/16/12 and determined to exist on 05/14/11. An acceptable Allegation of Compliance (AoC) was received on 02/22/12. Immediate Jeopardy was removed, effective 02/19/12, as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F323, F490, and F520) Findings include: A record review revealed the facility admitted Resident #4 on 12/08/09 with [DIAGNOSES REDACTED]. A review of the Comprehensive Care Plan for Falls, dated 11/17/11, revealed Resident #4 was at risk for falls related to an unsteady gait and impaired mobility. Interventions included assistance should be provided before the resident attempted to transfer or ambulate, updated 02/01/12. A personal clip alarm was to be used in the bed and wheelchair and staff were to observe for placement. Low bed with a mat placed on the floor and one helper rail, updated 02/15/12. High-sided mattress was placed on the bed, and dycem in the wheelchair. Call light and frequently used items were to be in reach of the resident. The resident removed the alarm at times; remind the resident of the importance of the personal clip alarm. Anti-rollbacks on the wheelchair and his/her bed against the wall, was added on 02/15/12. A review of the Fall Risk Analysis, dated 01/18/12, revealed the resident was assessed at high risk for falls. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #4 as moderately cognitively impaired and required extensive assistance of two staff for bed mobility and toileting. The resident required extensive assistance of one staff for ambulation, dressing, hygiene and bathing. A review of the Nurses' Note, dated 01/29/12 at 3:30 AM, revealed documentation of two quarter-sized purple discolorations to the left cheek from lying on the left side with his/her hand under his/her head. A review of the physician's progress notes, dated 01/29/12, revealed documentation by the Advance Practice Registered Nurse (APRN), who noted two quarter-sized dark bluish bruises on the resident's left cheek and forehead, and the resident stating he/she bumped that area trying to get out of the bed. A review of an Incident/Accident report, dated 01/29/12, identified two quarter-sized bruises on the left cheek and stated the cause was related to the resident lying on the left side with his/her hand under his/her head. For action to be taken, it was noted that the bruising would be monitored for ten days and then reassessed. Further review of the Incident /Accident report revealed to pad the bedside table, monitor bruising and start on anti-[MEDICAL CONDITION] medication in the morning. An interview with the Assistant Director of Nursing (ADON), on 02/16/12 at 3:55 PM, revealed Resident #4 mentioned that he/she fell and hit the table, so she added an intervention to pad the bedside table as a precautionary measure. A review of the care plan, dated 11/17/11, revealed no documented evidence the facility updated the resident's falls care plan to reflect the padding added to the bedside table. An observation of Resident #4, on 02/13/12 at 7:10 AM, revealed the resident was sitting in a wheelchair in his/her room. The resident was noted with a large pink and purple bruise on the left cheek. When questioned about what happened to his/her cheek, the resident stated he/she fell off the bed and hit his/her face on the table. Observation of the resident's room revealed no bedside table having padding. Interviews with Certified Medication Technician #1, on 02/16/12 at 11:10 AM, and State Registered Nurse Aide (SRNA) #11 and #12, on 02/16/12 at 12:20 PM, revealed that the facility had not padded the resident's bedside table prior to 02/16/12. The resident's Power of Attorney, on 02/16/12 at 12:30 PM, stated that she visits the resident weekly and had never witnessed the bedside table padded since the incident on 01/29/12. An interview with the Administrator, on 02/22/12 at 9:30 AM, revealed whenever there was an accident or incident, the licensed nurse was notified and that person initiated an investigation by utilization of the Incident/Accident Form, and also completed an investigative analysis which indicated the what, when, how, and why the incident occurred. When a determination was made, the physician and the family were notified. Every incident was addressed in the Abbreviated Quality Assurance (AQA) meeting held Monday through Friday. If the incident occurred on the weekend, the Staff Development/Week-end Supervisor reviewed it. In the AQA meeting, interventions are discussed. The licensed nurse is contacted with any questions. The resident's record is reviewed. The care plan and the the Nurse Aide Data Sheet are updated. A care plan progress note was documented in the care plan section of the resident's record. An acceptable Allegation of Compliance was received on 02/22/12 and detailed the following: The facility's system for screening was reviewed to establish the amount of supervision a resident required to avoid preventable falls. The process was modified to provide a consistent methodical process for determining whether or not a resident may sit on the bed or the toilet unsupervised. The modification enhanced the communication of this information to the facility staff. The revised process required a resident be evaluated for his/her fall risk using the facility's fall risk analysis tool. The falls analysis will be completed by the MDS Coordinator, Unit Charge Nurses and Licensed Nurses. This will be completed on admission, re-admission, quarterly, significant change, and after each fall. Upon completion of this screening tool, a resident who scored a ten or higher on the analysis should not be seated on the side of the bed or toilet by staff and left unsupervised. Supervision means the resident must be within arms' reach of the staff member. Even if a resident scored less than ten, there may be instances where the interdisciplinary team determined that a resident should be supervised. The determination as to whether or not the resident may be unattended on the bedside or toilet, based on the Falls Risk Analysis, will be placed on the resident's interdisciplinary plan of care by the Unit Charge Nurse/Licensed Nurse and updated after admission and readmission, quarterly, annually, significant change, and after each fall. It will be recorded on the resident's Nurse Aide Data Sheet, which is the instruction guide Nursing Assistants utilize to provide care to assigned residents. The Quality Management Nurse trained the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Staff Development in the process, on 02/17/12, and they were responsible for providing training to all other nursing staff to include Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses (LN), MDS/Care Plan Coordinators, Administrative Nurses and the Administrator, and to continue with nurses and nurses assistants on each oncoming shift until training is completed. A Falls Risk Analysis will be completed for all current residents by the Unit Managers, or other Licensed Nurse designee. The nurse who completed the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised, if indicated, on 02/16/12 and 02/17/12. The Care Plans and Nurse Aide Data Sheets for those residents were reviewed and/or revised to reflect their need for supervision while sitting unattended on the bedside or toilet. A Quality Assurance and Assessment meeting was conducted, on 02/17/12, to validate that the analysis were completed and the interventions based on the scores were added to the Interdisciplinary Care plans and the corresponding Nurse Aide Data Sheet. The nurse who completed the the falls risk analysis will be responsible for the revision of the care plan and the nurse aide data sheet. The DON or her designee will review for completion of this task through the admission audit process. The UM and/or DON or designee will review for completion after a fall through the Daily AQA process. The Quarterly Fall Risk Analysis will be checked by the designated MDS nurse responsible for the quarterly MDS. On weekends, the CN will be responsible to validate that all falls risk analysis were completed and the care plan and nurse aide data sheet are revise with the proper information. Verification of removal of Immediate Jeopardy was completed as follows: The Quality Management Nurse trained the DON, ADON, and the Staff Development on the process on 02/17/12, and they were responsible for providing training to all other nursing staff including Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses (LN), MDS/Care Plan Coordinators, and Administrative Nurses and the Administrator, and to continue with nurses and nurses assistants on each oncoming shift until training was completed, and verified by sign-in sheets initiated on 02/17/12. A Falls Risk Analysis will be completed by the Unit Managers or other Licensed Nurse designee for all current residents verified as completed on each unit. The nurse completing the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised, if indicated, on 02/16/12 and 02/17/12, and was verified by the care plan and the nurse aide data sheet for each resident on each unit. The Care Plans and Nurse Aide Data Sheets for those residents were reviewed and/or revised to refect the need for supervision with sitting unattended when placed on the bedside or toilet by staff, was verified as completed by review of the care plan and the nurse aide data sheet for each resident on each unit. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed , effective 02/19/12 , as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on interview and record review, it was determined the facility failed to ensure services provided or arranged by the facility were provided by qualified persons in accordance with each resident's plan of care for one resident (#3), in the selected sample of four residents. A review of the Comprehensive Care Plan for falls, dated 05/17/11, included an intervention for non-skid socks to be on at bedtime as the resident allowed. Further review of a Fall Risk Analysis, dated 01/03/12, revealed the resident was assessed as high risk for falls. On 02/14/12, the resident experienced a fall while using the toilet during which time the staff was assisting him/her. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/16/12 and determined to exist on 05/14/11. An acceptable Allegation of Compliance (AoC) was received on 02/22/12. Immediate Jeopardy was removed, effective 02/19/12, as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F323, F490, and F520) Findings include: A record review revealed the facility admitted Resident #3 on 04/27/11 with [DIAGNOSES REDACTED]. A review of the Comprehensive Care Plan, "At Risk for Falls," dated 05/17/11, included an intervention for non-skid socks to be on at bedtime as the resident allowed. A review of a Fall Risk Analysis, dated 01/03/12, revealed Resident #3 was at high risk for falls. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #3 as cognitively intact, requires extensive assistance of two staff for bed mobility, transfers, ambulation, toileting, and extensive assistance of one staff for personal hygiene and bathing. An interview with Resident #3, on 02/14/12 at 12:00 PM, revealed he/she experienced a fall "last night while I was using the toilet." Resident #3 stated while a State Registered Nurse Aide (SRNA) assisted him/her to pull up his/her pants, his/her feet slipped out from under him/her, and caused him/her to fall back onto the toilet. Resident #3 was not able to recall the staff who assisted him/her. The resident stated he/she required the staff's assistance to the toilet, on and off the toilet, and to pull his/her pants up and down due to hand weakness. On 02/15/12 at 9:20 AM, Resident #3 voiced complaints of hip pain, and was not sure the pain was associated with the recent fall on 02/14/12. On 02/15/12 at 11:30 AM, the resident stated the hip pain was "better." On 02/16/12 at 3:25 PM, Resident #3 stated the hip pain was worse and he/she could hardly sit on the commode. When asked if he/she wore non-skid socks the night of the fall, Resident #3 stated the non-skid socks he/she wore when the fall occurred, on 02/14/12, were worn out and did not prevent his/her feet from sliding. The resident stated the staff had been made aware of the need for new socks; however, the facility had not provided new socks until 02/15/12. The facility presented an Incident/Accident report, on 02/16/12 at 9:45 AM, which included three staff statements that did not address the incident as was reported by the resident. Licensed Practical (LPN) #1 was the charge nurse and her statement stated no fall was reported to her on the night of 02/13/12. SRNA #8's statement revealed she took Resident #3 to the toilet and the resident always "plops" down hard on the toilet and this was usual behavior for the resident so she did not feel the need to report it to the nurse. She stated the resident refused help with sitting down on the toilet and did not complain of pain. SRNA #9 denied any knowledge of the incident. The facility did not present evidence of an investigation which determined a root cause of the fall, identified the resident's non-skid socks were worn out or replaced the non-skid socks were implemented to prevent the fall. An interview with the Administrator, on 02/22/12 at 9:30 AM, revealed when there was an accident or incident, the licensed nurse was notified and that person was to initiate an investigation by utilization of the Incident/Accident Form. The nurse also filled out an investigative analysis which indicated the what, when, how, and why the incident occurred. When a determination was made, the physician and the family were notified. If it was an emergent situation, care was provided before this took place and the Administrator and the Director of Nursing (DON) were notified. An acceptable Allegation of Compliance was received on 02/22/12 and detailed the following: The facility's system for screening was reviewed to establish the amount of supervision a resident required to avoid preventable falls. The process was modified to provide a consistent methodical process for determining whether or not a resident may sit on the bed or the toilet unsupervised. The modification enhanced the communication of this information to the facility staff. The revised process required a resident be evaluated for his/her fall risk using the facility's fall risk analysis tool. The falls analysis will be completed by the MDS Coordinator, Unit Charge Nurses and Licensed Nurses. This will be completed on admission, re-admission, quarterly, significant change, and after each fall. Upon completion of this screening tool, a resident who scored a ten or higher on the analysis should not be seated on the side of the bed or toilet by staff and left unsupervised. Supervision means the resident must be within arms' reach of the staff member. Even if a resident scored less than ten, there may be instances where the interdisciplinary team determined that a resident should be supervised. The determination as to whether or not the resident may be unattended on the bedside or toilet, based on the Falls Risk Analysis, will be placed on the resident's interdisciplinary plan of care by the Unit Charge Nurse/Licensed Nurse and updated after admission and readmission, quarterly, annually, significant change, and after each fall. It will be recorded on the resident's Nurse Aide Data Sheet, which is the instruction guide Nursing Assistants utilize to provide care to assigned residents. The Quality Management Nurse trained the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Staff Development in the process, on 02/17/12, and they were responsible for providing training to all other nursing staff to include Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses (LN), MDS/Care Plan Coordinators, Administrative Nurses and the Administrator, and to continue with nurses and nurses assistants on each oncoming shift until training is completed. A Falls Risk Analysis will be completed for all current residents by the Unit Managers, or other Licensed Nurse designee. The nurse who completed the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised, if indicated, on 02/16/12 and 02/17/12. The Care Plans and Nurse Aide Data Sheets for those residents were reviewed and/or revised to reflect their need for supervision while sitting unattended on the bedside or toilet. A Quality Assurance and Assessment meeting was conducted, on 02/17/12, to validate that the analysis were completed and the interventions based on the scores were added to the Interdisciplinary Care plans and the corresponding Nurse Aide Data Sheet. The nurse who completed the the falls risk analysis will be responsible for the revision of the care plan and the nurse aide data sheet. The DON or her designee will review for completion of this task through the admission audit process. The UM and/or DON or designee will review for completion after a fall through the Daily AQA process. The Quarterly Fall Risk Analysis will be checked by the designated MDS nurse responsible for the quarterly MDS. On weekends, the CN will be responsible to validate that all falls risk analysis were completed and the care plan and nurse aide data sheet are revise with the proper information. Verification of removal of Immediate Jeopardy was completed as follows: The Quality Management Nurse trained the DON, ADON, and the Staff Development on the process on 02/17/12, and they were responsible for providing training to all other nursing staff including Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses (LN), MDS/Care Plan Coordinators, and Administrative Nurses and the Administrator, and to continue with nurses and nurses assistants on each oncoming shift until training was completed, and verified by sign-in sheets initiated on 02/17/12. A Falls Risk Analysis will be completed by the Unit Managers or other Licensed Nurse designee for all current residents verified as completed on each unit. The nurse completing the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised, if indicated, on 02/16/12 and 02/17/12, and was verified by the care plan and the nurse aide data sheet for each resident on each unit. The Care Plans and Nurse Aide Data Sheets for those residents were reviewed and/or revised to refect the need for supervision with sitting unattended when placed on the bedside or toilet by staff, was verified as completed by review of the care plan and the nurse aide data sheet for each resident on each unit. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed , effective 02/19/12 , as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure three residents (#1, #3, and #4), in the selected sample of four residents, received adequate supervision and assistance devices to prevent accidents. The facility failed to follow their "Falls" and "Incident/Accident" policies and procedures. The facility's staff failed to provide necessary supervision to prevent accidents, failed to ensure interventions were implemented to prevent fall occurrence, and failed to thoroughly investigate to identify causal factors of falls in order to prevent recurrence. The facility had assessed Resident #1 as high risk for falls upon admission and facility staff was knowledgeable that Resident #1 required extensive assistance, having poor sitting balance and was identified on the falling star program. On [DATE], at approximately 2:00 AM, the facility administered a PRN (as needed) dose of Lortab to Resident #1. At 4:00 AM, the staff assisted Resident #1 to the side of the bed to a sitting position, then left him/her alone in the room unsupervised. Resident #1 fell forward from the bed landing on the floor, sustaining an intracranial hemorrhage (bleeding within the skull) and subsequently expired on [DATE]. Intracranial Hemorrhage was listed as the underlying cause of death on a certified copy of Resident #1's death certificate. The facility's investigation failed to identify staff had not provided supervision to the resident, nor developed a care plan which identified all the falls risk factors. Resident #3 sustained a fall, on [DATE], when his/her feet slipped from under him/her as staff as staff assisted him/her to stand up from the toilet. The facility's investigation failed to identify the causal factor of the fall and failed to identify that facility staff did not ensure interventions were effective. Resident #4 who sustained a fall from bed which resulted in a bruise to the left cheek. The facility's investigation failed to address and investigate that resident's statements that he/she had fallen, failed to identify the causal factors and failed to ensure that preventive measures detailed on the investigation were care planned and implemented to prevent further occurrence. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F224, F279, F280, F282, F490, and F520) Findings include: A review of the facility's policy and procedure, "Falls," dated [DATE], revealed upon admission, the facility would identify residents at risk for fall by utilization of the "Falls Risk Analysis" form. Based on the falls analysis, preventive/safety measures would be implemented as appropriate, for residents identified at risk for falls. In the event of a fall, a post fall analysis was to be conducted to aid in identifying contributing factors. A review of the facility's policy and procedure, "Incident/Accident," dated [DATE], revealed residents were reviewed routinely and through the care planning process for factors that may place them at risk for incidents or accidents. Interventions wold be implemented based on the analysis findings. The facility would investigate incidents, accidents and injuries to identify the potential contributing factors Based on the findings of the investigation the care plan would be reviewed and revised if needed to include preventative interventions to decrease the potential of recurrence. 1. A record review revealed, on [DATE], the facility admitted Resident #1 with [DIAGNOSES REDACTED]. The resident also received Coumadin Therapy (a blood thinner). A review of the Falls Risk Analysis, dated [DATE], revealed upon admission the facility assessed the resident as high risk for falls related to having three or more falls in the past three months prior to admission to the facility. Further record review revealed the resident had balance problems, decreased muscular coordination, and was on four medications (Antihypertensive, Diuretic, Hypoglycemic, and a Narcotic) with side effects to include dizziness and unsteadiness. Predisposing factors for Resident #1 included Stoke, Fractures, Diabetes, and Anemia. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as cognitively intact. The assessment detailed that he/she required extensive assistance of two staff for bed mobility, transfers, ambulation and toileting. A review of the Comprehensive Care Plan for "Falls," dated [DATE], revealed Resident #1 was at risk for falls related to weakness, clavicle fracture, and impaired mobility; however, there was no evidence the facility addressed the resident's condition related to balance or the potential for dizziness and unsteadiness associated with his/her medication. An interview with Unit Nurse (UN), Registered Nurse (RN) #1, on [DATE] at 10:20 AM revealed on [DATE], she completed Resident #1's admission assessment. She stated the resident required much assistance, was weak, and not safe to sit up alone on the side of the bed. Interviews with SRNA #2 on [DATE] at 12:10 PM, SRNA #3 on [DATE] at 11:55 AM, SRNA #4 on [DATE] at 10:43 AM, SRNA #5 on [DATE] at 12:45 PM, SRNA #6 on [DATE] at !0:55 AM, and SRNA #7 on [DATE] at 10:00 AM, revealed Resident #1 had periods of weakness and was only able to maintain balance while sitting on the side of the bed for a maximum of ten minutes with assistance because the resident swayed and was "wobbly". Each of the SRNA interviews revealed it was not safe to leave Resident #1 alone sitting on the side of the bed. Interview with SRNA #1, on [DATE] at 9:27 AM, revealed SRNA #1 stated Resident #1 constantly asked for pain medication. She stated she let the nurse know on [DATE] that the resident requested medication for leg pain and the nurse gave pain medication to Resident #1. An interview with LPN #1, on [DATE] at 9:40 AM, revealed, on [DATE] at 2:00 AM, Resident #1 complained of leg cramps and Lortab was administered. She stated this was not unusual behavior as the resident frequently complained of leg cramps. Further interview with LPN #1 and interview with SRNA #1, on [DATE] at 10:30 AM, revealed that Resident#1 requested to sit up on the side of the bed due to leg cramps and the SRNA assisted the resident up on the side of the bed. Further interview with SRNA #1 revealed she assisted the resident to sit up on the side of the bed, propped a pillow under his/her left arm then left the room to go answer other call lights. leaving the resident unsupervised. She stated Resident #1 was able to brace himself/herself with the right hand while sitting on the side of the bed. There was Personal Clip (PC) alarm attached to the right (Rt) side of the resident's gown when she left the room. She stated she was in a room down the hall when she heard a loud noise, like a chair moving, and ran back down the hall to Resident #1's room to find the resident on the floor on the floor mat. Resident #1 was bleeding from his/her knees and from an area on his/her head. Both SRNA #1 and LPN #1 revealed the resident was found face down on the floor mat at the bedside. A review of the Skilled Assessment, dated [DATE] at 4:00 AM, revealed documentation by LPN #1. The documentation revealed Resident #1 was sitting on the side of the bed, fell forward and was found on the floor in his/her room. Additional documentation revealed the resident complained of severe pain to the left shoulder and left leg and a laceration was noted to the corner of Resident #1's left eye, which was swollen. Further interview with LPN #1 revealed Resident #1 told her that he/she lost his/her balance and fell forward on to the floor mat. LPN #1 stated the Lortab was administered prior to the resident's fall and may have caused the resident to be "light headed." She stated they should not have left the resident alone sitting up on the side of the bed. A review of the Post Fall Analysis, dated [DATE] at 4:00 AM, revealed Resident #1 was in his/her room, sitting on the side of the bed with a floor mat in place. The Personal Clip (PC) alarm was in place and sounded at the time of the fall. Detailed under "Environmental factors that may be related to the fall," was, "Resident was sitting on the side of the bed, lost his/her balance and fell forward." While the facility had assessed the resident as high risk related to left sided paralysis, balance problems, decreased muscular coordination requiring extensive assistance and had administered a narcotic two hours prior to the fall with side effects to include dizziness and unsteadiness; there was no documented evidence the facility's investigation had identified that staff had left the resident alone sitting on the side of the bed, unsupervised, prior to the fall. A second interview with SRNA #1 on [DATE] at 1:00 PM, revealed she was aware Resident #1 was on the Falling Star Program and detailed that meant the resident was a high falls risk. She stated residents on the Falling Star Program had alarms, floor mats, required assistance with bed mobility, transfer, ambulation and required two staff assistance at all times. She revealed she was alone while providing care for Resident #1 because SRNA #4, who was working with her that night, was down the hall answering lights. She stated she was aware Resident #1 was paralyzed on the left side, required extensive assistance all care. She stated Resident #1 would only want to sit up ,[DATE] minutes at a time, then would ask to lay back down. She stated she should not have left the resident alone sitting on the side of the bed, but it was a busy night and she "had to do what she had to do." An interview with SRNA#4 on [DATE] at 10:43 AM revealed at the time Resident #1 fell from the bed, she was in the shower room with another resident. When she entered Resident #1's room she observed the resident face down on the mat with blood under his/her head. Record review revealed the facility transferred the resident to the hospital where the resident was diagnosed with [REDACTED]. Interview with the Attending Physician on [DATE] at 9:10 AM, whose signature appeared on the certified copy of Resident #1's death certificate, revealed the Intracranial Hemorrhage listed as the underlying cause of death on Resident #1's death certificate was the result of the fall the resident sustained [REDACTED].#1's death. An interview with the MDS Coordinator, on [DATE] at 1:35 PM, and on [DATE] at 4:40 PM, revealed she was ultimately responsible for the accuracy of the individual care plans. She stated she did not address the issue of dizziness or unsteadiness on the falls care plan. She revealed side effects from narcotic use were addressed on the care plan for pain, and included monitoring for signs and symptoms of dizziness, unsteadiness, blurred vision and oversedation. She offered no explanation as to why no interventions were noted on either the initial care plan or the comprehensive care plan. An interview with the Administrator and the Director of Nursing (DON), on [DATE] at 3:00 PM, revealed Resident #1 was on the Falling Star Program which meant the resident was a high risk for falls and it should have been "common knowledge" that the resident should not be left sitting on the side of the bed. On [DATE] at 9:52 AM, the Administrator stated no further investigation was conducted related to the resident's fall from the bed because the resident said he/she lost his/her balance and fell ; therefore that was thought to be the cause of the fall. Any further investigation would only be completed if abuse, neglect or exploitation were involved. Review of the facility's investigation revealed no evidence the facility considered this accident as possible neglect. 2. A record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. A review of the Comprehensive Care Plan, dated [DATE], included Risk for falls revealed an intervention for non-skid socks to be on at bedtime as the resident allows. A Fall Risk Analysis, dated [DATE], revealed Resident # 3 was high risk for falls. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #3 to be cognitively intact, required extensive assistance of two staff for bed mobility, transfers, ambulation, and toileting, Extensive assistance of one staff was required for personal hygiene and bathing. An interview with Resident #3, on [DATE] at 12:00 PM, revealed he/she experienced a fall "last night while I was using the toilet." Resident #3 stated while an SRNA was assisting him/her to pull up his/her pants, his/her feet out slipped from under him/her causing him/her to fall back onto the toilet. Resident #3 was not able to recall the staff who was assisted her. The resident stated he/she required staff assistance to the toilet, on and off the toilet, and to pull his/her pant up and down due to hand weakness. On [DATE] at 9:20 AM, Resident #3 voiced complaints of hip pain, and was not sure the pain was associated with the recent fall on [DATE]. On [DATE] at 11:30 AM, the resident stated the hip pain was better. On [DATE] at 3:25 PM, Resident #3 stated hip pain was worst and he/she could hardly sit on the commode. When asked if he/she wore non-skid socks the night of the fall, Resident #3 stated the non-skid socks he/she wore when the fall occurred on [DATE] were worn out and did not prevent his/her feet from sliding. The resident stated staff as aware of the need for new socks. An interview with the Assistant Director of Nursing (ADON) and Unit Manager (UM) #1, on [DATE] at 6:00 PM, revealed they were unaware of an incident involving Resident #3 related to a fall in the bathroom. The ADON presented an Incident/Accident report on [DATE] at 9:45 AM which included three staff statements which did not address the incident as reported by the resident. LPN #1 was the charge nurse and her statement revealed no fall was reported to her on the night of [DATE]. SRNA #8's statement revealed she took Resident #3 to the toilet and the resident always "plops down hard"on the toilet and this was usual behavior for the resident so she did not feel it was necessary to report it to the nurse. She stated the resident refused assistance to sit down on the toilet and did not complain of pain. SRNA #9 denied any knowledge of the incident. The facility did not present documented evidence of an investigation establishing the root cause of the fall nor did it identify that the resident's non-skid socks were no longer embellished with the non-skid application to prevent falls. 3. A record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. A review of the Fall Risk Analysis, dated [DATE], revealed the facility assessed the resident as high risk for falls. A review of the Comprehensive Care Plan for Falls dated [DATE], revealed Resident #4 was at risk for falls related to an unsteady gait, and impaired mobility. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 as moderately cognitively impaired and required extensive assistance of two staff for bed mobility, and toileting. Further review revealed the resident required extensive assistance of one staff for ambulation, dressing, hygiene and bathing. A review of the Nurses' Notes, dated [DATE] at 3:30 AM, revealed documentation of two quarter-sized purple discolorations to the left cheek from lying on the left side with his/her hand under his/her head. A review of a Physician's Progress Note, dated [DATE], revealed documentation by the Advance Practice Registered Nurse (APRN), who noted two quarter-sized dark bluish bruises to the left cheek and forehead, and the resident stating he/she bumped that area trying to get out of the bed. A review of an Incident/Accident report, dated [DATE] identified two quarter-sized bruises on the left cheek and stated the cause was related to resident lying on the left side with his/her hand under his/her head. It was noted that the bruising would be monitored for ten days and then reassessed. Further review of the Incident/accident report revealed interventions to pad the bedside table, monitor bruising and the resident was to receive anti-inflammatory medication in the mornings. An interview with the ADON, on [DATE] at 3:55 PM, revealed the next day Resident #4 mentioned that he/she hit his/her head on the table, so she added an intervention to pad the bedside table as a precautionary measure. The occurrence of a fall from the bed was not mentioned in the report nor were causal factors identified related to the injury. Further interview with the ADON revealed she did not know why an investigation was not completed. An observation of Resident #4, on [DATE] at 7:10 AM, revealed the resident was sitting in a wheelchair in his/her room. The resident was noted with a large pink and purple bruise on the left cheek. When questioned about what happened to his/her cheek the resident stated he/she had fallen from the bed and hit his/her face on the table. Observation of the resident's room revealed no bedside table having padding. Furthermore, interviews with Certified Medication Technician #1, on [DATE] at 11:10 AM, and SRNA #11 and #12, on [DATE] at 12:20 PM, revealed that the facility had not padded the resident's bedside table prior to [DATE]. Interview with the resident's Power of Attorney, on [DATE] at 12:30 PM, revealed that she visits the resident weekly and had never witnessed the bedside table padded since the incident on [DATE]. The facility was unable to provide evidence of an investigation which determined causal factor to the injury despite the resident's continued statements to the APRN and the ADON that he/she bumped the area while trying to get out of the bed. Furthermore, there was no evidence that the facility implemented the intervention of padding the bedside table as detailed on the incident/accident report. Additionally, review of the resident's falls care plan revealed the facility had not revised the care plan to include the padded bedside table. An interview with the Administrator, on [DATE] at 9:30 AM, revealed whenever there was an accident or incident, the licensed nurse was notified and that person initiated an investigation by utilization of the Incident/Accident Form and filled out the investigative analysis which indicated the what, when, how, and why the incident occurred. When a determination was made, the physician and the family were notified. If it was an emergent situation, the resident was provided care before this took place and the Administrator and the DON were notified. Every incident was addressed in the Abbreviated Quality Assurance (AQA) meeting held Monday through Friday. If the incident occurred on the weekend, the Staff Development/Week-end Supervisor reviewed it. In the AQA meeting, interventions were discussed. The licensed nurse was contacted with any questions. The resident's record was reviewed. The care plan and the the Nurse Aide Data Sheet were updated. A care plan progress note was documented on the care plan section of the resident's record. If the resident was sent to the hospital they were to be reassessed upon return from the hospital. An acceptable Allegation of Compliance was received on [DATE] and detailed the following. Resident #1 was discharged from the facility on [DATE] to the hospital and expired on [DATE], so no additional measures were possible for him/her. The Fall Incident Reports of Resident #3 and Resident #4 were reviewed to identify additional factors that may have contributed to the falls. The care plans were reviewed and revised, and the Nurse Aide Data Sheets was revised to reflect new interventions as of [DATE]. Resident #3 was screened by Physical Therapy for evaluation and treatment. An order was obtained and the evaluation was completed on [DATE]. The resident's care plan was updated with the following interventions on [DATE] and [DATE]: the resident was unsafe to be seated on the side of the bed or toilet without supervision; the resident refused the recommendation of a PC alarm. Staff continued to encourage and advised the resident to follow the recommendations of the care plan team; restorative ambulation was discontinued; for toileting, transfer to the bedside commode only with assistance of one staff at this time and with resident's rolling walker; place the gait belt above the resident's chest level secondary to rib fractures; do not leave the resident alone on the bedside commode; and remove the bedside commode from the room when not in use per the resident's request. Resident #4 was reviewed for falls and for bruising concerns. The resident's care plan was revised, on [DATE] and [DATE], with the following interventions: the resident may have dizziness from psychoactive medication use and have increased risk for falls; Falls risk analysis indicated resident maybe unsafe to be seated on the side of the bed or on the toilet unsupervised; the resident refused to follow the facility's recommended interventions; PC alarms to the bed and the wheelchair; continue to encourage and advise to follow recommendations of care; non-skid footwear at bedtime; and bruises easily related to long-term steroid use for Rheumatoid Arthritis. The facility's system for screening for establishing the amount of supervision a resident required to avoid preventable falls was reviewed. The process was modified to provide a consistent methodical process to determine whether or not a resident may sit on a bed or toilet unsupervised. The modification enhanced the communication of this information to the facility staff. The revised process required that a resident be evaluated for his/her fall risk using the facility's fall risk analysis tool. The falls analysis will be completed by the MDS Coordinator, Unit Charge Nurses and Licensed Nurses. This will be completed on admission, or re-admission, quarterly, significant change, and after each fall. Upon completion of this screening tool, a resident who scored a ten (10) or higher on the analysis should not be seated on the side of the bed or toilet by staff and left unsupervised. Supervision meant the resident must be within arms' reach of the staff member. Even if a resident scored less than ten (10), there may be some instances where the interdisciplinary team determined that a resident should be supervised. The determination as to whether or not the resident may be unattended on the bedside or toilet, based on the Falls Risk Analysis, will be placed on the resident's interdisciplinary plan of care by the Unit Charge Nurse/Licensed Nurse, and updated after admission and readmission, quarterly, annually, significant change and after each fall. It will also be recorded on the resident's Nurse Aide Data Sheet, and the instruction guide Nursing Assistants utilized to provide care to each of the assigned residents. The Quality Management Nurse trained the DON, ADON, and the Staff Development on the process, on [DATE], and they were responsible for providing training to all other nursing staff to include Nursing Assistants (NA), Medication Aides (MA), Licensed Nurses, MDS/Care Plan Coordinators, and Administrative Nurses and the Administrator, to begin on [DATE], and to continue with nurses and NAs on each oncoming shift until training was completed. A Falls Risk Analysis will be completed for all current residents by the Unit Managers, or other Licensed Nurse designee. The nurse completing the analysis will be responsible for updating the care plan and the nurse aide data sheet. The Falls Risk Analysis for all current residents were reviewed and revised on [DATE] and [DATE]. The Care Plans and Nurse Aide Data Sheets were reviewed and/or revised to refect the need for supervision with sitting unattended when placed on the bedside or toilet by staff. A Quality assurance and Assessment meeting was conducted, on [DATE], to validate that the analyses were completed and the interventions based on the scores were added to the Interdisciplinary Care plans and the corresponding Nurse Aide Data Sheet. The nurse completing the the fall risk analysis will be responsible for the revision of the care plan and the nurse aide data sheet. The DON or her designee will review for completion of this task, on admission through the admission audit process. The UM and/or DON or designee will review for completion after a fall through the Daily AQA process. The Quarterly Fall Risk Analysis will be checked by the designated MDS nurse responsible for the quarterly MDS. On weekends, the CN will be responsible to validate that all falls risk analysis were completed and the care plan and nurse aide data sheet were revised with the proper information. Observations to monitor residents who have been identified as high risk began, on [DATE], to validate placement of interventions for these residents and will be completed by the charge nurses and licensed nurses every shift. In the event a resident refused supervision, attendance or other fall safety interventions, they will be informed of the risks associated with the refusal and offered alternatives. If they continued not to accept supervision, attendance, or other interventions, they will be asked to sign a Refusal of Treatment Form if alert and oriented. A Non-Compliance Form will be utilized for the resident with cognitive impairment and was discussed and reviewed with the responsible person. The facility will continue to develop /implement interventions to meet the residents safety needs while respecting the residents rights. The resident's choice to decline the recommended intervention will be on both the resident's plan of care and the nurse aide data sheet. The resident will be encouraged to accept the planned interventions, and alternatives to meet the residents' needs will be offered to the resident and or decision maker. This will be documented on the resident's plan of care. The Quality Management Nurse trained the DON, ADON, and the Staff Development in this process, on [DATE], and they were responsible for all other staff beginning [DATE] and continuing until completed. Housekeeping , laundry and dietary staff were educated, on [DATE], by the Development Coordinator, that if they observed a resident sitting independently on the side of the bed, they should alert the staff and continue to monitor the resident until such time as a nursing staff representative arrived to assist. The education will continue with on-coming shifts until completed. On [DATE], a training conducted by the Quality Management Nurse re-educated the Administrative Nurses, Licensed Nurses, and the MDS/Care Coordinator on the facility's Falls policy and procedure, including the completion of a prompt, through investigation that assisted in identifying contributing factors to the falls. The goal of the investigation was to identify what happened, when it happened, how it happened, where it occurred, who it happened to, what caused it, who might have information about what happened, and what can be done to prevent it from happening again. The same group was provided education on Falls Prevention, including numerous but not all inclusive, common factors that contribute to falls. Nurses that were not educated on [DATE] by the Quality Management Nurse, the DON, ADON, or the Staff Development, will be provided training on or before their next shift worked. The DON or her designee in her absence will monitor the investigation process for thoroughness, accuracy and appropriateness of interventions. A second review will be conducted by the Administrator A check-list will be utilized to validate that all tasks were completed. The check list will be reviewed in the AQA meeting and findings reviewed in the Quality Assurance and Assessment (QAA) Committee meeting. Verification of removal of Immediate Jeopardy was completed as follows: Review of Resident #3's record revealed all modifications were in place. Review of Resident #4's record reveled all modifications were in place. The Quality Management Nurse trained the DON, ADON,and the Staff Development, who educated licensed nurses about the process of falls, falls prevention, supervision conducting an investigation, interventions, implementing and updating the care plans, was initiated on [DATE] and verified by a sign in-sheet. Interview with RN #2, on [DATE] at 9:20 AM, revealed she was inserviced on falls and falls prevention, supervision, investigation, updating the care plan and abuse/neglect. Interviews with LPN #1 on [DATE] at 9:50 AM, LPN #2 on [DATE] at 9:10 AM, LPN #3 on [DATE] at 3:00 PM, and LPN #4 on [DATE] at 1:40 PM, revealed they were inserviced on falls and falls prevention, supervision, investigation, updating the care plan and abuse/neglect. Training on supervision by the Staff Development was initiated on [DATE] and verified by a sign-in sheet. Interview with SRNA #7 on [DATE] at 1:15 PM, SRNA #8 on [DATE] at 2:07 PM, SRNA #9 on [DATE] at 1:35 PM, and SRNA #10 on [DATE] at 9:30 AM, revealed they were inserviced about not leaving the resident sitting on the bed or the toilet unless they were independent and to keep dependent residents within arms' reach and to ensure all alarms were in place and in working order. Housekeeping, laundry and dietary staff were educated, on [DATE], and was verified, on [DATE], by a sign-in sheet and interviews with Housekeeper #1, Dietary staff #1 and Dietary staff #2, on [DATE] at 1:50 PM, and the Beautician on [DATE] at 2:05 PM. A Falls Risk Analysis will be completed for all current residents by the Unit Managers, or other Licensed Nurse designee verified by observation, on [DATE], of the analysis completed on all current residents and care plans and nurse aide data sheet that were updated as indicated. A Quality assurance and Assessment meeting, conducted on [DATE], validated that the analyses were completed and that the interventions based on the scores were added to the Interdisciplinary Care plans and the corresponding Nurse Aide Data Sheet. Verified by a sign-in sheet on [DATE]. Based on the above interviews and record reviews it was determined the Immediate Jeopardy was removed , effective [DATE] , as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on observation, interview, record review, review of the facility's policy and procedure, and review of the Administrator's job description, it was determined the facility failed to administer in a manner which enabled it to use it's resources effectively and efficiently to attain or maintain the highest practical, physical, mental, and psychosocial well-being for three residents (#1, #3 and #4), in the selected sample of four residents. The facility failed to have an effective system in place to ensure risk factors were properly identified and communicated, and to ensure adequate supervision was provided to prevent accidents for Resident #1. The facility failed to have an effective system in place to ensure Incident/Accidents were thoroughly investigated to identify the causal factors for Residents #1, #3 and #4. (Refer to F224, F279, F280, F282, F323, and F520) The facility assessed Resident #1 as a high risk for fall, and staff was knowledgeable regarding the resident's need for supervision due to balance concerns. On [DATE], at approximately 2:00 AM, the facility administered a PRN (as needed) dose of [MEDICATION NAME] (pain medication) to Resident #1. At 4:00 AM, the staff assisted Resident #1 upon the side of the bed to a sitting position and then left him/her alone in the room unsupervised. Resident #1 fell forward from the bed, sustaining an [MEDICAL CONDITION] (bleeding within the skull). Resident #1 subsequently expired on [DATE]. [MEDICAL CONDITION] was listed as the underlying cause of death on a certified copy of Resident #1's death certificate. The facility's investigation failed to identify staff left the resident without supervision despite their knowledge of the resident's needs and falls risk. Furthermore, the facility failed to identify through their investigation that neglect occurred which prevented the facility from taking necessary action to prevent recurrence associated with Resident #1's fall, related to no evidence the facility determined the resident, who was assessed as high risk for falls related to left sided paralysis, balance problems, decreased muscular coordination, and having received a narcotic two hours prior to the fall, which had side effects to include dizziness and unsteadiness, was left alone sitting on the side of the bed prior to the fall. Resident #3, on [DATE], and Resident #4, on [DATE], both experienced falls; however, the facility's investigation failed to identify causal factors which prevented the facility from implementing corrective action to prevent recurrence. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" based on the need to ensure the facility was administered effectively and efficiently. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F224, F279, F280, F282, F323, and F520) Findings include: A review of the Facility Administrator's job description, undated, revealed the Job Summary as overseeing patient/resident care, managing overall operation, employee management, fiscal management, and ensured compliance with State and Federal regulations. Job responsibilities included development of a facility organizational structure and participation in the development, interpretation and implementation of policies and procedures, ensured the facility was free of any unsafe conditions, reviewed, monitored and followed-up on incident reports, adverse incidents, and developed plans of action to correct and responded to identified quality and risk issues. A review of the facility's policy and procedure, "Falls," dated [DATE], revealed upon admission, the facility would identify residents at risk for falls by utilization of the "Falls Risk Analysis" form. Based on the falls analysis, preventive/safety measures were implemented as appropriate, for residents identified at risk for falls. In the event of a fall, a post fall analysis was to be conducted to aid in identifying contributing factors. A review of the facility's "Alleged Abuse Reporting/Investigation," revised [DATE], revealed the facility defined "Neglect" as a failure or omission on the part of the care giver to provide the care, supervision, and services necessary to maintain the physical and mental health of the disabled adult or elderly person, including but not limited to providing food, clothing, medicine, shelter, supervision and medical services that a prudent person would consider essential for the well being of the disabled adult or elderly person. Neglect can also mean the failure of care givers to make a reasonable effort to protect a disabled adult or elderly person from abuse, neglect or exploitation by others. Neglect can be either repeated conduct or a single incident of carelessness which produced or could be reasonably expected to result in serious physical or psychological injury or a substantial risk of death. A review of the Falls Risk Analysis for Resident #1, dated [DATE], revealed, upon admission to the facility, the facility assessed the resident as at risk for falls related to having three or more falls in the past three months prior to admission to the facility, having balance problems, decreased muscular coordination, being on four medications (Antihypertensive, Diuretic, Hypoglycemic, and a Narcotic) with side effects to include dizziness and unsteadiness. Predisposing factors for Resident #1 included Stoke, Fractures, Diabetes, and [MEDICAL CONDITION]. A Review of the POS [REDACTED]. It was documented the PC alarm sounded at the time of the fall. Further documentation revealed, under "Environmental factors that may be related to the fall," was "Resident was sitting on the side of the bed, lost balance and fell forward." The resident was assessed as high risk for falls related to left sided paralysis, balance problems, decreased muscular coordination, and had received a narcotic two hours prior to the fall with side effects to include dizziness and unsteadiness. There was no evidence the facility determined the resident was left alone sitting on the side of the bed prior to the fall; however, interview with State Registered Nurse (SRNA) #1, on [DATE] at 10:30 AM, revealed on the morning of [DATE], at approximately 4:00 AM, Resident #1 requested to sit up on the side of the bed. She stated she assisted the resident up on the side of the bed, then left the room to go answer other call lights. She stated a personal clip (PC) alarm was attached to the right side of the resident's gown as she left the room. She stated she was in a room down the hall when she heard a loud noise, like a chair moving, and ran back down the hall to Resident #1's room to find the resident on the floor mat. Resident #1 was bleeding from his/her knees and from an area on his/her head. She stated the resident's alarm did not sound. She stated she was aware Resident #1 was paralyzed on the left side, and required extensive assistance with all care. She stated Resident #1 only wanted to sit up ,[DATE] minutes at a time, then asked to lay back down. She stated she should not have left the resident alone sitting on the side of the bed, but it was a busy night and she "had to do what she had to do." An interview with SRNA #1, on [DATE] at 9:27 AM, revealed she made the nurse aware about Resident #1's request for medication for leg pain on the night of the fall. The nurse gave Resident #1 pain medication about an hour prior to the fall. Interview with SRNA #2 on [DATE] at 12:10 PM, SRNA #3 on [DATE] at 11:55 AM, SRNA #4 on [DATE] at 10:43 AM, SRNA #5 on [DATE] at 12:45 PM, SRNA #6 on [DATE] at 10:55 AM, and SRNA #7 on [DATE] at 10:00 AM, revealed Resident #1 had periods of weakness and was only able to maintain balance while sitting on the side of the bed for a maximum of ten minutes with assistance because the resident swayed and was "wobbly." Each of the SRNA interviews revealed it was not safe to leave Resident #1 alone sitting on the side of the bed. An interview with the MDS Coordinator, on [DATE] at 1:35 PM, and on [DATE] at 4:40 PM, revealed she was ultimately responsible for the accuracy of the individual care plans. She stated she did not address the issue of dizziness or unsteadiness on the falls care plan, She revealed side effects from narcotic use were addressed on the care plan for pain, and included monitoring for signs and symptoms of dizziness, unsteadiness, blurred vision and oversedation. She offered no explanation as to why no interventions were noted on either the initial care plan or the comprehensive care plan. An interview with the attending Physician, on [DATE] at 9:10 AM, whose signature appeared on the certified copy of Resident #1's death certificate, revealed the [MEDICAL CONDITION] listed as the underlying cause of death on Resident #1's death certificate was the result of the fall the resident sustained [REDACTED].#1's death. An interview with the Administrator and the Director of Nursing (DON), on [DATE] at 3:00 PM, revealed Resident #1 was on the Falling Star Program which meant the resident was a high risk for falls and it should have been "common knowledge" that the resident should not be left sitting on the side of the bed. On [DATE] at 9:52 AM, the Administrator stated no further investigation was conducted related to the resident's fall from the bed because the resident stated he/she lost his/her balance and fell ; therefore, that was thought to be the cause of the fall. 2. A record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan, "At Risk for Falls," dated [DATE], included an intervention for non-skid socks to be on at bedtime as the resident allowed. A review of a Fall Risk Analysis, dated [DATE], revealed Resident #3 was high risk for falls. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #3 as cognitively intact, required extensive assistance of two staff for bed mobility, transfers, ambulation, toileting, and extensive assistance of one staff for person hygiene and bathing. An interview with Resident #3, on [DATE] at 12:00 PM, revealed he/she experienced a fall "last night while I was using the toilet." Resident #3 stated while an SRNA assisted him/her to pull up his/her pants, his/her feet slipped out from under him/her, and caused him/her to fall back onto the toilet. Resident #3 was not able to recall the staff who assisted him/her. The resident stated he/she required the staff's assistance to the toilet, on and off the toilet, and to pull his/her pants up and down due to hand weakness. Resident #3 stated the non-skid socks he/she wore when the fall occurred, on [DATE], were worn out and did not prevent his/her feet from sliding. The resident stated the staff was aware of the need for new socks. The facility presented an Incident/Accident report, on [DATE] at 9:45 AM, which included three staff statements which did not address the incident as was reported by the resident. LPN #1 was the charge nurse and her statement revealed no fall was reported to her on the night of [DATE]. SRNA #8's statement revealed she took Resident #3 to the toilet and the resident always "plops down hard" on the toilet and this was usual behavior for the resident, so she did not feel it was necessary to report it to the nurse. She stated the resident refused assistance to sit on the toilet and did not complain of pain. SRNA #9 denied any knowledge of the incident. The facility did not present evidence of an investigation establishing the root cause of the fall. 3. A record review revealed the facility admitted Resident #4 to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan for Falls, dated [DATE], revealed Resident #4 was at risk for falls related to an unsteady gait and impaired mobility. A review of the Fall Risk Analysis, dated [DATE], revealed the resident was assessed to be at high risk for falls. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 as requiring extensive assistance of one staff for ambulation, dressing, hygiene and bathing. A review of the Nurses' Note, dated [DATE] at 3:30 AM, revealed documentation of two quarter-sized purple discolorations to the left cheek from lying on the left side with his/her hand under his/her head. A review of the physician's progress notes, dated [DATE], revealed documentation by the Advance Practice Registered Nurse (APRN), who noted two quarter-sized dark bluish bruises on the resident's left cheek and forehead, and the resident stating he/she bumped that area trying to get out of the bed. A review of an Incident/Accident report, dated [DATE], identified two quarter-sized bruises on the left cheek and stated the cause was related to the resident lying on the left side with his/her hand under his/her head. For action to be taken, it was noted that the bruising would be monitored for ten days and then reassessed. Further review of the Incident /Accident report revealed to pad the bedside table, monitor bruising and start on anti-[MEDICAL CONDITION] medication in the morning. An interview with the Assistant Director of Nursing (ADON), on [DATE] at 3:55 PM, revealed she did not know why an investigation was not completed. She stated the next day Resident #4 mentioned that he/she fell and hit the table, so she added an intervention to pad the bedside table as a precautionary measure. The occurrence of a fall from bed was not mentioned in the report. The facility was not able to provide evidence of an investigation as to the root cause of the injury. An observation of Resident #4, on [DATE] at 7:10 AM, revealed the resident was sitting in a wheelchair in his/her room. The resident was noted with a large pink and purple bruise on the left cheek. When questioned about what happened to his/her cheek, the resident stated he/she fell off the bed and hit his/her face on the table. An interview with the Administrator, on [DATE] at 9:30 AM, revealed when there was an accident or incident, the licensed nurse was notified and that person was to initiate an investigation by utilization of the Incident/Accident Form. The nurse also filled out an investigative analysis which indicated the what, when, how, and why the incident occurred. When a determination was made, the physician and the family were notified. If it was an emergent situation, care was provided before this took place and the Administrator and the DON were notified. Every incident was addressed in the AQA meeting held on Monday through Friday. If the incident occurred on the weekend, the Staff Development/Week-end Supervisor reviewed it. Intervention are discussed in the AQA meeting. The licensed nurse is to be contacted with any questions. The resident's record is to be reviewed. The care plan and the the Nurse Aide Data Sheet are updated. A care plan progress note is to be documented on the care plan section of the resident's record. If the resident was sent to the hospital they were reassessed upon return from the hospital. While the facility Administrator detailed this as their process the facility was unable to provide evidence that their process was thorough in in identifying causal factors, abuse, neglect in order to address concerns and prevent further recurrence. An acceptable Allegation of Compliance was received on [DATE] and detailed the following: The Administrator was re-educated by the Regional Vice President of operations from our resource team, on [DATE]. The requirement of the administrator to administer the facility in a manner that enabled it to use its' resources effectively and efficiently to attain or maintain the highest practical, physical, mental and psychosocial well-being of each resident. This included the need to oversee the investigative process for incidents and accidents and utilize the facility resources to validate the interventions were developed, care planned, communicated and implemented. It also included establishing and overseeing policies and procedures to avoid instance of abuse or neglect. As leader of the facility's Quality Assessment and Assurance Committee, the Administrator leads the group and supports them in implementing processes to identify areas of quality that may be deficient and to develop action plans to achieve desired quality and monitor the effectiveness of the plans. The ADON will be responsible to monitor oncoming shifts to assure that all staff scheduled to work have been trained in the planned education for their position. The ADON will train or assign a qualified designee to provide training to anyone oncoming who lacks the required training. Any employee not available for their training due to leave or valid reason, will be sent a certified letter instructing them that they may not work until they have successfully completed all training. A post test that covers training provided will be administered a week after training was initiated. The test will be tailored for each department to validate retention and understanding. Additional testing will be conducted monthly for three months and quarterly for one year. Education of the process will be included in the orientation of new employees in the respective departments Verification of removal of Immediate Jeopardy was completed as follows: Training of the Administrator, on [DATE], was verified by a review of the sign-in sheet on [DATE]. A review of the completed post test and a scheduled up-coming post test validated the process was in place on [DATE]. The facility presented a copy of the letter of notification mailed to staff on leave or otherwise absent instructing them that they may not work until they have successfully completed all training. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" based on the need of the facility to continue to evaluate the implementation of changes and quality assurance activities.

Based on interview, record review and review of the facility's policy and procedure, it was determined the facility's Quality Assurance Program failed to identify quality issues related to fall investigations, causal factor identification, and failed to develop and implement appropriate plans of action to correct identified quality deficiencies for three residents (#1, #3 and #4), in the selected sample of four residents. On [DATE], at approximately 2:00 AM, a PRN (as needed) dose of [MEDICATION NAME] (pain medication) was administered to Resident #1. At 4:00 AM, the staff assisted Resident #1 upon the side of the bed to a sitting position and then left him/her alone in the room, which resulted in Resident #1 falling from the bed, sustaining an [MEDICAL CONDITION] (bleeding within the skull). Resident #1 subsequently expired on [DATE]. [MEDICAL CONDITION] was listed as the underlying cause of death on a certified copy of Resident #1's death certificate. The facility's investigation failed to identify that the staff did not provide the necessary supervision to prevent accidents and the comprehensive care plan was not complete with risk risk factors Resident #3 sustained a fall, on [DATE], when his/her feet slipped from under him/her as staff pulled his/her underwear up, after being on the toilet. A review of the facility's Incident/Accident Report, dated [DATE], revealed the investigation did not include evidence of the cause of Resident #3's feet slipping from under him/her. Resident #4 sustained a fall from the bed resulting in a bruise to the left cheek. The facility's Incident/Accident Report, dated [DATE], submitted as an investigation, failed to address the issue of the fall from bed. The facility could provide no evidence that the Quality Assurance Program identified these quality issues and took action to prevent recurrence. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Substandard Quality of Care was identified at 483.13 Resident Behavior and Facility Practices and 483.25 Quality of Care. (Refer to F224, F279, F280, F282, F323, and F490) Findings include: A review of the facility's policy and procedure, Quality Assessment and Assurance Committee, revised [DATE], revealed the policy of the facility was to establish and maintain a Quality Assessment and Assurance Committee for the purpose of monitoring compliance with regulatory guidelines and identifying quality of care and quality of life issues within the scope of services provided by the facility. Procedures include the authority to supervise, and make recommendations and take corrective actions on concerns identified which impacted resident service or facility operations. The committee would have formal methods to identify issues in the facility which required review and would respond to identified issues. An interview with the Administrator, on [DATE] at 9:30 AM, revealed when there was an accident or incident, the licensed nurse was notified and that person was to initiate an investigation by utilization of the Incident/Accident Form. The nurse also filled out an investigative analysis which indicated the what, when, how, and why the incident occurred. When a determination was made, the physician and the family were notified. If it was an emergent situation, care was provided before this took place and the Administrator and the DON were notified. Every incident was addressed in the AQA meeting held on Monday through Friday. If the incident occurred on the weekend, the Staff Development/Week-end Supervisor reviewed it. Interventions are discussed in the AQA meeting. The licensed nurse is to be contacted with any questions. The resident's record is to be reviewed. The care plan and the the Nurse Aide Data Sheet are updated. A care plan progress note is to be documented on the care plan section of the resident's record. If the resident was sent to the hospital they were reassessed upon return from the hospital. An Interview with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Quality Management Nurse, on [DATE] at 3:00 PM, revealed all incidents are reviewed Monday through Friday in the Abbreviated Quality Assurance (AQA) meeting and if a trend was identified, they developed an action plan. An action plan was in place on [DATE] through [DATE], during which time inservices related to fall precautions and alarms were completed. The Licensed Nurses and Charge Nurses were to complete checks to ensure alarms were in place and working. Audits were completed, but were shredded after being verified as completed. Validation of the the process was completed by review of the the individual care plans, progress notes completed by the Minimum Data Set (MDS)Coordinator, Licensed Nurses, or the Unit Manager. During the period of [DATE] through [DATE], problems were identified regarding Resident #1 and were discussed in the AQA meeting on [DATE]. The facility's AQA identified the resident was sitting on the side of the bed unsupervised and fell forward. They initiated mandatory inservicing for all staff on [DATE], related to not leaving residents sitting on the side of the bed. They did not have a monitoring tool, as all departments (Housekeeping, Laundry, Dietary) were responsible for monitoring residents observed sitting on the side of the bed. The outcome was no other falls "like that" had occurred. Inservices continued through [DATE], which was a period of maintenance. While the facility's AQA process identified staff had left Resident #1 unsupervised and provided training to staff, the AQA system failed to identify that the resident's care plan did not detail all the fall's risk factors, the facility's investigation failed to initially identify that the facility staff left the resident unsupervised, and the facility did not identify that neglect had occurred. These failures prevented the facility from taking necessary action to correct the quality deficiencies. While the facility re-opened the Action Plan in [DATE], after an increase in falls had been identified by the AQA committee, there was no evidence that the facility had identified and took corrective action related to the failures in their investigations to ensure that causal factors were identified and effective interventions were implemented to prevent the recurrence. An interview with the Administrator and the Director of Nursing (DON), on [DATE] at 3:00 PM, revealed Resident #1 was on the Falling Star Program which meant the resident was high risk for falls. It should be "common knowledge" that the resident should not be left alone sitting on the side of the bed; therefore, it was not necessary to document risk factors related to balance. On [DATE] at 9:52 AM, the Administrator stated no further investigation was conducted related to the resident's fall from the bed, because the resident stated he/she lost his/her balance and fell ; therefore, that was thought to be the cause of the fall. An acceptable Allegation of Compliance was received on [DATE] and detailed the following. The members of the facility's Quality Assurance and Assessment (QAA) Committee include the Administrator, the DON, the Assistant Director of Nursing (ADON), Clinical Nurse Supervisor, MDS Coordinator, Unit Nurses, Rehab Director, Activities, Business Office, Admission Office, Dietary Manager, Environmental Services Manager, Medical Records, and Social Services. All were provided re-education to affirm that the committee is to facilitate a process that involved areas of the facility operation to systematically monitor the performance of the various areas of concern or quality deficiencies with facility systems, and develop action plans to correct areas identified. They were also educated that it was the responsibility of the committee to oversee the implementation of the plans, monitor the effectiveness of the plans and make adjustments to the plan if desired outcomes were not achieved. The QAA committee will review the audits and checklist utilized to monitor the completion of the task related to fall risk, care plan revisions and incident investigation through AQA meetings held daily on standard work days and at monthly QAA meetings. This education was provided by the Quality Management Specialist on [DATE], and will be repeated for any member not initially trained on their next scheduled work day. The Medical Director will be educated on or before her next visit. Verification of removal of Immediate Jeopardy was completed as follows: The education was initiated on [DATE] and verified by review of the sign-in sheet and an interview with LPN #1, on [DATE] at 2:10 PM, who was a QAA committee member, validated the content. Discussion with the Medical Director was completed, on [DATE], and validated by signature on the sign-in sheet. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective [DATE], as alleged in the AoC with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.