Every finding on record at Redbanks

Based on record review and staff, resident, and family interviews, the facility failed to ensure that residents and / or their representatives were afforded the opportunity to participate in the development and implementation of their person-centered plan of care. This failure was identified for Residents 16 and 86.The findings include: Review of the facility policy titled Resident Participation Assessment / Care Plans (Revised February 2021) revealed that it required that residents and their representatives were entitled to participate in care planning, set goals and expectations, be informed in advance of any changes, review and sign the plan after significant updates, and receive explanations, advance notice, and adequate time for discussion. The Social Services Director (or designee) was responsible for notifying residents / representatives and maintaining thorough records of all notices, contacts, participation, refusals, etc.A review of the medical record of Resident 86 (R86) revealed that she had a diagnosis of Peripheral Vascular Disease and a history of Cerebellar Stroke Syndrome. The resident's Comprehensive Minimum Data Set (MDS) indicated that she scored 15 of 15 on a Brief Interview for Mental Status (BIMS) test, which indicated that the resident had intact cognition, and the record also revealed that her short-term and long-term memory was OK.A progress note review for R86 revealed a comprehensive care plan review conducted on 05/27/2025 at 6:10 PM, with her son participating by phone. The next documented care plan conference did not take place until 03/03/2026, again with the son by phone. A review of the resident's electronic medical record revealed that the Power of Attorney (dated 08/19/2019) did not grant medical decision-making authority.During an interview with Resident 86 on 06/16/2026 at 10:30 AM, she stated that she had not received invitations to care plan meetings. Review of Resident 16's medical record revealed that she had a diagnosis of unspecified dementia, metabolic encephalopathy, and vascular dementia. R16's most current Comprehensive Minimum Data Set, dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive dysfunction.During a telephone interview conducted on 06/16/2026 at 9:21 AM with Family #11, the party responsible for Resident 16 (R16), reported that she used to participate by phone but was not invited to attend for over a year.During an interview with the Social Services Director on 06/17/2026 at 1:55 PM, the Social Services Director described his documentation practices for care plan meetings and family contacts. He maintained records through a separate email file and schedule rather than in resident charts. Regarding R86, he stated that the resident's son had participated by phone in March 2026, but the resident herself did not attend. He admitted that he was not consistent in documenting residents' refusals to participate. For Resident 16, the last formal care plan meeting per his records was held on 10/29/2024. He could not provide a specific reason for the gap or any evidence of attempts to contact Resident 16's representative (Family #11).During an interview with the Director of Nursing (DON) On 06/17/2026 at 3:10 PM, the Director of Nursing (DON) confirmed that R86 made her own medical decisions. During an interview with the DON on 06/17/2026 at 4:53 PM, the DON stated that Social Services notified families and residents by call or letter, but the current method and documentation location were unclear. The DON acknowledged that contact should have been tracked but could not identify where it was documented or explain the one-year gap in documentation for a care plan conference. The facility used a specific care plan conference template, and the MDS Coordinator was responsible for initiating notifications. Both the MDS Coordinator and Social Services shared responsibility for setting care plans.During an interview with the MDS Coordinator on 06/17/2026 at 5:06 PM, the MDS Coordinator stated that she added assessments to a shared Outlook Calendar, after which the Social Services Director was responsible for calling families / residents to schedule conferences. She was not involved when a conference was missed.During an interview with the Executive Director on 06/17/2026 at 5:11 PM, the Executive Director explained that residents and their legal representatives (guardians or POA) must have been invited to care plan meetings. Inclusion of non-POA family members for care plan meetings required a specific request from the resident, which should have been documented as an order or care plan note. Families were expected to have been invited by mail or telephone, with clear evidence maintained in the records. The facility policy titled Resident Participation Assessment / Care Plans (Revised February 2021) required that residents and their representatives were entitled to participate in care planning, set goals and expectations, be informed in advance of any changes, review and sign the plan after significant updates, and receive explanations, advance notice, and adequate time for discussion. The Social Services Director (or designee) was responsible for notifying residents / representatives and maintaining thorough records of all notices, contacts, participation, and refusals.

Based on observation, interview, and review of facility policy, it was determined that the facility failed to store food in accordance with professional standards for food service safety and quality. Opened foods were not dated. Expired foods and/or foods which were past their use by date were available for use and service to residents. This failure had the potential to affect 129 of 131 residents who consume food from the facility's kitchen and/or unit refrigerators. The findings include: Review of the facility policy titled Food: Preparation, with a revision date of 02/2023, revealed Item 17 stated that all refrigerated, ready-to-eat Time/Temperature Control for Safety (TCS) prepared foods that are to be held for more than 24 hours at a temperature of 41 degrees F or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). Observation of the walk-in refrigerator, on 06/10/2025 at 6:25 AM, revealed one partial box of cabbage containing two bags of cabbage with showed a use by date of 06/08/2025. One opened bag of lettuce had a use by date of 06/08/2025 and showed browning of the lettuce. Observation of the reach-in refrigerator, on 06/10/2025 at 6:35 AM, revealed one partial container of ham salad with a use by date of 05/03/2025, one partial container of potato salad with a use by date of 05/25/25, and one open container of parmesan cheese with an open date of 04/08/2025. Ongoing observation of the Reach-in Refrigerator for Cooks revealed two chicken salad sandwiches dated with a use by date of 06/09/2025. In addition, this refrigerator contained an open gallon jug of mayonnaise that was undated (no open date), and an open jug of teriyaki sauce with a received date of 05/28/2025 which did not list an open date. Observation on 06/12/2025 at 1:15 PM of the Central nursing station resident food refrigerator revealed 15 single-serve grape juice containers with best by dates of 01/17/2025 and 06/08/2025. Observation on 06/12/2025 at 1:30 PM of the South Port nursing station resident food storage revealed seven single-serve grape juice containers with a best by date of 01/17/2025. Interview with the Dietary Manager (DM) on 06/10/2025 at 6:30 AM, revealed that dietary staff should have removed the items which were beyond their use by date from the refrigerator. Additional interview with the DM, on 06/12/2025 at 2:03 PM, revealed that once food leaves the kitchen, it is a team effort of the floor staff and kitchen staff to ensure items are not stored beyond the best by date for food safety to prevent food related illness. In an interview with the Dietary Supervisor (DS) on 06/12/2025 at 2:10 PM, the DS stated that it was his expectation that staff provide nutritious and filling meals without bacterial growth. He stated once food was past the beyond use date, there was the potential to allow bacteria to grow and potentially cause foodborne illness. He added that in the cooler, longer storage times would allow increased moisture to form that alters the environment and may allow for contamination or cross contamination. In an interview with the Director of Nursing (DON) on 06/12/25 at 3:42 PM, the DON stated that it was the responsibility of the kitchen to remove the beyond use juices from the unit refrigerators. She stated the dietary department has a stock list and pantry list that is brought to each unit every day that includes juices, as well as other items, and the juices should be switched out every day by the dietary staff when they bring out the new tray of juices. Interview with the Executive Director on 06/12/25 at 4:15 PM revealed she expected food items to be labeled and dated to prevent potential food-borne illnesses.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for four (Resident (R)109, R93, R37, and R41) of five sampled residents reviewed for infection control. Facility staff failed to indicate, via signage, the need for precautions, as well as provide and/or ensure the use of Personal Protective Equipment (PPE) and hand hygiene by staff and visitors for R109, who was on contact isolation precautions. Action to protect others from the risk of infection was not taken when R109 was out of her room for non-essential purposes. In addition, staff failed to follow manufacturer's instructions after cleaning/disinfecting a used glucometer used on R41. During medication pass for R93 and R37, staff handled medications with bare hands, did not perform hand hygiene as required and/or administered medication that had fallen on top of the medication cart. Findings include: 1. Review of R109's Face Sheet revealed that the facility admitted the resident on 01/11/2025 with diagnoses including non-traumatic brain dysfunction and unspecified dementia. R109 was placed on the facility's secured memory care unit. Review of R109's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/19/2025, revealed a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated the resident had moderate cognitive impairment. Per this MDS, the resident required substantial/maximal assistance from staff with transfers and was occasionally incontinent of both bowel and bladder. Review of R109's current physician's orders revealed a new order, dated 06/07/2025 at 6:56 PM, for Macrobid (antibiotic) 100 milligrams (mg) oral capsule twice daily for a diagnosis of extended-spectrum beta-lactamase (ESBL - a type of Multidrug Resistant Organism (MDRO). Further review of physician's orders revealed an order dated 06/08/25 at 11:06 AM for Contact Isolation Precautions. Review of this order revealed it did not note whether the resident's infection was contained or not and did not indicate that the resident could leave their room. a. Review of the facility policy titled, Infection Control: Standard Precautions and Isolation, revised 10/2018, revealed its purpose is to guide care for residents known or suspected to have serious illnesses that are easily transmitted through direct contact or contact with contaminated items in the resident's environment. Further review of the policy revealed staff are to wear gloves (clean, nonsterile gloves are adequate) when entering the room if any contact is to be made with the resident or items in the room; change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage); and remove gloves before leaving the resident's environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. The policy also stated to wear a gown (a clean, nonsterile gown is adequate) when entering the room if substantial contact is anticipated with the resident, environmental surfaces, or items in the room, or if the resident is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing; and to remove the gown before leaving the resident's environment. The policy failed to address whether signage was required to be posted to indicate when precautions are in place. Observation of R109's room on 06/10/2025 at 6:30 AM revealed R109 was asleep in her bed. The resident's room contained two large red bins with lids marked with biohazard signage. Continued observation revealed no signage was posted either outside or inside the room to indicate that R109 was on any type of precautions. There was no Personal Protective Equipment (PPE) such as gloves and gown required for Contact Precautions present at the door prior to entering the room or visible inside the room. Observation of R109's room on 06/10/2025 at 6:42 AM revealed State Registered Nurse Aide (SRNA) 3 entered the room without donning PPE (including gloves or gown) and, using his bare hands, placed a large yellow plastic bag into one of the two red biohazard bins in the rooms. He then exited the room without performing hand hygiene. In a brief interview conducted at 6:43 AM, SRNA3 stated the red bins were needed because R109 was on precautions, and One bin is used for soiled linens, and the other for dirty diapers. In an interview with Licensed Practical Nurse (LPN) 4 on 06/11/2025 at 3:40 PM, she stated that Contact Precautions are required when there is a risk of exposure to infectious organisms, such as ESBL, which may be present on surfaces or linens. She reported that whenever a resident is placed on Contact Precautions, a sign should be posted immediately on the door of the resident's room, adding: People must be made aware. b. Further review of the facility policy titled, Infection Control: Standard Precautions and Isolation, revised 10/2018, revealed that the movement of a resident on Contact Precautions should be restricted, stating: Limit the movement and transport of the resident from the room to essential purposes only. Additionally, the policy directed that If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment. However, the policy failed to explain how precautions were to be maintained when a resident was outside of their room, nor did it specify what actions should be taken to minimize the risk of transmission in these circumstances. Observation of the facility's memory care unit dining room on 06/10/2025 at 12:56 PM revealed R109 was in the dining room for lunch, seated at a square, four-person table, with one resident seated to her left and another to her right. Two staff members were also seated at the table, positioned between the residents, and were providing assistance throughout the meal. This assistance included offering verbal encouragement and prompting to eat, as well as handing the residents their drinks and utensils. Neither the staff members nor R109 were wearing any PPE. SRNA11 was observed asking the resident if she was feeling uncomfortable while gently patting her back. She then requested assistance from another aide, and they helped reposition R109 in her wheelchair with their bare hands. After repositioning R109, neither of the two staff was observed to perform hand hygiene. c. Observation of R109's room on 06/11/2025 at 1:07 PM revealed that, after surveyor intervention, a yellow organizer was now hanging on the door with PPE stored in its pockets. A sign was now also posted, indicating that the resident was on Contact Precautions. The sign instructed visitors to speak with nursing staff before entering and outlined the required PPE, including donning gloves and a gown prior to room entry. Observation at this time revealed R109 was in her room with two visitors, Family Member (FM) 109A and FM109B. Neither of the visitors were wearing any PPE. At 1:11 PM, LPN4, the unit charge nurse, approached the doorway and informed the visitors that they should be wearing PPE. FM109-A responded, 'We didn't think we needed to wear anything since she was in the dining room when we got here. Further interview with FM109-A on 06/11/2025 at 1:20 PM revealed that she had been informed by staff during a visit on 06/08/2025 that she should wear gloves and avoid bodily fluids. However, she then expressed confusion about the need to wear PPE, stating that during her visit that day (06/11/2025) a staff member had entered R109's room without donning any PPE. An interview with FM109-B, conducted at the same time, revealed that she was also unclear regarding the PPE requirement. She stated, No one told us (about the Contact Precautions). I saw the sign, but I thought it was okay (to not don PPE) because [R109] was in the dining room when we got here. She added that by the time LPN4 informed them they should don PPE, they had already been visiting with R109 in her room for an hour and a half. In an interview with SRNA6 on 06/11/2025 at 2:20PM, she described the protocol for Contact Precautions for ESBL as business as usual; they do their day-to-day things without any special stuff. SRNA6 stated that the PPE needed for Contact Precautions included a gown, gloves, and mask, but added that this PPE would just be for changing and dressing. She stated the purpose of putting residents on Contact Precautions was that infection can be passed along through clothing or on your body. Although the policy related that movement for residents on Contact Precautions was to be restricted, SRNA6 stated that residents on Contact Precautions can attend communal dining, saying, I think so as long as it is contained, like it is in their urine or in a catheter, or they have bandages covering it. SRNA 6 indicated that there were different signs to indicate whether a resident's infection was contained (making isolation unnecessary.) Review of the sign at R109's door with SRNA6 at this time revealed that SRNA6 could not tell if R109's infection was contained or whether the resident should stay in their room, except for essential purposes only. Further interview revealed SRNA 6 could not recall the last time she received any training on infection control precautions such as Contact Precautions, and that all staff members were responsible for explaining PPE requirements to visitors. In an interview with SRNA7 on 06/112025 at 2:40 PM, she stated that she was unclear about the specific requirements for Contact Precautions, stating she thought it required staff to wear gloves. However, she then described that while providing care for a resident with an infection in the urine, she would need to wear a mask, gown, and gloves, throw everything away or put items in the hazard bins away after care was provided, and perform hand hygiene. She explained that the yellow caddies hanging on a resident's door indicate that staff need to wear PPE while providing care because the resident has some type of infection that staff need to protect others from. SRNA7 reported being under the impression that residents on Contact Precautions were supposed to remain in their room but expressed uncertainty, exclaiming, I am sorry; I am getting them all mixed up. When asked how she would know if a resident can leave their room, she stated, Typically I get told by the nurse, but the door signage would also tell me. However, review of the door signage revealed it did not indicate whether the resident could leave the room. SRNA 7 further stated that she had recently returned to work at the facility and received some training on infection control practices at that time; however, her last in-depth training on the topic occurred approximately one year ago. In an interview with LPN 4 on 06/11/2025 at 3:40 PM, she stated that Contact Precautions were used because, They [the residents] have some kind of organism you could contract if you came into contact with it. She added that for Contact Precautions, You have to wear the gear every time you go in the room because you may come into contact with it; it may be in the room or on soiled linen. Regarding R109, she reported that R109 was on Contact Precautions due to ESBL in the urine but was unsure when the precautions were initiated. When asked about the protocol for Contact Precautions, she stated: If it [the infection] is contained, like the urine is the issue, they [residents] can still come out [of their rooms]. LPN4 stated that R109 is allowed to come and go as she pleases; she can go to therapy or sit in the common area. However, she acknowledged that because R109 does not don PPE, such as a gown, when exiting her room, her clothing could pose a risk for spreading ESBL and admitted that could be an issue. LPN4 stated that on the dementia unit where R109 resided, With these people back here, a lot of them are cognitively impaired, so it is up to staff to monitor it and make sure it isn't getting spread. [R109] does not do her own incontinent care, but if she sits on something it would have to be sanitized, but her room is infected and so her hands may not be clean. When asked whether they utilize any specific clinical criteria to determine whether a resident on Contact Precautions can participate in communal dining, she stated: I feel that if the staff is supervising the area and the resident has been toileted, it is okay for them to attend the meal. No risk assessment is completed. When asked how visitors would be informed and educated about the need to follow Contact Precautions/use PPE, she replied: We need to ensure everyone that goes in that room is wearing PPE .Visitors could take the organism home to their family. Staff are risking every one of these residents getting it. On 06/11/2025 at 3:55 PM, an interview was conducted with the Infection Control and Prevention Nurse (IP), along with Advanced Practice Registered Nurse (APRN) 1 and Advanced Practice Registered Nurse (APRN) 2. APRN1 stated that a resident would be placed on Contact Precautions for ESBL because it is highly contagious; it's so I can keep them away from the other residents. APRN1 then added that the decision to place a resident with ESBL on Contact Precautions is made on a case-by-case basis. However, no evidence was provided as to how this case-by-case decision was made relative to R109. APRN2 stated that R109 is permitted to leave her room, including to eat lunch in the communal dining hall at a table with other residents, because We can't confine them to their rooms; that wouldn't be good for them. However, she later stated that staff do make efforts to keep them in their room. The IP stated, We try to encourage them, but we can't make them stay in their room, and acknowledged that staff should be attempting to put a gown on her. She stated that there were no additional written policies outlining these protocols. Because staff made comments about different isolation requirements between contained and non-contained infections, a request was made on 06/12/25 at 9:06 a.m. with the IP for any policies differentiating Contact Precautions for contained versus non-contained infections. On 06/12/2025 at 9:35 a.m., the IP reported that there were no additional policies delineating the need for isolation in non-contained versus contained infections. The IP stated that it was up to the provider who initiates the orders to determine which should be followed. She stated that the order should contain that specification. Review of the physician's order confirmed that it did not distinguish between a contained or non-contained infection and called for Contact Isolation Precautions. In an interview with the Executive Director on 06/12/2025 at 4:33 PM, she stated that Contact Precautions require signage, PPE (gloves and gowns), red bins, and documentation in the resident's care plan. She reported that visitors are encouraged-but not required-to wear PPE, and staff are expected to read signage and don appropriate PPE upon entry. She explained that residents on Contact Precautions may leave their rooms based on psychosocial needs, though no formal assessment is used to determine this. She acknowledged the risk of exposure in shared spaces like the dining room and suggested that affected residents should avoid close contact with others, stating, Hopefully they won't touch anyone else. Hopefully they are not touching the area. Further interview with the Executive Director revealed that the failure to observe Contact Precautions included the potential for Spread of infection to residents, staff, family. 2. Review of the facility's policy and procedure titled, Administering Medication, revised 12/2012, revealed staff shall follow established facility infection control procedure (e.g. hand washing, antiseptic technique, gloves, isolation, precautions, etc.) for the administrations of medication, as applicable. a. Record review revealed R93's current medications orders included an order for Linzess oral capsule 72 micrograms (mcg) by mouth once a day for constipation. Observation during a medication pass on 06/10/2025 at 7:08 AM revealed Certified Medication Aide (CMA) 1 dropped a Linzess 72 mcg capsule into her bare hand, then proceeded to put it in the medication cup and administer it to R93.Observation revealed CMA1 failed to perform hand hygiene prior to touching the resident's medication with her bare hand. Interview with CMA1, on 06/10/25 at 07:15 AM, revealed it was not best practice to give a pill that had been placed in her bare hand, and it should have been put in a medication cup to administer. b. Record review revealed R37's medication orders included a 12/02/2024 order for Aspirin 325 mg one time a day by mouth for cerebrovascular accident (CVA- stroke). Observation during a medication pass on 06/10/2025 at 7:20 AM revealed CMA1 dropped R37's Aspirin 325mg, on top of the medication cart. CMA1 then proceeded to pick up the medication with her bare hand and administer it to R37.Further observation revealed that CMA1 failed to perform hand hygiene prior to picking up the pill with her bare hand. Interview with CMA1, on 06/10/25 at 07:29 AM, revealed that a medication should not be given after it had been dropped on top of the medication cart, but discarded and staff should administer another one. A joint interview was conducted with the Director of Nursing (DON) and Executive Director on 06/12/2025 at 4:33 PM. During the interview, the DON stated that nursing staff or CMAs were to discard a contaminated pill in the sharps container and get another one to administer. The DON added that the expectation of the staff is to use proper hand hygiene and standard precautions when giving medications. Further interview with the Executive Director revealed the expectation that if a medication was dropped or touched, it should be disposed of and not administered to residents. 3. Review of the facility's undated policy and procedure titled, Obtaining A Fingerstick Glucose Level revealed Step 18 stated staff were to Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of the manufacturer's instructions on the purple-topped container of Super Sani Wipes (used for disinfecting/sanitizing glucometers) revealed that staff were to Wipe Surface thoroughly. Allow surface to remain visibly wet for two minutes. Let airdry. Observation during a medication pass on 06/12/2025 at 11:55 AM, revealed that, per physician's orders dated 05/25/2025, CMA4 obtained a blood glucose reading on R41. After completing the test, CMA4 placed the soiled glucometer on top of the medication cart with no barrier. CMA4 then wiped the soiled glucometer three times for less than a total of ten seconds with a Super Sani Wipe from a purple-topped container. After using the wipe, CMA4 then immediately placed the glucometer on top of clean medical supplies on the medication cart. The product was not allowed to dwell (remain visibly wet) for two minutes, and then airdry before it was placed on supplies which were to be used for other residents. Interview with CMA4, on 06/10/25 at 11:30 AM, revealed that a soiled glucometer should not be placed directly on the medication cart without a barrier. Instead, it should be placed on a barrier and then cleaned. CMA4 stated education was received on how to clean the glucometer; however, she was unsure how long to allow the solution to dwell. A joint interview was conducted with the DON and Executive Director on 06/12/2025 at 4:33 PM. The DON stated that it was an expectation that the CMAs would place the dirty glucometer on a barrier and clean it for thirty seconds and allow it to dry, according to manufacturer's recommendations, and to dispose of/not use any clean supplies that dirty equipment may have contaminated. The Executive Director confirmed it was the expectation was that nursing staff or CMAs would clean the glucometers with the designated bleach wipes and use proper contact and dry times per policy. Per the Executive Director, if a dirty glucometer was placed on clean supplies, staff should dispose of the supplies and clean the glucometer.

AMENDED Based on observation, interview, record review, and facility policy review, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or stored and labeled in accordance with currently accepted professional principles, including the expiration date when applicable. Medications and nutritional supplements were opened but not labeled with a date as to calculate the discard date. Medications were found loose, without identification as to whom they belonged and/or what they were. This failure affected three of three medication rooms observed (out of a total of five rooms) and two of five medication carts observed (out of a total of nine carts.) The findings include: Review of the facility's policy, titled Storage of Medications, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner and the nursing staff shall be responsible for maintaining medication storage. Additionally, drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Review of the facility's policy, titled Administering Medications, revised 12/2012, revealed the expiration/beyond use date on the medication label must be checked prior to administering and that when opening a multi-dose container, the date opened shall be recorded on the container. 1. Items not dated upon opening: a. An observation of the [NAME] Unit Medication Cart 1 on 06/12/2025 at 8:55 AM revealed one 8.3-ounce bottle of PEG 335 Polyethylene Glycol for R141, as well as one 4.1-ounce bottle of PEG Clear Lax for R140, which were opened but not dated. b. Observation of the [NAME] Unit medication room on 06/12/2025 at 8:45 AM revealed one 32-fluid ounce container of Med Plus NSA 1.7, High Calorie, High Protein Nutritional Drink, Vanilla Flavor, one 32-fluid ounce container of Med Plus 2.0, High Calorie, High Protein Nutritional Drink, Butter Pecan Flavor, and one 46- fluid ounce container of ReadyCare Thickened Orange Juice in the refrigerator that were opened. None of these containers had a date indicating when the containers were opened, resulting in no way of determining the use by date. In an interview with Licensed Practical Nurse (LPN) 4 during observation of the [NAME] Unit medication room on 06/12/2012 at 8:50 AM, she stated that she writes the date on anything she opens and that is what should be done by everyone. c. An observation of the South medication room on 06/11/2025 at 3:39 PM revealed a 32- ounce container of Med Pass that was opened but not dated. Interview with Certified Medication Aide (CMA) 8 revealed that containers should be dated by whoever opened them. CMA 8 stated the container should be thrown away since staff would not be sure of how long it had been opened and opened containers should be discarded 30 days after opening them. During an interview with Registered Nurse (RN) 1 on 06/11/2025 at 3:55 PM, she stated all medicine should be dated when opened and should not be given to the residents as it could be expired. During an interview with the South Hall Unit Manager (UM) on 06/12/2025 at 4:10 PM, she stated the CMAs and Nursing staff were responsible to check the medication rooms weekly as part of their assigned duties. She stated the facility uses a lot of Med Pass, but she expected staff to date the container as they open it. During an interview with the Director of Nursing (DON) on 06/12/2025 at 3:40 PM, she stated she expected staff to date and initial any item when they open it. Additionally, she stated that central supply staff are to check supply expiration dates on their daily rounds, and if an item was not dated, it should be disposed of. The DON stated the unit manager was responsible for checking the medication rooms for expired medications as part of their weekly rounds. Interview with the Executive Director on 06/12/25 at 4:15 PM, revealed that containers of nutritional drinks/supplements should be dated when opened and that dietary staff and nurses putting new items in a refrigerator should check dates. 2. Expired Supplies: a. An observation of the [NAME] Unit Medication room on 06/12/2025 at 08:45 AM revealed one bag of 0.45% potassium chloride in normal saline 1000 milliliters, dated 05/25. In an interview with LPN4 during this observation, she stated that expiration dates should be checked prior to using any IV fluids and, The IV bag should have been thrown out. b. Observation of the [NAME] Unit medication room on 06/12/2025 at 8:45 AM revealed an Intel Swab Covid 19 Rapid Test on the supply shelf with an expiration date of 11/30/2024. Observation of the Harbor Unit medication room on 06/12/2025 at 9:25 AM also revealed an OHC Covid-19 Antigen Self-Test on the supply shelf with an expiration date of 01/27/2024. Interview with LPN5 during the observation of the Harbor Unit medication room on 06/12/2025 revealed that covid tests should be thrown away when expired. In an interview with the DON on 06/12/2025 at 3:40 PM, she stated that central supply staff are to check supply expiration dates on their daily rounds. She stated if containers are expired, there is a chance to have a negative outcome for the resident. In an interview on 06/12/25 at 4:15 PM, the Executive Director stated that expired medications should be thrown out. She added that the responsibility to check expiration dates falls on the nurse using the product, and they should check the expiration date before using a product. 4. Unlabeled/Unidentified Medications: a. Observation of [NAME] Medication Cart 1 at 8:56 AM on 06/12/2025 revealed loose medications in the drawers without identifying information such as the name of the resident for whom it was prescribed, and the name/dose of the medication. In the left side Drawer 2, there was a capsule which was gray on one end and brown on the other end and Lifestar 404 printed on the capsule. (Per a pill identifier, this capsule was nitrofurantoin 100 milligrams (mg) (an antibiotic).) In the left side Drawer 3, there was a green, oval tablet with E imprinted on one side and 47 imprinted on the other. (Per a pill identifier, this tablet was losartan potassium 100mg (used to treat high blood pressure).) In the left side Drawer 4, there was a white, round tablet with ZC41 imprinted on one side. (Per a pill identifier, this tablet was carvedilol 12.5mg (used to treat conditions related to the heart and blood vessels).) In an interview with LPN 4 during observation of the [NAME] Unit medication room on 06/12/2012 at 8:50 AM, she stated that it is easy for pills to pop out of their cards when being replaced in the cart but they should have been removed from the draw and wasted. b. An observation of the South Medication Room on 06/11/2025 at 3:39 PM revealed a paper medicine cup in a drawer that contained a half tablet inside of the cup. The bottom of the medication cup had a handwritten note identifying the tablet as Keppra 250mg. During an interview with CMA8, she stated she did not know who the Keppra tablet belonged to or how long it had been in the drawer, adding that it should be discarded. During an interview with RN1 on 06/11/2025 at 3:55 PM, she stated she was not aware of the Keppra being in the drawer and did not know how long it had been there, adding that it should be discarded. She stated the nurses were responsible for checking the medication rooms but did not know how often it should be done. During an interview with the South Hall Unit UM on 06/12/2025 at 4:10 PM, she stated she did not have an explanation as to why the Keppra was found in a drawer. She stated it was in a drawer on the side of the medication room that was not often even used and had no idea why it was in there. Further interview revealed her statement that the CMAs and Nursing staff were responsible to check the medication rooms weekly as part of their assigned duties. In an interview with the DON on 06/12/2025 at 3:40 PM, she stated that she would not expect to find loose pills in medication carts, but it can happen, and her expectation was that staff would check for things like that. Additionally, she stated her expectation was that that the unit managers would check the medication rooms weekly and that medication carts would be cleaned weekly.

Based on interview, record review and facility policy review, it was determined the facility failed to notify the resident's responsible party of a change in condition for one (1) of ten (10) sampled residents (Resident #1). The findings include: Review of the facility policy titled, Change in a Residents' Condition or Status, dated [DATE] revealed the facility nurse was to promptly notify the resident, his or her attending physician or the physician on-call, and resident's representative of significant changes in the resident's medical or mental condition and or status. Further review revealed the nurse was to record the information relative to the changes in the resident's medical or mental condition or status in the resident's medical record. Closed record review revealed the facility admitted Resident #1 on [DATE], with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued record review revealed Resident #1 had expired at the hospital on [DATE] at 7:05 PM. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated moderate cognitive impairment. Review of the facility's Routine Skin Observation dated [DATE] for Resident #1, signed by the Director of Nursing (DON) revealed the following pressure related skin concerns: Stage 1 pressure injury to coccyx which measured 1.4 cm x 1.2 centimeters (cm); Stage 1 pressure injury to left heel which measured 3 cm x 3 cm; suspected Deep Tissue Injury (DTI) to right heel which measured 4.5 cm x 5 cm. Continued review revealed the right heel documentation included notation of a fluid filled blister with clear fluid seeping from the heel during the assessment. Further review revealed a dark purple area to proximal aspect of right heel which was a suspected DTI. Review of the facility's Wound Observation dated [DATE] for Resident #1 signed by the Wound Nurse, revealed a pressure injury with suspected DTI to the right heel measuring 4.5 cm x 5 cm, with no exudate. Further review revealed notation of Necrotic Tissue Type which was adherent soft black eschar was marked and the amount indicated greater than 50% but less than 75% (of eschar to good tissue ratio on the resident's foot). Further review revealed however, no documented evidence of other pressure injuries being present. Review of the facility's Initial Wound Evaluation and Management Summary dated [DATE], from an outside wound specialist revealed Resident #1's right heel had an unstageable deep tissue injury measuring 6 cm x 4 cm with moderate drainage. Review revealed a Surgical Excisional Debridement Procedure notation which documented the wound physician discussed the treatment risks and benefits and possible need for additional procedures on the right heel wound were explained on [DATE] to the patient who indicated agreement to proceed with the procedure. Continued review revealed the right heel pressure injury was surgically debrided on [DATE], with 7.2 cm of tissue removed. Further review of the outside wound specialist's documentation revealed on [DATE], 11.55 cm of tissue was removed and on [DATE], 9.0 cm of tissue was removed for a total of 27.75 cm of tissue removed. However, further record review revealed no documentation to indicate the wound nurse had informed or made Resident #1's POA aware of the surgical procedures performed by the outside wound specialist to the resident's right heel. Review of the facility's Skin/Wound Note dated [DATE] at 2:27 PM for Resident #1 revealed the wound nurse had called Resident #1's POA and informed her of the resident's wound status, the physician's visits and orders. However, further review revealed no documented evidence the facility had notified the POA of the wound having been surgically debrided on [DATE] and [DATE]. Interview on [DATE] at 4:00 PM, with Resident #1's Power of Attorney (POA) revealed she was Resident #1's legal medical POA and had requested the facility inform her of any medical issues the resident experienced. She stated she had requested Resident #1's medical record from the facility and reviewed it. Continued interview revealed on [DATE], when her family member, Resident #1 had been admitted to the facility, she had been informed the resident had a small sore that looked like a blister on his/her right heel. Resident #1's POA stated the nurse had asked about a consult for Resident #1 to see the wound specialist and she (the POA) had agreed. She stated she had never been informed of the pressure wound details or any surgical procedures that had been performed at the facility, even after asking nursing staff several times. Interview revealed she had informed the facility that Resident #1 had lost seventeen (17) pounds in a year and had a poor appetite. The POA stated however, she had not been informed at any time that Resident #1 had not been not eating or drinking. She stated due to COVID she had not been able to visit the facility and on [DATE], she received a call from one of the therapists telling her Resident #1 had declined significantly. According to the POA, she immediately called the facility and was told only Hospice residents were allowed visitors at that time. She said she had been so upset she asked the facility to admit Resident #1 to Hospice just so she could enter the facility to see her loved one. Interview revealed on [DATE], she had been on her way to the facility to see Resident #1 when she received a call and had been told the resident coded at the facility and had passed away at the hospital. The POA stated she had been in shock at how Resident #1 looked when she his/her body at the funeral home. Per the POA, Resident #1 had looked like an Auschwitz concentration camp victim because he/she was so emaciated with a sunken in face. Further interview revealed the POA stated Resident #1 looked nothing like he/she had just three (3) weeks before. The POA further stated she discovered during her review of the resident's medical record that Resident #1 had just weighed eighty-nine (89) pounds and had lost seven (7) pounds in just two (2) weeks. In addition, the POA stated she did not see how someone could not have seen how severely malnourished Resident #1 had been prior to his/her death. Interview on [DATE] at 12:27 PM and [DATE] at 11:58 AM, with the Wound Nurse (a Registered Nurse) revealed she had been responsible for updating residents' family members with changes if a resident had any wounds. She stated the facility had used an outside source for Resident #1's wound care and the outside wound staff came every week to the facility to see the resident. Continued interview revealed Resident #1's POA had given verbal consent on the day of Resident #1's admission in a telephone call with the Director of Nursing (DON) for the resident to have a wound consult. She stated surgical debridement had been a part of the services provided by the outside source wound physician. Per the Wound Nurse, she had updated Resident #1's POA on [DATE], when the wound had first been debrided; however, she was unaware how a family member would know that procedure entailed. Continued interview revealed she had not called the POA with any other updates after [DATE] (Even though Resident #1 experienced two [2] other surgical debridement's after that day). She stated that once the facility had gotten the approval for Resident #1's wound care it had been discussed with the family that procedures would be done at the resident's bedside and some procedures would be serial like (done more than once) debridement's. The Wound Nurse stated if a simple procedure like a scrape was done, the facility would not notify the resident's family, but if a significant change or decline in a resident's wound status occurred the resident's family would be notified. However, further record review revealed no documented evidence that Resident #1's wound care procedures or details of the procedures had been discussed with the resident's POA. Interview on [DATE] at 11:14 with the DON revealed she had no way of knowing what communication or documentation of what took place regarding Resident #1's wound care; however, the Wound Care Nurse would know. She stated the facility had a Wound Care Certified Nurse who was responsible for the residents' wounds in the facility, and her expectation was that the Wound Nurse would notify the resident's family following the wound physician's visits with any changes. Continued interview revealed family members were not notified of residents' meal refusals or hydration alerts unless it triggered an alert and a change in condition had been completed. She further stated if a resident refused two (2) to three (3) consecutive meals in a day it would trigger an alert to the dashboard (computerized triggered information which notified staff a resident had not met his/her daily hydration or meal intake goal) in the facility's Point Click Care (PCC) system.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of ten (10) sampled residents (Resident #1) The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person Centered, dated [DATE], revealed a comprehensive, person-centered care plan which included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was to be developed and implemented for each resident. Further review revealed the assessments of residents were to be ongoing and care plans were to be revised as information about the residents and the residents' condition changed. Closed record review revealed the facility admitted Resident #1 on [DATE] with Mild Cognitive Impairment, Fracture of Unspecified Part of Neck of Right Femur, Cognitive Communication Deficit, Initial Encounter for Closed Fracture, and Dysphagia. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed the facility had assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated he/she was moderately cognitively impaired. Continued record review revealed Resident #1 had expired at the hospital on [DATE] at 7:05 PM. Review of facility's admission assessment note dated [DATE] at 6:10 PM, revealed Resident #1's daughter had informed the DON that Resident #1 had experienced a seventeen (17) pound weight loss in the last year following the death of her spouse and he/she had a poor appetite. Review of the admission assessment note further revealed Resident #1's daughter had requested vitamin supplements and collagen bone broth to be given to the resident which she (the daughter) would provide to the facility. Review of the facility's Comprehensive Care Plan initiated on [DATE], revealed the facility had care planned Resident #1 to have a nutritional problem or potential nutritional risk. Continued review revealed the care plan had been revised by the dietician on [DATE] to include Resident #1 being at nutrition risk related to: Body Mass Index (BMI) less than nineteen (19); pressure injuries, diagnosis; inadequate oral intakes; and he/she was at risk for dehydration. Review revealed the goal was for Resident #1 to maintain an adequate nutritional status as evidenced by maintaining weight within (X) % of (SPECIFY BASELINE), (This was a generic goal which was not addressed until [DATE]) - no signs and symptoms of malnutrition, and the resident consuming at least fifty percent (50%) of at least two (2) or more meals daily through the review date of [DATE]. Per review of the care plan, the care plan goal was revised on [DATE] to include Resident would gain two (2) pounds in a month to a goal weight of one hundred and two pounds (102 lbs) with his/her wounds to be improved through the next review date of [DATE]. Further review revealed the interventions included: staff were to monitor and report as needed any signs and symptoms of Dysphagia including refusing to eat, choking, coughing, drooling, and holding food in his/her mouth. Review revealed the interventions additionally included staff to monitor Resident #1's intakes and record the results. Review of the care plan revealed however, no evidence of care plan interventions to address how: staff were to know how to assess Resident #1's appetite; anticipate his/her food and fluid needs; when his/her weights were to be obtained to ensure he/she gained the two (2) pounds in a month; or how to utilize the data derived from recording the resident's food and fluid intakes. (This indicated the facility had not addressed Resident #1's inadequate oral intakes and risk for dehydration until [DATE] even though the facility had been aware of that information when Resident #1 was admitted on [DATE].) In addition, review of Resident #1's Self Care Deficit care plan revealed the resident noted as able to feed self independently after tray set up. Continued review of the Self Care Deficit care plan revealed Resident #1 may require assistance at times with eating. Further review of the care plan revealed however, no documentation for staff which noted how they were to determine when they should provide the assistance Resident #1 might need with eating. Further record review revealed no documented evidence of how staff were to know when to obtain Resident #1's weight to ensure he/she gained two (2) pounds in a month; how they were to know how to assess the resident's appetite and anticipate his/her fluid and food needs; or how and when staff were to use the recorded data regarding the resident's fluid and food intakes as per the care plan. Additionally, revealed revealed no evidence of documentation to indicate the facility had a system in place to ensure staff implemented Resident #1's care plan. Review of the facility's CNA Bedside Kardex Report revealed the information documented noted Resident #1 as able to feed self independently after tray set up and he/she might require assist at times. Interview on [DATE] at 10:14 AM, with Unit Manager #1 revealed the admitting nurse initiated residents' baseline care plans. She revealed the nurses should update residents' care plans with any changes. Interview on [DATE] at 4:44 PM, with LPN #3 revealed the Certified Nursing Assistant (CNA) should report to nurses immediately if a resident was not eating or drinking well. She stated a Stop and Watch (a tool that staff completed when a change in a resident was observed or noted) should be completed with residents' meal refusals and with their decreased intake of fluids or meals. Continued interview revealed if notified she would assess the resident, offer substitutions and notify the Advanced Practice Registered Nurse (APRN) and family. She further revealed nurses updated residents' care plans with new physician's orders, and staff should follow the care plans. Interview with the MDS Nurse on [DATE] at 9:56 AM, revealed the purpose of residents' care plans was for staff to know what type of care the residents' needed and how to provide the care. She stated the baseline care plan was initiated by the admissions nurse and the floor nurses and unit managers updated the care plan if needed with new orders. Continued interview revealed the care plan was updated with each MDS Assessment. She stated the dietician updated residents' dietary/nutrition care plans. Further interview revealed possible outcomes with residents' care plans not being updated and revised as necessary would be residents might not receive the care they needed. Interview with the Director of Nursing (DON) on [DATE] at 12:04 PM, revealed she completed the admission assessment for Resident #1 and the POA informed her at that time of Resident #1's loss of seventeen (17) pounds in the past year since the death of his/her spouse. She stated the POA had requested bone broth on Resident #1's meal trays and extra vitamins to be administered to the resident. According to the DON, the resident's POA told her she (the POA) would provide the vitamins and bone broth to the facility. According to the DON, Resident #1 did not eat well and having a poor appetite was the resident's baseline; however, the DON stated she had not been aware that weight loss had been a current problem for the resident. Further interview revealed residents' weights were obtained on: admission; daily for three (3) days following admission; weekly times four (4) weeks; then monthly if the weights were determined as stable. In addition, the DON stated residents' care plans were updated by the nurses and unit managers and the care plans were to be as person centered as possible.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents identified as at nutritional risk were monitored and provided nutritional services to meet the needs of the resident to prevent severe weight loss for one (1) of ten (10) sampled residents (Resident #1). Resident # 1 was admitted to the facility on [DATE], with a history of a seventeen (17) pound weight loss in the past year, and of having a poor appetite since the death of his/her spouse. Resident #1 refused to be weighed on admission and the first documented weight for the resident was on 02/15/2021, with his/her weight documented as 94.6 pounds (lbs). Additionally, on 02/16/2021 Resident #1's weight was noted at 96.4 lbs and he/she was not weighed again until 03/03/3021, with the resident's weight noted as 89 lbs on that date. Resident #1's weight loss was determined as 7.6% weight loss in fourteen (14) days, which was indicative of severe weight loss. The findings include: Review of the facility policy titled, Nutrition (Impaired/Unplanned Weight Loss - Clinical Protocol dated 09/2017, revealed nursing staff were to monitor and document the weights and dietary intakes of all residents. Review revealed staff and the physician would define the individual resident's current nutritional status through review of weights, food/fluid intakes and pertinent laboratory values, and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition. Further review revealed staff would report to the physician significant weight gains or losses in residents, or any abrupt or persistent changes from baseline in a resident's appetite or food intake. Review of the facility policy titled, Weight Assessment and Intervention dated 09/2017, revealed the nursing staff were to measure residents' weight on admission, the next day and weekly for two (2) weeks thereafter. Further review revealed if no weight concerns were noted at that point, weights would be measured monthly thereafter. Closed record review revealed the facility admitted Resident #1 on 02/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated he/she was moderately cognitively impaired. Review of the facility's admission assessment note dated 02/11/2021 at 6:10 PM, revealed Resident #1's daughter had informed the DON that Resident #1 had experienced a seventeen (17) pound weight loss in the last year following the death of her spouse, and he/she had a poor appetite. Review further revealed Resident #1's daughter requested collagen broth and vitamin supplements be given to the resident which she would provide. Review of the facility's meal intake sheets dated 02/11/2021 through 03/04/2021, revealed Resident #1's meal consumption's had been noted as: a total of seven (7) meal refusals; thirty-six (36) meals documented as 25% or less consumed; thirteen (13) meals noted as 26% to 50%; four (4) meals documented as 51% to 75%; and two (2) meals noted as 76% to 100%. Further review revealed however, no documented evidence located in Resident #1's medical record to indicate the facility notified had notified the resident's physician or POA that Resident #1 was not consuming his/her meals very well. Review of the Health Status Notes dated 02/11/2021 through 03/04/2021 for Resident #1 revealed no documented evidence noting Resident #1 had experienced decreased meal intakes and refusal of his/her meals. Continued review of the Health Status Notes revealed on 03/03/2021, the APRN saw Resident #1 due to a hydration alert; however, did not address the resident's decreased meal intakes. Further review revealed no documented evidence Resident #1's family had been notified of the resident's decreased meal and fluids. In addition, review of the Health Status Notes further revealed weight refusals by Resident #1 on 02/11/2021 at 6:00 PM, 02/12/2021 at 5:40 PM, 02/13/2021 at 6:59 PM and 02/15/2021 at 5:35 AM. Review of the facility's Clinical and Order Alert Listing Report, revealed on 02/19/2021 and 02/28/2021, documentation that Resident #1 refused two (2) of three (3) meals with no documented evidence the facility had notified the physician/APRN or POA to make them aware the meal refusals. Continued review revealed on 02/19/2021 and 02/20/2021, it was noted an alternative meal or supplement had been offered to Resident #1 with less than 50% of meals or supplements consumed five (5) times in the last three (3) days. Review revealed on 02/26/2021, 02/19/2021, 02/25/2021, 02/26/2021, 03/01/2021, and 03/03/2021, staff were alerted that Resident #1 had consumed less than the desired amount of fluids for three (3) consecutive days. Review of the Hydration Alert Assessments dated 02/17/2021, 02/20/2021, 02/25/2021, 02/26/2021, and 03/02/2021, revealed no signs or symptoms had been noted on any of the completed assessments. Continued review revealed no documentation related to a Stop and Watch having been completed Resident #1, nor of a change of condition been completed for the residents. Review revealed the APRN had addressed one (1) of the Hydration Alerts for Resident #1 on 03/03/2021. Further review revealed however, no documented evidence the Physician or POA had been made aware of all the information regarding Resident #1's low intakes of food and fluids. Review of APRN #1's Note dated 02/17/2021, a telehealth visit, revealed Resident #1 had been seen per request of his/her family. Continued review of the 02/17/202 Note revealed Resident #1 had been noted as at risk for nutritional deficit and bone broth had been ordered for increased healing and nutrition. Review of APRN #1's visit noted dated 02/25/2021, revealed Resident #1 was being seen due to dietary recommendation to start Med Pass (a dietary supplement) to help with the resident's wound healing at incision site and to meet his/her nutritional status. Continued review of the 02/25/2021 Note revealed Resident #1 continued to be at risk for nutritional deficit with the Med Pass supplement being added. However, review of the 02/25/2021 Note revealed no documentation documenting APRN #1 had been made aware of Resident #1's decreased meal and fluid intake. Review of APRN #1's Note for a visit dated 03/03/2021, revealed Resident #1 was being seen due to a hydration alert for insufficient fluid intakes for three (3) consecutive days. Continued review of the 03/03/2021 Note revealed Resident #1 had been in no acute distress and stated she was drinking to thirst, and the resident's skin turgor was normal, and his/her oral mucosa was pink and moist. Further review of the 03/03/2021 Note revealed the APRN documented Resident #1 had minimal cognitive impairment with no treatment; however, that did cause the resident to have periods of decreased intake. Review of the 03/03/2021 APRN Note revealed Resident #1's fluid intake had been between 680 milliliters (ml) to 1400 ml over the past week with no signs and symptoms of dehydration. Review of the Nutrition Risk assessment dated [DATE] for Resident #1 revealed the resident weighed 96.4 lbs, had a body mass index (BMI) of 17.6 (which indicated the resident was underweight) and received a regular diet with chicken bone broth as a supplement. Continued review revealed Resident #1 was consuming 41% of meals and less than 1000 ml's of fluid a day. Further review revealed a recommendation was made for Med Pass 2.0, 60 ml's three (3) times a day. Review of the Nutrition Review-Other for Resident #1 dated 03/03/2021, revealed Resident #1's weight was 96.4 lbs with the last weight obtained previously on 02/16/2021. Resident #1's BMI had been 17.6 and his/her meal intake was 16% and fluid intake was 335 ml per day, and was consuming the supplement regularly. Interview on 02/22/2022 at 11:18 AM, 02/25/2022 at 12:28 PM and on 02/28/2022 at 11:40 AM, with the Registered Dietician (RD) revealed residents were weighed on admission, daily for three (3) days after admission, weekly for four (4) weeks then monthly if no weight concerns were identified. The RD stated residents with weight loss were monitored weekly during the facility's Nutritionally at Risk (NAR) meetings. He stated the facility's Point Click Care (PCC) system alerted staff when residents had weight loss. Continued interview revealed a resident would have to be weighed for the notification to occur. The RD stated he was aware the facility's policy stated residents were weighed weekly for two (2) weeks. He stated nursing was responsible for obtaining residents' weights and the Director of Nursing (DON) tracked new admissions on the whiteboard (a board posted at the nurse's station utilized by staff to document and obtain specific resident information) According to the RD, nursing recorded residents' weights and the residents were added to the NAR for weekly review. He stated monitoring for weight loss would include nursing staff monitoring the residents' weights closely and monitoring of their meal intakes. Further interview revealed he had completed a nutrition review of Resident #1 on 03/03/2121, and he noted a seven (7) pound weight loss had occurred from the last documented weight on 02/16/2021. He further revealed Resident #1 had not been being reviewed during the weekly NAR meeting and he could not think of any reason why the resident had not been included in the NAR meetings. The RD stated Resident #1 had refused to be weighed a few times; however, he could not recall if an alert had been triggered for his/her weight loss. He further stated he had recommended snacks between meals and a multivitamin. Interview with the Dietary Manager on 02/28/2022 at 11:25 AM, he became revealed he had looked back at the dates and Resident #1 had not been weighed for two (2) weeks and had not been on the facility's NAR list. He revealed residents with weight or intake concerns were discussed in the clinical portion of the facility's daily morning meeting. Further interview revealed since 03/01/2021, he had checked residents' weights each week. Interview on 02/22/2022 at 12:04 PM with APRN #1 revealed Resident #1 had shown a decline since he/she had been admitted to the facility in 2020; however, could not recall a lot about the resident. She stated the family had requested Resident #1 receive bone broth when admitted in February 2021. Continued interview revealed she had addressed the facility's hydration alerts for Resident #1, and was aware of the resident's decreased appetite. The APRN stated she could not recall what Resident #1's meal intakes had been though. She stated Resident #1 had been receiving medication for appetite and depression, and she had communicated with the Medical Director when she had concerns regarding residents. Further interview revealed the facility nurses also notified the Medical Director if needed. In addition, she stated she had not contacted the Medical Director regarding any concerns related to Resident #1 however. Interview with the Speech Language Pathologist (SLP) on 02/24/2021 at 11:40 AM, revealed she had noted a significant decline in Resident #1 on 03/04/2021. She stated she downgraded the resident's diet, completed a Stop and Watch and gave it to the nurse. Further interview revealed she could not recall who the nurse had been though. Review of the Stop and Watch tool completed and signed by the SLP on 03/04/2021, revealed Resident #1 overall needed more help, seemed different than usual, and talked and communicated less than before. Further review revealed a handwritten note regarding downgrading Resident #1's diet to puree and recommending the resident be a total feed. Interview with Certified Nursing Assistant (CNA) #1 on 2/22/2022 at 7:03 PM and 02/25/2022 at 12:50 PM, revealed she recalled Resident #1 because of the bone broth he/she received. She stated Resident #1 had a poor appetite and had not drank a lot. Continued interview revealed Stop and Watch forms were completed and given to the nurse when residents refused their meals. She stated a Stop and Watch form was not completed if residents were eating less than twenty-five (25%) percent. Further interview revealed residents were weighed on admission and for three (3) days then monthly after that. She further revealed residents' weights were on the whiteboard for staff to review and the residents' Kardexes had whether they were a lift or not when obtaining there weights, and if the resident was noted to be a lift, then that's how staff obtained their weight. Interview with Certified Medication Aide (CMA) #1 on 02/23/2022 at 4:03 PM, revealed she recalled Resident #1, who had received bone broth at mealtimes twice daily. She stated Resident #1 drank some of the broth, but not all of it. CMA #1 stated she encouraged Resident #1 to drink all the bone broth. Continued interview revealed Resident #1 had not had much of an appetite and substitutes were offered at mealtimes when the resident did not eat well. The CMA stated however, Resident #1 still only took a bite or two of any substitutes offered. Further interview revealed a Stop and Watch tool should be completed when a resident had a change in their eating or drinking. In addition, she stated whoever charted residents' meal intakes were responsible for completing the Stop and Watch tool and ensuring it was given to the nurse. Interview with CNA #2 on 02/24/2022 at 4:52 PM, revealed she would report to the nurse if a resident had not been eating or drink well. She further stated she would also complete a Stop and Watch form and offer the resident other things to eat or drink. Interview with CNA #4 on 02/25/2022 at 12:52 PM, revealed residents' weights were on the whiteboard at the nurse's station. She stated she would look at the resident's Kardex to see how a resident was weighed or see how they had been weighed previously. Further interview revealed a Stop and Watch tool should be completed for residents who had a decrease in their meal intakes or drinking, and the tool was to be given to the nurse. Interview with Licensed Practical Nurse (LPN) #3 on 02/24/2022 at 4:44 PM, revealed staff should immediately report to the nurses if a resident had not been eating or drinking well. She stated staff were to complete a Stop and Watch tool for residents' meal or fluid refusals and any decreased intake. Continued interview revealed she would report that kind of information to the APRN or physician and document all the information in the resident's medical record. LPN #3 stated the Stop and Watch information was charted as a progress note by the nurse once it was received from staff. Further interview revealed nurses got hydration alerts when residents' fluid intakes were low; however, she was not sure about alerts for resident's decreased meal intakes. She further stated if a resident refused two (2) meals an SBAR (Situation Background Assessment Recommendation which was an assessment the nurse completed when a resident had a change in condition) was completed, and the APRN and family were updated on that information. In addition, she stated if a resident was eating less than 25% of their meals, then that was a potential for weight loss for the resident. Interview with Unit Manager #1 on 02/23/2022 at 10:14 AM and 02/25/2022 at 11:51 AM, revealed a Stop and Watch tool was to be completed when a resident refused two (2) meals in a day or with repeated decreased oral intake. She stated staff completed the Stop and Watch tools and gave them to the nurse. According to Unit Manager #1, the nurse notified the APRN and completed a Stop and Watch Progress Note and an SBAR. Continued interview revealed residents' weights were obtained monthly, or weekly if the resident was receiving their meal intake as tube feedings. Per the Unit Manager, if residents' weights were off, the residents were re-weighed. She stated some residents were on daily weights. The Unit Manager stated the facility's process for newly admitted residents was for their weights to be obtained on admission, then for the following three (3) days, then monthly thereafter. Further interview revealed the nurse added which residents needed to be weighed to the whiteboard and the CNA's checked that at the beginning of their shifts. She stated the residents' Kardexes included the information for how a resident was to be weighed, and if it did not contain that information the CNA's were to ask the nurse. Further interview revealed the facility monitored for residents' weight loss by doing the three (3) day weights, notifying the dietician, and monitoring the residents' intakes by looking at the meal record. In addition, she stated residents' meal refusals triggered an alert, and the CNA completed a Stop and Watch as a result of the alert. The Unit Manager further stated the nurse assessed those residents and completed a Stop and Watch progress note in the resident's medical record. Interview on 02/24/2022 at 8:54 AM, with Registered Nurse (RN) #1 revealed he had provided care for Resident #1 one (1) day. He stated he recalled Resident #1 had not eaten or drank very well that day, and the resident had a poor appetite. Further interview revealed he had not received a Stop and Watch tool though; however, if he had received the tool he would have initiated a Stop and Watch progress note or SBAR. Interview with RN #2 on 02/25/2022 at 11:32 AM, revealed weights can be different for each resident. Weights can be daily, weekly, or monthly. She revealed weights are obtained on admission and for three (3) days. She revealed she did not know what the facility policy said on weights. She revealed orders for weights are obtained and that shows on the TAR. We write on the whiteboard, so the CNAs know who needs to be weighed. We do re-weigh if the weight is off using the same scale. She revealed the CNA's know what device to use by looking at the Kardex. She revealed the dietician would follow and monitor residents for weight loss by looking at intakes, meal refusal triggers an alert. The CNAs complete a Stop and Watch when a resident has a change in eating or drinking. Interview on 02/25/2022 at 12:30 PM with RN #3 revealed she was not aware of how often facility residents were weighed; however, thought it was daily for four (4) or five (5) days after their admission. RN #3 stated she was not sure what the facility's policy said regarding how often residents' weights were to be obtained. Further interview revealed residents' weights showed up in the facility's computer system for when they were to be obtained, and for newly admitted resident the admission nurse put the order in for obtaining resident's weights. Interview on 02/25/2022 at 11:40 AM with Unit Manager #2 revealed residents were weighed on admission and for three (3) days afterwards. She stated orders for residents' weights were entered in the computer and showed up on the residents' Treatment Administration Records (TARs) for which residents needed to be weighed. Further interview revealed the CNAs knew what to use for weighing residents, and if a resident was transferred using a lift, then that resident was to be weighed using the lift. Unit Manager #3 stated the dietician monitored residents for any weight loss. Interview on 02/23/2022 at 12:04 PM and 02/28/2022 at 11:14 AM, with the DON revealed she admitted Resident #1 to the facility on [DATE], and had completed the resident's admission assessment. The DON stated during the resident's admission, she had spoken with Resident #1's Power of Attorney, and the POA had told her the resident had lost seventeen (17) pounds over the past year following the death of his/her spouse. Continued interview revealed the POA reported to her that Resident #1 had a poor appetite, and the POA requested the resident receive bone broth at mealtime as well as extra vitamins which she (the POA) would provide the facility with. The DON stated hydration alerts were completed when the computer system alerted clinical staff that a resident's fluid intake was insufficient. She stated Hydration Assessments were completed by the nurse when there was an alert regarding the resident's fluid intake. According to the DON, Resident #1's Hydration Alerts had been completed with no signs and symptoms of dehydration noted. Further interview revealed the facility received no alerts on meal intakes until a resident refused 2-3 consecutive meals in a day. The DON further revealed the APRN reviewed residents' charts in the Point Click Care (PCC) system and addressed any alerts that a resident might have had. She stated the family was not notified of a resident's meal refusals unless it triggered an alert and a SBAR (change in condition form) was completed. In addition, the DON stated the facility obtained residents' weights on admission, daily for three (3) days after that, then weekly for four (4) weeks, then monthly thereafter if the resident's weight was stable. She further revealed Resident #1 had not eaten well because his/her baseline had been the resident having a poor appetite. Interview on 03/04/2022 at 3:44 PM, with the Executive Director revealed Resident #1 had a poor appetite when admitted to the facility. She stated Resident #1's poor intakes were not new and his/her family was aware the resident had a poor appetite as they had requested the bone broth and extra vitamins. Further interview revealed Resident #1 signed himself/herself in at admission, and had not been adjudicated as unable to make decisions regarding his/her care. In addition, the Executive Director stated Resident #1 had been able to make his/her own choices regarding care and had refused to be weighed. She further revealed Resident #1 had been educated by Speech Therapy regarding nutrition.

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). Resident #1 was identified by staff to be removing his/her sensor alarm and to get up and walk; however, the facility failed to revise the care plan to address the resident's behavior. The findings include: Review of facility policy titled, Comprehensive Care Plans, last revised September 2010, revealed the Comprehensive Care Plan is an individualized plan developed to include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs. Care Plans are ongoing and revised as information about the resident and the resident's condition changes, and at least quarterly. Record review revealed the facility admitted Resident #1 on 08/17/15 with diagnoses, which included Dysphagia, Oropharyngeal Phase, Cognitive Communication Deficit, Dementia, [CONDITION(S)] (COPD), and Paralysis of Vocal Cords and Larynx. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/17/2020, 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. Interviews with State Registered Nurse Aide (SRNA) #1 on 06/09/2020 at 12:30 PM, SRNA #2 on 06/10/2020 at 2:13 PM, and SRNA #3 on 06/10/2020 at 1:40 PM, revealed staff have witnessed the resident transferring self from bed and wheelchair to toilet self. The Aides stated the staff and resident's family were aware the resident would turn off sensor pad alarm. Review of Resident #1's Comprehensive Care Plan for High Risk for Falls related to history of falls, dated 08/08/15, revealed interventions for a sensor pad alarm while in bed and wheelchair, and to check for proper functioning when providing care. However. there was no documented evidence the care plan was revised to address the resident turning off the alarm. Interview with Licensed Practical Nurse (LPN) #1, on 06/10/2020 at 2:43 PM, revealed all nurses were responsible to review and revise residents' care plans as changes occur. Interview with the Director of Nursing (DON) on 06/12/2020 at 2:30 PM, revealed she was not aware Resident #1 would turn off his/her sensor alarm. She stated if licensed staff were aware resident turned off sensor alarm, she would expect care plan to reflect this information.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflects the resident's status for two (2) of thirty-four (34) sampled residents (Resident #10 and Resident #141). Resident #10's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/19, Section I Active Diagnosis, was coded as no infections during the seven (7) day look back period; however, review of the physician's orders [REDACTED]. Resident #141's Quarterly MDS Assessment, dated 11/25/19, Section J Health Conditions, was coded as no falls since prior assessment; however, review of the Fall Incident Reports, revealed the resident sustained [REDACTED]. The findings include: Interview with the MDS Coordinator, on 03/11/2020 at 5:00 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for accuracy of assessments. Additionally, the Assessment process included communication with licensed and non-licensed direct care staff members, and review of the medical record. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2017, revealed the primary purpose of the MDS Assessment was to identify resident care problems, address resident problems in individualized care plans, and monitor the quality of care provided to residents. Additional review revealed the Assessment should be an accurate reflection of the resident's status. 1. Review of Resident #10's medical record revealed the facility admitted the resident on 04/30/14 with [DIAGNOSES REDACTED]. Review of Resident #10's Progress Notes, dated 12/02/19 at 2:34 PM, revealed the facility transferred the resident to the emergency room related to behaviors and combativeness. Additionally, a Progress Note, dated 12/02/19 at 9:27 PM, revealed the resident was admitted to the hospital with [REDACTED]. Review of the Progress Note, dated 12/04/19 at 4:20 PM, revealed the resident had a midline to the left upper arm and received intravenous Ertapenem (antibiotic) every twenty-four (24) hours. Further, a Progress Note, dated 12/04/19 at 8:13 PM, revealed the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Review of Resident #10's physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of Resident #10's Progress Notes, dated 12/06/19 at 1:21 PM, revealed the resident continued on IV antibiotics for UTI; IV site clean with dry dressing intact. Additionally, a Progress Note, dated 12/07/19 at 8:40 PM, revealed the resident continued in isolation for UTI with IV [MEDICATION NAME] (Ertapenem) daily to midline left upper extremity. Review of the Progress Note, dated 12/09/19 at 2:52 AM, revealed the resident was tolerating IV [MEDICATION NAME] for UTI; midline flushes with some resistance due to positioning. Further, a Progress Note, dated 12/10/19 at 5:06 PM, revealed the resident's IV antibiotics, for UTI, were completed for that shift. Continued review revealed a Progress Note, dated 12/11/19 at 5:53 AM, revealing the resident continued on Antibiotics for UTI with ESBL, with midline to left upper arm and remained in contact isolation. The Progress Note, dated 12/12/19 at 11:09 AM, revealed the resident was taken off isolation precautions due to being asymptotic and completion of IV antibiotics; provider will remove midline. Review of Resident #10's Quarterly MDS Assessment, dated 12/11/19, revealed the facility did assess the resident as receiving six (6) days of antibiotic medication and IV medication, during the seven (7) day look back period for the Assessment. However, Section I Active Diagnosis, revealed the facility assessed the resident as having no Infections present. 2. Review of Resident #141's medical record revealed the facility admitted the resident on 10/12/17 with [DIAGNOSES REDACTED]. Review of Resident #141's Fall Incident Report, dated 10/10/19 at 10:51 AM, revealed the resident reported he/she fell when trying to sit down on the commode and fell to the left side hitting his/her arm on the grab rail in the bathroom. Additionally, the immediate action taken was applying nonskid strips in from of the commode. Per the Report, the resident was alert and oriented to person, place and time and had no obvious injury. Further, there was no predisposing environmental, physiological or situational factors contributing to the fall event. Review of Resident #141's Fall Incident Report, dated 11/05/19 at 5:00 AM, revealed the nurse heard resident yell for help. Per the Report, the nurse entered the resident's room and the upper half of the resident's body was on the bed with his/her legs twisted between the wheelchair and the bed. The resident stated he/she became dizzy and fell over in the bed while making up the bed. Continued review revealed the immediate action taken was assessment of the resident and new orders for [MEDICATION NAME] (antiemetic medication which may be used to treat [MEDICAL CONDITION]) as needed. Further, the resident was alert and oriented to person, place and time and had no obvious injury. Per the Report, there were no environmental or situational factors contributing to the fall event; however, the resident did have a current UTI. However, review of Resident #141's Quarterly MDS Assessment, dated 11/25/19, Section J Health Conditions, revealed the facility assessed the resident as having no falls since the prior assessment. Conversely, review of the medical record revealed since the previous assessment, the resident had fall events on 10/10/19 and 11/05/19. Interview with Licensed Practical Nurse (LPN) #5/MDS Coordinator, on 03/12/2020 at 4:17 PM, revealed she had worked in the building in this role for five (5) years. Additionally, she used the RAI guidelines to ensure accurate MDS Assessments. Per interview, when collecting data to complete MDS Assessments, she interviewed staff and the resident; completed a face-to-face assessment of the resident, and reviewed the medical record to its entirety. Per interview, it was important to ensure MDS Assessments were accurate and reflected the current status of the resident because the MDS Assessment helped develop and revise the Comprehensive Plan of Care. Further interview with LPN #5/MDS Coordinator, revealed after review of Resident #10's physician's orders [REDACTED].#141's Fall Incident Reports, dated 10/10/19 and 11/05/19, falls should have been coded on Resident #141's Quarterly MDS Assessment, dated 11/25/19. Interview with the Director of Nursing (DON), on 03/12/2020 at 5:26 PM, revealed she expected the MDS Assessments to be accurate, as per RAI guidelines. Per interview, LPN #5/MDS Coordinator was responsible for section I Active [DIAGNOSES REDACTED]. After review of Resident #10's medical record, she stated an active [DIAGNOSES REDACTED]. Continued interview revealed after review of Resident # 141's medical record, the Quarterly MDS Assessment, dated 11/25/19, falls should have been coded on the 11/25/19 Quarterly MDS Assessment. Further interview revealed the MDS Assessments guided the development or revision of the Comprehensive Care Plans and therefore the MDS Assessment was to be an accurate reflection of the resident's status in order for residents to receive appropriate services and individualized care. Interview with the Executive Director, on 03/12/2020 at 5:49 PM, revealed the facility was to utilize the RAI Manual as a resource to ensure accuracy of the MDS Assessments. Per interview, it was important for MDS Assessments to accurately reflect a resident's current status in order to ensure the Care Plan was developed or revised to address each resident's individual needs and to ensure resources were provided as necessary to meet resident care needs.

Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for three (3) of thirty-four (34) sampled residents (Resident #87, Resident #109, and Resident #141). Resident #87 was diagnosed and treated for [REDACTED]. Resident #109 was diagnosed and treated for [REDACTED]. Resident #141 had a fall event on 11/05/19; however, the CCP was not revised to related to the actual fall, nor was the CCP updated with a new intervention to prevent further falls of the same nature. The findings include: Review of the facility Comprehensive Care Plans Policy, revised September 2010, revealed the Comprehensive Care Plan is an individualized plan developed to included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. Additionally, the Interdisciplinary Team identifies problem areas, risk factors, treatment goal, and professional services to prevent or reduce declines in the resident's functional status level and enhance optimal functioning. Per policy, concerns triggered during the resident assessment are added to the care plan. Further, Care Plans are ongoing and revised as information about the resident and the resident's condition changes, at least quarterly. Interview with the MDS Nurse, on 03/12/2020 at 4:17 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for Care Plans. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #87's medical record revealed the facility admitted the resident on 03/10/17 with [DIAGNOSES REDACTED]. Review of Resident #87's Comprehensive Care Plan (CCP), initiated 02/14/18, revealed the resident had the potential for UTI. The Goal stated the resident would be monitored for signs and symptoms of UTI. The interventions included monitor/document/report as needed signs and symptoms of UTI. Continued review of Resident #87's CCP, revised 06/04/19, revealed the resident had a history of [REDACTED]. The Goal stated the resident's UTI's would resolve without complication. The interventions included check every two (2) hours for incontinence, dated 04/04/18; give antibiotics therapy as ordered, dated 04/04/18; monitor intake and output, dated 02/01/19; and monitor vitals, dated 03/19/2020. Review of Resident #87's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/2020, revealed the facility assessed the resident as having severe cognitive impairment. Additionally, the resident required total assistance with Activities of Daily Living, had an indwelling catheter and was always incontinent of bowel. Per the Assessment, the resident had the [DIAGNOSES REDACTED]. Review of Resident #87's physician's orders [REDACTED]. Review of Resident #87's Medication Administration Record [REDACTED]. Further, the MAR indicated [REDACTED]. Review of Resident #87's Urinalysis, dated 03/04/2020 revealed greater than 100,000 organisms; Citobacter fruendii (anaerobic gram negative bacteria of the family [MEDICATION NAME]). However, further review of the CCP, revealed there was no documented evidence the Care Plan was revised to include the actual UTI, identified on 03/05/2020. 2. Review of Resident #109's medical record revealed the facility admitted the resident on 04/26/19 with [DIAGNOSES REDACTED]. Review of Resident #109's Quarterly Minimum Data Set (MDS) Assessment, dated 02/10/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating intact cognition. Further, the resident had the [DIAGNOSES REDACTED]. Review of Resident #109's Chest X-ray, dated 03/04/2020 revealed a modest infiltrate in the right lower lobe, indicating Pneumonia. Review of Resident # 109's physician's orders [REDACTED]. Review of Resident #109's Medication Administration Record [REDACTED]. However, review of Resident #109's Comprehensive Care Plan (CCP), revealed no documented evidence the Care Plan was revised to include the acute Respiratory Infection/Pneumonia, identified on 03/04/2020. Interview with Licensed Practical Nurse (LPN) #3, on 03/12/2020 at 3:42 PM, revealed she had worked at the facility for one (1) month. Per interview, direct care nurses were responsible to revise the CCP with changes in resident conditions, including new acute illnesses. Additionally, Resident # 87 should have had an acute Care Plan revision related to the UTI on 03/05/2020 and Resident #109 should have had an acute Care Plan revision related to Pneumonia on 03/04/2020. Further, the Care Plan was used by direct caregivers as a reference in providing care and should be accurate and up to date. 3. Review of the facility Falls and Fall Risk, Managing Policy, revised March 2018, revealed the facility would identify interventions to prevent the resident from falling and to minimize complications from falling. Additionally, resident-centered approaches to managing falls would be implemented with recurring falls. Further, despite previous interventions, additional or different interventions will be implemented to manage falls. Review of Resident #141's medical record revealed the facility admitted the resident on 10/12/17 with [DIAGNOSES REDACTED]. Review of Resident #141's Quarterly MDS Assessment, dated 08/27/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating moderate cognitive impairment. Additionally, the facility assessed the resident as requiring supervision and oversight with Activities of Daily Living and not steady, but could stabilize without assistance during transition. Per the Assessment, the resident had no falls since the previous Assessment. Further, the facility assessed the resident as receiving six (6) days of Restorative Nursing: ambulation and active Range of motion during the seven (7) day look back period. Review of Resident #141's Comprehensive Care Plan, revised on 10/10/19 revealed the resident was a high fall risk related to deconditioning, and gait/balance problems. The Goal stated the resident would be free of minor injury and would not sustain major injury. The interventions included, but were not limited to: anticipate and meet the resident's needs, initiated 10/12/17; non-skid socks when out of bed and no shoes worn, initiated 10/12/17; resident enjoys making the bed, initiated 11/20/17; and wheelchair safety device anti-rollbacks, initiated 12/26/19. Review of Resident #141's Fall Incident Report, dated 11/05/19 at 5:00 AM, revealed the nurse heard the resident yell for help. Per the Report, the nurse entered the resident's room and the upper half of the resident's body was on the bed with his/her legs twisted between the wheelchair and the bed. Additionally, the resident stated he/she fell over in the bed while making up the bed when he/she became dizzy. Continued review revealed the immediate action taken was assessment of the resident and new orders for [MEDICATION NAME] (antiemetic medication used to treat [MEDICAL CONDITION]) as needed. Further, the resident was alert and oriented to person, place and time and had no obvious injury. Per the Report, there were no environmental or situational factors contributing to the fall event; however, the resident did have a current UTI. Review of Resident #141's physician's orders [REDACTED]. Review of Resident # 141's Progress Notes: Fall Risk Review, dated 11/07/19 at 1:30 PM, revealed the Root Cause was the resident stated he/she became dizzy and fell over the bed while making it. Further, the current intervention was [MEDICATION NAME] PRN. However, further review of the Comprehensive Care Plan, revealed no documented evidence the Care Plan was revised to indicate the resident had an actual fall on 11/05/19, or to include an additional or different intervention status [REDACTED]. Interview with LPN #2, on 03/12/2020 at 3:42 PM, revealed she had worked at the facility for five (5) years. Additionally, direct care nurses were responsible to revise the CCP with changes in a resident's condition, including acute infections and fall events. Per interview, Resident #87 and Resident #109 should have had revisions to their CCP in March 2020 to reflect their acute illnesses. Continued interview revealed Resident #141's CCP should have been revised to include an intervention status [REDACTED]. Further, the Care Plan was a guide used by all staff to ensure resident care needs were met. Interview with the MDS Coordinator, on 03/12/2020 at 4:17 PM, revealed she had worked at the facility for five (5) months. Per interview, she used the RAI guidelines to ensure the CCP was revised as necessary. Continued interview revealed direct care nurses were responsible to complete revisions to the CCP for acute changes in the residents including new infection [DIAGNOSES REDACTED]. Further, the Nurse Manager reviewed orders each morning and revised the CCP as necessary. Per interview, after review of Resident #87 and Resident #109's physician's orders [REDACTED]. After review of Resident #141's CCP and Fall investigation dated 11/05/19, the MDS Coordinator stated the resident's CCP should have been revised status [REDACTED]. Further, it was important to have a current accurately revised Care Plan to ensure direct care staff knew how to provide care to residents in order to meet their needs. Interview was conducted on 03/12/2020 at 4:45 PM, with the Assistant Director of Nursing (ADON), who was the Interim Manager for the 100 hallway where Resident #87, Resident #109 and Resident #141 resided. She stated direct care nurses were responsible to revise the CCP to indicate new [DIAGNOSES REDACTED]. Further, the CCP was to be revised status [REDACTED]. Continued interview revealed she reviewed all new orders each morning and revised the Care Plans as necessary. However, she stated Resident #87 and Resident #109's CCPs should have been revised to include their acute illness in March 2020 and Resident #141's Care Plan should have been revised to include the fall with a new intervention to prevent falls status [REDACTED]. Additionally, the Care Plan should be accurate and revisions should be made to ensure resident needs were met. Interview with the Director of Nursing (DON), on 03/12/2020 5:26 PM, revealed she expected the CCPs to be revised accurately, as per the facility policies and RAI guidelines. Per interview, direct care nurses were responsible for the revision of the CCP to include acute illness and status [REDACTED]. Per interview, the Unit Managers were to check to ensure the CCPs had been revised as necessary with the morning reviews. Continued interview revealed Resident #87's and Resident #109's CCP should have been revised to include the acute infections, a measurable goal and appropriate interventions related to the identified infections. Further, after review of Resident #141's fall investigation, dated 11/05/19, she stated the CCP should have been revised to indicate the resident sustained [REDACTED]. Interview with the Administrator, on 03/12/2020 at 5:49 PM, revealed the facility was to utilize the RAI Manual and facility policies as resources to ensure the CCP was revised as necessary. Per interview, it was important for the CCP to be revised accurately to reflect a resident's current status and ensure the CCP addressed each resident's individual needs.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure position change alarms used as a fall prevention strategy were monitored to ensure efficacy and to ensure the alarms were the least restrictive device prior to implementation and on an on-going basis for three (3) of thirty-four (34) sampled Residents (Resident #10, Resident #96, and Resident #148). Although Resident #10 was Care Planned for the Sensor Alarm to bed and wheelchair on 01/29/19, there was no documented evidence of an Assessment for the Sensor Alarms until 03/16/19, over two (2) weeks later, in order to ensure the Alarms were effective and to ensure the Alarms were the least restrictive device to use as a fall prevention strategy. In addition, there was no documented evidence of ongoing monitoring of the device quarterly as per policy, as the next Assessment for the device was not completed until 01/31/2020, ten (10) months later. Further, Resident #10's Comprehensive Care Plan (CCP) was revised on 05/04/19, to include an intervention for the use of an Alarming Floor Mat; however, there was no documented evidence the facility completed an Assessment for the device in order to ensure the device was effective and the least restrictive device until 01/31/2020, over eight (8) months later. Furthermore, observation of Resident #96 on 03/09/2020, 03/10/2020, and 03/11/2020, revealed a Sensor Alarm to the bed; however, there was no documented evidence the facility completed an Assessment to ensure efficacy and to ensure the Alarm was the least restrictive device to use as a fall prevention strategy. Moreover, Resident #148 was initially assessed for the use of a Sensor Alarm, on 09/19/19; however, there was no documented evidence the facility monitored ongoing to ensure efficacy and to ensure the Alarm was the least restrictive device to use as a fall prevention strategy. The findings include: Review of the facility's Resident Safe Environment Policy, revised December 2017, revealed restraints would be medically justified to treat a medical symptom or condition that endangers the physical and/or psychosocial wellbeing of the resident. Additionally, the Comprehensive Device Assessment would be utilized for the use of protective devices quarterly and as indicated by the occurrences of events within the facility, or as the resident's status changed. Further, the facility would utilize the least restrictive type of restraint/device for the shortest period of time possible. 1. Review of Resident #10's medical record revealed the facility admitted the resident on 04/30/2014 with [DIAGNOSES REDACTED]. Observation of Resident #10, on 03/09/2020 at 2:00 PM; 03/10/2020 at 12:20 PM, and 03/11/2020 at 4:00 PM, revealed the resident was sitting in his/her wheelchair with a Sensor Alarm to the wheelchair. Observation of Resident #10's room, on 03/09/2020 at 2:00 PM; 03/10/2020 at 9:40 AM; 03/11/2020 at 11:00 AM, and on 03/12/2020 at 2:00 PM, revealed an Alarming Mat at bedside. Interview with Resident #10, on 03/11/2020 at 11:00 AM. revealed he/she was not aware of the alarms in use or their purpose. Review of Resident #10's the Comprehensive Care Plan (CCP), revised 10/02/19, revealed the resident was at high risk for falls related to unaware of safety needs, sensory deficits and incontinence. The goal stated the resident would be free from falls. Interventions included, but were not limited to: left side of the bed against wall, initiated 01/27/17; anti-roll back to wheelchair, initiated 09/28/17; Sensor Alarm to bed and wheelchair at all times for safety, initiated 01/29/19; alarming floor mat at bedside due to decreased safety awareness, initiated 05/14/19; and bell placed on bedside table to be used when resident needs to go to the bathroom, initiated 09/16/19. Although the resident was Care Planned for the Sensor Alarm to bed and wheelchair on 01/29/19, there was no documented evidence of a Comprehensive Device Assessment for the Sensor Alarms until 03/16/19, over two (2) weeks later. Review of Resident #10's Comprehensive Device Assessment, dated 03/16/19, related to Sensor Alarms, revealed the resident had poor trunk control and attempted to get up unassisted. Additionally, the resident required limited assistance with mobility. Per the Assessment, the resident was at high risk for falls; had no history of falls; and demonstrated good use of the call light. Further, the least restrictive alternative attempted was modification of personal furniture and personalization of the resident's room. Per the Assessment, the resident's potential benefits for decreased risk for fall/injury and promotion of independent locomotion with the use of the Sensor Alarm outweighed risks associated with the Alarm. Per the Assessment, the Sensor Alarms were the least restrictive device recommended due to poor safety awareness. Review of Resident #10's Monthly March 2020 physician's orders [REDACTED]. Review of Resident #10's Quarterly Minimum Data Set (MDS) Assessment, dated 12/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (07) out of fifteen (15) indicating severe cognitive impairment. Additionally, the facility assessed the resident to use a bed, chair and floor alarm daily to monitor and alert the staff of the resident's movements. Although facility policy dictated the Comprehensive Device Assessment would be completed at least quarterly, there was no documented evidence the Assessment for the Sensor Alarms for the bed and wheelchair was completed from 03/16/19, until 01/31/2020, ten (10) months later. In addition, although the CCP was revised on 05/04/19, to include an intervention for the use of an Alarming Floor Mat; there was no documented evidence the facility completed an Assessment for the device in order to ensure the device was effective and the least restrictive device until 01/31/2020, over eight (8) months later. Review of Resident #10's Comprehensive Device Assessment, dated 01/31/2020, for the Sensor Alarms, revealed the resident had unsteady gait/falls and attempted to get up unassisted. Additionally, the resident required assistance, up to limited assistance with mobility. Per the Assessment, the resident was at high risk for falls; had no history of falls; and demonstrated good use of the call light. Further, the least restrictive alternative attempted was modification of personal furniture, door buzzer/alarms, and personalization of the resident's room. Per the Assessment, the resident's potential benefits of decrease risk for fall/injury outweighed the resident's risk associated with use of the Alarm. Continued review of the Assessment, revealed the Sensor Alarms to the chair, bed, and floor were the least restrictive devices recommended due to unsafe transfers and history of falls. 2. Review of Resident #96's medical record revealed the facility admitted the resident on 11/04/2016 with [DIAGNOSES REDACTED]. Observation of Resident #96, on 03/09/2020 at 1:35 PM; 03/10/2020 at 9:40 AM and 1:05 AM; and 03/11/2020 at 11:09 AM and 4:00 PM, revealed the resident was lying in bed with a Sensor Alarm at the head of the bed. Interview with Resident #96, on 03/09/2020 at 1:35 PM, revealed the Sensor Alarm to the head of the bed was used to let staff know when he/she was getting out of bed and also to remind him/her to wait for help. Further interview revealed the resident could not recall how long the Sensor Alarm had been on the bed. However, review of Resident #96's Quarterly MDS Assessment, dated 02/04/2020, revealed the facility assessed the resident as having a BIMS score of twelve, (12) out of fifteen (15) indicating moderate cognitive impairment. Further, the facility assessed the resident as not utilizing alarms to monitor and alert the staff of the resident's movements. Additionally, review of Resident #96's current physician's orders [REDACTED]. Furthermore, review of Resident #96's Comprehensive Care Plan, revealed no documented evidence of an intervention for a Sensor Alarm to the bed. Moreover, Resident #96's medical record revealed no documented evidence of a Comprehensive Device Assessment for a Sensor Alarm to the bed. Interview with State Registered Nursing Assistant (SRNA) #1, SRNA #2 and SRNA #3, on 03/11/2020 at 5:00 PM, revealed they were frequently assigned to Resident #96, but were not aware of when the Sensor Alarm was placed to Resident #96's bed. Interview with Licensed Practical Nurse (LPN) #3, on 03/12/2020 at 3:42 PM, who was assigned to Resident #96, revealed she had worked at the facility for one (1) month. Additionally, direct care nurses completed Comprehensive Device Assessments when an alarm was initially implemented. Per interview, the purpose of completing the Assessment was to ensure the device was not a restraint and to ensure the resident's safety. Further, she was not familiar with the facility's Resident Safe Environment policy related to alarms and was uncertain who was responsible to complete ongoing evaluation/assessments of alarms or the frequency in which alarms should be evaluated/assessed. Continued interview revealed she was not aware of the date in which Resident #96's Sensor Alarm was implemented; however, she stated the Comprehensive Device Assessment should have been completed for Resident #96's Sensor Alarm prior to initiation of the Alarm to ensure the Alarm was appropriate for this resident. 3. Review of Resident #148's medical record revealed the facility admitted the resident on 09/19/19 with [DIAGNOSES REDACTED]. Observation of Resident #148, on 03/09/2020 at 2:00 PM, revealed the resident was in the recliner with the Sensor Alarm attached. Additional observations on 03/10/2020 at 11:15 AM; 03/11/2020 at 4:10 PM, and on 03/13/2020 at 3:00 PM, revealed the resident was in his/her bed with a Sensor Alarm attached to the resident's bed. Interview with Resident #148, on 03/13/2020 at 3:00 PM, revealed the Sensor Alarm was used because he/she had a history of [REDACTED]. Review of Resident #148's Comprehensive Device Assessment, dated 09/19/19, for the Sensor Alarm, revealed the resident was assessed as having visual and hearing impairment and dementia. Additionally, the resident required extensive assistance with mobility. Per the Assessment, the resident was at moderate risk for falls; had no history of falls; and demonstrated good use of the call light. Further review revealed the least restrictive alternative attempted was modification of personal furniture. Further, the resident's potential benefits of the Sensor Alarm for decreased risk for fall/injury and promotion of safety/security outweighed the resident's risk related to use of the Alarm. Further, the Sensor Alarm was the least restrictive device. Review of the Comprehensive Care Plan (CCP), revised 10/02/19, revealed the resident was at high risk for falls related to incontinence. The goal stated the resident would be free from falls. Interventions included, but were not limited to gait belt with all transfers; ensure frequently used items were in reach; nonskid strips in front of recliner; and Sensor Alarm at all times/ensure the device is in place as needed, initiated 09/20/19. Review of Resident #148's Quarterly Minimum Data Set (MDS) Assessment, dated 02/28/2020, revealed the facility did not assess the resident's cognitive pattern. Further, the facility assessed the resident as using a chair and bed alarm daily to monitor and alert the staff of the resident's movements. Review of Resident #148's physician's orders [REDACTED]. Although facility policy dictated the Comprehensive Device Assessment would be completed at least quarterly, there was no documented evidence of an Assessment for the Sensor Alarm after 09/19/19. Interview with Licensed Practical Nurse (LPN) #2, on 03/12/2020 at 3:42 PM, revealed the direct care nurses completed Comprehensive Device Assessments when an alarm was initially implemented. Per interview, the purpose of completing the Assessment was to ensure the device was the least restrictive device to maintain the resident's safety. Further, she was familiar with the facility's Resident Safe Environment policy related to alarms and direct care nurses were responsible to complete ongoing evaluation/assessments of alarms quarterly. Continued interview revealed she was not aware the Comprehensive Device Assessments were not being completed upon initiation of the Sensor Alarms and quarterly as per policy. Interview with the MDS Nurse, on 03/12/2020 at 4:17 PM, revealed she had worked at the facility for five (5) months. Per interview, direct care nurses were responsible to complete initial assessments of alarms when a new alarm was implemented and then ongoing quarterly. Continued interview revealed it was important to routinely assess alarms to ensure they were effective interventions, necessary and the least restrictive device for the resident. Additionally, she was unaware Resident #96 used a bed alarm. Per interview, if a direct care nurse implemented an alarm for Resident #96, there should be a physician's orders [REDACTED]. Further, Resident #10 and Resident #148 had a history of [REDACTED]. Interview was conducted on 03/12/2020 at 4:45 PM, with the Assistant Director of Nursing (ADON), who was the Interim Manager for the 100 hallway where Resident #10, Resident #96 and Resident #148 resided. Per interview, she was not aware Resident #96 had a bed alarm until 03/12/2020, and on that date she completed a Comprehensive Device Assessment related to the Sensor Alarm. Per interview, based on the Assessment and interviews with staff, it was identified Resident #96 had increased confusion and a bed alarm was a good idea to reduce his/her risk for falls. However, she stated the Comprehensive Alarm Assessment should have been completed before the alarm was implemented to ensure the device was the least restrictive device and an effective fall intervention. Further, the Physician should have been notified for an order for [REDACTED]. Additional interview with the ADON, revealed all alarms should be reviewed/evaluated quarterly by a nurse according to the MDS schedule to ensure the alarm was the least restrictive device for the resident and continued to be an effective intervention. She stated she was unaware Resident #10 and Resident #148 did not have Comprehensive Device Assessments completed quarterly for Sensor Alarms as per policy. Per interview, it was important to complete the Assessments related to the Alarms to ensure the Alarms continued to be beneficial to the residents and were the least restrictive device used in an an attempt to prevent falls. Interview with the Director of Nursing (DON), on 03/12/2020 at 5:26 PM, revealed she expected the facility policy on Resident Safe Environment, to be followed. Per interview, she expected the direct care nurse initiating an alarm to complete a Comprehensive Alarm Assessment to ensure the alarm was effective, the least restrictive device, and the safest device to benefit the resident. Continued interview revealed the MDS nurses were responsible to complete quarterly Comprehensive Alarm Assessments according to the MDS schedule. Further, the Comprehensive Device Assessment should be utilized quarterly and with changes in the resident's status to ensure the least restrictive type of device was used for the shortest period of time. Per interview, the Interdisciplinary Team shared the responsibility to consistently evaluate alarms for their effectiveness and to modify interventions to prevent falls as necessary. Interview with the Administrator, on 03/12/2020 at 5:49 PM, revealed she expected regulations and facility policies to be maintained in order to ensure the necessity of alarms. Per interview, consistent evaluation of alarms, per the facility policy ensured the least restrictive devices were used for residents and their safety and quality of life was maintained. Additionally, she expected an assessment of alarms to be completed prior to implementing an alarm and quarterly thereafter. Further, the facility's Quality Assurance Audits for alarms had not identified concerns related to Assessments not being consistently completed prior to initiation of the alarm and quarterly to ensure effectiveness and to ensure it was the least restrictive device .

Based on interview, record review, review of the facility investigation, and facility policy review, it was determined the facility failed to ensure medications were not misappropriated for one (1) of three (3) sampled residents (Resident #1). On 11/29/19, Receptionist Clerk (RC) #1 pretended to be a licensed nurse, called the pharmacy, and ordered narcotics to be delivered to the reception desk that were meant for Resident #1. However, the medications were never given to the nurse on the floor. The findings include: Review of the facility policy titled, Prohibiting Abuse, Neglect and Misappropriation and Exploitation, not dated, revealed the facility believes that it is each individual's right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion (including any physical or chemical restraint no required to treat the resident's medical symptoms), as well as neglect and exploitation. Any alleged incidences of abuse, neglect misappropriation or exploitation, or incidents that you may have knowledge of, must be reported immediately (not later than two (2) hours if abuse or serious bodily injury; or, twenty-four (24) hours if not abuse and does not result in serious bodily injury) to your supervisor and/or the Administrator of the facility. The Administrator or their designee will then immediately notify the Department of Community Based Services, the Office of the Inspector General (OIG) and other appropriate state/local agencies as required by law. Misappropriation of Resident Property, means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Record review revealed the facility admitted Resident #1 on 07/01/16 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/25/19, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #1's November 2010 Physician Orders revealed an order for [REDACTED]. Interview with Resident #1 on 12/17/19 at 10:45 AM, revealed to his/her knowledge he/she has never missed any medications and the staff always give it around the same time every day. He/She stated he/she takes pain medication mainly before and after [MEDICAL TREATMENT] treatment; which is three (3) days a week. Review of the facility initial report to the Office of Inspector General (OIG), dated 12/02/19 under Part B description of incident, revealed today a Certified Medication Aide (CMA) attempted to reorder [MEDICATION NAME] for Resident #1 as there was only two (2) doses left and was told the medication was filled and delivered on 11/29/19. A pharmacy delivery receipt signed by the receptionist showed [MEDICATION NAME] was received at the reception desk on 11/29/19. The resident had no injuries and had not missed any medication doses. Further review of the report in Part C, revealed the investigation was in process and final report will be submitted within five (5) days. Interview with CMA #1 on 12/16/19 at 3:17 PM, revealed she had called the pharmacy on 12/02/19 to request a refill on the medications ([MEDICATION NAME]) for Resident #1, and was told by the pharmacy it had already been ordered STAT (immediate order) and thirty (30) pills were delivered on 11/29/19 to a nurse named Karen. CMA #1 stated there was no nurse by that name that worked Resident #1's unit. She revealed when the pharmacy told her this information she asked the pharmacy for the delivery receipt, and pharmacy faxed her a copy of the delivery receipt. She stated when she looked at the signature on the receipt it was unreadable, so at that point she went immediately to the Director on Nursing (DON), and the DON took over. Interview with Receptionist Clerk (RC) #1 on 12/16/19 at 3:40 PM, revealed she worked at the facility for eight (8) days, and was terminated due to a misunderstanding regarding medications that came up missing after she signed for them. RC #1 stated she did sign for the medications; however, she did not know what happened to those medications. RC #1 she laid them down, and maybe they slipped behind the desk or fell on the floor and maybe someone took them. RC #1 further revealed she did not call and order the medications, as that would be done by a nurse and her duties as a receptionist were to answer the phone, transfer calls, bake cookies, and give people directions. She stated on 11/29/19 the pharmacy person walked in and asked her to sign for the medications, and she did. She said now she is being accused of stealing them, because they are missing. She further revealed the Kentucky State Police (KSP) have been calling her and asking her about missing medications and she knows nothing about the missing medications. She further stated I don't know where they went, maybe someone picked them up off the desk without me looking. She revealed she did not take them to the nurses station, as she did not know where they went nor did she call anyone to inquire where the medications were supposed to be taken to. She further stated Do not call me back about this, as I do not have anymore information. Interview with Receptionist Clerk (RC) #5 on 12/16/19 at 8:57 AM, revealed she was the person assisting with RC #1's orientation, as RC #1 was being orientated to take over her responsibilities. RC #5 stated during orientation she told RC #1 the pharmacy delivery persons are required to deliver medications directly to the nurses desk, because the nurses have to sign for for the medications. She stated she told her to direct the pharmacy person back to the nurses station as they are not allowed to leave the front desk. She stated if needed, the receptionist can call the nurse and tell them pharmacy was here with a delivery, but as a rule the pharmacy takes the medications to the nursing unit. She stated she was working with RC #1 on 11/29/19 the day the incident allegedly occurred; however she was not at the reception desk when the pharmacy delivered the medication and she was unsure where she may have been during that time; possibly across the hall in the payroll office. She was not aware of the concern until 12/02/19 when the administrator asked her about it. Interview with the Executive Director of PCA Pharmacy on 12/17/19 at 9:18 AM, revealed he became aware of the concern somewhere between 12/02/19 and 12/03/19, he was not sure of the exact date when the administration called to make him aware of the missing medications. He stated once Pharmacy was aware of the concern, they sent four (4) phone audio recordings for the Administrator to listen to. The person on the recording indicated she was a nurse and this was a stat order, and the medication was to be left at the front desk for her to sign. He stated this would have been an acceptable practice for the delivery courier even though normally the courier would have delivered the medication to the nurse's station. He revealed the person on the phone indicated she was a nurse and for the medication to be delivered to the desk. Since the person at the desk indicated she was a nurse it was acceptable for the deliverer to leave the medications with her. He stated the Pharmacy did not charge the resident for the medications, and made sure the medication was filled so the resident did not miss any medications. Interview with KSP Detective on 12/17/19 at 12:16 PM, revealed the investigation was still on going. Interview with the Administrator on 12/13/19 at 3:10 PM and 12/17/19 at 4:00 PM, revealed she was made aware of the concern on 12/02/19 by the DON, and she called the Executive Director of PCA Pharmacy to discuss the concern of the missing medication. She stated Pharmacy sent the facility the voice recordings of the phone calls RC #1 had made to the pharmacy requesting the medication to be sent STAT and to be delivered to the nurse's station. She revealed during the review of the recordings RC #1 told the pharmacy personnel she was the only nurse in the building Nurse(NAME)and to leave them at the front desk. She further revealed there was a total of (4) phone recordings they listened to, and at one point RC #1 also identified herself as another nurse called Melissa. She stated at one point RC #1 called the pharmacy back to see what time the medications were to be delivered, as she wanted to make sure the medication were delivered on her shift. She stated RC #1 was very convincing to the pharmacy on the phone. She revealed the DON and her listened to the tapes to validate it was RC #1's voice, and it was. She stated the facility substantiated the allegation because it did occur. However, no resident was affected, the resident never missed any medications, the pharmacy never charged the resident for the medications and we followed our hiring policy. She revealed they were the facility was still in the process of working with KSP, regarding the investigation. She stated as of 12/16/19, the facility installed a camera that will have full view of the front desk. *** The facility implemented the following actions to correct the deficient practice: 1. Reception Clerk (RC) #1 was terminated from employment on 12/02/19. 2. All STAT (immediate) medications orders were reviewed for the time frame of 11/21/19 through 11/29/19, by the DON on 12/03/19. 3. Director of Nursing (DON) educated Reception Clerk staff by 12/06/19 on misappropriation of resident's property, and non-clinical staff are not permitted to receive, handle or sign for any medications delivered. 4. All controlled medication delivery slips will be reviewed by the Director of Nursing on a daily basis, and the medications delivered over the weekend delivery slips are to be placed in her mailbox for review on the following Monday. She will validate the signature with the medications received, as well as all STAT orders when they are received will be reviewed by the DON. All receptionist staff will receive additional education regarding misappropriation and pharmacy delivery process by the Human Resource (HR) Director. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Interview with RC #1 on 12/16/19 at 3:40 PM, revealed she had been terminated on 12/02/19. 2. Interview with DON on 12/16/19 at 3:40 PM, revealed all STAT (immediate) orders were reviewed for the time frame on 11/21/19 through 11/29/19, and completed on 12/03/19 with no concerns noted. Interview with the Administrator on 12/13/19 at 3:10 PM and 12/17/19 at 4:00 PM revealed the PCA Nurse Consultant came out on 12/02/19 and completed a full house audit of every medication cart in the-facility. She stated the first thing the facility did was review the STAT (immediate) slips received from 11/21/19 to 11/29/19 to validate the residents received their medications, and we found no concerns. Interview with the Pharmacy Nurse Consultant on 12/17/19 at 9:00 AM, revealed an audit was completed on 12/03/19, to validate all STAT orders had been received during the time frame of 11/21/19 through 11/29/19, because that was the days RC #1 had worked. She revealed a full house wide medication cart audit was done on 12/03/19, specific to narcotics with no concerns noted. She revealed a third (3) audit on 12/05/19 was completed and included a review of all medication carts, medication rooms and also observed a medication pass with no concerns. 3. Interview on 12/16/19 with RC #5 at 8:57 AM, and interviews on 12/17/19 with RC #2 at 11:41 AM, RC #3 at 11:48 AM and RC #4 at 11:51 AM, revealed they had received education regarding abuse, neglect, misappropriation and reception staff not handling medications. Interview with the Administrator on 12/17/19 at 4:00 PM revealed all the front desk staff all have received education related to not accepting medications from the pharmacy they are to direct the pharmacy staff to the nurse's station, and education on abuse, neglect and misappropriation. 4. Interview (Post Survey) with the Director of Nursing on 01/06/2020 at 1:40 PM revealed, she will be reviewing all controlled medication delivery slips on a daily basis, and medication's delivered over the weekend are to be placed in her mailbox for review on the following Monday. She stated she will validate signature with the medications received, as well as all STAT orders. She revealed she will be completing this on a daily basis until the next QAPI meeting on 01/21/2020, and at that time they review and discuss the process. Interview (Post Survey) with the Director of Human Resources on 01/06/2020 at 1:48 PM, revealed she will be monitoring the understanding of the misappropriation with additional education and the pharmacy delivery process with a quiz and post test one (1) time a month times four (4) months to ensure the reception staff understand the pharmacy delivery process, and the policy related to misappropriation. She stated this education will also be included for any new staff who are hired for the reception position.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the comprehensive care plan was implemented for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned for the assistance of two (2) staff for turning, repositioning, and toileting needs: however. Certified Nurse Aide (CNA) #1 provided incontinent care without the assistance of a second staff member, as per the care plan. The findings include: Review of the facility's policy MDS Manual, Care Plans, dated (MONTH) (YEAR), revealed CNA care plan updates/changes are to be done in accordance with the Resident Assessment Instrument (RAI) Manual as part of an ongoing process. The RAI assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident's status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving and maintaining his/her highest practicable level of well-being. Record review revealed the facility readmitted Resident #1 on 09/29/18 with diagnoses, which included Acute Kidney Failure and Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/08/19, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #1 required extensive assistance of two (2) staff with bed mobility and toileting. Review of Resident #1's Comprehensive Care Plan dated 09/29/18; and CNA Care Guide, not dated, revealed to provide extensive assistance of two (2) staff members for turning and repositioning; and toileting needs. However, review of the Facility Reported Incident dated 08/25/19, revealed CNA #1 provide incontinent care to Resident #1 without the assistance of another staff member. Resident #1 became combative during care and sustained bruising to his/her arms. Interview with CNA #1 on 09/03/19 at 2:53 PM, revealed she had performed a partial bath and incontinent care on 08/24/19 between 9-11 PM, for Resident #1 because the resident had an incontinent episode of liquid stool. CNA #1 stated the resident was combative during the care. CNA #1 revealed she performed the care without another staff member's assistance. She stated she did not normally provide care to Resident #1 and did not review the care guide prior to providing care. She stated Resident #1 is a two person assist for bed mobility and bathing and she should not have provided the care without a second staff member. CNA #1 revealed staff follow the care guides when providing care to residents to ensure its done properly and safely. Interview with Licensed Practical Nurse (LPN) #1 on 09/04/19 at 10:20 AM, revealed CNA #1 had made her aware of Resident #1's combative behaviors while she was providing care. LPN #1 further stated she told CNA #1 the resident could be combative at times because she was resistive to care and many times would refuse. She stated she did not see any bruising to Resident #1's eye or hands during her shift on 08/24/19. LPN #1 stated Resident #1 is care planned for two assist with ADL care and the aides use the care guide as a reference. Interview with the Director of Nursing (DON) on 09/04/19 at 11:47 AM , revealed she expected the aides to follow the residents' care guides when providing care. She stated Resident #1 is combative during care at times and CNA #1 should have had another staff member assisting her with the care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents received adequate supervision to prevent accidents (Resident #1). Resident #1 was assessed and care planned to require/assistance of two (2) staff for bed mobility and toileting; however, Certified Nurse Aide (CNA) #1 performed care without the assistance of another staff. Resident #1 sustained bruising to both arms as he/she was combative during the care. The findings include: Review of the facility policy titled, Accidents and Incidents-Investigating and Reporting, last revised (MONTH) 2014, revealed all accidents or incidents involving residents occurring on the premises, shall be investigated and reported to the Administrator. Review of the facility's policy MDS Manual Care Plans, dated (MONTH) (YEAR), revealed CNA care plan updates/changes are to be done in accordance with the Resident Assessment Instrument (RAI) Manual as part of an ongoing process. The RAI assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident's status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving and maintaining his/her highest practicable level of well-being. Record review revealed the facility readmitted Resident #1 on 09/29/18 with diagnoses, which included Acute Kidney Failure and Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/08/19, revealed a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident's cognition was severely impaired and he/she was not interviewable. Further review of the Quarterly MDS revealed Resident #1 required extensive assistance of two (2) staff with bed mobility and toileting. Review of Resident #1's Comprehensive Care Plan dated 09/29/18, revealed the resident to have an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance, limited mobility and confusion. Further review of the care plan revealed Resident #1 required extensive assistance of two (2) staff members for turning and repositioning and toileting needs. In addition, review of the CNA Care Guide, not dated, revealed Resident #1 required extensive assistance of two (2) staff members for turning and repositioning and toileting needs. Review of a Facility Reported Incident dated 08/25/19, revealed staff reported Resident #1 was noted to have a thin bruise under the left eye, and bruised areas to the top of both his/her hands. Staff reported Resident #1 was combative during care on the night of 08/24/19 and resident demonstrated rubbing his/her left eye due to itching and denied anyone bothering his/her eye. Resident #1 stated a white girl came in his/her room and hit her arms. The resident denied ever seeing this person before and stated she came in only to hit her and did not give him/her any care. The facility interviewed all staff that had worked the unit in the forty-eight (48) hours prior to the bruising being reported. Further review of the incident revealed an interview with CNA #1 revealed while she was bathing Resident #1 to clean up an incontinent episode of liquid stool, Resident #1 was combative, striking her and reaching behind her, swinging his/her baby doll, and hit an overbed table knocking off a water cup. The staff member was removed from resident care and sent home during the investigation. The facility provided training to CNA #1 on the Hand in Hand program prior to returning to resident care. The facility unsubstantiated the allegation of abuse. Interview with CNA #1 on 09/03/19 at 2:53 PM, revealed she had performed a partial bath and incontinent care on 08/24/19 between 9-11 PM, for Resident #1 because the resident had an incontinent episode of liquid stool. CNA #1 stated the resident was combative during the care, swinging his/her baby doll at her, striking at her, and hit the overbed table, knocking off a cup of water. She further stated she had taken the baby doll and laid it at the foot of the bed because the resident was swinging it around, attempting to hit her. CNA #1 stated she performed the care without another staff members assistance, but she did report the resident's combative behavior to the nurse on duty. CNA #1 stated she did not normally provide care to Resident #1 and did not review the care guide prior to providing care. She stated Resident #1 is a two person assist for bed mobility and bathing and she should not have provided the care without a second staff member. CNA #1 revealed staff follow the care guides when providing care to residents to ensure its done properly and safely. CNA #1 stated the baby doll head was heavy and the resident was swinging it around and it may have injured his/her hands. CNA #1 denied seeing any bruising to Resident #1's left eye or hands during her shift on 08/24/19. Interview with Licensed Practical Nurse (LPN) #1 on 09/04/19 at 10:20 AM, revealed CNA #1 had made her aware of Resident #1's combative behaviors while she was providing care. LPN #1 further stated she told CNA #1 the resident could be combative at times because she was resistive to care and many times would refuse. She stated she did not see any bruising to Resident #1's eye or hands during her shift on 08/24/19. Interview with the Director of Nursing (DON) on 09/04/19 at 11:47 AM, revealed she expected the aides to follow the residents' care guides when providing care. She stated Resident #1 is combative during care at times and CNA #1 should have had another staff member assisting her with the care.

Based on observation, interview, record review, and review of facility policy and procedure, it was determined the facility failed to ensure a resident who needs respiratory care, including [MEDICAL CONDITION] care, is provided such care, consistent with professional standards of practice and the comprehensive care plan for one (1) of forty-six (46) sampled residents (Resident #12). Observations on 01/04/19 at 8:40 AM, revealed staff failed to provide [MEDICAL CONDITION] care for Resident #12, using aseptic (sterile) technique per facility policy and the resident's comprehensive care plan. The findings include: Review of the facility policy titled [MEDICAL CONDITION] Care, last revised August, 2013, revealed the purpose of this procedure is to guide [MEDICAL CONDITION] care. Aseptic technique must be used during all dressing changes and during [MEDICAL CONDITION] changes, either reusable or disposable. Record review revealed the facility admitted Resident #12 on 12/10/14, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #12 to have severely impaired cognition as the Resident never or rarely made decisions; useful hearing was absent; the Resident was non-verbal; had highly impaired vision; was rarely or never understood; and rarely or never understood. Therefore, Resident #12 was unable to complete a Brief Interview of Mental Status (BIMs) assessment and was not interviewable. Further review of the MDS revealed the resident required extensive to total care with activities of daily living. Review of the (MONTH) 2019 Physician Orders, revealed to provide [MEDICAL CONDITION] care and cleanse inner cannula using sterile technique every evening shift. Review of the Comprehensive Care Plan, last revised 01/03/19, revealed Resident #12 had a [MEDICAL CONDITION] with interventions to provide [MEDICAL CONDITION] care and change inner cannula using sterile technique every day shift and every evening shift. Observation of Licensed Practical Nurse (LPN) #1 on 01/04/19 at 8:40 AM, revealed she contaminated the sterile field three times while providing [MEDICAL CONDITION] care. She contaminated the sterile field by manipulating the contents of a sterile [MEDICAL CONDITION] (trach) kit with non-sterile gloves; placing [MEDICAL CONDITION], that had been initially placed on the bedside table, onto a sterile field.; and, using a previously contaminated fenestrated drape, placing sterile items from [MEDICAL CONDITION] onto the contaminated drape. LPN #1 realized the field was contaminated only after this surveyor stopped care and made her aware she had contaminated the field. This required her to use three new [MEDICAL CONDITION] care kits while providing care to Resident #12. Interview with LPN #1 on 01/04/19 at 9:10 AM revealed she realized she contaminated the sterile field when the surveyor brought her attention to it. She stated she should not have had to use three (3) [MEDICAL CONDITION] care kits during care and she should be more mindful of maintaining the sterile field. She stated she [MEDICAL CONDITION] every day and does not have the problems with contamination she had during this observation. Interview with the Director of Nursing (DON) on 01/04/19 at 10:25 AM revealed she expected licensed staff to maintain a sterile field when [MEDICAL CONDITION] per the facility policy and comprehensive care plans.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of forty-six (46) sampled residents who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Observation on 01/02/19 revealed the nurse did not check Resident #78's feeding tube for placement prior to flushing and administering medication per facility policy. The findings include: Review of the facility policy and procedure titled, Specific Medication Administration Procedures, last revised 12/07/12, revealed to verify tube placement by unclamping the tube and use either of the following procedures: a. Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds; or b. Aspirate stomach contents with a syringe. Record review revealed the facility admitted Resident #78 on 04/24/18 with [DIAGNOSES REDACTED]. Observation of a medication pass, on 01/02/19 at 5:20 PM, revealed Licensed Practical Nurse (LPN) #1 did not check tube placement prior to administering a flush to Resident #78's peg tube. Interview with LPN #1, on 01/03/19 at 8:30 AM, revealed she should have checked the placement of the tube prior to administering the flush. Interview with the Administrator, on 01/04/19 at 8:30 AM and the Director of Nursing (DON), on 01/04/19 at 9:39 AM, revealed they expected the nurse to check for tube placement prior to administering anything through it.

Based on interview, record review and review of the Resident Assessment Instrument (RAI) manual, it was determined the facility failed to ensure a Minimum Data Set (MDS) Re-entry was completed for one (1) of forty-six (46) sampled residents (Resident #78). Resident #78 was transferred to the hospital on [DATE] with return anticipated and returned on 11/08/18; however, a Reentry MDS was not initiated and/or completed upon the resident's return to the facility. The findings include: Interview with the MDS Coordinator on 01/04/19 at 10:45 AM revealed the facility follows the Resident Assessment Instrument (RAI) manual for completion of the MDS assessments. Review of the RAI manual, (MONTH) (YEAR), revealed Reentry refers to the situation when all three of the following occurred prior to this entry: the resident was previously in the facility, was discharged return anticipated, and returned within 30 days of discharge. Upon the resident's return to the facility, the facility is required to complete an Entry tracking record. In determining if the resident returned to the facility within 30 days, the day of discharge from the facility is not counted in the 30 days. Record review revealed the facility admitted Resident #78 on 04/24/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS submission list revealed on 11/05/18 a Discharge-Return Anticipated Assessment was completed. Review of the Hospital Discharge Summary, dated 11/08/18 revealed Resident #78 was discharged from the hospital and returned to the nursing facility on 11/08/18. However, further review of the resident's assessments revealed there was not a Reentry Assessment completed upon Resident #78's return to the facility on [DATE]. Interview with Registered Nurse (RN) #1, MDS Coordinator, on 01/04/19 at 10:46 AM, revealed a Reentry Assessment should have been completed when Resident #78 returned to the facility, but it was an over-sight and it was not completed. Interview with the Administrator on 01/04/19 at 2:18 PM revealed she expected the MDS Coordinator to follow the RAI manual when completing the MDS assessment.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure it developed or implemented a comprehensive person-centered care plan for three (3) of forty-six (46) sampled residents (Resident #12, #142, and #166). Observation on 01/04/19 revealed [MEDICAL CONDITION] care was not provided per sterile technique according to Resident #12's Comprehensive Care Plan. Observations on 01/02/19-01/04/19 revealed staff failed to ensure foot protectors were on and a pillow or blanket was in place between the resident's knees according to Resident #142's care plan. In addition, Resident #166 returned to the facility with a [DIAGNOSES REDACTED]. The findings include: Review of the facility policy titled, Comprehensive Person-Centered Care Planning, not dated, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The services provided or arranged by the facility, as outlined by the comprehensive care plan must meet professional standards of quality and be provided by qualified persons in accordance with each resident's written plan of care. 1. Record review revealed the facility admitted Resident #12 on 12/10/14, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #12 to have severely impaired cognition as the resident never or rarely made decisions; useful hearing was absent; the resident was non-verbal; had highly impaired vision; was rarely or never understood; and rarely or never understood. Therefore, Resident #12 was unable to complete a Brief Interview of Mental Status (BIMS) assessment and was not interviewable. Further review of the MDS revealed the resident required extensive to total care with activities of daily living. Review of the Comprehensive Care Plan, last revised 01/03/19, revealed Resident #12 had a [MEDICAL CONDITION] with an Interventions to provide [MEDICAL CONDITION] care and change inner cannula using sterile technique every day shift and every evening shift. However, observation of Licensed Practical Nurse (LPN) #1 on 01/04/19 at 8:40 AM, revealed she contaminated the sterile field when she manipulated the contents of a sterile [MEDICAL CONDITION] (trach) kit with non-sterile gloves; placed [MEDICAL CONDITION], that had been initially placed on the bedside table, onto a sterile field; and, used a previously contaminated fenestrated drape, placing sterile items from [MEDICAL CONDITION] onto the contaminated drape. LPN #1 realized the field was contaminated only after this surveyor stopped care and made her aware she had contaminated the field. Interview with LPN #1 on 01/04/19 at 9:10 AM revealed she realized she contaminated the sterile field when the surveyor brought her attention to it. She stated she should not have had to use three (3) [MEDICAL CONDITION] care kits during care. LPN #1 further revealed she should be more mindful of maintaining the sterile field, and stated she [MEDICAL CONDITION] every day and does not have the problems with contamination she had during this observation. Interview with the Director of Nursing (DON) on 01/04/19 at 10:25 AM revealed she expected staff to maintain a sterile field when [MEDICAL CONDITION] per policy and per the comprehensive care plans. 2. Record review revealed the facility admitted Resident #142 on 02/19/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/18/18, revealed the facility assessed Resident #142's cognition as severely impaired with a BIMS score of zero (0) which indicated the resident was not interviewable. Review of Resident #142's Comprehensive Care Plan, At Risk for Pressure Ulcer Development/Skin Breakdown, last revised 09/04/18, and Visual/Bedside Kardex Report, not dated, revealed to apply foot protectors to bilateral feet at all times for skin care, and keep pillow/blanket between knees when resident lays on side. However, observations on on 01/02/19 at 4:52 PM and on 01/03/19 at 10:41 AM, revealed the resident was positioned on back, with knees together and legs positioned toward left side without a pillow or blanket between his/her knees; and, observations on 01/03/19 at 10:41 AM and 01/04/19 at 10:30 AM revealed the resident did not have foot protectors on both feet. Interviews with Certified Nursing Assistant (CNA) #4, on 01/04/19 at 10:50 AM, and CNA #3 on 01/03/19 at 10:30 AM revealed Resident #142 was to have foot protectors to both feet per care plan. CNA #4 stated the resident should also have a pillow between knees to relieve pressure to left foot and prevent further skin breakdown. Interview with the LPN #4 and the Unit Manager, on 01/04/19 at 11:15 AM, revealed rounds are made every two (2) hours to ensure care needs are met. Interview with the DON, on 01/04/19 at 3:13 PM, revealed she would expect staff to follow care plan interventions related to Resident #142's skin care to promote healing and minimize potential of any further skin breakdown. 3. Record review revealed the facility admitted Resident #166 on 11/29/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 12/06/18, revealed the facility assessed Resident #166's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of Resident #166 record revealed the resident was treated for [REDACTED]. Interview with Licensed Practical Nurse #2, on 01/04/19 at 11:05 AM, revealed nursing staff is responsible to develop and/or implement resident care plans. She stated the Unit Managers and MDS Coordinators follow up to ensure care plans are developed and implemented as to meet the resident's care needs. Interview with the Unit Manager, on 01/04/19 at 11:15 AM, revealed each resident should have a care plan to reflect care needs and she would expect the resident's care plan to reflect listed diagnoses. Interview with the DON, on 01/04/19 at 3:13 PM, revealed she expected the staff to follow the resident's care plan and for each resident's comprehensive care plan to reflect the care needs of the resident.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure a resident receives care, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing for one (1) of forty-six (46) sampled residents (Resident #142). The facility failed to ensure Resident #142's foot protectors were on both feet and a pillow or blanket was between the resident's knees, at all times to promote healing of a pressure ulcer to left foot. The findings include: Review of the facility's policy and procedure, Pressure Ulcer Treatment, revised (MONTH) 2013, revealed the purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Review the resident's care plan to assess for any special needs of the resident. Record review revealed the facility admitted Resident #142 on 02/19/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/18/18, revealed the facility assessed Resident #142's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of zero (0) which indicated the resident is not interviewable. Further review of MDS; Section M - Skin Conditions, revealed the facility assessed Resident #142 at risk of pressure ulcers. Review of Resident #142's Wound Observation record, dated 06/27/18, revealed the facility identified a Stage lll pressure ulcer to left metatarsal head. Review of Resident #142's Comprehensive Care Plan, At Risk for Pressure Ulcer Development/Skin Breakdown, last revised 09/04/18, and Visual/Bedside Kardex Report, not dated, revealed to apply foot protectors to bilateral feet at all times for skin care, may remove each shift for skin care; and, keep pillow/blanket between knees when resident lays on side. Review of the Physician order [REDACTED]. Observations of Resident #142, on 01/02/19 at 4:52 PM and on 01/03/18 at 10:41 AM, revealed the resident was positioned on back, with knees together and legs positioned toward left side without a pillow or blanket between his/her knees. Interview with Certified Nursing Assistant (CNA) #4, on 01/04/19 at 10:50 AM, revealed Resident #142 was to have foot protectors to both feet and pillow between the knees to relieve pressure to left foot and prevent further skin breakdown. Observation of Resident #142, on 01/03/19 at 10:41 AM, revealed the resident did not have on bilateral foot protectors. Further observation revealed a staff member removed the resident's foot protectors out of the resident's closet and put them on the resident's feet. Interview with CNA #3, on 01/03/19 at 10:30 AM, revealed Resident #142 is to have the foot protectors on at all times to keep pressure off of wound on left foot. CNA #3 did not identify why the foot protectors were not on the resident's feet. Observation on 01/04/19 at 10:50 AM, revealed Resident #142 lying in bed positioned on back with a foot protector on the right foot and the foot protector for the left foot was around the resident's left lower shin instead of foot. Observation of Resident #142's wound care, on 01/03/19 at 10:23 AM, performed by the Assistant Director of Nursing (ADON), revealed a wound to underneath side of left great metatarsal head (where big toe connects to foot) measuring approximately 1.5 centimeters (cm) in length and 2 cm in width. Further observation revealed the wound was circular shaped, and the wound bed was red in color with a scant amount of white slough at edge of wound bed and white maceration surrounding the outer edge of wound. A small to moderate amount of serosangious drainage was noted on old bandage removed. The ADON identified the wound as a Stage lll pressure ulcer. Interview with the Licensed Practical Nurse (LPN) #4 and the Unit Manager, on 01/04/19 at 11:15 AM, revealed rounds are made every two (2) hours and as needed at which time residents are assessed to ensure care needs are met. Interview with the Director of Nursing (DON), on 01/04/19 at 3:13 PM, revealed she would expect staff to follow interventions related to Resident #142's skin care to promote healing and minimize potential of any further skin breakdown.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] to the extent possible for two (2) of forty-six (46) sampled residents (Residents #138 and #142). Observations of incontinent care for Residents #138 and #142 revealed staff failed to wash hands after removing used gloves after cleaning feces from each resident, and failed to wash hands prior to placing a clean brief on each resident. The findings include: Review of the facility policy and procedures titled, Perineal Care, last revised (MONTH) 2010, revealed the purposes of this procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Place the equipment on the bedside stand, arrange supplies so they can be easily reached, wash and dry your hands thoroughly. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back (1) Separate labia and wash area downward front to back. (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (4) Gently dry perineum. Instruct or assist the resident to turn to side with top leg slightly bent, if able. d. Rinse wash cloth and apply soap of cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. f. Rinse thoroughly using the same technique as described in e above. g. Dry area thoroughly. 1. Record review revealed the facility admitted Resident #142 on 02/19/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/18/18, revealed the facility assessed Resident #142's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of zero (0) which indicated the resident was not interviewable. Observation of incontinent care to Resident #142, on 01/03/19 at 10:41 AM, by Certified Nursing Assistant (CNA) #3 and CNA #4 revealed the resident was incontinent of stool. CNA #3 entered the room, put on gloves, cleansed the resident's perineal area, changed gloves, and cleansed the rectal area of stool. CNA #3 then removed her gloves, put on clean gloves before she put a clean adult brief on the resident, changed fitted sheet on the bed and underpad, removed her gloves, left the room to get the nurse, returned, and put on a clean pair of gloves and continued to provide the resident's care. CNA #3 failed to wash her hands upon entering the room and each time she changed her gloves which included after cleansing the resident of stool. Additionally, CNA #3 failed to cleanse her hands prior to leaving the resident's room, and upon returning to the resident's room. Interview with CNA #3, on 01/03/19 at 3:01 PM, revealed she stated, I didn't wash my hands before I started with the resident's incontinent care, after cleaning the bowel movement, I changed my gloves, but I did not wash my hands. Further interview revealed CNA #3 failed to wash her hands and change gloves after cleaning stool and before putting a clean sheet on the resident's bed and a clean brief on the resident. 2. Record review revealed the facility admitted Resident #138 on 05/02/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/17/18, revealed the facility assessed Resident #138's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS, Section H0300 - Urinary Continence revealed the facility assessed Resident #138 as frequently incontinent of urine; Section H0400 - Bowel Continence revealed the facility assessed the resident as always incontinent of bowel. Review of Resident #138's Physician Order Report revealed the resident was treated for [REDACTED]. Interview with Resident #138, on 01/02/19 at 3:34 PM, revealed he/she had to be treated for [REDACTED]. Resident #138 stated, I am not being cleaned properly. The staff have to clean me, I go all the time and don't realize it until it's to late. Observation of incontinent care for Resident #138, on 01/04/19 at 10:55 AM, by CNA #3 revealed CNA #3 failed to wash her hands prior to providing incontinent care, and after cleaning the resident of a bowel movement, prior to putting on a clean adult brief on the resident. Interview with CNA #3, on 01/04/19 at 3:53 PM, revealed she failed to wash her hands prior to starting incontinent care. She also stated she failed to wash her hands and put on a new pair of gloves after cleaning the resident of bowel movement, and before applying a clean brief. Interview with Licensed Practical Nurse (LPN) #2, on 01/04/19 at 11:05 AM, revealed staff should wash hands after cleaning a bowel movement and before putting on a clean pair of gloves when providing incontinent care. LPN #2 stated she would expect staff to cleanse their hands before providing resident care and before leaving a resident's room. Interview with the Unit Manager, on 01/04/19 at 11:15 AM, revealed staff was expected to wash hands with soap and water after cleaning bowel movement and before applying clean gloves. Interview with the Director of Nursing (DON), on 01/04/19 at 3:13 PM, revealed she expected staff to wash hands prior to performing incontinent and/or any resident care. She stated staff should wash hands and change gloves prior to applying a clean brief and staff should wash hands after removing gloves and prior to leaving a resident's room.

Based on observation, interview, record review, review of the facility's policy and procedures, and review of the hospital emergency room Report, Consultation Report, and Operative Report, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of four (4) sampled residents (Resident #1) and one (1) unsampled resident (Resident A). Resident #1 was assessed and care planned to require the assistance of two (2) staff with bed mobility to ensure adequate supervision to prevent accidents. On 06/14/15, State Registered Nurse Aide (SRNA) #6 provided incontinent care to Resident #1 with no assistance and when she rolled the resident over to his/her side, the side rail broke and the resident fell to the floor. Resident #1 sustained a broken left femur which required surgery and a laceration to his/her left temporal area which required five (5) sutures. The findings include: Review of the facility's Nursing Specific Safety Guidelines, no date, revealed when moving patients staff should always ask for and wait for help to arrive before attempting to lift or transfer a patient who is unable to assist in moving. Record review revealed the facility admitted Resident #1 on 04/22/11 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 06/01/15; Comprehensive Care Plan, dated 07/03/15; and State Registered Nurse Aide (SRNA) Kardex (CNA care plan) revealed the facility assessed and care planned Resident #1 required total assist of two (2) staff with bed mobility. Review of Nurse's Note, dated 06/14/15 at 10:34 AM, revealed SRNA #6 came to the nursing station and stated the resident was in the floor and she needed help. The Nurse documented upon entering the room, the resident was in the floor with a moderate amount of blood around his/her head and was found to have a laceration to the left temporal area. 911 was called by another staff member and the resident was sent to the hospital for sutures. Review of the emergency room (ER) Report, dated 06/14/15 at 10:47 AM, revealed Resident #1 received sutures to a two (2) centimeter laceration on the left side of the head and departed the ER at 1:37 PM on 06/14/15. Further review of the Nurse's Notes, dated 06/14/15, revealed at 1:35 PM, the resident returned from the emergency room with five (5) sutures to his/her left temporal area in no acute distress. Review of a Nurse's Note, dated 06/14/15 at 3:00 PM, revealed the dressing was removed from the resident's left stump area and swelling was noted. The physician was notified of the edema and gave an order for [REDACTED]. At 3:20 PM, the stump appeared more edematous and the physician was notified and at 5:11 PM, the nurse noted the dressing to the stump appearing more snug and the physician was notified again with an order received for an x-ray of the left stump at 5:17 PM. At 7:17 PM, Mobile X-Ray arrived at the facility and x-rays were obtained and at 8:20 PM, the physician was notified of the x-ray results and an order was obtained to send the resident to the emergency room . Review of a Nurse's Note, dated 06/15/15 at 3:57 AM, revealed the nursing facility called the hospital to check on Resident #1 and he/she had been admitted to the medical unit and a consult was requested with an orthopedic surgeon. Review of a Consultation Report, dated 06/15/15, revealed radiograph reports showed a fracture of the left femoral shaft. Review of the Operative Report, dated 06/16/15, revealed a postoperative [DIAGNOSES REDACTED]. Interview with SRNA #6, on 07/08/15 at 10:40 AM, revealed on 06/14/15 she told the Charge Nurse, Licensed Practical Nurse (LPN) #1, she was going into Resident #1's room to provide care and was told by LPN #1 she would be in shortly to assist her. She stated when she entered the resident's room, the resident had feces all over the front and back of him/her; she waited for assistance, but when no one came, she proceeded to clean the resident rolling him/her to his/her right side facing the window. She said she had her left hand placed on Resident #1's right hip and reached around to obtain a clean wash cloth and she felt the resident's body give and he/she rolled out of the bed onto the floor. She stated the side rail was up on the side of the bed she rolled the resident towards, but it gave way. Further interview revealed she turned the resident's call light on to summon help and when no one came, she went to the hallway and yelled for help. She stated LPN #1 came to the room and assessed Resident #1 who was found to have blood coming from his/her left side of the head and the resident was transferred to the emergency room for evaluation of the laceration to his/her head. She revealed she was aware of the resident's Kardex indicated the resident required two (2) staff assistance for bed mobility, but she did not want to wait any longer for assistance to arrive. Interview with Licensed Practical Nurse (LPN) #1, on 07/07/15 at 2:30 PM, revealed she was working on 06/14/15 when Resident #1 fell from the bed causing harm to the resident. She stated SRNA #6 expected her to come in the room to provide wound care; however, SRNA #1 did not wait for her to arrive before she provided care to Resident #1 resulting in the resident being injured from a fall from the bed. Interview with the Maintenance Technician, on 07/08/15 at 1:35 PM, revealed the side rail that broke on Resident #1's bed was on the bed via a universal side rail kit from a different manufacturer than that of the bed. He revealed he had never seen a side rail give way resulting in a resident being injured until 06/14/15 when the incident occurred with Resident #1. Additional observation and interview revealed the bar under the bed mattress, which was part of the universal side rail kit, broke and not the side rail. He was unsure how the break occurred and review of the audit logs conducted monthly on all of the universal side rail adapter kits, revealed Resident #1's side rails and kit were checked on 06/01/15 with no concerns noted. Interview with a Representative from the Manufacturer of Resident #1's bed, on 07/09/15 at 8:35 AM, revealed the universal kit was appropriate for the bed; however, they recommended use of side rails they sold to go on their beds. 2. Record review revealed the facility admitted Unsampled Resident A, on 10/03/13 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 06/01/15; Comprehensive Care Plan, dated 03/26/14; and the SRNA Kardex, dated 03/26/15, revealed Unsampled Resident A required extensive assist of two (2) staff assistance for bed mobility. Observation on 07/08/15 at 9:45 AM, revealed SRNA #9 was providing incontinent care for Unsampled Resident A. SRNA #9 was turning and repositioning the resident on his/her side without the assistance of another staff to ensure adequate supervision was provided which placed the resident as risk for injury. Interview with SRNA #9, on 0708/15 at 9:45 AM, revealed Unsampled Resident A required one (1) person assist with bed mobility because the resident was able to hold on to the side rail and assist with turning in bed; however, the SRNA Kardex revealed the resident required two (2) staff assistance for bed mobility. Interviews on 07/07/15 with Registered Nurse (RN) #3 at 2:20 PM and RN #4 at 2:45 PM; and interviews on 07/08/15 with RN #5 at 12:15 PM, RN #1 at 2:55 PM, RN #2 at 2:22 PM, LPN #2 at 2:12 PM and LPN #3 at 2:34 PM revealed they were responsible to ensure the residents were receiving care with the adequate amount of supervision. Interview with the Director of Nursing (DON) , on 07/09/15 at 11:45 AM, revealed she expected the SRNAs to follow the resident's Kardex and to ask for and wait for assistance to arrive before putting a resident in harms way.

Based on observation, interview, record review, facility policy review, and review of the hospital emergency room Report, Consultation Report, and Operative Report, 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 written plan of care for one (1) of four (4) sampled residents (Resident #1) and one (1) unsampled resident (Resident A). (Refer to F323) On 06/14/15, Resident #1 was care planned for the total assist of two (2) staff for bed mobility; however, on 06/14/15, SRNA #6 failed to follow the Comprehensive and State Registered Nurse Aide (SRNA) Kardex (care plan) for Resident #1 when she provided incontinent care in the bed by rolling the resident over without assistance. When SRNA #1 rolled the resident over, the siderail broke and Resident #1 fell from the bed to the floor sustaining a laceration to the left temporal area requiring five (5) sutures and a broken left hip requiring surgery. The findings include: Review of the facility's policy and procedure, titled Nursing Specific Safety Guidelines, not dated, revealed staff was to always have the appropriate amount of assistance and to refer to the Kardex/care plan for specifics as to how many staff are required to care for a resident safely. Record review revealed the facility admitted Resident #1 on 04/22/11 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 06/01/15, revealed the facility assessed Resident #1's cognitive status as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. In addition, the resident required extensive assistance of two (2) staff for bed mobility. Review of Comprehensive Care Plan for bed mobility, dated 07/03/15, and (SRNA) Kardex (care plan) dated 06/20/15, revealed Resident #1 required bed mobility assistance of two (2) staff members. Review of Nursing Notes, dated 06/14/15, the emergency room Report, dated 06/14/15 at 10:47 AM, and interviews with SRNA #6, on 07/08/15 at 10:40 AM, and Licensed Practical Nurse (LPN) #1 on 07/07/15 at 2:30 PM revealed on 06/14/15, SRNA #6 asked LPN #1 for assistance and the LPN said she would be in shortly. SRNA #6 entered Resident #1's room and she noted the resident had feces all over the front and back of him/her. The SRNA went ahead and provided care to the resident when the LPN did not come. The SRNA rolled the resident to his/her side and when the SRNA turned and reached for a wash cloth the resident rolled on over, the side rail broke, and the resident fell to the floor. The SRNA turned on the call light to summon help but no one responded so she went to the hallway and yelled for help. LPN #1 came to the room and assessed the resident who had blood coming from his/her left side of the head. Resident #1 was left on the floor until Emergency Medical Support (EMS) arrived and took the resident to the emergency room for evaluation of the laceration to his/her head. Resident #1 returned to the facility on [DATE] at 1:35 PM, with five (5) sutures to his/her left temporal area. After return from the hospital, staff identified the resident's left stump began to have swelling. An x-ray was taken and the resident was sent back to the hospital on [DATE] at 8:20 PM. Review of a Consultation Report, dated 06/15/15, revealed radiograph reports showed a [MEDICAL CONDITION] femoral shaft. Review of the Operative Report, dated 06/16/15, revealed a postoperative [DIAGNOSES REDACTED]. Further interview with SRNA #6, on 07/08/15 at 10:40 AM, revealed she was aware of the resident's Kardex indicated the resident required two (2) staff assistance for bed mobility, but she did not want to wait any longer for assistance to arrive. Further interview with Licensed Practical Nurse (LPN) #1, on 07/07/15 at 2:30 PM, revealed SRNA #6 expected her to come in the room to provide wound care; however, SRNA #1 did not wait for her to arrive before she provided care to Resident #1 resulting in the resident being injured from a fall from the bed. 2. Record review revealed the facility admitted Unsampled Resident A, on 10/03/13 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 06/01/15, revealed the facility assessed Unsampled Resident A's cognition as cognitively intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. In addition, the resident required extensive assist of two (2) staff for bed mobility. Review of the Comprehensive Care Plan, dated 03/26/14, and the SRNA Kardex, dated 03/26/15, revealed Unsampled Resident A required extensive assist of two (2) staff for bed mobility. Observation on 07/08/15 at 9:45 AM, revealed SRNA #9 was providing care to Unsampled Resident A, who required two (2) staff assist for bed mobility unassisted. SRNA #9 was providing incontinent care for Resident #1 which required the resident to be turned and positioned on his/her side putting the resident at risk for injury related to SRNA #9 providing care unassisted. Interview with SRNA #9, on 07/08/15 at 9:45 AM, revealed Unsampled Resident A required one (1) person assist with bed mobility because the resident was able to hold on to the side rail and assist with turning in bed. SRNA #9 stated she was aware she was supposed to go by the SRNA Kardex; however, the SRNA Kardex revealed the resident required two (2) staff assistance for bed mobility. Interviews with SRNA #5, on 07/07/15 at 3:00 PM, SRNA #7, at 3:08 PM, SRNA #8, at 3:35 PM, SRNA #13 at 7:15 AM, SRNA #11 at 7:14 AM, SRNA #12 at 7:17 AM, and SRNA #10 at 7:05 AM, SRNA #9 on 07/08/15 at 9:45 AM, revealed they were aware of the need to follow the resident's care plan/Kardex to ensure care was provided to meet the resident's needs safely. However, three (3) of the SRNAs interviewed (SRNA #13, SRNA #5, SRNA #9), revealed they provided care with one (1) person assist even though the Kardex indicated the resident required two (2) person assist because other staff members were busy and could not assist them. Interviews on 07/07/15 with Registered Nurse (RN) #3 at 2:20 PM, RN #4 at 2:45 PM, and interviews on 07/08/15 with RN #5 at 12:15 PM, RN #1 at 2:55 PM, RN #2 at 2:22 PM, LPN #2 at 2:12 PM and LPN #3 at 2:34 PM revealed they were responsible to ensure the residents were receiving care that meets safety requirements and the SRNAs were following the Kardex for each resident. The interviews revealed they made rounds on the halls, checked Activities of Daily Living documentation to ensure the correct amount of assistance was being documented and provided, and ensured the SRNAs knew they could ask for assistance from other staff (charge nurses) rather than depending on each other. Interview with the Director of Nursing (DON), on 07/09/15 at 11:45 AM, revealed she expected the SRNAs to follow the resident's Kardex and were not to provide care unassisted if the Kardex indicated otherwise. She stated all licensed staff were responsible for ensuring resident safety and ensuring the care plan/Kardex was being followed.

Based on interview, record review and and review of the facility's policy and procedures, it was determined the facility failed to ensure the comprehensive care plan was periodically reviewed and revised by a team of qualified persons after each assessment for one (1) of three (3) sampled residents (Resident #1). Resident #1 was identified by staff to have a noticeable change in condition starting [DATE] and continuing on through [DATE] when he/she was sent to the hospital per family request. Further review revealed there was no revision to the care plan to address the resident's change in condition related to intake and declines in function. Resident #1 was sent to the hospital on [DATE] with [DIAGNOSES REDACTED]. He/She was admitted to the Hospital In-house Hospice Care and expired on [DATE]. The facility's failure to revised the care plan when a resident had a decline in intake and function has 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]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of Immediate Jeopardy on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" 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 findings include: Review of the facility's policy and procedure, titled "Development of a Care Plan", (no date), revealed the facility should make sure updates/changes to the care plan were completed as soon as possible (within ,[DATE] hours of occurrences). The facility should use the "quickie" care plans ready for immediate implementation after making them resident specific (infections, wounds, falls, etc.). Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1's Brief Interview of Mental Status (BIMS) score was fifteen (15) and the mood score was five (5). He/She required supervision and setup for meals. Review of the Comprehensive Care Plan, titled "At risk for choking and aspiration", last revised [DATE], revealed Resident #1 required supervision with all meals/fluids and was to be monitored for signs and symptoms of dysphagia (difficulty swallowing); pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusal to eat. Interview with Certified Nursing Assistant (CNA) #5, on [DATE] at 2:37 PM, revealed she had worked with Resident #1 on [DATE] on the 7 AM-7 PM shift and noticed a change as the resident was unable to stand as well and appeared as though he/she may have had a stroke. The resident was also having difficulty speaking and eating/drinking. She stated she reported her concerns to the Charge Nurse Licensed Practical Nurse (LPN) #1 and was told the nurse did an exam on the resident and did not see any change. She stated she was unsure if the nurse went back in to check on the resident but she knew the resident had been sent to the hospital on Saturday ([DATE]). Interview with Certified Medication Aide (CMA/CNA) #4, on [DATE] at 1:57 PM, revealed on [DATE], during medication pass, Resident #1 was having increased difficulty swallowing medications and it was also reported to her by CNA #5 that Resident #1 had not eaten well that evening and this was also reported to LPN #1. She revealed when she returned to work on [DATE], Resident #1 had been sent to the hospital. Interview with LPN #1, on [DATE] at 8:38 AM, revealed she did document on the Interact Charting Log (24-hour report log), dated [DATE], the resident was not swallowing well and Speech Therapy was to evaluate. However, per interview, she did not see a change in Resident #1's condition; therefore, she revealed there was no reason for further documentation or care plan revision. Interview with CNA #7, on [DATE] at 3:00 PM, revealed she worked with the resident on [DATE] on the 7 PM-7 AM shift and noticed a change in the residents' ability to transfer and lack of weight bearing and the resident appeared as she had had a stroke. She stated she reported the change to the Charge Nurse, LPN #3 but was unsure if a follow-up was completed. Interview with LPN #3, on [DATE] at 2:44 PM, revealed she worked the 7 PM to 7 AM shift on [DATE], [DATE], and [DATE] and she did not see a change in the resident that would warrant a revision to the resident's care plan. However, per interview, she did report to the oncoming charge nurse the resident was having increased difficulty swallowing for the past two (2) to three (3) days and a Speech Therapy evaluation was requested. Review of the facility's intake records, dated [DATE] through [DATE], revealed Resident #1 had a decline in fluid intake of 1500 milliliters (ml) on [DATE] and [DATE], to 960 ml on [DATE], 840 ml on [DATE], and 120 ml on [DATE]. Further review of Resident #1's medical record revealed a Nursing Progress Note, dated [DATE] at 10:40 PM, which stated due to Resident #1 refusing all of the evening medications and the evening snack, the Charge Nurse (LPN #3) was unable to assess the resident's difficulty swallowing. Further review of the Comprehensive Care Plan, dated [DATE], revealed there were no revisions to the care plan related to the resident's decline in ability to swallow. Interview with MDS Coordinator #1, on [DATE] at 3:30 PM, revealed MDS nurses were responsible for updating care plans with new orders or changes in resident's condition. She revealed each discipline was responsible for updating their care plans (i.e. Nutrition, Activity, Social Services) and Nursing was responsible for the other areas of concern. Interview with MDS Coordinator #2, on [DATE] at 3:45 PM, revealed new orders were reviewed in the morning meetings and any changes needed to the care plans were completed at that time. She revealed if one of the MDS Coordinators was not in the building, charge nurses had the capability to update care plans. Interview with LPN #7, on [DATE] at 4:00 PM, revealed she had never had to update a care plan but if she needed to she knew how and knew to do so. Interview with the Director of Nursing (DON), on [DATE] at 3:50 PM, revealed the MDS nurses were ultimately responsible for revision of the care plans and any new orders or changes in condition were brought to the morning meeting each day (Monday through Friday) and care plans were revised as needed. She stated Resident #1's care plan should have been revised when staff noted the resident's change in condition. **The facility implemented the following actions to remove the Immediate Jeopardy: Resident #1 transferred to the hospital on [DATE] and never returned. 1. The facility Registered Nurses (RNs), RN Minimum Data Set (MDS) Coordinators, and RN Supervisors conducted assessments of all residents to determine if any changes in condition had occurred. These assessments were completed between [DATE] through [DATE] with any changes in condition identified reported to the physician and responsible party. 2. The facility RNs, RN MDS Coordinators, and RN Supervisors completed reviews of the current resident's Nursing Progress Notes and the facility twenty-four (24) hour reports for the previous 30 days. These reviews were conducted on [DATE] through [DATE] and all changes in condition identified were followed up on by licensed nursing staff and reported to the physician and responsible parties. 3. MDS Nurses, Director of Case Management, DON, and the Registered Dietician reviewed the care plans of all residents with [DIAGNOSES REDACTED]. The care plan reviews began on [DATE] and continued through [DATE]. 4. The facility completed reviews of medical records of residents with unplanned transfer to the hospital to determine if any change in condition was recognized and acted upon in a timely manner. The reviews were conducted by RNs, RN/MDS Nurses, and RN Supervisors, on [DATE] and completed on [DATE]. 5. The facility implemented a form referred to as "INTERACT Stop and Watch", on [DATE] to be used for a change in a resident's condition and is to be used by facility licensed staff, non-licensed staff, any department within the nursing facility, and family members to report a change in condition of a resident. If a change in condition is identified, the physician and responsible party will be notified immediately with documentation completed of the change and notifications. These forms are being reviewed in each morning Interdisciplinary (IDT) meeting. Members of the IDT team included the Executive Director (ED), DON, SDC, Director of Case Management, Dietician, Activities Director, ADON, and MDS Nurses. 6. On [DATE], the Staff Development Coordinator (SDC), DON and ADONs from a sister facility initiated education with all facility staff related to change in condition of resident status, including use of the INTERACT Stop and Watch forms, to include physician and responsible party notification. Additional educated provided to all licensed nurses included when and what to include in assessment documentation, notification of the physician and responsible party, and hydration. The education was completed on [DATE]. 7. Staff interviews were conducted, from [DATE] through [DATE], by the MDS Nurses to determine Licensed Nurses timely actions when a change in condition was reported. 8. The facility's Executive Director (ED) and Director of Nursing (DON) were educated on [DATE], by contracted Administrative and Nurse Consultants through Well Health Systems, on matters including, but not limited to developing the AoC, the Action Plan, Systemic Changes, and specific monitoring tools. 9. The Quality Assurance (QA) tool for monitoring of Notification of Change will be completed weekly x 4, then monthly x 2, then quarterly as per the QA calendar under the supervision of the DON. Any problems identified will have a corrective plan implemented and the plan will be reported to the QA committee with updated audit results at the next monthly meeting. 10. The QA tool to review medical records of residents with an unplanned transfer will be completed daily for two (2) weeks, then five (5) a week for two (2) weeks, then monthly for two (2) months, under the supervision of the DON. The results of the audits was to be reported to the QA Committee by the DON or QA Nurse each month. If at any time a concern arose with the change of condition process, the monitoring tool would be re-implemented with a schedule approved by the QA Committee. 11. The QA tool to interview staff members regarding timely action for resident's with a change in condition will be completed with six (6) staff members weekly for four (4) weeks, then monthly for four (4) months under the supervision of the DON. Results of the meeting to be brought to the QA meeting for review. 12. The QA Tool for monitoring the RAI process (which included development and revision of care plans) was implemented and will be monitored by the Director of Case Management weekly for four (4) weeks, monthly for three (3) months, then quarterly thereafter. The tool included areas of comprehensive assessment, frequency of assessment/reviews, and comprehensive care plan. 13. The QA Committee will meet weekly or more often as necessary until the facility demonstrated substantial compliance with the corrective actions described in the plan. A corrective action plan was developed by members of the QA Committee for any areas identified as not in compliance with the plan. Members of the QA committee includes the ED, DON, SDC, Medical Director, Social Services, Dietary Services Manager, Registered Dietician, Activities Director, Business Office Manager, ADONs and MDS Nurses. 14. The QA Committee convened on [DATE] and [DATE] to review the monitoring of results and made recommendations for interventions based on the results. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the assessments conducted revealed 100% of all residents had assessments completed to determine if any changes in condition had occurred. These assessments were conducted by the RNs, RN MDS Coordinators & RN supervisors and were completed between [DATE] through [DATE] with any changes that needed to be reported to the physician and family completed. 2. Review of twenty-four (24) hour reports and reviews of current resident's Nursing Progress Notes for the previous 30 days, revealed any and all changes in condition of a resident were identified and the physician and responsible parties were notified as well as updates of the care plans between [DATE] and [DATE]. These reviews were conducted by the RNs, RN MDS Coordinators, and RN Supervisors. 3. Review of reports of reviews of care plans for residents with [DIAGNOSES REDACTED]. Reviews were conducted between [DATE] through [DATE]. 4. Review of a list of medical records of residents with unplanned transfers to the hospital revealed the QA audit tool dated from [DATE] through [DATE] was used to determine if the residents who were transferred had appropriate measures (assessment, physician/responsible party notification) taken related to a change of condition (if applicable). 5. Review of the systemic changes, revealed the facility implemented a INTERACT Stop and Watch form on [DATE] and the form was to be used by all employees to identify and report any change of condition in a resident. The form was to be used by family members and all staff including contract employees. Tour of the facility revealed the Stop and Watch forms were posted throughout the facility for easy access to everyone. Review of the IDT Committee meetings revealed the Stop and Watch forms were being brought to the meetings and reviewed on Monday through Friday each week. The Stop and Watch forms completed on Saturday and Sunday were brought to the meeting as well and reviewed with any concerns documented and followed up on with Interact charting implemented for seventy-two (72) hours for any changes of condition identified. 6. Interviews conducted on [DATE] with Certified Medication Aide (CMA) at 12:00 PM, CNA #14 at 12:10 PM, CNA #15 at 12:15 PM, CNA #16 at 12:20 PM, CMA #17 at 12:30 PM, RN # 1 at 12:40 PM, Unit Assistant #1 at 12:49 PM, LPN/ADON #16 at 12:58 PM, RN #5 at 1:04 PM, Activity Tech #20 at 1:13 PM, Activity Tech #21 at 1:20 PM, CNA #21 at 1:27 PM, Restorative Aide (RA) #22 at 1:34 PM, CNA #22 at 1:40 PM, CNA #23 at 1:47 PM, CNA #24 at 1:54 PM, RA #23 at 1:56 PM, Activity Tech #24 at 2:05 PM, CNA #25 at 2:11 PM, CNA #26 at 2:15 PM, LPN #21 at 2:37 PM, CNA #10 at 2:44 PM, CNA #12 at 2:50 PM, CNA #9 at 2:55 PM, CMA #8 at 3:05 PM, CNA #27 at 3:12 PM, LPN #22 at 3:36 PM, and RN #21 at 3:46 PM revealed: Licensed staff were educated on the following: A. Utilizing the INTERACT guidelines to aide in identifying a change in resident condition. B. Performing and documenting resident assessments based on the Stop and Watch communication forms from staff, family members and visitors. Assessment education included: Head to toe physical assessment using the Physical Assessment User Defined Assessment, review of recent Nursing Progress Notes, and review of Point of Care documentation for significant parameters including, but not limited to, fluid intake, vital signs, and bowel and bladder activity. C. Notification of the Physician and responsible party of any change of condition in a resident according to Federal regulation and according to company policy on Notification of Change. Non-Licensed staff were educated on the following: A. INTERACT Stop and Watch change of condition reporting process. Following chain of command if they have concerns about adequate Licensed Nurses follow-up. 7. Review of the interviews performed by members of the IDT team with the Licensed Nurses for the week of [DATE] and [DATE], revealed staff interviews were being conducted with six (6) staff members regarding the Licensed Nurse response to a change of condition of a resident. 8. Review of the education sign-in sheet, dated [DATE], (no time) revealed education was provided, to the ED and DON, on [DATE], (no time) by the Contracted Administrative and QA Nurse Consultants through Wells Health Systems regarding developing the Allegation of Compliance (AoC), the Action Plan, Systemic Changes, and Specific Monitoring Tools. Other education included regulatory guidelines for F280 (care plan revision) including, but not limited to revising the care plans to meet the needs in accordance with the assessment of a resident. Interview with the ED on [DATE] at 4:00 PM, and the DON on [DATE] at 4:10 PM, revealed they had been re-educated by the Contracted Administrative and QA Nurse Consultants through Wells Health Systems regarding developing the Allegation of Compliance (AoC), the Action Plan, Systemic Changes, and Specific Monitoring Tools. Other education included regulatory guidelines for F280 (care plan revision) including, but not limited to revising the care plans to meet the needs in accordance with the assessment of a resident. 9. Interview with the DON, on [DATE] at 1:15 PM, revealed the QA monitoring tool for monitoring of Notification of Change was being reviewed in the morning IDT meetings and any significant findings related to change of condition were being addressed and followed up on accordingly as well as physician and responsible party notification as needed. 10. Interview with the DON, on [DATE] at 1:15 PM, and review of the QA Tool revealed medical records of residents with unplanned transfers to the hospital would be ongoing daily for two (2) weeks, then five (5) a week for two (2) weeks, then monthly for two (2) months, under the supervision of the DON. 11. Interview with the DON, on [DATE] at 1:15 PM, and review of the QA Tool revealed interviews with Licensed Nurses regarding timely response to a resident's change in condition were ongoing with six (6) staff members weekly for four weeks, then monthly for four (4) months under the supervision of the DON. 12. Review of the QA Tool for monitoring the RAI process (which included development and revision of care plans) revealed it was in use to monitor assessments and revision of care plans and being monitored by the Director of Case Management weekly for four (4) weeks, monthly for three (3) months, then quarterly thereafter. The tool included areas of comprehensive assessment, frequency of assessment/reviews, and comprehensive care plan. 13. Review of the QA calendar, revealed QA Committee was meeting as per the AoC. Dates of the last three (3) QA meetings were [DATE], [DATE], and [DATE]. 14. Review of the QA meeting minutes, dated [DATE], revealed the committee met to review monitoring results and recommended interventions based on those results. A meeting was held on [DATE] for ongoing monitoring of results and recommendations for interventions based on monitoring of the results.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to notify the physician and responsible party regarding a change in condition for one (1) of three (3) sampled residents (Resident #1). On [DATE], Resident #1 was noted with a decline in functional status as he/she was unable to assist with standing, was experiencing increased difficulty swallowing/eating and difficulty speaking. The resident continued to decline and experienced a decrease in his/her fluids. The facility failed to notify the resident's Physician and Responsible Party of the resident's change in condition from [DATE]-[DATE]. On [DATE], the resident's family asked staff to send the resident to the hospital. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to In-patient Hospice Unit on [DATE] and expired on [DATE]. The facility's failure to notify the physician and the responsible party of a significant change in a resident has 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]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of Immediate Jeopardy on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" 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 findings include: Review of the facility's policy and procedure, titled "Physician/Legal Representative Notification" (no date), revealed it was the policy of the facility to immediately inform the resident, consult with the resident's physician, and notify the resident's legal representative or an interested family member when there was a significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) and/or a need to alter treatment significantly. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Interview with Certified Nursing Assistant (CNA) #5, on [DATE] at 2:37 PM, revealed she had worked with Resident #1 on [DATE] on the 7 AM-7 PM shift and noticed a change as the resident was unable to stand as well and appeared as though he/she may have had a stroke. The resident was also having difficulty speaking, eating and drinking. She stated she reported her concerns to the Charge Nurse, Licensed Practical Nurse (LPN) #1 and was told the nurse did an examination on the resident and did not see any change. She stated she was unsure if the nurse went back in to check on the resident, but she knew the resident had been sent to the hospital on Saturday ([DATE]). Interview with CNA #6, on [DATE] at 2:40 PM, revealed she worked with the resident on [DATE] on the 7 AM-7 PM shift and noticed a change in the resident and it appeared he/she was more droopy and it reminded her of someone who had a stroke. She stated the resident drooled a lot that day and was not communicating like he/she normally did. She revealed she spoke with multiple aides and asked if they had noticed a change in the resident as well as asking the Charge Nurse (LPN #1) and the nurse did not act like there was a concern, so she did not push the matter further. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 8:38 AM, revealed she worked with Resident #1 on [DATE], [DATE], and [DATE] (the three days prior to the resident going to the hospital), from 7 AM-7 PM. LPN #1 would not say if staff reported any change in condition in the resident to her but stated if anyone came to her and reported a change in Resident #1's condition, she would have gone and assessed the resident. LPN #1 revealed if she did not see a change or concern then she was not obligated to document anything because the facility had a policy of "charting by exception". Interview with CNA #7, on [DATE] at 3:00 PM, revealed she worked with the resident on [DATE] on the 7 PM-7 AM shift and noticed a change in the resident's ability to transfer and lack of weight bearing. She stated the resident appeared as he/she had had a stroke. She stated she reported the change to the Charge Nurse/LPN #3 but was unsure if a follow up was completed. Interview with LPN #3, on [DATE] at 2:44 PM, revealed she worked the 7 PM-7 AM shift on [DATE], [DATE], and [DATE] and she had not seen a change in the resident; however, per interview, she reported to the oncoming Charge Nurse (Registered Nurse (RN) #1) the resident was having increased difficulty swallowing for the past two (2) to three (3) days and a Speech Therapy evaluation was requested. LPN #3 stated the resident was to be monitored for problems with swallowing and she did not consider this a change for the resident. Review of the facility's intake records, dated [DATE] through [DATE], revealed Resident #1 had a decline in fluid intakes with intakes of 1500 milliliters (ml) on [DATE], 1500 ml on [DATE], 960 ml on [DATE], 840 ml on [DATE], and 120 ml on [DATE]. Review of the Interact Charting Log (24-hour report log), dated [DATE], revealed LPN #1 did document the resident was "not swallowing well" and Speech Therapy was to evaluate; however, per interview, LPN #1 insisted she did not see this as a change in the resident's condition. Review of a Nursing Progress Note, dated [DATE] at 10:40 PM, revealed due to Resident #1 refusing all of the evening medications and the evening snack; she was not able see the resident swallowing to identify if the resident was having difficulty swallowing. However, there was no documented evidence the physician or family were notified. Review of a Nursing Progress Note, dated [DATE] at 9:31 AM, revealed Resident #1 was having difficulty swallowing, fluids running from his/her mouth with attempts to drink and unable to verbalize; however, there was no documented evidence the physician or family were notified. Interview with Resident #1's son, on [DATE] at 8:55 AM, revealed he was not informed by the facility staff that Resident #1 had a change in condition. He stated he had visited Resident #1 on [DATE] and there did not appear to be a change in the resident's condition. Further interview with Resident #1's son at 4:30 PM, revealed he visited again on [DATE] and noticed a change in Resident #1's condition as he/she was not responding as normal, was in the bed which was abnormal for him/her, and just looked horrible, but he had not been notified of a change. He revealed he visited the resident on on [DATE], and the resident was in the dining room and was unable to eat or drink and was by him/herself. He stated he went to the Charge Nurse, Registered Nurse (RN) #2 and asked for Resident #1 to be sent out for evaluation. Interview with Minimum Data Set (MDS) Coordinator #2, on [DATE] at 8:45 AM, revealed she would assess the resident and notify the physician and responsible party if a change in condition of a resident was brought to her attention by staff. Interview with the Assistant Director of Nursing (ADON) #1, on [DATE] at 8:50 AM, revealed if a concern was brought to her attention related to a change in condition of a resident, she would assess the resident, notify the physician and the responsible party. Interview with ADON #2, on [DATE] at 1:16 PM, revealed if there was a change in condition of a resident, the physician and Power of Attorney (POA) should have been notified. Interview with the Advanced Register Nurse Practitioner (ARNP), on [DATE] at 1:45 PM, revealed she could not recall if the Nursing Home staff notified her or not related to a change in condition of Resident #1 and it was common sense that they would notify her or the on call physician if there was a change in condition in a resident. Interview with Resident #1's Primary Care Physician, on [DATE] at 10:50 AM, revealed he expected to be notified of a change in a any resident's condition. **The facility implemented the following actions to remove the Immediate Jeopardy: Resident #1 transferred to the hospital on [DATE] and never returned. 1. The facility Registered Nurses (RNs), RN Minimum Data Set (MDS) Coordinators, and RN Supervisors conducted assessments of all residents to determine if any changes in condition had occurred. These assessments were completed between [DATE] through [DATE] with any changes in condition identified reported to the physician and responsible party. 2. The facility RNs, RN MDS Coordinators, and RN Supervisors completed reviews of the current resident's Nursing Progress Notes and the facility twenty-four (24) hour reports for the previous 30 days. These reviews were conducted on [DATE] through [DATE] and all changes in condition identified were followed up on by licensed nursing staff and reported to the physician and responsible parties. 3. MDS Nurses, Director of Case Management, DON, and the Registered Dietician reviewed the care plans of all residents with [DIAGNOSES REDACTED]. The care plan reviews began on [DATE] and continued through [DATE]. 4. The facility completed reviews of medical records of residents with unplanned transfer to the hospital to determine if any change in condition was recognized and acted upon in a timely manner. The reviews were conducted by RNs, RN/MDS Nurses, and RN Supervisors, on [DATE] and completed on [DATE]. 5. The facility implemented a form referred to as "INTERACT Stop and Watch", on [DATE] to be used for a change in a resident's condition and is to be used by facility licensed staff, non-licensed staff, any department within the nursing facility, and family members to report a change in condition of a resident. If a change in condition is identified, the physician and responsible party will be notified immediately with documentation completed of the change and notifications. These forms are being reviewed in each morning Interdisciplinary (IDT) meeting. Members of the IDT team included the Executive Director (ED), DON, SDC, Director of Case Management, Dietician, Activities Director, ADON, and MDS Nurses. 6. On [DATE], the Staff Development Coordinator (SDC), DON and ADONs from a sister facility initiated education with all facility staff related to change in condition of resident status, including use of the INTERACT Stop and Watch forms, to include physician and responsible party notification. Additional educated provided to all licensed nurses included when and what to include in assessment documentation, notification of the physician and responsible party, and hydration. The education was completed on [DATE]. 7. Staff interviews were conducted, from [DATE] through [DATE], by the MDS Nurses to determine Licensed Nurses timely actions when a change in condition was reported. 8. The facility's Executive Director (ED) and Director of Nursing (DON) were educated on [DATE], by contracted Administrative and Nurse Consultants through Well Health Systems, on matters including, but not limited to developing the AoC, the Action Plan, Systemic Changes, and specific monitoring tools. 9. The Quality Assurance (QA) tool for monitoring of Notification of Change will be completed weekly x 4, then monthly x 2, then quarterly as per the QA calendar under the supervision of the DON. Any problems identified will have a corrective plan implemented and the plan will be reported to the QA committee with updated audit results at the next monthly meeting. 10. The QA tool to review medical records of residents with an unplanned transfer will be completed daily for two (2) weeks, then five (5) a week for two (2) weeks, then monthly for two (2) months, under the supervision of the DON. The results of the audits was to be reported to the QA Committee by the DON or QA Nurse each month. If at any time a concern arose with the change of condition process, the monitoring tool would be re-implemented with a schedule approved by the QA Committee. 11. The QA tool to interview staff members regarding timely action for resident's with a change in condition will be completed with six (6) staff members weekly for four (4) weeks, then monthly for four (4) months under the supervision of the DON. Results of the meeting to be brought to the QA meeting for review. 12. The QA Tool for monitoring the RAI process (which included development and revision of care plans) was implemented and will be monitored by the Director of Case Management weekly for four (4) weeks, monthly for three (3) months, then quarterly thereafter. The tool included areas of comprehensive assessment, frequency of assessment/reviews, and comprehensive care plan. 13. The QA Committee will meet weekly or more often as necessary until the facility demonstrated substantial compliance with the corrective actions described in the plan. A corrective action plan was developed by members of the QA Committee for any areas identified as not in compliance with the plan. Members of the QA committee includes the ED, DON, SDC, Medical Director, Social Services, Dietary Services Manager, Registered Dietician, Activities Director, Business Office Manager, ADONs and MDS Nurses. 14. The QA Committee convened on [DATE] and [DATE] to review the monitoring of results and made recommendations for interventions based on the results. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the assessments conducted revealed 100% of all residents had assessments completed to determine if any changes in condition had occurred. These assessments were conducted by the RNs, RN MDS Coordinators & RN supervisors and were completed between [DATE] through [DATE] with any changes that needed to be reported to the physician and family completed. 2. Review of twenty-four (24) hour reports and reviews of current resident's Nursing Progress Notes for the previous 30 days, revealed any and all changes in condition of a resident were identified and the physician and responsible parties were notified as well as updates of the care plans between [DATE] and [DATE]. These reviews were conducted by the RNs, RN MDS Coordinators, and RN Supervisors. 3. Review of reports of reviews of care plans for residents with [DIAGNOSES REDACTED]. Reviews were conducted between [DATE] through [DATE]. 4. Review of a list of medical records of residents with unplanned transfers to the hospital revealed the QA audit tool dated from [DATE] through [DATE] was used to determine if the residents who were transferred had appropriate measures (assessment, physician/responsible party notification) taken related to a change of condition (if applicable). 5. Review of the systemic changes, revealed the facility implemented a INTERACT Stop and Watch form on [DATE] and the form was to be used by all employees to identify and report any change of condition in a resident. The form was to be used by family members and all staff including contract employees. Tour of the facility revealed the Stop and Watch forms were posted throughout the facility for easy access to everyone. Review of the IDT Committee meetings revealed the Stop and Watch forms were being brought to the meetings and reviewed on Monday through Friday each week. The Stop and Watch forms completed on Saturday and Sunday were brought to the meeting as well and reviewed with any concerns documented and followed up on with Interact charting implemented for seventy-two (72) hours for any changes of condition identified. 6. Interviews conducted on [DATE] with Certified Medication Aide (CMA) at 12:00 PM, CNA #14 at 12:10 PM, CNA #15 at 12:15 PM, CNA #16 at 12:20 PM, CMA #17 at 12:30 PM, RN # 1 at 12:40 PM, Unit Assistant #1 at 12:49 PM, LPN/ADON #16 at 12:58 PM, RN #5 at 1:04 PM, Activity Tech #20 at 1:13 PM, Activity Tech #21 at 1:20 PM, CNA #21 at 1:27 PM, Restorative Aide (RA) #22 at 1:34 PM, CNA #22 at 1:40 PM, CNA #23 at 1:47 PM, CNA #24 at 1:54 PM, RA #23 at 1:56 PM, Activity Tech #24 at 2:05 PM, CNA #25 at 2:11 PM, CNA #26 at 2:15 PM, LPN #21 at 2:37 PM, CNA #10 at 2:44 PM, CNA #12 at 2:50 PM, CNA #9 at 2:55 PM, CMA #8 at 3:05 PM, CNA #27 at 3:12 PM, LPN #22 at 3:36 PM, and RN #21 at 3:46 PM revealed: Licensed staff were educated on the following: A. Utilizing the INTERACT guidelines to aide in identifying a change in resident condition. B. Performing and documenting resident assessments based on the Stop and Watch communication forms from staff, family members and visitors. Assessment education included: Head to toe physical assessment using the Physical Assessment User Defined Assessment, review of recent Nursing Progress Notes, and review of Point of Care documentation for significant parameters including, but not limited to, fluid intake, vital signs, and bowel and bladder activity. C. Notification of the Physician and responsible party of any change of condition in a resident according to Federal regulation and according to company policy on Notification of Change. Non-Licensed staff were educated on the following: A. INTERACT Stop and Watch change of condition reporting process. Following chain of command if they have concerns about adequate Licensed Nurses follow-up. 7. Review of the interviews performed by members of the IDT team with the Licensed Nurses for the week of [DATE] and [DATE], revealed staff interviews were being conducted with six (6) staff members regarding the Licensed Nurse response to a change of condition of a resident. 8. Review of the education sign-in sheet, dated [DATE], (no time) revealed education was provided, to the ED and DON, on [DATE], (no time) by the Contracted Administrative and QA Nurse Consultants through Wells Health Systems regarding developing the Allegation of Compliance (AoC), the Action Plan, Systemic Changes, and Specific Monitoring Tools. Other education included regulatory guidelines for F280 (care plan revision) including, but not limited to revising the care plans to meet the needs in accordance with the assessment of a resident. Interview with the ED on [DATE] at 4:00 PM, and the DON on [DATE] at 4:10 PM, revealed they had been re-educated by the Contracted Administrative and QA Nurse Consultants through Wells Health Systems regarding developing the Allegation of Compliance (AoC), the Action Plan, Systemic Changes, and Specific Monitoring Tools. Other education included regulatory guidelines for F280 (care plan revision) including, but not limited to revising the care plans to meet the needs in accordance with the assessment of a resident. 9. Interview with the DON, on [DATE] at 1:15 PM, revealed the QA monitoring tool for monitoring of Notification of Change was being reviewed in the morning IDT meetings and any significant findings related to change of condition were being addressed and followed up on accordingly as well as physician and responsible party notification as needed. 10. Interview with the DON, on [DATE] at 1:15 PM, and review of the QA Tool revealed medical records of residents with unplanned transfers to the hospital would be ongoing daily for two (2) weeks, then five (5) a week for two (2) weeks, then monthly for two (2) months, under the supervision of the DON. 11. Interview with the DON, on [DATE] at 1:15 PM, and review of the QA Tool revealed interviews with Licensed Nurses regarding timely response to a resident's change in condition were ongoing with six (6) staff members weekly for four weeks, then monthly for four (4) months under the supervision of the DON. 12. Review of the QA Tool for monitoring the RAI process (which included development and revision of care plans) revealed it was in use to monitor assessments and revision of care plans and being monitored by the Director of Case Management weekly for four (4) weeks, monthly for three (3) months, then quarterly thereafter. The tool included areas of comprehensive assessment, frequency of assessment/reviews, and comprehensive care plan. 13. Review of the QA calendar, revealed QA Committee was meeting as per the AoC. Dates of the last three (3) QA meetings were [DATE], [DATE], and [DATE]. 14. Review of the QA meeting minutes, dated [DATE], revealed the committee met to review monitoring results and recommended interventions based on those results. A meeting was held on [DATE] for ongoing monitoring of results and recommendations for interventions based on monitoring of the results.

Based on observation, interview, record review, and review of the facility's policy and procedure, and hospital history and physical and discharge summary, it was determined the facility failed to ensure necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was reported to have exhibited declines in weight bearing, transferring, swallowing, fluid intake, and verbalizing beginning [DATE] with a continuous decline through [DATE] when he/she was sent to the hospital per family request. On [DATE], Resident #1's change in condition was reported to Licensed Practical Nurse (LPN) #1; however, there was no documented evidence licensed staff had conducted an assessment related to the resident's decline. Resident #1 was admitted to the hospital on [DATE] per family request with [DIAGNOSES REDACTED]. The facility's failure to ensure necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care when a resident had a decline in intake and function has 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]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of Immediate Jeopardy on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" 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 findings include: Review of the facility's Policy and Procedure titled, "Management of Acute Change in Resident Status-Recommended Protocol", last revised [DATE], revealed when an acute change in status of a resident was identified licensed staff should assess the resident and determine the resident's code status, vital signs, level of consciousness and conduct a neurological exam. If vital signs were stable and there was no change in level of consciousness, licensed staff should then assess all other signs/symptoms of the change in condition. Licensed staff should then contact the physician to notify of the findings and to obtain orders; then contact the family/responsible party to notify. Staff should then thoroughly document all events, precise times, and actions in the nursing notes, and on any other related forms as indicated. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1's Brief Interview of Mental Status (BIMS) score was fifteen (15) and the mood score was five (5). He/She required supervision and setup for meals. Review of the Comprehensive Care Plan, titled "At risk for choking and aspiration", last revised [DATE], revealed Resident #1 required supervision with all meals/fluids and was to be monitored for signs and symptoms of dysphagia (difficulty swallowing); pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusal to eat. Interview with Certified Nursing Assistant (CNA) #5, on [DATE] at 2:37 PM, revealed she had worked with Resident #1 on [DATE] on the 7 AM-7 PM shift and noticed a change as the resident was unable to stand as well and appeared as though he/she may have had a stroke. The resident was also having difficulty speaking and eating/drinking. She revealed she reported her concerns to the charge nurse (LPN #1) and was told she did an exam on the resident and did not see any change. She stated she was unsure if the nurse went back in to check on the resident but she knew the resident had been sent to the hospital on Saturday, [DATE]. Interview with CNA #6, on [DATE] at 2:40 PM, revealed she worked with the resident on [DATE] on the 7 AM-3 PM shift and noticed a change in the resident and it appeared he/she was more droopy and it reminded her of someone who had a stroke. She stated the resident drooled a lot that day and was not communicating like he/she normally did. She revealed she spoke with multiple aides and asked if they had noticed a change in the resident as well as asking the nurse (LPN #1) and the nurse did not act like there was a concern, so she did not push the matter further. Interview with LPN #1, on [DATE] at 8:38 AM, revealed she worked with Resident #1 on [DATE], [DATE], and [DATE] (three days prior to the resident going to the hospital), on the 7 AM-7 PM shift. LPN #1 would not confirm if the aides had reported to her that Resident #1 was having difficulty swallowing. She did state that if anyone came to her and reported a change in Resident #1's condition, she would have gone and assessed the resident and if she did not see a change or concern then she was not obligated to document anything because the facility had a policy of "charting by exception". However, review of the Interact Charting Log (24-hour report log), dated [DATE], revealed LPN #1 did document the resident was not swallowing well and Speech Therapy was to evaluate. Per interview, LPN #1 she still insisted she did not notice a change in the resident's condition. Interview with CNA #7, on [DATE] at 3:00 PM, revealed she worked with the resident on [DATE], on the 7 PM to 7 AM shift, and noticed a change in the residents' ability to transfer and lack of weight bearing and the resident appeared as she had had a stroke. She stated she reported the change to the charge nurse (LPN #3) but was unsure if a follow up was completed. Interview with LPN #3, on [DATE] at 2:44 PM, revealed she worked the 7 PM to 7 AM shift on [DATE], [DATE], and [DATE] and she specifically remembered the morning of [DATE] the resident had been gotten out of bed, showered, and placed in his/her wheel chair. She revealed she did not see a change in the resident; however, she reported to the oncoming charge nurse the resident was having increased difficulty swallowing for the past two (2) to three (3) days and a Speech Therapy evaluation was requested. Review of the Resident #1's Intake Records, dated [DATE] through [DATE], revealed Resident #1 had a decline in fluid intake. On [DATE] and [DATE] the facility had documented an intake of 1500 milliliters (ml). However, the resident's fluid intake declined to 960 ml on [DATE], 840 ml on [DATE], and 120 ml on [DATE]. Review of the Nursing Notes, dated [DATE] through [DATE], revealed there was no documented evidence a licensed staff had assessed Resident #1 related to the staff reported decline in condition and the documented decline in fluid intake per the facility's policy and procedure. Review of a Nursing Progress Note, dated [DATE] at 10:40 PM, revealed due to the resident refusing all evening medications and the evening snack, the Charge Nurse (LPN #3) was unable to assess the resident's swallowing to identify if the resident was having any difficulty swallowing. Review of a Nursing Progress Note, dated [DATE] at 9:31 AM, revealed Resident #1 was having difficulty swallowing, fluids were running from his/her mouth with attempts to drink, was unable to verbalize and had been experiencing difficulty swallowing for the past two (2) to three (3) days. Interview with the resident's son, on [DATE] at 4:30 PM, revealed on [DATE], he was talking to the nurse and another person jumped in and said the resident "hasn't been eating or drinking for three or four days". He stated he found the resident was in the dining room and was not verbalizing or able to eat. He went to Registered Nurse (RN) #2 and told her of the resident's decline, requested the resident be sent to the hospital, and the resident was transferred to the hospital on [DATE]. Review of the Hospital History and Physical, dated [DATE], revealed Resident #1 had been bed bound at the nursing facility for the past two (2) to three (3) days, was non-communicative and not eating/drinking or taking medications per family history. Clinical impression revealed Resident #1 was admitted to the hospital with [REDACTED]. Review of the Hospital Discharge Summary, dated [DATE], revealed Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. He/she was continued on intravenous (IV) hydration, however the patient's condition deteriorated. A Speech Therapy swallow evaluation was conducted in the hospital with a recommendation of honey thickened liquids to be provided but the resident was unable to tolerate anything liquid or take any medications. Resident #1's family made the decision to place the resident on Hospice care at the hospital on [DATE] and the resident expired on [DATE]. Interview with the hospital admitting physician, on [DATE] at 3:38 PM, revealed the family accompanied the resident to the hospital on [DATE] and informed him that they had been told by nursing home staff the resident had not eaten or drank hardly anything in three (3) days. He revealed upon assessment of the resident, his/her tongue was sticking to the roof of his/her mouth because he/she was so dehydrated and that was why he/she could not speak. He stated laboratory results, dated [DATE] at 11:45 AM, revealed an increased Blood/Urine/Nitrogen (BUN) indicating severe dehydration and [MEDICATION NAME] were being spilled over in the urine which was indicative of the body going into starvation mode. The admitting [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on [DATE] at 3:50 PM, revealed if anyone came to a charge nurse and told them a resident appeared to have had a stroke, she would expect them to assess the resident. She stated she also expected the assessments to be documented and notifications made regardless of the findings. Interview with the Executive Director (ED), on [DATE] at 4:25 PM, revealed the facility had a policy on "charting by exception" and that was what she would expect from a nurse who assessed a resident and did not identify a significant change in condition. She stated the best practice would be to document any and all findings and notifications made, but she did not expect nursing staff to document if they did not have a concern. Interview with Resident #1's Primary Care Physician, on [DATE] at 10:50 AM, revealed he would expect the facility nursing staff to assess and document changes in a resident's condition. **The facility implemented the following actions to remove the Immediate Jeopardy: Resident #1 transferred to the hospital on [DATE] and never returned. 1. The facility Registered Nurses (RNs), RN Minimum Data Set (MDS) Coordinators, and RN Supervisors conducted assessments of all residents to determine if any changes in condition had occurred. These assessments were completed between [DATE] through [DATE] with any changes in condition identified reported to the physician and responsible party. 2. The facility RNs, RN MDS Coordinators, and RN Supervisors completed reviews of the current resident's Nursing Progress Notes and the facility twenty-four (24) hour reports for the previous 30 days. These reviews were conducted on [DATE] through [DATE] and all changes in condition identified were followed up on by licensed nursing staff and reported to the physician and responsible parties. 3. MDS Nurses, Director of Case Management, DON, and the Registered Dietician reviewed the care plans of all residents with [DIAGNOSES REDACTED]. The care plan reviews began on [DATE] and continued through [DATE]. 4. The facility completed reviews of medical records of residents with unplanned transfer to the hospital to determine if any change in condition was recognized and acted upon in a timely manner. The reviews were conducted by RNs, RN/MDS Nurses, and RN Supervisors, on [DATE] and completed on [DATE]. 5. The facility implemented a form referred to as "INTERACT Stop and Watch", on [DATE] to be used for a change in a resident's condition and is to be used by facility licensed staff, non-licensed staff, any department within the nursing facility, and family members to report a change in condition of a resident. If a change in condition is identified, the physician and responsible party will be notified immediately with documentation completed of the change and notifications. These forms are being reviewed in each morning Interdisciplinary (IDT) meeting. Members of the IDT team included the Executive Director (ED), DON, SDC, Director of Case Management, Dietician, Activities Director, ADON, and MDS Nurses. 6. On [DATE], the Staff Development Coordinator (SDC), DON and ADONs from a sister facility initiated education with all facility staff related to change in condition of resident status, including use of the INTERACT Stop and Watch forms, to include physician and responsible party notification. Additional educated provided to all licensed nurses included when and what to include in assessment documentation, notification of the physician and responsible party, and hydration. The education was completed on [DATE]. 7. Staff interviews were conducted, from [DATE] through [DATE], by the MDS Nurses to determine Licensed Nurses timely actions when a change in condition was reported. 8. The facility's Executive Director (ED) and Director of Nursing (DON) were educated on [DATE], by contracted Administrative and Nurse Consultants through Well Health Systems, on matters including, but not limited to developing the AoC, the Action Plan, Systemic Changes, and specific monitoring tools. 9. The Quality Assurance (QA) tool for monitoring of Notification of Change will be completed weekly x 4, then monthly x 2, then quarterly as per the QA calendar under the supervision of the DON. Any problems identified will have a corrective plan implemented and the plan will be reported to the QA committee with updated audit results at the next monthly meeting. 10. The QA tool to review medical records of residents with an unplanned transfer will be completed daily for two (2) weeks, then five (5) a week for two (2) weeks, then monthly for two (2) months, under the supervision of the DON. The results of the audits was to be reported to the QA Committee by the DON or QA Nurse each month. If at any time a concern arose with the change of condition process, the monitoring tool would be re-implemented with a schedule approved by the QA Committee. 11. The QA tool to interview staff members regarding timely action for resident's with a change in condition will be completed with six (6) staff members weekly for four (4) weeks, then monthly for four (4) months under the supervision of the DON. Results of the meeting to be brought to the QA meeting for review. 12. The QA Tool for monitoring the RAI process (which included development and revision of care plans) was implemented and will be monitored by the Director of Case Management weekly for four (4) weeks, monthly for three (3) months, then quarterly thereafter. The tool included areas of comprehensive assessment, frequency of assessment/reviews, and comprehensive care plan. 13. The QA Committee will meet weekly or more often as necessary until the facility demonstrated substantial compliance with the corrective actions described in the plan. A corrective action plan was developed by members of the QA Committee for any areas identified as not in compliance with the plan. Members of the QA committee includes the ED, DON, SDC, Medical Director, Social Services, Dietary Services Manager, Registered Dietician, Activities Director, Business Office Manager, ADONs and MDS Nurses. 14. The QA Committee convened on [DATE] and [DATE] to review the monitoring of results and made recommendations for interventions based on the results. ** The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the assessments conducted revealed 100% of all residents had assessments completed to determine if any changes in condition had occurred. These assessments were conducted by the RNs, RN MDS Coordinators & RN supervisors and were completed between [DATE] through [DATE] with any changes that needed to be reported to the physician and family completed. 2. Review of twenty-four (24) hour reports and reviews of current resident's Nursing Progress Notes for the previous 30 days, revealed any and all changes in condition of a resident were identified and the physician and responsible parties were notified as well as updates of the care plans between [DATE] and [DATE]. These reviews were conducted by the RNs, RN MDS Coordinators, and RN Supervisors. 3. Review of reports of reviews of care plans for residents with [DIAGNOSES REDACTED]. Reviews were conducted between [DATE] through [DATE]. 4. Review of a list of medical records of residents with unplanned transfers to the hospital revealed the QA audit tool dated from [DATE] through [DATE] was used to determine if the residents who were transferred had appropriate measures (assessment, physician/responsible party notification) taken related to a change of condition (if applicable). 5. Review of the systemic changes, revealed the facility implemented a INTERACT Stop and Watch form on [DATE] and the form was to be used by all employees to identify and report any change of condition in a resident. The form was to be used by family members and all staff including contract employees. Tour of the facility revealed the Stop and Watch forms were posted throughout the facility for easy access to everyone. Review of the IDT Committee meetings revealed the Stop and Watch forms were being brought to the meetings and reviewed on Monday through Friday each week. The Stop and Watch forms completed on Saturday and Sunday were brought to the meeting as well and reviewed with any concerns documented and followed up on with Interact charting implemented for seventy-two (72) hours for any changes of condition identified. 6. Interviews conducted on [DATE] with Certified Medication Aide (CMA) at 12:00 PM, CNA #14 at 12:10 PM, CNA #15 at 12:15 PM, CNA #16 at 12:20 PM, CMA #17 at 12:30 PM, RN # 1 at 12:40 PM, Unit Assistant #1 at 12:49 PM, LPN/ADON #16 at 12:58 PM, RN #5 at 1:04 PM, Activity Tech #20 at 1:13 PM, Activity Tech #21 at 1:20 PM, CNA #21 at 1:27 PM, Restorative Aide (RA) #22 at 1:34 PM, CNA #22 at 1:40 PM, CNA #23 at 1:47 PM, CNA #24 at 1:54 PM, RA #23 at 1:56 PM, Activity Tech #24 at 2:05 PM, CNA #25 at 2:11 PM, CNA #26 at 2:15 PM, LPN #21 at 2:37 PM, CNA #10 at 2:44 PM, CNA #12 at 2:50 PM, CNA #9 at 2:55 PM, CMA #8 at 3:05 PM, CNA #27 at 3:12 PM, LPN #22 at 3:36 PM, and RN #21 at 3:46 PM revealed: Licensed staff were educated on the following: A. Utilizing the INTERACT guidelines to aide in identifying a change in resident condition. B. Performing and documenting resident assessments based on the Stop and Watch communication forms from staff, family members and visitors. Assessment education included: Head to toe physical assessment using the Physical Assessment User Defined Assessment, review of recent Nursing Progress Notes, and review of Point of Care documentation for significant parameters including, but not limited to, fluid intake, vital signs, and bowel and bladder activity. C. Notification of the Physician and responsible party of any change of condition in a resident according to Federal regulation and according to company policy on Notification of Change. Non-Licensed staff were educated on the following: A. INTERACT Stop and Watch change of condition reporting process. Following chain of command if they have concerns about adequate Licensed Nurses follow-up. 7. Review of the interviews performed by members of the IDT team with the Licensed Nurses for the week of [DATE] and [DATE], revealed staff interviews were being conducted with six (6) staff members regarding the Licensed Nurse response to a change of condition of a resident. 8. Review of the education sign-in sheet, dated [DATE], (no time) revealed education was provided, to the ED and DON, on [DATE], (no time) by the Contracted Administrative and QA Nurse Consultants through Wells Health Systems regarding developing the Allegation of Compliance (AoC), the Action Plan, Systemic Changes, and Specific Monitoring Tools. Other education included regulatory guidelines for F280 (care plan revision) including, but not limited to revising the care plans to meet the needs in accordance with the assessment of a resident. Interview with the ED on [DATE] at 4:00 PM, and the DON on [DATE] at 4:10 PM, revealed they had been re-educated by the Contracted Administrative and QA Nurse Consultants through Wells Health Systems regarding developing the Allegation of Compliance (AoC), the Action Plan, Systemic Changes, and Specific Monitoring Tools. Other education included regulatory guidelines for F280 (care plan revision) including, but not limited to revising the care plans to meet the needs in accordance with the assessment of a resident. 9. Interview with the DON, on [DATE] at 1:15 PM, revealed the QA monitoring tool for monitoring of Notification of Change was being reviewed in the morning IDT meetings and any significant findings related to change of condition were being addressed and followed up on accordingly as well as physician and responsible party notification as needed. 10. Interview with the DON, on [DATE] at 1:15 PM, and review of the QA Tool revealed medical records of residents with unplanned transfers to the hospital would be ongoing daily for two (2) weeks, then five (5) a week for two (2) weeks, then monthly for two (2) months, under the supervision of the DON. 11. Interview with the DON, on [DATE] at 1:15 PM, and review of the QA Tool revealed interviews with Licensed Nurses regarding timely response to a resident's change in condition were ongoing with six (6) staff members weekly for four weeks, then monthly for four (4) months under the supervision of the DON. 12. Review of the QA Tool for monitoring the RAI process (which included development and revision of care plans) revealed it was in use to monitor assessments and revision of care plans and being monitored by the Director of Case Management weekly for four (4) weeks, monthly for three (3) months, then quarterly thereafter. The tool included areas of comprehensive assessment, frequency of assessment/reviews, and comprehensive care plan. 13. Review of the QA calendar, revealed QA Committee was meeting as per the AoC. Dates of the last three (3) QA meetings were [DATE], [DATE], and [DATE]. 14. Review of the QA meeting minutes, dated [DATE], revealed the committee met to review monitoring results and recommended interventions based on those results. A meeting was held on [DATE] for ongoing monitoring of results and recommendations for interventions based on monitoring of the results.

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure supervision to prevent accidents for one (1) of twenty-eight (28) sampled residents (Resident #18). Resident #18 was assessed by the facility to have weakness in the upper extremities with decreased dexterity in his/her hands and was care planned to have his/her meals set-up, which included opening beverages. On 02/25/13 during the breakfast meal service, Resident #18 was given a cup of coffee with a lid on it, when the resident attempted to remove the lid on his/her own, the coffee spilled onto Resident #18's mid chest area, which resulted in a second degree burn measuring eight (8) by four and a half (4.5) centimeters (cm). The findings include: Review of the facility's policy titled "Event Report Investigation", not dated, revealed an event report was to be completed for any occurrence which was not considered a normal occurrence, such as a burn. Further review of the policy revealed it was the purpose of the report to assure that events were investigated comprehensively in order to prevent the occurrence from happening again. Review of the medical record revealed the facility admitted Resident #18, on 03/11/96, with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 02/11/13, revealed the facility assessed Resident #18 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed Resident #18 to require extensive assistance of two (2) staff for bed mobility, transfers and dressing and set-up assistance by one staff for eating. Review of the Comprehensive Plan of Care, dated 12/07/12, revealed Resident #18 required assistance to perform activities of daily living, which included eating related to physical weakness, decreased strength and due to having [DIAGNOSES REDACTED]. Review of Nurse's Notes and the facility's Event Report Investigation, dated 02/25/13, revealed during the breakfast meal service Resident #18 removed the lid from a cup of coffee and spilled hot coffee to the mid chest area directly to the resident's skin. Further review of the investigation revealed the resident had sustained an eight (8) by four and a half (4.5) centimeter (cm) reddened area with peeling skin. The report listed the possible causative factor was the resident 'took top off coffee cup'. Observation, on 03/07/13 at 9:15 AM, of Registered Nurse (RN) #3 conducting a dressing change to Resident #18's burn to the chest area revealed a black scabbed area measuring approximately 8.0 x 4.5 cm. Interview with RN #3, at that time, revealed she believed the burn was a second degree burn because it blistered when it occurred. Further interview with RN #3, on 03/08/13 at 4:00 PM, revealed State Registered Nursing Assistant/Restorative Aide (SRNA/RA) #23 had called her to the dining room on the morning of 02/25/13 because the resident had removed the lid from a cup of coffee and spilled coffee on himself/herself. She stated the resident's hand dexterity was compromised and Resident #18 should have been supervised and assisted with the hot coffee. Interview with Resident #18 during the dressing change, on 03/07/13, revealed he/she had spilled a cup of coffee on himself/herself a few weeks ago and it had really hurt on her chest. RN #3 stated "tell her how you spilled it" and Resident #18 replied "I took the lid off" as held his/her head down as he she spoke. Interview with SRNA/RA #23, on 03/08/13 at 4:15 PM, revealed Resident #18 had one hand that did not work well. She stated she was in the dining room when Resident #18 was burned. She stated Resident #18 had a long history of taking the lids off of coffee cups and he/she should have been closely supervised during meals. An interview with SRNA/RA #22, on 03/08/13 at 4:10 PM, revealed she would set the resident up for a meal by cutting up his/her meat, opening and adding salt, pepper and butter and open milk cartons and removing the lids on cold drinks. Further interview revealed she was not allowed to remove the lid from coffee cups; only the residents were allowed to remove the lids. She stated residents were encouraged not to remove the lids from coffee because there was a little hole in it and they were supposed to leave them on and drink from the cup. An interview, on 03/08/13 at 5:35 PM, with the Administrator and Consultant Nurse revealed on 02/04/13 they had identified, at a behavior meeting that the facility needed to do a hot beverage assessment on all residents; however, this was not initiated prior to Resident #18's burn. The Consultant Nurse stated they also decided to order new liquid absorbing clothing protectors for all residents, but at this point had only ordered one for Resident #18 after his/her burn. The Consultant Nurse stated the facility staff had not completed a hot beverage assessment on the residents because they were waiting until they had the equipment available so when the assessments were completed the equipment such as clothing protectors and spill proof cups would be available for use. Further interview revealed that once Resident #18 was burned they did assess her and implemented the liquid absorbing clothing protector and spill proof cup, but had not assessed other residents for the need of assistive devices or the ability to handle hot liquids independently to prevent possible burns for other residents.

Based on observation, interviews, record review and review of facility policy it was determined the facility failed to ensure care plan interventions were implemented for one (1) of twenty-eight (28) sampled residents (Residents #18). Resident #18 was assessed by the facility to have weakness in the upper extremities with decreased dexterity in his/her hands and was care planned to have his/her meals set-up, which included opening beverages. On 02/25/13 during the breakfast meal service, Resident #18 was given a cup of coffee with a lid on it. When the resident attempted to remove the lid on his/her own, the coffee spilled onto Resident #18's mid chest area, which resulted in a second degree burn measuring eight (8) by four and a half (4.5) centimeters (cm). The findings include: Review of the medical record revealed the facility admitted Resident #18, on 03/11/96, with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 02/11/13, revealed the facility assessed Resident #18 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed Resident #18 to require extensive assistance of two (2) staff for bed mobility, transfers and dressing and set-up assistance by one staff for eating. Review of the Comprehensive Plan of Care, dated 12/07/12, revealed Resident #18 required assistance to perform activities of daily living, which included eating related to physical weakness, decreased strength and due to having [MEDICAL CONDITION]. Review of Nurse's Notes and the facility's Event Report Investigation, dated 02/25/13, revealed during the breakfast meal service Resident #18 removed the lid from a cup of coffee and spilled hot coffee to the mid chest area directly to the resident's skin. Further review of the investigation revealed the resident had sustained an eight (8) by four and a half (4.5) centimeter (cm) reddened area with peeling skin. The report listed the possible causative factor was the resident 'took top off coffee cup'. During observation on 03/06/13 at 4:00 PM of Resident #18, Resident #18 revealed he/she had a burn to his/her chest related to a coffee burn. A record review of aide care plan dated 03/13, revealed Resident # 18 was assessed by the facility to need set-up assistance with eating and was assessed to have decreased dexterity in his/her right hand. Additionally, review of the Comprehensive Care Plan with revision dates of, 12/07/12, 02/20/12, and, 05/12/13 revealed set-up meal tray for resident for independent eating with each meal. Interview with State Registered Nursing Assistant/Restorative Aides (SRNA/RA) #23, on 03/08/13 at 4:15 PM, revealed Resident #18 had one hand that did not work well. She stated Resident #18 had a long history of taking the lids off of coffee cups and he/she should have been closely supervised during meals. An interview with SRNA/RA #22, on 03/08/13 at 4:10 PM, revealed she would set the resident up for a meal by cutting up his/her meat, opening and adding salt, pepper and butter and open milk cartons and removing the lids on cold drinks. Further interview revealed she was not allowed to remove the lid from coffee cups; only the residents were allowed to remove the lids. She stated residents were encouraged not to remove the lids from coffee because there was a little hole in it and they were supposed to leave them on and drink from the cup.

Based on interview and record review, it was determined the facility failed to ensure adequate supervision to prevent accidents for one resident (#17) in the selected sample of 28. The facility failed to follow the "Resident's Safe Environment" policy and procedure and failed to follow care plan interventions to prevent falls for Resident #17. The facility assessed and care planned Resident #17 as being high risk for falls and requiring two staff to assist with all toileting needs. On 09/05/10, facility staff left Resident #17 unassisted and unsupervised while toileting. The resident fell and sustained nondisplaced distal radial fracture and a fracture through the distal ulna including the ulnar styloid (forearm bones). Findings include: A review of the facility's policy entitled "Resident's Safe Environment" revealed it was the policy of the facility to evaluate all residents for fall risks. The policy further stated that each resident would be evaluated for fall risks by using the FAST evaluation form. The policy directed to follow interventions outlined in the recommendations for each level of risk identified by the FAST evaluation. Interventions outlined for a high level of risk included continuous supervision and attendance in the shower or bathroom. 1. A record review revealed Resident #17 was admitted to the facility, on 04/05/10, with [DIAGNOSES REDACTED]. A review of Resident #17's Fall Assessment Screening Tool (FAST), dated 07/19/10, revealed the resident had scored 80 on the assessment tool, with a score of 65 or greater indicating a high risk for falls. A review of the significant change Minimum Data Set (MDS) assessment information, dated 07/27/10, revealed the facility identified Resident #17 as moderately cognitively impaired, at risk for falls and requiring extensive assistance of two staff members for transfer and toileting. A review of Resident #17's care plan, dated last reviewed 07/30/10, revealed the facility staff was to provide Resident #17 with extensive assistance of two staff for transfer onto and off the toilet. Review of the at risk for falls/injury care plan detailed Resident #17 was at risk for falls due to Dementia, impaired safety awareness, decreased strength and endurance with physical weakness. A review of Resident #17's Certified Nursing Assistant (CNA) care plan, dated September of 2010, revealed the staff was to provide resident #17 with "two person assist" for toileting in the bathroom. A review of nurse's notes, dated 09/05/10 at 3:00 PM, revealed the resident had been assisted to the bathroom and had sustained an "un-witnessed" fall. The facility notified Resident #17's family and physician regarding the fall. The facility transferred resident #17 to the emergency room of the local hospital, at 4:03 PM. A review of an x-ray report for Resident #17, dated 09/05/10, revealed a nondisplaced distal radial fracture as well as a fracture through the distal ulna including the ulnar styloid. (forearm) . An interview with CNA #1, on 09/23/10 at 9:40 AM, revealed she assisted Resident #17 to the bathroom, on 09/05/10 at approximately 3:00 PM. CNA #1 stated she remained with the resident for a short period of time, when another resident's call light sounded. She asked Resident #17 to pull the emergency light when finished using the bathroom and left Resident #17 alone in the bathroom to answer the call light. Shortly afterward, another CNA came and informed the CNA that Resident #17 had sustained a fall. CNA #1 stated she was aware Resident #17 was a two person assist for transfers and toileting. An interview with the Certified Medication Aide (CMA) #1, on 09/23/10 at 10:00 AM, revealed the family of Resident #17's roommate yelled out for help when Resident #17 fell . CMA #1 entered the bathroom to find Resident #17 lying on the floor on his/her right side. She informed the licensed staff on duty. An interview with LPN #1, on 09/23/10 at 10:15 AM, revealed she responded to CMA #1's request for assistance after Resident #17 sustained the fall. LPN #1 stated the fall was unwitnessed, as CNA #1 left the resident in the bathroom alone. She assessed the resident prior to moving him/her and noted a scrape on the resident's right knee and a reddened area to the right cheek. After assisting the resident to the chair, LPN #1 also noted a hematoma was developing to the resident's right eye and wrist. She then notified the physician and family and had Resident #17 transferred to the local emergency room at 4:03 PM. An interview with the Unit Program Manager, on 09/23/10 at 1:30 PM, revealed she expected the staff to remain with Resident #17 at all times when toileting, due to the resident's high risk for falls and cognitive impairment. An interview with the Director of Nursing (DON), on 09/23/10 at 2:10 PM, revealed she would expect staff to remain in the bathroom with Resident #17 at all times, due to the resident being high risk for falls and being cognitively impaired. Interviews with the Unit Program Manager, on 09/23/10 at 1:30 PM, and with Resident #17's private sitter, on 09/23/10 at 8:30 AM, revealed Resident #17 could no longer feed himself/herself independently since the resident sustained [REDACTED]. The facility could provide no evidence that continuous supervision was provided for Resident #17 on 09/05/10 while toileting. Therefore, the facility did not ensure care plan interventions were being followed by staff to ensure the safety of resident's at risk for falls.

Based on observation, interview and record review, it was determined the facility failed to ensure care was provided in accordance with care plan interventions for one resident (#17), in the selected sample of 28. The facility assessed and care planned Resident #17 as requiring assistance of two staff members for transfer to and from the toilet. On 09/05/10, the facility left Resident #17 unsupervised and unassisted on the toilet, the resident fell and sustained a fracture to the right radius and ulnar (forearm bones). Additionally, the facility failed to ensure a sensor pad alarm was functional as directed by Resident #17's plan of care. Findings include: 1. A record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #17's Fall Assessment Screening Tool (FAST), dated 07/19/10, revealed the resident had scored 80 on the assessment tool, with a score of 65 or greater indicating a high risk for falls. A review of the significant change Minimum Data Set (MDS) assessment information, dated 07/27/10, revealed the facility identified Resident #17 as moderately cognitively impaired, at risk for falls and requiring extensive assistance of two staff members for transfer and toileting. A review of Resident #17's care plan, dated last reviewed on 07/30/10, for the "Inability to perform activities of daily living (ADL) of bathing, dressing, grooming, bed mobility, toileting, transferring, ambulating, locomotion, and eating", related to decreased strength and endurance, physical weakness, Diabetes Mellitus, Dementia, and Diabetic Peripheral [MEDICAL CONDITION] included interventions to set up the meal tray for the resident for independent dining every meal and provide extensive assistance of two staff for all toileting needs every two hours and as needed. Resident #17's care plan revealed the problem, at risk for falls/injury related to Dementia, Diabetes, Chronic [MEDICAL CONDITION], impaired safety awareness, decreased strength and endurance with physical weakness, dated 04/15/10 with a review date of 07/30/10. Interventions for the fall care plan included, alarming floor mat at all times. The CNA care plan, dated September 2010, noted two person assist with toileting in the bathroom was required for Resident #17 and an alarm mat was to be by the bed at all times. A review of the nurse's notes, dated 09/05/10 at 3:00 PM, revealed the resident had been assisted to the bathroom and had sustained an "un-witnessed" fall. The resident complained of pain to the right eye, right cheek, right wrist, right hip, and right knee. The facility notified Resident #17's family and physician regarding the fall. The facility transferred the resident to the emergency room of the local hospital, at 4:03 PM. A review of an x-ray report for Resident #17, dated 09/05/10, revealed a nondisplaced distal radial fracture as well as a fracture through the distal ulna including the ulnar styloid. An interview with CNA #1, on 09/23/10 at 9:40 AM, revealed she assisted Resident #17 to the bathroom on 09/05/10 at approximately 3:00 PM. CNA #1 stated she had remained with the resident for approximately five minutes when another call light sounded. She asked the resident to pull the emergency light when the resident had finished using the bathroom. CNA #1 revealed she left Resident #17 alone in the bathroom to answer the other call light. Shortly afterward, another CNA came and informed her Resident #17 had sustained a fall in the bathroom. CNA #1 revealed she was aware Resident #17 was a two person assist for transfers and toileting but had been unable to find another CNA when the resident needed to use the bathroom. An interview with the Certified Medication Aide (CMA) #1, on 09/23/10 at 10:00 AM, revealed she had been working the back hall on 09/05/10 when she heard a noise and then the family of Resident #17's roommate began yelling for help. CMA #1 then entered the bathroom to find Resident #17 lying in the floor on his/her right side. She stated she notified the licensed staff on duty. An interview with LPN #1, on 09/23/10 at 10:15 AM, revealed she had responded when CMA #1 needed assistance after Resident #17 had sustained the fall. LPN #1 stated the fall was unwitnessed as CNA #1 had left the resident in the bathroom alone. An observation of Resident #17, on 09/21/10 at 4:00 PM, revealed the resident was asleep in a reclining chair by the bed with a cast present to the resident's right wrist. A padded mat was beside the bed and under the footrest of the recliner. Under the padded mat was a sensor alarm mat that did not alarm when pressure was applied and released. An observation of Resident #17, on 09/21/10 at 5:10 PM, revealed the alarm mat was still not functioning. An interview with the Licensed Practical Nurse (LPN) #2, on 09/21/10 at 5:10 PM, revealed LPN #2 stepped on the sensor mat to determine if the mat was functioning and mat did not alarm. LPN #2 then checked the alarm and noted the alarm was turned off. She stated it was the CNAs responsibility to ensure all alarms were functioning properly every shift. An interview with the Unit Program Manager, on 09/23/10 at 1:30 PM, revealed she expected the staff to follow the resident's plan of care to determine how to safely transfer the resident. She stated the CNA should also always explain the procedure being completed. The Unit Program Manager revealed Resident #17 was a high fall risk and should have never been left alone in the bathroom. She stated all high fall risk residents should never be left alone in the bathroom especially a resident who was also cognitively impaired. Furthermore she stated that she expected all sensor alarms to be on and functional as directed by the plan of care. An interview with the Director of Nursing (DON), on 09/23/10 at 2:10 PM, revealed she would expect staff to remain in the bathroom with Resident #17 at all times due to the resident being high risk for falls and being cognitively impaired. The DON stated she expected all residents care to be provided as directed by the plan of care and for all alarms to be in place and functional if staff was not present with the resident. Interviews with the Unit Program Manager, on 09/23/10 at 1:30 PM, and Resident #17's private sitter, on 09/23/10 at 8:30 AM, revealed Resident #17 could no longer feed him/herself independently since sustaining the fractures.