Every finding on record at Richwood Nursing & Rehab

Based on observation, interview, record review, and facility policy review, the facility failed to ensure performance review evaluations were completed for every Certified Nursing Assistant (CNA) at least once every 12 months for 4 out of 4 CNA's personnel records reviewed, CNA 21, CNA 22, CNA 23, and CNA 24. The findings include: Review of the facility policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022, revealed Competency was defined as, a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Continued review revealed the policy stated, Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that gaps in education are identified and addressed. Further policy review revealed tracking or mechanisms are in place to evaluate effectiveness of training. Review of the facility policy titled, Performance Evaluations undated, revealed, The job performance of each employee shall be reviewed and evaluated at least annually. Review of CNA 21's personnel file revealed a hire date of 08/17/2022. Continued review revealed CNA 21 completed 8.25 hours of annual online Relias training for healthcare organizations and eight hours in person classroom training with skill assessments/checkoffs for the timeframe of 08/17/2023 through 08/17/2024. Further review revealed however, no documented evidence of a performance evaluation during that 12-month period. Review of CNA 22's personnel file revealed a hire date of 08/03/2023. Continued review revealed CNA 22 completed 9.75 hours of annual online Relias training for healthcare organizations and eight hours in person classroom training with skill assessments/checkoffs for the timeframe of 08/03/2023 through 08/03/2024. Review further revealed however, no documented evidence of a performance evaluation during that 12-month period. Review of CNA 23's personnel file revealed a hire date of 12/04/2023. Continued review revealed CNA 23 completed 6.5 hours of annual online Relias training for healthcare organizations and eight hours in person classroom training with skill assessments/checkoffs during the timeframe of 12/04/2023 through 12/4/2024. Further review revealed however, there was no documented evidence of a performance evaluation during that 12-month period. Review of CNA 24's personnel file revealed a hire date of 01/20/2021. Continued review revealed CNA 24 completed 14.25 hours of annual online Relias training for healthcare organizations for the timeframe of 01/20/2024 through 01/20/2025. Additional review revealed however, no documented evidence of a performance evaluation during that 12-month period. In interview with the Director of Nursing (DON) on 03/13/2025 at 4:31 PM stated, Every department director is responsible for annual staff performance reviews, I am responsible for nurses and CNA reviews. She said the purpose of the performance evaluation was to look at how staff want to grow and what their goals were. The DON explained previous overall job satisfaction could be assessed through the performance evaluations. She stated a potential outcome (if performance evaluations) were not performed could be morale might be affected and staff members might not get a raise. The DON reported, CNA training is determined by regulation, that is 12 hours annually that results and assists in staff performance. She said corporate could add training as necessary. The DON stated possible additions could be situational, for example, customer assistance which could assist in growth. She said, We also provide competency skills checkoffs. We look at needs or complaints for training opportunities. The DON stated she was aware of regulation regarding performance evaluation; however, would have to ask Human Resources (HR) for the specifics. She reported last year, sometime, the facility switched to Workday an electronic system for evaluations and stopped doing handwritten performance evaluations for staff. The DON stated, Typically, the date of hire is used for the staff annual performance date, but in October, it will not be the date of hire anymore. She explained all annual evaluations would be completed every October afterwards. The DON stated was not aware CNA evaluations had not been completed. She further stated when she was completing performance evaluations handwritten, she would have HR provide a monthly list of nurses and CNA's. In interview with the Administrator on 03/13/2025 at 4:50 PM stated, The department heads are responsible for annual staff performance reviews. He said the purpose of performance evaluations for staff was for equal parts to assess their role and make sure proper training had occurred. The Administrator reported the purpose was also to reward those who deserved it with a pay raise. He stated a potential outcome if performance reviews were not done in a timely manner was not catching training needs that should be done. The Administrator further stated, leadership and the individual need to be on the same page. If staff is not on the same page, it could cause dysfunction.

Based on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 33 sampled residents (Resident (R)16). Observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed multiple wheelchairs, wheelchair leg extenders and boxes observed on the other side of room from R16's bed. The findings include: Review of the facility policy, Homelike Environment, revised February 2021, revealed facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting which included personalized furniture and room arrangements. Review of the facility policy, Resident Rights, revised February 2021, revealed the facility assessed each resident to have the right to privacy, and retain and use personal possessions to the maximum extent that space and safety permit. Review of R16's Admission Record and medical record revealed the facility admitted the resident on 02/14/2015, with diagnoses which included abnormal posture, muscle weakness, and epilepsy. Observation on 03/11/2025 at 11:10 AM, revealed R16 lying on her bed on the A side of the room. Per observation, there were multiple personal items stacked on R16's dresser. Further observation revealed the B side of the room contained the following items stored there: four wheelchairs, multiple wheelchair leg extenders, and a large box. Observation on 03/12/2025 at 1:39 PM, revealed R16 sitting up in a wheelchair receiving a breathing treatment from the nurse. Per observation, the B side of the room contained the following: two wheelchairs, multiple leg extenders, and the large box. Continued observation revealed the nurse had to walk close to those items to get to R16's bathroom and wash his hands. Observation on 03/13/2025 at 9:07 AM, revealed R16 lying on her bed on the A side of the room. Continued observation revealed the B side of the room contained three wheelchairs, multiple leg extenders, and the large box. During interview on 03/11/2025 at 11:10 AM, R16 stated the facility used the other side of her room for storage. The resident said staff came and got the wheelchairs or other items when they needed them and then returned the items to her room. During interview on 03/13/2025 at 9:18 AM, the Social Services Director (SSD) stated the facility encouraged residents to make their rooms have a homelike environment and to be comfortable. She said she was unsure why equipment was being stored in R16's room, but equipment should not be stored in the resident's room as it did not make the room homelike for her. During interview on 03/13/2025 at 12:02 PM, the Director of Nursing (DON) stated she was unsure who stored equipment in R16's room. She reported however, that could cause R16 to have a loss of privacy and dignity with staff going in and out of the resident's room to get the equipment and then return it. During interview on 03/13/2025 at 4:55 PM, the Administrator stated equipment should be stored in the facility's basement. He said it was sometimes a little hard for therapy however, to go downstairs to get the equipment. The Administrator reported the facility was getting two storage sheds because it was a [NAME] podge of trying to get equipment stored in different areas of the facility. He stated it was not appropriate to store equipment in a resident's area as that was not a homelike environment, and he would not like having equipment stored in his bedroom. Additionally, he stated R16's room needed to be a clean space in which the resident lived.

Based on interview, record review and review of facility policy, the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 sampled residents investigated for hospitalizations out of a total sample of 33 residents, (Resident (R)69 and R43). Review of R69's and R43's medical records revealed no documented evidence the facility provided notice of the residents' transfer to the hospital to the Office of the State Long-Term Care Ombudsman as required. The findings include: Review of the facility's policy titled, Bed Hold Transfer and Discharge Policy, undated, revealed under the Receipt of Notice heading, the facility was to notify the resident, and if known, family and a legal representative of the resident before the resident was transferred or discharged . Per review, that notification was to be made in writing. Continued review of the policy revealed the facility was to contact the resident, and if known, the resident's family and legal representative at the time of discharge, and notification was to also be sent by mail. Further review revealed if in an emergency situation, the facility was to notify the family and legal representative of the resident's (transfer) as soon as practicable. 1. Review of R69's admission Record revealed the facility admitted the resident on 09/17/2024, with diagnoses of displaced fractures of the lateral malleolus of the left and right fibulas, displaced fracture of the medial malleolus of the right tibia, unspecified fracture of shaft of right fibula, mild protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD). Review of R69's Progress Notes in the resident's Electronic Medical Record (EMR) revealed on 03/10/2025 at 6:44 PM, the resident had new orders to be transferred out to the hospital due to an unstoppable nosebleed. Per review of the Progress Notes, R69 returned to the facility 03/10/2025 at 10:05 PM with his daughter and son-in-law. Further review of R69's Progress Notes revealed however, no documentation of notification of the resident's transfer to the hospital made to the Ombudsman. 2. Review of R43's admission Record revealed the facility admitted the resident on 12/04/2024, with diagnoses of: chronic diastolic (congestive) heart failure, cognitive communication deficit, presence of cardiac pacemaker, complete atrioventricular block, and chronic respiratory failure with hypoxia. Review of R43's, Notice of Proposed Transfer/Discharge V2.0, dated 12/18/2024, revealed the facility discharged the resident to a local hospital on [DATE], due to the transfer being necessary for the resident. Continued review of the Notice of Proposed Transfer/Discharge V2.0 under II.A. Ombudsman Services, it was noted, Social Services to notify. Review of R43's Progress Notes in the EMR revealed the resident had been transferred to the hospital on [DATE]. Further review revealed however, there was no documentation of notification to the Ombudsman of R43's transfer to the hospital. In interview on 03/13/2025 at 12:40 PM, the Social Services Director (SSD) stated she sent a monthly log via email to the Ombudsman of residents who were transferred to a hospital that was unplanned, or a facility initiated transfer. When the State Survey Agency (SSA) Surveyor asked the SSD for the emails, the SSD stated she would work on getting that information together. In interview on 03/13/2025 at 2:49 PM, the SSD she said she had the information for R69 and R43. The SSD provided the SSA Surveyor with two pieces of paper, one for R69 and the other for R43. Per review of the papers, on the top, it read, Monthly Ombudsman Report, and under that was the residents' names, the month, date, and year. Further review of the papers provided revealed at the bottom it read, sent to: To: nhoa@ombuddy.org. In interview on 03/13/2025 at 3:22 PM, the SSD said she had additional information and provided the SSA Surveyor with two different papers which resembled an email; however, had no date or time, and was not a message or body of the email. The SSA Surveyor then asked the SSD for copies of her sent emails, as proof of having sent the notification of transfer to the Ombudsman. The SSD expressed understanding of what the SSA Surveyor was asking her for. However, in additional interview on 03/13/2025 at 4:08 PM, the SSD reported she had not emailed the Ombudsman the monthly log since November 2024. She further stated she would immediately start sending the logs again and would send the Ombudsman the backlogs of the months she had missed. In interview with the Director of Nursing (DON) on 03/13/2025 at 4:31 PM, she stated the SDD was responsible for notifying the Ombudsman of any transfers out to the hospital. She stated that was done to let the Ombudsman know when the residents were in and out of the building. The DON reported if the notification to the Ombudsman was not being completed, it was a possibility the residents would not be allowed to come back to the facility, or the Ombudsman would not know where the residents were located. In interview with the Administrator on 03/13/2025 at 4:50 PM, he stated Social Services took care of the notifications to the Ombudsman. He stated, She does a good job, I don't know how often, (she notifies the Ombudsman) I guess it's every time (a resident is transferred to the hospital). The Administrator said the reason for the notification to the Ombudsman was to make sure residents' rights were being followed. He further stated, We value our relationship with the Ombudsman. The Administrator additionally reported if the notification to the Ombudsman was not being done, it was possible the resident won't have a voice.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement the comprehensive person-centered care plan for 2 of 33 sampled residents (Resident (R)28 and R259). 1. On 12/09/2024 and 12/17/2024, R28 experienced a fall without injury, and the facility updated the resident's care plan with an intervention to educate staff to place dycem (a nonslip material used to stabilize objects) in the resident's wheelchair. 2. Additionally, the facility care planned R259 for one person assist with eating on 03/07/2025. Observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed however, R259 eating meals in her room without staff present to provide assistance. The findings include: Review of the facility policy, Falls and Fall Risk, Managing revised March 2018 revealed staff were to try to prevent the resident from falling and identify interventions related to the resident's specific risks and causes. Per review, risk factors included heart failure and cognitive impairment. Continued review revealed staff were to implement a resident-centered plan for fall prevention to reduce specific risk factors of falls for each resident with a history of falls or at risk for falls. Policy review further revealed staff were to continue the interventions if interventions had been successful in preventing falling. The facility did not provide a policy for care plans. 1. Review of R28's clinical record revealed the facility admitted the resident on 10/22/2021 and readmitted the resident on 11/15/2021. Continued review revealed R28's diagnoses included immobility syndrome, congestive heart failure, and weakness. Review of the facility's Comprehensive Care Plan (CCP) for R28 dated 11/03/2021, revealed the facility identified the resident as at risk for falls with an intervention for dycem to the wheelchair (w/c) dated 11/08/2023. Continued review of the CCP revealed on 08/14/2024, an intervention for staff education to place dycem in R28's w/c, which was revised on 12/09/2024. Further review of R28's care plan for risk of falls, revealed an intervention for staff education for dycem to the resident's w/c dated 12/17/2024. Review of a progress note dated 12/09/2024, revealed the facility noted R28 sat on the ground in the resident's bathroom beside the w/c. Review of a progress note dated 12/16/2024, revealed R28 had been found on the floor beside the bed and an intervention to evaluate chair and add dycem was documented. Review of the Speech Therapy Medicare SLP Evaluation and Plan of Treatment dated 12/09/2024, revealed R28 had been assessed as at risk for falls. Further review revealed R28 had been assessed to have a St. Louis University Mental Status. (SLUMS) Examination score of one out of 30, indicating her level of cognition was severe. Review of the facility's, Record of In-Service Training dated 08/14, revealed the Infection Preventionist (IP), who was also the facility's Quality Assurance (QA) person, trained staff to ensure (R28's) dycem was in the w/c (as care planned). Review of the facility's, Class Attendance Record dated 12/17, revealed staff signatures documented for an attached Google search printout for dycem info for wheelchairs, which noted dycem was non-clip and ideal for adhering cushions and inserts to wheelchairs. Observation of R28 on 03/11/2025 at 10:42 AM, revealed the resident sitting up in a w/c near the nurse's station. In interview on 03/13/2025 at 11:59 AM, the Director of Nursing (DON) stated she participated in the facility's morning meetings where they discussed root cause analysis when a resident fell . She reported the meeting reviewed residents' care plan (CP) interventions to determine if they did or did not work, and new interventions were added if needed. The DON said residents' CP's were for each individual resident and she expected staff to follow anything on the resident's CP. She further stated the CP was a plan for each individual resident, which allowed for more person-centered care and was important for a resident's safety. In an additional interview with the DON on 03/13/2025 at 2:23 PM, she stated when the morning meeting reviewed R28's fall on 11/14/2024 (after the resident sustained a fall on 11/13/2024) they looked at previous interventions, which included the dycem to the w/c. She reported on 12/17/2024, the staff present in the morning meeting reviewed R28's fall on 12/16/2024 and referred the resident to therapy to evaluate the w/c. The DON further stated therapy added dycem to R28's w/c, between the w/c seat and the w/c cushion. In further interview on 03/13/2025 at 3:49 PM, the DON stated R28 threw the dycem out of the w/c. She said the dycem kept things from sliding and she was unsure when the resident had thrown it away. The DON reported that had been discovered during the (fall) investigation. She further stated the IP audited residents' safety interventions to ensure they were in place. In interview on 03/13/2025 at 3:58 PM and at 4:07 PM, the IP stated during the morning meeting they reviewed residents' interventions to ensure they matched the orders, and she updated the CP as necessary. She reported she completed weekly visual audits of care plan interventions; however, she did not document her visual audits. The IP said at one point R28 had thrown away the dycem in the w/c, but she (the IP) never identified the dycem as missing during her visual audits. She further stated she educated staff on ensuring R28's dycem was in place in the w/c. In further interview on 03/13/2025 at 4:44 PM, the IP stated she could not find the documentation where staff were educated to place the dycem in R28's w/c after the resident fell on [DATE]. She said she should not have to educate staff more than once to ensure R28's dycem was in place. The IP further stated the purpose of the intervention for educating staff to place the dycem (on R28's CP) was to ensure the dycem was placed where it needed to be at all times, or the resident could fall again. In interview on 03/13/2025 at 4:49 PM, the Administrator stated he expected residents' falls interventions be in place; however, said he could not recall discussion regarding R28's dycem not being in the w/c. The Administrator reported he did not know the reason staff were educated multiple times on ensuring the dycem was in R28's w/c. He further stated he expected residents' falls interventions be in place. 47852 2. Review of R259's Admission Record revealed the facility admitted the resident on 03/03/2025, with diagnoses which included metabolic encephalopathy, muscle weakness, dysphagia, cognitive communication deficit, and diabetes. Review of the Occupational Therapy (OT) Evaluation for R259 dated 03/03/2025, revealed the OT assessed the resident as requiring moderate assistance with self-feeding. Review of R259's CCP revealed on 03/07/2025, the facility identified R259 as at risk for further Activities of Daily Living (ADL) decline and as requiring assistance related to acute illness, weakness, impaired mobility, and impaired cognition. Further review of the CCP revealed an intervention that R259 required assistance of one staff for eating. Observation on 03/11/2025 at 8:50 AM, revealed R259 sitting in a wheelchair eating breakfast with no staff present in her room. Per observation, R259 had consumed 25% of her meal and had milk spilled, covering her dining tray. Continued observation revealed R259 had a slight tremor to her hand and was having difficulty lifting her glass to her mouth. Additionally, observation revealed R259 had food spilled on her shirt. Observation on 03/12/2025 at 1:18 PM, revealed R259 sitting in a wheelchair, eating her lunch meal with no staff present in her room to provide assistance as per the care plan. Per observation, lids were on two of the bowls on R259's meal tray. Continued observation revealed R259 removed the lid from the pudding with her hand shaking which caused the bowl to shake while opening the resident was removing the lid. Observation on 03/13/2025 at 8:50 AM, revealed R259 sitting in her wheelchair in her room eating breakfast with no staff present to assist the resident as per the care plan intervention. During interview on 03/11/2025 at 8:50 AM, R259 stated she was new to the facility and said she hated to ask for help. During interview on 03/13/2025 at 10:36 AM, the MDS Nurse stated she had written R259's care plan based upon the therapy evaluation performed on the resident's admission. She said R259 required assistance with eating, and it was important for staff to follow the resident's care plan to make sure the resident's needs were met. The MDS Nurse reported if a care plan change was needed, staff could discuss it with the nursing managers or the MDS nurse. She further stated and any needed changes could be discussed in the facility's morning interdisciplinary meeting. During interview on 03/13/2025 at 12:02 PM, the DON stated she did not usually write residents' care plans. She reported however, she expected staff to follow the residents' care plans because it was important to ensure the residents received proper care. In interview on 03/13/2025 at 4:49 PM, the Administrator stated he participated in the facility's morning meetings and discussed any root causes of incidents. He further stated he expected residents' falls interventions be in place.

Based on observation, interview, record review and review of facility policy, the facility failed to provide sufficient and timely activities of daily living (ADL) for 2 of 33 sampled residents who were unable to perform their ADLs (Resident (R)25 and R259). 1. The facility failed to assist R25 in maintaining his personal hygiene and comfort related to incontinence. R25 reported calling out for assistance for incontinence assistance; however, not receiving the assistance in a timely manner. He expressed feeling miserable after being left wet for as much as two hours at night and occasionally during the day. 2. Additionally, the facility assessed and care planned R259 for one person assist with eating on 03/07/2025. However, observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed no staff present in R259's room to assist the resident while she was eating her meals. The findings include: Review of the facility policy, Activities of Daily Living, (ADL), Supporting, revised March 2018, revealed residents were to be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out their ADL's. Continued review revealed appropriate care and services were to be provided for residents who were unable to carry out their ADL's independently with the consent of the resident and in accordance with their plan of care, including appropriate support and assistance with elimination (toileting). 1. Review of the facility policy, Urinary Continence and Incontinence - Assessment and Management, revised in July 2022, revealed relevant information related to urinary incontinence included observations, such as a wet bed or clothing and/or (the resident's) use of diuretics. Per review, staff were to define each individual's level of continence, referring to the criteria in the Minimum Data Set (MDS) Assessment as follows: continent indicating the resident had been continent of urine for at least seven days with no episodes of incontinence; occasionally incontinent defined as the resident having had less than seven bladder incontinence episodes in the past week. Continued review revealed the level of continence definitions also included: frequently incontinent defined as the resident having had at least seven episodes of bladder incontinence in the previous seven days; however, the resident had at least one continent void; or always incontinent defined as the resident having had no continent voids in the past seven days. Further review revealed an incontinent episode defined as any amount of urine sufficient to dampen undergarments, briefs or pads. Additionally, review revealed nursing staff and the physician were to identify (a resident's) risk factors for becoming incontinent or for worsening of recurrent incontinence, including. urinary tract infections (UTI's), and environmental factors including immobility or lack of access to toilet. Review of R25's medical record revealed the facility admitted the resident on 06/10/2022, with diagnoses including acute on chronic combined systolic and diastolic congestive heart failure (CHF); chronic kidney disease, stage 3; and hemiplegia and hemiparesis following cerebral infarction affecting the resident's left non-dominant side. Review of R25's Annual MDS assessment dated [DATE], revealed the facility assessed him with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Continued MDS review revealed under Section H, Bowel and Bladder, the facility assessed R25 as frequently incontinent of both bladder and bowel. Further review of the MDS Assessments revealed no documented evidence the facility assessed R25 for his toileting hygiene under Section GG. Review of R25's Kardex (the nursing assistants' care plan) revealed information noting the resident as incontinent of bowel and bladder. Further Kardex review revealed the expected intervention included to check and change R25 on rounds, upon request and as needed. Review of R25's clinical Physician's orders revealed an order for R25 to receive furosemide (a diuretic) 80 milligrams (mgs) daily for his CHF. Observation of R25 on 03/12/2025 at 9:42 AM revealed the resident was wearing a watch which he referenced for telling time. Continued observation revealed R25 also had a clock in sight from of the head of his bed. During interview with R25 on 03/12/2025 at 8:33 AM, he stated he was concerned about the quality of the agency staff used at the facility. R25 said he felt agency staff did not really do their job, at night mostly. He reported last night it took two hours to get somebody in here after he called out that he was wet, and that happened two different times. R25 stated he called out for assistance at about 10:00 PM and she (the aide) did not respond until nearly midnight. He said he called out again at around 2:00 AM; however, no staff responded until about 4:00 AM. R25 reported in both instances he was aware of the time because there was a clock on the wall straight ahead of him and he also looked at his watch. He explained he was forced to lay in bed wet during those hours and it made him feel miserable. R25 stated staff knew he took diuretic medication and therefore he emptied his bladder more frequently. He stated he felt agency staff just did not care as much because they would not be back at work the next day. The resident said night staff were more a problem than during the day, although sometimes it was on days also. R25 stated there were some days when people called off and the facility just had to use agency staff. He reported he estimated he saw agency aides at least four nights per week on average. R25 stated the Administrator and Director of Nursing (DON) had told him they were trying to get regular staff hired. During interview with Certified Nursing Assistant (CNA) 8 he stated staff should round on residents every two hours. He stated some residents called out, others might not be able to, so the expectation was to round every two hours. The CNA said there should not be a reason for staff to delay a resident's incontinence care unless an emergency was happening elsewhere. He reported the reason not delaying a resident's incontinence care was because that was less time spent wet or soiled, and less chance of skin breakdown or urinary tract infection (UTI). CNA 8 stated he usually cared for 12 to 15 residents on a shift at the facility and was able to get his work done with that ratio. He said most staffing agencies wanted seasoned nursing assistants, so the expectation was that agency staff could walk in and be ready to work. The CNA further stated he had not received a specific orientation to the workings of the facility; however, could rely on staff employed there. He additionally stated he based the residents' care on the Kardex which were consistently up to date at the facility. During interview with CNA 10 on 03/12/2025 at 2:34 PM, she stated she was responsible for six resident rooms, and that could be providing care for as many as 12 residents. She stated for incontinence care, the expectation was to check and change residents every two hours. The CNA said some residents should be checked more often if they were known to void more frequently, for example, if they were on Lasix (a diuretic medication). She reported staff went by the residents' Kardex which were kept on the inside of each closet door to know what each resident's care needs were. CNA 10 explained staff should be able to keep residents clean and dry, and the residents should not have to wait two hours to receive care if they needed it. She stated if she was having to work alone to care for all 12 rooms, she would not be able to keep up the way she did now. The CNA said however, she would still prioritize keeping her residents clean and dry. She further stated that was important to protect the residents' skin and prevent breakdown or UTI. During interview with CNA 7 on 03/13/2025 at 12:13 PM, she stated some agency staff were good, but some were not. She further stated some did not complete all the necessary care for residents and she had found residents wet when starting her shift. During telephone interview with CNA 11 on 03/12/2025 at 10:25 PM, she stated she worked for an agency and started coming to the facility a lot since December, and usually picked up a lot every week. She stated she floated all over the facility and said there were usually only three aides working on the three halls after 11:00 PM. The CNA reported the expectation was to check and change residents every two hours; however, some residents required extra checks as they voided more often, and so they were rounded on more often. CNA 11 explained she made extra checks as told, such as for a resident on every 15-minute checks. She stated other than emergencies, for the most part one aide on each hall was enough even with getting some residents up in the morning before day shift arrived. The CNA said it might depend on how fast you work, but you should be able to get the resident checks and changes done and keep residents dry with just one aide on each hall. She explained if you check the residents regularly, then most of the time they might be a little wet but not flooded, unless they were just prone to void more often and if so, they should be checked on more often. She reported there was no reason outside of an emergency that anybody should be soaked. The CNA stated if she was in a resident's room and saw a call light on, she would go answer the light, as it was sometimes about getting changed anyway. She said she tried to answer residents' call lights as soon as she could. CNA 11 further stated it was important to keep the residents clean and dry so they did not have skin breakdown, UTI's, yeast infections or even infections of a surgical wound. She additionally stated it would be upsetting to have to sit in feces or urine. During telephone interview with CNA 12 on 03/13/2025 at 1:37 AM, she stated had been a nursing assistant for [AGE] years, and currently worked for an agency. She stated she had not been to the facility for two to three years, and that day was only her second day on the assignment. The SRNA said the previous night she had been in one resident's room, and there had been no other call lights on when she entered that room. She reported however, when she exited that room, the call light was on in the next room and so she went in there. CNA 12 stated she thought it had been no more than 15 minutes from the time she entered the other resident's room. The CNA further stated they were expected to round on residents every two hours for continence care or more often if a resident put on their call light. During telephone interview with Licensed Practical Nurse (LPN) 11 on 03/12/2025 at 8:04 PM, she stated the expectation was for staff to round for toileting and check/change every two hours. She stated they usually had two aides on day shift, who had 11 residents each. The LPN said that was a good number and it was possible to keep up with that workload. She explained they passed on in shift report any changes in a resident's diuretic use to ensure staff were checking those residents more frequently. She stated there were fewer aides at night, and at 11:00 PM, they picked up more residents which be more like 15 or 16 residents. LPN 11 stated while there were fewer aides, there were fewer tasks to accomplish besides the checking and changing. She said there was no reason for a resident to be left wet for two hours, and there should not be a reason for a resident's call light to remain unanswered for two hours. The LPN reported it was important to keep residents clean and dry to protect their skin, that it was uncomfortable for a resident to be wet or soiled, and would also be a dignity issue. She stated she could tell the difference when working with or following agency staff. LPN 11 explained agency staff did not know the residents or their routines, so some tasks did not get done. She further stated she could tell the difference when following agency staff; however, said she could not say anything about residents being left wet because the day shift aides just take care of it and go on to the next task. During telephone interview with LPN 10 on 03/12/2025 at 9:38 PM, he stated he usually had three aides for the three wings on his unit. He stated on some nights that was doable, though some nights it was harder and just three aides was not enough. The LPN said the facility used agency staff now, although was working to hire their own staff. He reported keeping the residents dry could be challenging with more agency staff being used; however, the house supervisor was really good to help on the unit. He stated having more facility staff, rather than agency, would be a good thing. LPN 10 reported sometimes agency staff seemed unprepared for the work that was necessary, but there was no reason for a resident to be left wet for two hours after the called out. He stated it was important to keep residents clean and dry for their dignity, because nobody wanted to sit in urine and feces. The LPN said it was important to keep the residents dry to prevent skin breakdown, and with diabetic patients, skin integrity was even more important. He reported he tried to keep eye on the nursing assistants to ensure care was completed as required, looking at such things as how much trash was coming out of the residents' rooms and how much linen was being used. LPN 10 stated he followed up with the aides about whether residents had not voided, and to ensure they were reporting that. During interview with Unit Manager (UM) 1 on 03/13/2025 at 9:50 AM, she stated they did use agency staff, but had recently hired quite a few nurses and aides. She stated they used less agency now than even a month ago. UM 1 reported agency staff received an orientation packet, and she showed them around the unit, connected them with a peer for resource, and showed them the resident Kardexes that were kept in the closets. She said the Kardexes were updated daily or as needed. The UM stated the expectation was for staff to be at least checking residents who were prone to incontinence every two hours. She further stated there was no reason for a resident to ever be left wet, and the aides and nurses should pass along in report any changes to a resident's toileting needs. During interview with Nurse Practitioner (NP) 1 on 03/13/2025 at 11:51 AM, she stated patients told her they could not wait for regular staff to get back, that they loved their own people. She stated she noticed everywhere she worked that having to use agency staff had the good point of having staff available in the building; however, those staff did not know the residents like the facility staff did. During interview with the DON on 03/13/2025 at 4:06 PM, she stated her expectation was for the checking and changing of residents to occur every two hours around the clock. She said some residents who needed checking and changing were cognitively intact, and staff must still check those residents who retained the option to refuse that care. The DON stated the aide should report any refusals to the nurse who should document that information. She reported she expected staff to respond to residents' call lights in a timely manner, for example, if going to a room and the next door light came on, she expected staff to communicate to the resident with your aide is already next door and will be here as soon as she is done. In continued interview on 03/13/2025 at 4:06 PM, the DON stated they strived to have two aides on the memory care unit and three on each of the other units from 11:00 PM to 7:00 AM. The DON said in her experience you could have three people on the hall, and the less you had the better the work gets done. She stated the only reasons for a resident being left wet would be if they refused or staff were not doing their job. The DON explained resident care should take precedence over other tasks, the residents should be fed, clean and comfortable. She further stated continence care was important for the residents' comfort and it was especially a huge dignity issue, as the residents had been continent since they were small children. The DON additionally said continence care was also important for protecting the residents' skin integrity. During interview with the Administrator on 03/13/2025 at 4:53 PM, he stated prior to coming to the facility he had not dealt with agency staff. The Administrator stated he depended on the DON for assessing and alerting him of staffing needs. He reported having a ton of agency staff made continuity of care for residents difficult, while their own staff got to know the residents and had a personal relationship with the residents. The Administrator said it was more effective to hold your own staff accountable; and he was about coaching staff to be the best they can be. He stated he could not do that as well with people who were only there for a day or two. The Administrator reported he deferred to the DON regarding staffing and felt her assessment of staff was that the numbers were sufficient, and he felt residents should be able to get the care they needed. He further stated resident care was important in residents having good quality of life and a homelike environment and that continence care was important to prevent infections, thus failing to do that could create harm. The Administrator additionally said continence care was also important for maintaining the residents' dignity. 47852 2. Review of R259's Admission Record revealed the facility admitted the resident on 03/03/2025, with diagnoses which included metabolic encephalopathy, muscle weakness, dysphagia, cognitive communication deficit, and diabetes. Review of the Comprehensive Care Plan (CCP) for R259 revealed on 03/07/2025, the facility identified a care plan for the resident as at risk for further Activities of Daily Living (ADL) decline. Per review of the ADL care plan, the facility also assessed R259 to require assistance related to impaired cognition, weakness, acute illness, and impaired mobility. Review of the CCP further revealed the facility assessed R259 as requiring assistance of one (1) with eating. Review of the Occupational Therapy (OT) Evaluation dated 03/03/2025, for R259 revealed OT assessed the resident as requiring moderate assistance with self-feeding. Review of R259's Speech Therapy (ST) Evaluation dated 03/04/2025, revealed ST assessed the resident as having a severe cognitive communication impairment characterized by difficulty with memory, problem solving, and executive functioning. Review of R259's Eating Task revealed the facility provided set up assistance for the resident for all three (3) meals on 03/07/2025, 03/09/2025, 03/10/2025, and 03/12/2025. Further review revealed the facility assessed R259 as independent with meals on 03/08/2025 at lunch (and set up assistance with the other two (2) meals on 03/08/2025), and as independent on 03/11/2025 with all three (3) meals. Review of R259's Meal Intake documentation revealed the facility noted the resident to have eaten 0-25% of her meal on 03/04/2025 at lunch and 26%-50% of her breakfast and dinner meals on 03/04/2025 and 03/11/2025 for all meals. Observation on 03/11/2025 at 8:50 AM, revealed R259 sitting in a wheelchair eating breakfast alone in her room. Further observation revealed 25% of meal eaten and milk spilled, covering dining tray. Continued observation revealed R259 had a slight tremor to her hand and had difficulty getting the glass to her mouth. Additionally, food was noted to be spilled on R259 ' s shirt. Observation, on 03/12/2025 at 1:18 PM, revealed R259 sitting in a wheelchair alone in her room eating lunch. Further observation revealed lids on two (2) bowls on tray. Continued observation revealed R259 removed the lid from the pudding with a shaky hand causing the bowl to shake while opening the lid. Observation, on 03/13/2025 at 8:50 AM, revealed R259 sitting in her wheelchair in her room eating breakfast alone. During an interview, on 03/11/2025 at 8:50 AM, R259 stated she was new to the facility and stated she hated to ask for help. During an interview, on 03/13/2025 at 10:36 AM, the Minimum Data Set (MDS) nurse stated she wrote R259 ' s care plan based upon the therapy evaluation (eval) on admission, and R259 did require assistance with eating. She further stated it was important to follow the care plan to make sure the resident ' s needs were met and the CNA could not alter the care plan. She continued to state if a care plan change was needed, staff could discuss it with the nursing managers or the MDS nurse and the needed change could be discussed in the morning interdisciplinary meeting. During an interview, on 03/13/2025 at 12:02 PM, the Director of Nursing (DON) stated she does not usually write care plans but she expected staff to follow care plans because it was important to ensure residents received proper care.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free from accidents as possible for 1 of 33 sampled residents, (Resident (R)28). The facility developed a care plan for R28's risk for falls which included an intervention for dycem (a nonstick material used to stabilize objects) to the resident's wheelchair on 11/08/2023. On 12/09/2024, R28 sustained a noninjury fall and the facility updated the resident's fall risk care plan on 12/09/2024, for staff to be educated to place dycem in her wheelchair. On 12/16/2024, R28 experienced another noninjury fall, and the facility updated R28's fall risk care plan on 12/17/2024, again with the intervention for staff to be educated on ensuring the dycem was in the resident's wheelchair. The findings include: Review of the facility's policy, Falls and Fall Risk, Managing revised March 2018, revealed staff were to identify interventions related to the resident's specific risks to try to prevent the resident from falling. Per review, risk factors included cognitive impairment and heart failure. Continued policy review revealed staff were to implement a resident-centered fall prevention plan to reduce specific risk factors of falls for each resident at risk or who had a history of falls. Further review of the policy revealed if interventions were successful in preventing falling, staff were to continue those interventions. Review of the clinical record for R28 revealed the facility admitted the resident on 10/22/2021 and readmitted the resident on 11/15/2021. Per review, R28's diagnoses included congestive heart failure, immobility syndrome, and weakness. Review of R28's care plan dated 11/03/2021, revealed the facility identified the resident as at risk for falls and developed the care plan with an intervention for dycem to the wheelchair (w/c) on 11/08/2023. Per care plan review, staff were educated to place dycem in R28's w/c on 08/14/2024 and the care plan was revised on 12/09/2024 and 12/17/2024, with the intervention for staff education regarding placing dycem to the resident's w/c. Review of the progress note dated 12/09/2024, revealed R28 sat on the ground beside her w/c in her bathroom. Review of the progress note dated 12/16/2024, revealed staff found R28 on the floor beside her bed and an intervention was noted to evaluate chair and add dycem. Review of the Speech Therapy Medicare SLP Evaluation and Plan of Treatment for R28 dated 12/09/2024, revealed the therapist assessed the resident to have a St. Louis University Mental Status (SLUMS examination score of one out of 30, indicating the resident's level of cognition was severe .and (the resident was) at risk for falls. Review of the facility's, Record of In-Service Training dated 08/14 (no year noted) revealed the Infection Preventionist (IP), also the facility's Quality Assurance (QA) staff person, trained staff to ensure the dycem was in (R28's) w/c. Review of the facility Class Attendance Record dated 12/17 (no year noted) revealed staff signatures documented. Continued review of the Class Attendance Record revealed an attached Google search printout for dycem info for wheelchairs which noted it was ideal for adhering cushions and inserts to wheelchairs, and was non-slip. Observation of R28 on 03/11/2025 at 10:42 AM, revealed the resident sitting up in a w/c near the nurse's station. In interview on 03/13/2025 at 9:46 AM, the Physical Therapy Assistant (PTA) stated R28 was able to self-propel in her w/c; however, was not able to stand on her own. She stated R28 had sustained falls trying to take herself to the bathroom. In interview on 03/13/2025 at 11:59 AM and 03/13/2025 at 2:23 PM, the Director of Nursing (DON) stated residents' falls were discussed in the facility's morning meeting the day following the fall, for the root cause analysis (RCA) of the fall. She stated when R28 fell on [DATE], the fall was reviewed in the morning meeting on 11/14/2024. The DON reported during that meeting they reviewed R28's previous interventions, which included dycem to her w/c (however, review of the care plan revealed the current intervention for dycem to the resident's w/c was dated 11/08/2023). She said R28 experienced a fall on 12/16/2024, and the resident was referred to therapy on 12/17/2024. The DON further stated therapy added dycem to the resident's w/c as an intervention on 12/17/2024. In additional interview on 03/13/2024 at 3:49 PM, the DON stated R28 was throwing the dycem (in her w/c) away, which had been discovered during the facility's investigation. She reported the dycem was made of silicone and helped keep things from sliding. The DON further stated the IP checked to ensure residents' safety interventions were in place. In interview on 03/13/2025 at 3:59 PM and 03/13/2025 at 4:07 PM, the IP/QA stated she was responsible for QA at the facility. She stated as part of QA, she conducted weekly visual audits throughout the facility; however, did not record (document) her audits. The IP/QA said her audits included making sure the dycem (for R28) was in her w/c. She reported she had not found R28's dycem missing during her audits, but R28 had thrown the dycem away at one point. The IP/QA further stated she educated staff to place the dycem in R28's w/c when the dycem was missing. She additionally stated she conducted that education once; however, could not recall when she conducted the education. In an additional interview on 03/13/2025 at 4:44 PM, The IP/QA stated she could not find her training logs for the staff education provided on 12/09/2024, regarding placing R28's dycem in her w/c. She reported she should not have had to educate staff more than once on that subject (to place the dycem in the w/c). The IP/QA further stated the purpose of the staff education was to ensure the dycem was where it needed to be at all times, because if the dycem was not in place, R28 could fall again. In interview on 03/13/2025 at 4:49 PM, the Administrator stated he participated in the facility's morning meetings where they discussed incidents and any root causes. He stated his role was to find the nurses the resources they needed to take care of the residents the best they can. The Administrator said he did not recall any discussions related to R28's falls or regarding if the dycem was not in her w/c. He reported he did not know the reason staff were educated for the dycem to be in R28's w/c on three different occasions. The Administrator stated he deferred to the nursing department to deal with that. He further stated he was not familiar with dycem and could not say what could be a potential issue if the dycem was not in place. The Administrator additionally stated he expected residents' falls interventions be in place as required.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care were provided such care consistent with professional standards of practice. Observation on 03/11/2025 and 03/12/2025 revealed R13's nasal cannula was not bagged while not in use. The findings include: Review of the facility's policy, Receipt and Storage of Supplies and Equipment, revised November 2009, revealed all supplies and equipment must be stored in accordance with the manufacturer's recommendations. Review of R13's Admission Record revealed the facility admitted the resident on 12/10/2016, with diagnoses which included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and pulmonary hypertension due to left heart disease. Review of R13's Physician Orders revealed an order dated 01/30/2025, for oxygen at two (2) liters per minute (LPM) per nasal cannula to keep the resident's oxygen saturation above 90%. Review of R13's Comprehensive Care Plan (CCP) dated 02/28/2025, revealed the facility care planned the resident as at risk for respiratory complications related to CHF, COPD, and chronic respiratory failure with hypoxia with oxygen per orders. Further review revealed the facility developed interventions for R13's oxygen therapy and for staff to follow (the facility's) infection control protocol for universal/standard precautions. Observation on 03/11/2025 at 8:35 AM, revealed R13 eating breakfast while wearing her oxygen per nasal cannula which was attached to an oxygen concentrator. Further observation revealed a nasal cannula attached to the portable oxygen tank on R13's wheelchair which was not bagged and was hanging off the wheelchair. Observation on 03/12/2025 at 1:20 PM, revealed R13 lying on her bed with eyes closed with oxygen on per nasal cannula that was attached to the concentrator. Further observation revealed the nasal cannula attached to R13's portable oxygen tank on her wheelchair was wrapped around the wheelchair handle and was not stored in a bag. During an interview on 03/11/2025 at 8:35 AM, R13 stated she used oxygen all the time and had pneumonia last month. During an interview on 03/13/2025 at 10:05 AM, with the Infection Preventionist (IP), she stated the floor nurse or respiratory nurse should change the resident's oxygen tubing (nasal cannula) weekly. She reported the oxygen tubing (nasal cannula) should always be stored in a bag when not in use to prevent infection and keep it from getting germs. The IP said the facility placed bags in all rooms where residents had oxygen for the purpose of staff storing their nasal cannula's in when not in use. She further stated if nasal cannula's were left unbagged, germs could get on the tubing and get into the resident's lungs which was very unsanitary.

Based on observation, interview, record review and review of facility policy, it was determined that the facility failed to prevent accidents for one (Resident (R) 19) of twenty-two sampled residents. On [DATE], R19, whose mobility was per wheelchair, fell from the back of a transport van when staff released the safety restraints before assuring that the hydraulic lift was in place. R19 flipped backwards over her wheelchair, falling over 10 feet from the van onto the pavement, landing headfirst. R19 sustained actual harm, including a closed head injury, right and left rib fractures, and cervical spine strain as a result of the accident. The findings include: Review of a facility policy titled, Safety and Supervision of Residents, revised [DATE], revealed resident safety, supervision, and assistance to prevent accidents are facility-wide priorities, and facility employees shall be trained on potential accident hazards, and try to prevent avoidable accidents. Review of a facility policy titled Falls and Falls Risk Managing, revised [DATE], revealed the facility staff will identify interventions related to the resident's specific risk and causes to try and prevent the resident from falling and to try to minimize complications from falling. Review of a facility policy titled, Facility Vehicle Driver Safety Policy, dated [DATE], which was in place at the time of R19's fall, revealed that it did not address the steps that staff were to follow regarding the use of the mechanical lift to ensure a safe exit from the facility van. Closed record review of a Face Sheet revealed R19 was admitted to the facility on [DATE], and discharged to the hospital on [DATE], where she subsequently expired. The resident's diagnoses included Parkinson's Disease, muscle weakness; lack of coordination and abnormalities of gait and mobility. Review of an admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of ,d+[DATE]. Per the MDS, the resident used a wheelchair for mobility, required partial to moderate assistance with transfers. Review of a quarterly MDS, with an ARD of [DATE] revealed R19 was still assessed as cognitively intact, required staff assistance with mobility and used a wheelchair for locomotion. Review of a nursing progress note, dated [DATE] at 2:33 PM, revealed that while taking R19 to an appointment at a local hospital complex, Certified Nursing Assistant (CNA) 1 was preparing the resident and her belongings to be pushed back on to the van's mechanical lift. Per the note, R19 was attempting to grab her purse and other belongings. CNA1 told R19 to wait while the CNA was gathering up her things. The progress note stated R19 then started propelling herself backwards towards the open back end of the transport van, and the lift was not up at the van floor level. CNA1 told R19 to stop and she would help her, but the resident did not stop propelling herself backwards. CNA1 attempted to reach the resident's wheelchair but could not reach the resident in time and R19 flipped out backwards out of the van onto the parking lot, landing headfirst. Review of R19's Emergency Department Discharge After Visit Summary, dated [DATE], revealed R19's injuries included a closed head injury, left rib fracture, right rib fracture, and a cervical spine strain. The resident did not require surgical intervention for her injuries and returned to the facility the same day. Observation of the surveillance video of the incident, dated [DATE] and timestamped at 12:34 PM, revealed R19 rolling backwards, falling out of the facility's transport van, flipping over her wheelchair backwards and landing headfirst onto the pavement at the 12:35:25 mark. The hydraulic lift gate was observed to be on the ground at the time of the fall. Observation of the van on [DATE] at 10:07 AM revealed that the distance which the resident fell from the bed of the van to the ground was 10 feet, 4 inches. In an interview with R19 's daughter (FM19) on [DATE] at 5:54 PM, she stated she was out of town the weekend of the accident and was notified by the hospital needing permission to take care of her mother because she was the Power of Attorney (POA) and R19 was in and out of consciousness after a fall accident. FM19 stated her mother, who passed away in ,d+[DATE], was foggy on the details of her accident and only remembered being on her back, and then going to the ER. Interview with CNA1, on [DATE] at 10:38 AM, revealed she was taking R19 to a doctor's appointment and they were parked under the porch area of the entrance to the building. CNA1 stated the wheelchairs were hooked up on chains while the residents were being transported in the van. She stated the wheels on the wheelchair were also to be locked. CNA1 stated she had just unlocked the wheels on the wheelchair and unhooked R19 from the safety restraints in the van when R19 started pushing back in her wheelchair. CNA1 stated she told the resident, No, don't do that; however, R19 continued to push back in the wheelchair with her legs as she thought it was time for her to go. CNA1 stated that at this time, the lift was still down on the ground. R19 did not wait for the lift to return up to the van before she rolled back and that was how she fell . CNA1 said she went over to try and grab hold of R19 when she saw the resident begin to fall backwards but did not make it to her in time. CNA1 stated she got out of the van immediately and went and checked on R19. Once she determined the resident was OK, she went inside the building and got some help. In continued interview with CNA1, on [DATE] at 10:38 PM, she stated she called the Administrator and told him what happened with R19. CNA1 added that the Administrator was out of town when it happened, so the Director of Nursing (DON) called her and advised her to send R19 to the emergency room (ER). She stated she stayed at the hospital with R19 afterwards, and she thought that the resident was fine. CNA1 said R19 did state to her she had pain but otherwise was OK and returned to the facility that night after she was treated in the ER. Further interview with CNA1 revealed that she should have waited until the lift was in place before she unlocked the resident's wheelchair wheels. CNA1 stated that she should have looked back and made sure the lift was in place because she was aware of the resident's impulsive behaviors. In an interview with CNA2 on [DATE] at 8:12 PM, she stated she worked at the facility for three years, leaving in ,d+[DATE]. She stated that she was with CNA1 transporting R19 and another resident on the day of the accident. CNA2 stated they got one resident (Resident 20) down out of the van. She stated the van was parked on a slanted slope, so she was trying to safely park Resident 20 she had gotten out of the van by first locking the resident's wheels so that her wheelchair would stay put and not roll away by itself. CNA2 said that as soon as she turned around after securing this first resident, she then saw R19 rolling out the transport van backwards and fall. CNA2 stated when she saw R19 roll out, she thought she saw CNA1 standing in front of her but was unable to tell what CNA1 was doing because she (CNA2) was on the ground off to the side with Resident 20. CNA2 stated she did not recall receiving formal training and CNA1 had been the staff who trained and instructed her on how to operate the hydraulic lift. In an interview with the DON on [DATE] 4:25 PM, she stated that CNA1 called her after the incident and reported it to her. She directed CNA1 to stay with the resident and ensure she was safe. The DON stated R19 frequently went out in the transport van to appointments and was very familiar with the process and how to maneuver getting in and out of the van with the lift and she felt that was most likely why the resident was comfortable with proceeding to exit the vehicle despite CNA1's pleas for the resident to stop and wait for her to assist her. In an interview with the Administrator on [DATE] at 3:02 PM, he stated he was out of town when the incident occurred but got a phone call from staff and was notified of the incident that day. The Administrator stated that, based on what was described to him, the root cause was R19 had anticipated that the lift was coming up quickly and she rolled back, and it was not there. Although the aide told her to stop, instead the resident had kept going. Interview with the Administrator revealed that, prior to R19's fall, their policy and procedures did not detail the steps that staff were to follow when using the mechanical van lift to remove residents from the van, including the need to check that the mechanical lift was in place prior to releasing the resident to exit the van. The facility implemented to following: 1. Record review revealed R19 was evaluated and treated at the ER for injuries received in the accident on [DATE] and discharged back to the facility that evening. In an interview with CNA 1 on [DATE] at 10:38 AM, she stated that she accompanied R19 to the ER and remained there with her until she returned to the facility. 2. In an interview with the Administrator on [DATE] at 3:02 PM he stated that there had been no other incidents of with the transport van. 3. Review of the facility's allegation of compliance revealed DON and Administrator were educated by the Regional Director of Clinical Services on [DATE]. In an interview with the Administrator on [DATE] at 3:02 PM, he stated he received education from the regional director of clinical services on [DATE]. Additional review and interview with CNA 1 revealed she received training from the facility regarding transportation safety. 4. Review of facility document titled Vehicle Checklist Review revealed the facility checked the vehicle log once a week for 4 weeks then monthly there after.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were free from abuse for one (1) of twenty-four (24) sampled residents, Resident #7. Resident #7 was physically assaulted by Resident #6, on 02/20/2021, resulting in superficial injuries to his/her left wrist and forehead. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents had the right to be free from abuse, including physical abuse. Continued review revealed the facility was committed to protect the resident from abuse by anyone, including another resident. Review of Resident #6's medical record revealed the facility admitted the resident, on 02/08/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #6, in a Quarterly Minimum Data Set (MDS) Assessment, dated 02/17/2021, as severely cognitively impaired with both short and long term memory problems. Continued review of the MDS Assessment revealed the resident was rarely understood and rarely understood others. Resident #6 exhibited no behaviors during the 7-day look back period. Review of Resident #6's comprehensive care plan, initiated on 02/12/2020, revealed a Mood and Behavior care plan with interventions in place, which included assessing and attempting to identify causes of agitation; observing and recording behavioral episodes; and notifying the physician or psychiatrist of changes in mood and behavior. Review of Resident #7's medical record revealed the resident was admitted to the facility, on 04/08/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #7, in a Significant Change MDS Assessment, dated 01/13/2021, as scoring twelve (12) of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Further review revealed Resident #7 was usually understood and usually understood others and had no behaviors during the 7-day look back period. Review of the facility's Incident Report (IR), initiated on 02/20/2021 and concluded on 02/24/2021, revealed Licensed Practical Nurse (LPN) #9 witnessed Resident #6 grab the left wrist of Resident #7, who was standing in the doorway of a common area. Then, Resident #6 struck Resident #7 in the forehead with the ball of his/her hand. Continued review revealed it took three (3) staff to remove Resident #6's hand from Resident #7's wrist. The IR revealed Resident #7 was noted to have a small abrasion to his/her forehead and scattered redness on his/her left chin. The IR stated the residents were separated, with Resident #6 placed on one-to-one (1:1) supervision until he/she could be transferred out for an inpatient psychiatric evaluation. Per the IR, Resident #7 was placed on seventy-two (72) hour monitoring for any change of condition. Further review revealed x-rays were performed on Resident #7's wrist, arm, and forehead, with all results being negative. Review of Progress Notes written by LPN #9, on 02/20/2021 at 2:18 PM, revealed Resident #6 became agitated as Resident #7 was in the doorway to the common area where Resident #6 wanted to go. The note stated Resident #6 grabbed Resident #7's left wrist, twisting it backwards, and struck Resident #7 in the forehead. Review of Resident #7's Nursing Body Assessment, dated 02/20/2021 at 2:15 PM, revealed a small patch or red rash like area to the left chin and a slightly raised tender area above the left wrist, with full range of motion (ROM) without pain. Review of Resident #7's Nursing Body Assessment, dated 02/22/2021 at 2:16 PM, revealed the rash like area on the chin was clearing, the back of the left wrist was slightly discolored, yellowish-green, with a small raised tender area, which was smaller and less tender than yesterday. LPN #9 was no longer employed at the facility and could not be reached for interview during the course of the survey. Interview with Resident #7, on 10/21/2021 at 9:40 AM, revealed the resident did not recall any event with former Resident #6. Resident #7 stated he/she was treated well by staff and by other residents. Interview with State Registered Nurse Aide (SRNA) #10, on 10/20/2021 at 11:37 AM, revealed Resident #6 was a big old teddy bear, but did have mood swings. She stated one (1) minute Resident #6 was happy, the next he/she was not happy. She stated she did not witness the altercation with Resident #7 but knew Resident #6 had been sent out for inpatient psychiatric help on multiple occasions. Interview with the Director of Social Services, on 10/20/2021 at 1:39 PM, revealed she remembered a little about the incident in February 2021 involving Resident #6 and Resident #7. She stated Resident #6 started having increasing behaviors, eventually leading to his/her placement elsewhere. Further, she stated she did follow-up interviews with both residents and did not recall any changes in Resident #7. Interview with Registered Nurse (RN) #1, on 10/20/2021 at 3:45 PM, revealed Resident #6 was over six (6) feet tall, but she described him/her as a big teddy bear. She stated a lot of staff and residents were intimidated by Resident #6, and he/she did have bouts of aggression. She stated as Resident #6's dementia progressed, he/she would get agitated unexpectedly. She stated, although she did not recall the incident with Resident #7, she did remember a red spot on Resident #7's forehead after the incident occurred. Interview with the Director of Nursing, on 10/21/2021 at 11:15 AM, revealed she had been present at the facility since July 2021. She stated she expected residents to be safe and protected and free from abuse and mistreatment. Interview with the Administrator, on 10/21/2021 at 2:09 PM, revealed Resident #6 was a big focus for a long time, with staff putting a lot of time into trying to determine what provoked him/her. The Administrator stated it was determined, for the incident with Resident #7, that Resident #7 standing in Resident #6's way in the doorway provoked him/her, which was added to Resident #6's care plan as a provocation. The Administrator stated he expected residents and families to feel the residents were safe and that there be zero abuse in the facility. He further stated he expected staff to be trained to recognize abuse. The Administrator also stated he expected staff to look for opportunities where abuse might occur, be proactive in preventing it, and develop a plan to deal with it, if abuse did happen.

Based on interview, record review, facility policy review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to follow professional standards of practice for one (1) of twenty-four (24) sampled residents, Resident # 2, by failing to administer medications to the resident as ordered and in a safe manner. The findings include: Review of the KBN, AOS #14, Roles of Nurses in the Implementation of Patient Care Orders, revised May 2018, revealed nurses were responsible and accountable for making decisions based upon the individual's educational preparation and current clinical competence in nursing and required licenses to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (APRN). This included preparing and administering medications in the prescribed dosage, route, and frequency. Review of the facility's policy titled, Administering Oral Medications, revised October 2010, revealed staff was to remain with the resident until all medications had been taken. Review of Resident #2's medical record revealed the facility admitted the resident, on 09/28/2020, with diagoses including Unspecified Dementia with Behavioral Disturbance, Abnormal Weight Loss, and Generalized Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2021, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), indicating intact cognition. Review of the Resident Grievance Form, dated 09/08/2021, revealed Resident #2's daughter and guardian reported a grievance of medications for Resident #2 being left in the resident's room, unsupervised, on 09/08/2021. Therefore, Resident #2 missed his/her medications. Telephone interview with Resident #2's daughter, on 10/21/2021 at 10:17 AM, revealed she visited her parent on 09/08/2021. She stated she saw some medications in the room. She stated she looked for the nurse but could not find her, so she told the clerk about the medications and was assured that the clerk would inform the nurse. She left the facility, she said, and called the Social Services Director and told her there were medications in Resident #2's room. Interview with the Social Services Director (SSD), on 10/20/2021 at 1:41 PM, revealed she had spoken with Resident #2's daughter on the phone. The SSD stated the daughter told her there were medications in Resident #2's room. The SSD stated she got the Advanced Practice Registered Nurse (APRN) and went to the room. The SSD stated they searched the room and found the medications in a medication cup in the resident's room. The SSD stated she then gave the medications to the Director of Nursing (DON) and the Administrator who were in a meeting in the Human Resources Office. Interview with the APRN, on 10/20/2021 at 2:40 PM, revealed she went into Resident #2's room with the SSD. The APRN stated there were about four (4) or five (5) pills in a medication cup in the room. She stated the medications were [MEDICATION(S)] (a [CONDITION(S)] replacement) 100 micrograms; Sodium Chloride 1 gram; [MEDICATION(S)] (helps breathing by opening up the airways) 400 milligrams (mg); [MEDICATION(S)] (an anti-depressant) 25 mg; [MEDICATION(S)] (an anti-[CONDITION(S)] medication 125 mg; [MEDICATION(S)] (a beta-blocker that affects the heart and circulation) 50 mg; and Omeprazole (a proton-pump inhibitor used to reduce acidity in the stomach) 40 mg. The APRN stated it was dangerous to leave the resident's medications at the bedside because the resident would not receive needed medications, and the resident's roommate or another resident could potentially see the medications and take them. Interview with the DON, on 10/21/2021 at 12:47 PM, revealed the SSD brought some medications that were smashed together in a medicine cup, which she could not identify, to the Human Resources Office. She stated she was in the Human Resources Office having a meeting with the Administrator and the Assistant Director of Nursing (ADON). According to the DON, after this incident, she did do random checks to assure no medications were at the residents' bedsides. She also provided nursing staff with education on the Administering Oral Medications policy. Interview with the Administrator, on 10/21/2021 at 2:31 PM, revealed he thought the SSD came to him about the incident. He also stated he thought there could have been a potentially unsafe situation with leaving medications in Resident #2's room.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to provide pharmaceutical services related to receiving, and administering controlled medication to meet the needs of each resident for one (1) of five (5) sampled residents (Resident #3). Resident #3 was on palliative care and review of Physician Orders, dated June 2020, revealed orders for [MEDICATION NAME] (Concentrate) 20 MG (milligrams)/ML(milliliter), give ten (10) MG by mouth every two (2) hours scheduled for pain control, with a start date of 06/06/2020 and this order was discontinued on 06/10/2020 at 7:43 PM by Registered Nurse (RN) #1. Further review revealed physician's orders [REDACTED]. Interview with RN #1, revealed on 06/09/2020 before 9:00 PM, she notified the Physician that Resident #3 had no more [MEDICATION NAME] in the narcotic drawer, and she obtained a Verbal Order to discontinue the scheduled [MEDICATION NAME] and start [MEDICATION NAME] 20 MG/ML; give ten (10) mg by mouth every two (2) hours PRN for pain/shortness of air; however, she did not enter the new Verbal Order for [MEDICATION NAME] into the Electronic Health Record (EHR) or obtain the medication from the pharmacy or Emergency Medication Box at the facility. Resident #3's Controlled Drug Record (CDR), revealed the resident received [MEDICATION NAME] 0.5 ML on 06/09/2020 at 12:00 AM; however, there was no documented evidence [MEDICATION NAME] was administered again until 06/12/2020 at 11:40 AM; forty seven (47) hours and forty (40) minutes later. Interview with the Pharmacist and Director of Nursing, revealed the facility had no processes in effect to ensure re-ordered controlled medications were maintained. The findings include: Review of the facility's Pharmacy Services Overview Policy, dated April 2019, revealed the facility would accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications, and services of a licensed pharmacist. Additionally, Pharmacy Services were available to residents twenty-four (24) hours a day, seven (7) days a week. Continued review revealed residents should have sufficient supply of their prescribed medications in a timely manner. Further, Nursing staff were responsible to communicate prescriber orders to the pharmacy and contract the pharmacy if a resident's medication is not available for administration. Review of the facility's Reordering, Changing, and Discontinuing Orders Policy, dated 10/31/2016, revealed medications that exhaust the number of refills may require a new order and/or prescription. Additionally, the facility was encouraged to reorder medication electronically. Further, the pharmacy would indicate if the reorder was confirmed and/or required pharmacy follow up, and would contact the facility as necessary. Review of the facility's Prospective Item Withdrawal Instructions (Emergency Medications at the facility), undated, revealed a verbal authorization prior to use from pharmacy was required. Further, the authorized withdrawal quantity was documented on the Controlled Substance Authorization Log. Review of the contents of the facility Emergency Medication, revealed one (1) multi-dose bottle of [MEDICATION NAME] 20 MG/ML solution (15 ML bottle). Review of Resident #3's medical record revealed the facility admitted the resident on 07/11/2010 with [DIAGNOSES REDACTED]. Further, Palliative Care was initiated on 06/05/2020. Review of Resident #3's Significant Change Minimum Data Set (MDS) Assessment, dated 06/11/2020, revealed the facility assessed the resident as having unclear speech, rarely understood or understanding others. Additionally, the facility assessed the resident as having short and long term memory problems. Further review of the MDS Assessment, revealed the facility assessed the resident as receiving scheduled and PRN (as needed) pain medication during the last five (5) days of the assessment reference period and as having no signs and symptoms of pain. Review of Resident #3's Monthly physician's orders [REDACTED]. give ten (10) mg by mouth every two (2) hours scheduled for pain control, with a start date of 06/06/2020. On 06/10/2020 at 7:43 PM, RN #1 discontinued this order with the reason noted, Already on (1) hour as needed (PRN). Further review of Resident #3's physician's orders [REDACTED]. Per record review, all orders for [MEDICATION NAME] medication were discontinued on 06/10/2020, and there was no documented evidence of new orders for [MEDICATION NAME] until 06/12/2020, two (2) days later. On 06/12/2020, new orders were received for [MEDICATION NAME] (Concentrate) 20 MG/ML; give ten (10) mg by mouth every two (2) hours as needed for pain/shortness of air. However, interview with RN #1 on 06/17/2020 at 5:30 PM, revealed she had received a Verbal Order on 06/09/2020 before 9:00 PM for [MEDICATION NAME] (Concentrate) 20 MG/ML; give ten (10) mg by mouth every two (2) hours PRN for pain/shortness of air and did not enter the order into the Electronic Health Record (EHR). Review of Resident #3's Medication Administration Record [REDACTED]. Additional review revealed the resident received scheduled [MEDICATION NAME] every two (2) hours from 06/07/2020 at 12:00 AM until 06/09/2020 at 12:00 AM. Further review revealed the resident did not receive [MEDICATION NAME] from 06/09/2020 at 12 AM until 06/12/2020 at 11:35 AM; forty-seven (47) hours and forty (40) minutes after his/her last dose. Review of Resident #3's Controlled Drug Record Form (CDR), revealed on 06/07/2020, the facility received [MEDICATION NAME] 20 mg/ml solution, twenty (20)- 0.5 milliliters (ml) syringes. Continued review revealed all twenty (20) syringes were signed out to Resident #3, from 06/07/2020 until 06/09/2020 at 12:00 AM. However, additional review of Resident #3's CDR Form, dated 06/12/2020, revealed the resident did not receive [MEDICATION NAME], for forty-seven (47) hours and forty (40) minutes, from 06/09/2020 at 12:00 AM until 06/12/2020 at 11:40 AM as there was no [MEDICATION NAME] available for administration. Further interview with Registered Nurse (RN) #1, on 06/17/2020 at 5:30 PM, revealed she was an agency nurse and had worked at the facility for approximately two (2) months. Per interview, she did not know the process for reordering medications through the Electronic Health Record (EHR) or utilizing the Emergency Medications at the facility. Per interview, she relied on other nurses at the facility to help when she was uncertain on what to do. She stated she had Face Time called the Provider on 06/09/2020 before 9:00 PM, and explained Resident #3 needed [MEDICATION NAME] as there was none in the Controlled Medication drawer, and also discussed the need for the order to be changed from every two (2) hours scheduled to every two (2) hours PRN, as well as the need for a multi-dose bottle versus a unit dose syringe. Per interview, during this call she received a Verbal Order for [MEDICATION NAME] (Concentrate) 20 MG/ML; give ten (10) mg by mouth every two (2) hours PRN for pain/shortness of air. Additional interview with RN #1, revealed after receiving the Verbal Order from the Provider, she discontinued the order for [MEDICATION NAME] every two (2) hours scheduled, but she did not enter the new Verbal Order for [MEDICATION NAME] every two (2) hours PRN into the EHR because she was unsure how to enter the orders, and she assumed the Provider would enter the order because he told her he would call the pharmacy. Additional interview revealed she did not receive the [MEDICATION NAME] from the pharmacy or remove it from the Emergency Medications at the facility during her shift on 06/09/2020. Further, she did not follow up with the pharmacy or the Provider during the remainder of her shift to ensure the medication was being sent to the facility and was not aware the medication was available in the Emergency Medications. Continued interview revealed she did not pass along in report to the oncoming nurse that she had spoken with the Provider related to Resident #3's [MEDICATION NAME] nor did she inform them the medication had not been received from pharmacy. When questioned what an acceptable timeframe would be for a palliative resident to receive pain medications once ordered and pharmacy was made aware, she stated she was uncertain, but twenty-four (24) hours or less. However, she stated medications should be administered to residents as per physician's orders [REDACTED]. Phone interview with the Pharmacy Manager, on 06/16/2020 at 4:30 PM, revealed on 06/09/2020 at 9:00 PM, the facility's Physician called the Pharmacy and gave authorization for the facility to obtain the multi-dose bottle of [MEDICATION NAME] 20 MG/ML solution (15 ML bottle), from the Emergency Box for Resident #3. Per interview, the Pharmacy called the facility six (6) times before Midnight to give authorization to the nursing staff to access the Emergency box; however, they were not able to get anyone to answer the calls. Continued interview revealed at midnight the authorization from the Physician would be invalid and a new script would be required. The Pharmacy Manager stated there was no documented evidence of the six (6) phone call attempts. Further, she was unable to contact the pharmacy staff on duty the night of 06/09/2020, to determine what the pharmacy's actions were after unsuccessfully reaching the nursing staff at the facility. However, she stated it was Pharmacy protocol to continue either making calls to the facility until contact was made, or pass the information along to the oncoming Pharmacy shift to continue to reach out to the facility. Additional interview with the Pharmacy Manager, on 06/16/2020 at 4:30 PM, revealed the Pharmacy received an electronic discontinue order on 06/10/2020 at 3:00 AM for the [MEDICATION NAME] 20 MG/ML every two (2) hours and assumed the resident had passed away and did not fill the [MEDICATION NAME] order. Per interview, the Pharmacy did not contact the facility to confirm the resident did in fact pass away and there was no further need for the [MEDICATION NAME]. Continued interview revealed the Pharmacy should have called to verify the discontinue order with the facility on 06/10/2020 because they had received a script for [MEDICATION NAME] 20 MG/ML from the Physician. Further, the Pharmacy did not have any inquiry from the facility related to Resident #3's [MEDICATION NAME] on 06/11/2020; however, on 06/12/2020 the facility contacted the Pharmacy and verbal authorization was given to obtain the multi-dose bottle of [MEDICATION NAME] 20 MG/ML solution (15 ML bottle), from the Emergency Box for Resident #3. Per interview, it was important for the Pharmacy to have systems and processes in place to ensure controlled medications were provided to meet the needs of each resident. Interview with Director of Nursing (DON), on 06/16/2020 at 12:10 PM, revealed she had worked at the facility for four (4) years. Per interview, the facility ran out of Resident #3's [MEDICATION NAME] on 06/09/2020, and notified the Pharmacy who in turn stated a new prescription was needed for the [MEDICATION NAME]. Additionally, on 06/10/2020, the facility notified the Physician several times about needing a new prescription for the medication. Per interview, on 06/11/2020 at 5:00 PM, the Physician called the facility and spoke with the DON inquiring about Resident #3's [MEDICATION NAME] status; however, the Pharmacy was closed and the DON did not call the Pharmacy. Continued interview revealed on the morning of 06/12/2020, the DON called the Pharmacy to confirm the pharmacy had received a prescription for Resident #3's [MEDICATION NAME]. At that time she was given verbal authorization to obtain the [MEDICATION NAME] from the Emergency box. Further, the Pharmacy stated they would also STAT over the medication to the facility. Continued interview with the DON, on 06/16/2020 at 12:10 PM, revealed it was facility protocol for the direct care nurse to notify the pharmacy if there was a need for a controlled medication. The pharmacy would inform the direct care nurse if a new prescription was required from the Physician. Then the direct care nurse would contact the Physician informing him of the need for a new prescription and obtain a verbal order for the medication. Additionally, the direct care nurse would enter the order into the EHR, which would automatically be sent to the Pharmacy and the direct care nurse would follow up with pharmacy to ensure they received the order and script. Per interview, the direct care nurse would also place paper documentation of the new order for controlled medications in a box by the DON's office. Further, the DON would review all new orders in the EHR, the paper documentation in the box and pharmacy deliveries of controlled medication each morning during clinical meeting to ensure medications that were ordered were received timely and necessary follow up was made. Interview with DON, on 06/18/2020 at 4:00 PM, revealed since the COVID-19 pandemic, hallways had been closed off for the past six (6) weeks, and the above process was impossible. Per interview, this was because offices moved and hallways were closed down and access to her office from all hallways was not possible. The DON stated she had not been monitoring controlled medication using this process. Additionally, she had not identified any concerns with obtaining medications to meet resident needs until this occurrence with Resident #3. Per interview, forty-seven (47) hours and forty (40) minutes was not an acceptable timeframe for medications to be unavailable for administration to a resident. She stated it was her expectation direct care nursing staff follow up with the Pharmacy and the DON if there was a delay in obtaining medications. Per interview, she also expected the Pharmacy to follow up with the facility to ensure medications were provided as ordered to residents. Further, it was important residents receive appropriate care, and ensure comfort and no pain. Interview with the Administrator, on 06/18/2020 at 4:40 PM, revealed he had been at the facility for four (4) years. Per interview, it was his expectation pharmacy services was a partner with good communication to ensure physician's orders [REDACTED]. Per interview, he ensured this process was followed through Quality Assurance committee meetings, which the Pharmacy staff attended, and pharmacy reports. Continued interview revealed this process did not identify any concerns or issues and the facility was currently satisfied with pharmacy services. However, he stated it was his expectation facility nursing staff and pharmacy staff ensure medications were provided to meet the needs of the resident (s) in a reasonable timeframe. Further, it was important for residents not to suffer a painful condition when help could be in place to comfort them, such as ordered pain medications.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of seven (7) sampled residents was free from sexual abuse, Resident #2. Resident #1 grabbed and squeezed Resident #2's breast as he/she walked past Resident #2 in the hallway. The findings include: Review of the policy Abuse Prevention Program, revised November 2010, revealed the facility was committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals. The policy further revealed comprehensive policies and procedures were developed to aid the facility in the prevention of abuse, neglect, or mistreatment of [REDACTED]. Observation of Resident #2, on 01/22/2020 at 3:35 PM, revealed the resident was neatly dressed, groomed and seated in a wheelchair. Interview during observation revealed a black guy grabbed Resident #2's breast in the hallway and he/she screamed when it happened. Observation revealed Resident #2 demonstrated the incident by squeezing his/her breasts. Review of the clinical record revealed the facility admitted Resident #2 on 10/15/13 with [DIAGNOSES REDACTED]. Review of the annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eleven (11) out of fifteen (15) and determined he/she was interviewable. Observation of Resident #1, on 01/22/2020 at 12:47 PM, revealed the resident seated in the common area adjacent to the main dining room. Observation, on 01/22/2020 at 3:45 PM, revealed Resident #1 seated in his/her room. Interview during observation revealed the resident denied touching Resident #2. According to Resident #1, he/she pushed Resident #2's wheelchair out of the way as he/she walked down the 200 hall. Review of the clinical record revealed the facility admitted Resident #1 on 03/06/19 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined he/she was interviewable. Interview with the Housekeeping Aide #1, on 01/23/2020 at 2:06 PM, revealed she observed Resident #1 reach down and squeeze Resident #2's breast as he/she walked past the resident seated in the hallway. According to the Aide, Resident #2 became very upset and yelled do not ever touch my breast again. She revealed there were no other witnesses to the incident and stated she immediately reported the incident to the Unit Manager (UM). The Housekeeping Aide further revealed she provided a witness statement to the Social Services Director (SSD) with another staff member present. Interview with the SSD, on 01/23/2020 at 3:12 PM, revealed she interviewed the Housekeeping Aide, Resident #1, and Resident #2 regarding the abuse allegation. According to the SSD, Resident #1 was unhappy and reported a man touched his/her breast. The SSD revealed she was not aware if anyone reviewed video surveillance of the incident and stated the Administrator was the only person with access. Interview with Certified Nursing Assistant (CNA) #1, on 01/26/2020 at 4:13 PM, revealed she monitored ambulatory residents by checking on them as often as she could and stated it was important to supervise residents to ensure their safety. Interview with CNA #5, on 01/28/2020 at 9:50 AM, revealed she monitored residents by checking on them every hour but it was hit and miss. She stated most of the time residents were around so staff could see them. CNA #5 revealed she sometimes did not have to check on ambulatory residents because they could come get her if they needed anything. The Aide stated it was important to monitor residents to make sure they were safe. Interview with Registered Nurse (RN) #1, on 01/27/2020 at 9:29 AM, revealed she monitored residents by performing hourly rounds, walking the hallway, and interacting with residents. According to RN #1, Resident #1 was really independent. Interview with the Director of Nursing (DON), on 01/29/2020 at 11:23 AM, revealed a housekeeping aide observed the incident between Resident #1 and Resident #2. She revealed Resident #1 was talking to Resident #2, went to grab the resident's hand, and accidentally touched the resident's breast. She stated Resident #2 yelled out you touched my boob; the Housekeeping Aide separated the residents, and reported the incident. Continued interview with the DON revealed the facility investigated the incident and interviewed Resident #1 who stated he/she tried to shake Resident #2's hand, but could not recall touching the resident's breast. The DON further revealed the facility investigation determined Resident #1 accidentally touched Resident #2's breast and there was no sexual intent. The Director stated she had no access to the facility's video surveillance of the incident. Further interview with the DON revealed staff walked the hallway all day and supervised residents; however, it just so happened Resident #1 and Resident #2 passed in the hall. She stated she did not know what other supervision should have been provided. Interview with the Administrator, on 1/27/2020 at 9:27 AM, revealed there was no copy of the video footage and no documented review of the footage. Further interview with the Administrator, on 01/29/2020 at 2:30 PM, revealed he reviewed video footage of the incident involving Resident #1 and Resident #2. The Administrator further revealed it appeared Resident #1 extended his/her hand to shake Resident #2's hand, touched the resident's breast instead of his/her hand, and Resident #2 reacted to the touch. He stated the facility separated the residents and initiated an investigation. The Administrator revealed the facility unsubstantiated sexual abuse because Resident #1 did not grasp Resident #2's breast. He further revealed the facility adequately supervised Resident #1.

Based on interview, record review, and facility policy review it was determined the facility failed to revise the care plan for activities of daily living (ADL) for one (1) of seven (7) sampled residents, Resident #5. The facility failed to revise the care plan with interventions to ensure Resident #5's safety during transfers with the mechanical lift. The findings include: Review of the policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Further review of the policy revealed assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed. The Interdisciplinary Team (IDT) must review and update the care plan when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident was readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Review of the policy Safe Lifting and Movement of Residents, revised July 2017, revealed resident safety, dignity, comfort and medical condition would be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the clinical record revealed the facility admitted Resident #5 on 04/06/2019 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the resident was totally dependent upon staff for transfers. Review of the facility's incident report, dated 01/13/2020 at 8:23 PM, revealed Resident #5 caught his/her left middle finger on the lift pad during a transfer with the mechanical lift. Further review of the report revealed there were no predisposing environmental, physiological, or situation factors that contributed to the incident. Review of Resident #5's Progress Notes, dated 01/15/2020 at 2:47 PM, revealed the nurse obtained a physician's orders [REDACTED]. Review of Radiology Results, dated 01/15/2020, of Resident #5's left hand revealed moderate diffuse metacarpal swelling and modest [MEDICAL CONDITION] with no fracture or dislocation. Review of Resident #5's History & Physical (H&P), dated 01/16/2020, revealed the resident's left wrist/index finger were slightly swollen and tender to palpation. Review of Resident #5's Care Plan for Activities of Daily Living (ADL), revised 05/06/19, revealed the resident was dependent and would have all needs anticipated and met by staff through the next review date. Further review revealed an intervention for transfers with a mechanical lift and two (2) staff assistance; however, there were no additional interventions regarding the use of the lift, to ensure the resident's finger would not be caught on the lift pad during transfer. Interview with the Director of Nursing (DON), on 01/29/2020 at 10:40 AM, revealed the facility did not conduct an investigation related to Resident #5's hand injury. Interview with the Unit Manager (UM) for A Unit, on 01/29/2020 at 4:02 PM, revealed the purpose of the care plan was to ensure staff knew how to care for residents correctly. She revealed the interdisciplinary team (IDT) reviewed new incident reports during daily clinical meeting and decided on any new interventions as a team. The UM revealed the IDT did not revise Resident #5's care plan because nothing was done incorrectly. Interview with the MDS Coordinator, on 01/29/2020 at 3:50 PM, revealed the care plan communicated how to monitor and provide care for the resident. She stated the IDT reviewed incident reports during morning clinical meeting and care plans were revised as needed. The MDS Coordinator further revealed it would be important to review the investigation and the root cause of an incident to determine if a care plan should be revised. She stated she could not recall the incident related to Resident #5. Further interview with the DON, on 01/29/2020 at 4:16 PM, revealed the IDT reviewed incident reports during the morning clinical meeting and revised the care plan based on root cause, injury, resident rights and preferences. Interview with the Administrator, on 01/29/2020 at 2:30 PM, revealed he was not aware of the incident report for Resident #5.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to investigate an accident to ensure resident safety for one (1) of seven (7) sampled residents, Resident #5. Resident #5 reportedly injured his/her hand when staff transferred the resident with the mechanical lift; however, the facility failed to investigate to determine the root cause of the injury. The findings include: Review of the policy Safe Lifting and Movement of Residents, revised July 2017, revealed resident safety, dignity, comfort and medical condition would be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the policy Safety and Supervision of Residents, revised July 2017, revealed the facility strived to make the environment as free from accident hazards as possible. The policy further revealed safety risks and environmental hazards were identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility - wide commitment to safety at all levels of the organization. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team should target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Observation, on 01/22/2020 at 11:07 AM, revealed Resident #5 lying in bed with a touch pad call light on the pillow. Interview during observation revealed the resident's left hand was injured when his/her fingers got caught in the straps of the lift pad during a transfer with the mechanical lift. The resident stated he/she reported to staff that the hand hurt and the nurse wrote up an incident report. Review of the clinical record revealed the facility admitted the resident on 04/06/2019 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Review of the facility's incident report, dated 01/13/2020 at 8:23 PM, revealed Resident #5 reported his/her left middle finger got caught on the lift pad when staff transferred the resident back to bed with the lift. The resident reported a pain level of seven (7) out of ten (10) and the nurse administered pain medication and offered an ice pack. According to the report, there were no observed injuries at the time of the incident and no predisposing environmental, physiological, or situation factors that contributed to the incident. Review of Resident #5's Progress Notes, dated 01/15/2020 at 2:47 PM, revealed the resident complained of left finger pain and the nurse obtained a physicians order for an x-ray of the left hand. Review of Radiology Results, dated 01/15/2020, of Resident #5's left hand revealed moderate diffuse metacarpal swelling and modest [MEDICAL CONDITION] with no fracture or dislocation. Review of Resident #5's History & Physical (H&P), dated 01/16/2020, revealed the resident reported left hand pain and the wrist/index finger were slightly swollen and tender to palpation. Interview with Certified Nursing Assistant (CNA) #3, on 01/29/2020 at 10:19 AM, revealed he assisted to transfer Resident #5 back to bed and was not aware of any injury or complaints of pain. Surveyor attempted phone interviews with CNA #9; however, the CNA did not return the calls. Interview with Registered Nurse (RN) #2, on 01/29/2020 at 9:34 AM, revealed Resident #5 reported injuring his/her finger in the lift pad during a transfer and she filled out an incident report. The RN stated she also notified the Director of Nursing (DON), the physician, and responsible party of the incident. RN #2 further revealed she did not interview the CNA's who transferred the resident to determine the root cause of the incident. Interview with the DON, on 01/29/2020 at 10:40 AM, revealed the facility did not conduct an investigation related to Resident #5's hand injury. Further interview with the DON, on 01/29/2020 at 11:43 AM, revealed Resident #5 complained of hand pain the day following the alleged incident and the hand was x-rayed. She further revealed the nurse and the APRN assessed the resident's hand and there was no bruising, redness, or swelling. She stated the facility completed an incident report because of the resident report; however, the CNA's denied the incident occurred. According to the DON, the resident had a history of [REDACTED]. The DON stated she would have investigated the incident if there was an injury; however, she did not feel it was a legit incident. Interview with the Administrator, on 01/29/2020 at 2:30 PM, revealed he was not aware of the incident report for Resident #5. He revealed the resident had a history of [REDACTED]. According to the Administrator, there would be no reason to investigate further if the nurse did not observe an injury.

Based on observation, interview, and facility policy review it was determined the facility failed to ensure medication was securely stored on one (1) of two (2) nursing units, A Unit. Two (1) medication carts and one (1) treatment cart were left unlocked and unattended. The findings include: Review of the policy Medication Storage, revised April 2019, revealed nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy further revealed unlocked medication carts should not be left unattended. Observation on the 200 Hall, on 01/23/2020 at 10:34 AM, revealed an unlocked, unattended medication cart located outside room [ROOM NUMBER]. Further observation revealed both sides of the cart were unlocked and there was a glucometer and glucose strips stored on top of the cart. Interview with Licensed Practical Nurse (LPN) #4, on 01/23/2020 at 10:35 AM, revealed the medication cart should be locked when unattended; however, she just went in the room for a minute to help a resident. She stated a resident could potentially get in the unlocked cart, take a medication, and get sick or die. Observation of the 200 hall, on 01/27/2020 at 9:11 AM, revealed an unlocked, unattended treatment cart. Interview with LPN #2, on 01/27/2020 at 9:12 AM, revealed the treatment cart should be locked at all times to keep residents from getting in the cart and potentially ingesting a medication. Interview with LPN #4, on 01/27/2020 at 9:14 AM, revealed she forgot to lock the treatment cart when she walked away to get supplies. She stated a resident could get a medication out of the cart and put it in their mouth. Observation on the 100 hall, on 01/27/2020 at 3:23 PM, revealed a medication cart unlocked medication cart located outside an oxygen storage room. Interview with LPN #5, on 01/27/2020 at 3:24 PM, revealed she forgot to lock the cart after the medication count because she was assisting a resident to sign out. Interview with the Director of Nursing, on 01/29/2020 at 11:43 AM, revealed the Staff Development Coordinator audited random medication carts weekly to ensure they were locked and stated the findings were reviewed during the facility's Quality Assurance meeting. She stated medication carts should be locked when out of the nurse's sight to ensure residents or visitors did not have access to medications. Interview with the Administrator, on 01/29/2020 at 2:30 PM, revealed he was not aware of any systemic issues related to unlocked medication carts.

Based on observation, interview, record and policy review it was determined the facility failed to ensure two (2) out of the twenty-four (24) sampled residents, were able to obtain their personal funds on the weekends, Resident #91 and Resident #94. The findings include: Record review of the undated policy, Policy for Resident Trust, revealed the banking hours for the residents would be on weekends, Saturday and Sunday, from 10:00 AM to 12:00 PM. The policy further revealed the request for the personal fund must be made to the nurses' station by the posted time in order to receive the funds that day. The charge nurse would contact one of two employees and one of them would come to the facility to fulfill the request. Observation of the entrance lobby, on 07/26/19, revealed the Policy for Resident Trust was posted on a table near the front entrance. 1. Observation of Resident #91, on 07/23/19 at 11:44 AM, revealed the resident seated in an extra wide wheelchair in the day room. Interveiw with Resident #91 at the time of observation revealed Resident #91 was alert and responded appropriately. Review of the clinical record revealed the facility admitted Resident #91 on 03/16/13 and readmitted Resident #91 on 4/09/17 with [DIAGNOSES REDACTED]. Record review of Resident #91's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/11/19 and a completion date of 07/15/19, revealed the facility conducted a Brief Interview for Mental Status (BIMS) assessment and determined the resident had a score of fifteen (15) out of fifteen (15), which indicated Resident #91 was cognitively intact and interviewable. Interview with Resident #91, on 07/24/19 at 4:10 PM, revealed he/she had a personal fund account with the facility. However, the resident stated if he/she needed money on the weekends they would have to go to the business office and ask for it on Friday because the office was not open on the weekends. 2. Review of the clinical record revealed the facility admitted Resident #94 on 10/09/17 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #94's annual MDS assessment with an ARD of 07/03/19 and a completion date of 07/16/19 revealed the facility conducted a BIMS examination and determined the resident had a score of fifteen (15) out of fifteen (15), which indicated Resident #94 was cognitively intact and interviewable. Observation of Resident #94, on 07/23/19 at 11:56 AM, revealed he/she was lying in bed on the right side on a pressure relief mattress. Resident was alert and responded appropriately. Interview with Resident #94, on 07/24/19 at 10:10 AM, revealed he/she could get money during the week; however the personal funds were not available on the weekends because the office was closed. Resident #94 stated he/she requested the money on Thursday if he/she needed money on the weekends. Resident #94 stated if residents did not ask for money ahead of time residents would just have to wait to get it when the office opened up on Monday. Interview with Licensed Practical Nurse (LPN) #3, on 07/25/19 at 3:45 PM, revealed she worked weekends, but not routinely. LPN #3 revealed she did not know if a resident could get their personal funds on the weekends and if a resident asked she would have to call Social Services to see how residents obtained the money. LPN #3 stated the facility used to have a receptionist on the weekends who would take care of the funds; however the receptionist had been gone three (3) or four (4) months and she did not know if the facility replaced the receptionist or not and no one on the unit had access to the funds. Interview with the Unit Manager of the A Unit, on 07/25/19 at 3:45 PM, revealed if a resident asked for their personal funds on the weekend they would have to go to the receptionist, however, she was not sure if anyone was in the office on the weekend. The Unit Manager revealed she would have to call Social Services to find out what to do if a resident asked for their money on the weekend. Interview with the Director of Nursing (DON), on 07/26/19 at 9:04 AM, revealed the residents of the facility should have access to their personal funds during the week and on the weekends. The DON stated the office was open on the weekends and the front receptionist would get the money for the residents if they requested it. The DON revealed the one receptionist was gone but she thought the facility replaced her with someone else. Interview, on 07/26/19 at 12:55 PM, with the Administration Assistant revealed residents had asked her for their personal funds and the facility had a procedure to follow when asked. The resident would ask for some money and if they had it in their fund she would write out a receipt and they both signed it and the resident would get a receipt and the money. The Administration Assistant further revealed the office was not open on the weekends now. The receptionist left about two (2) months ago. She further revealed the nurses knew they were supposed to contact either her, the administrator, or the office manager if a resident requested money on the weekend. She stated they all lived close to the facility and could be there in fifteen (15) minutes and they were available twenty-four (24) hours a day for seven (7) days a week. Interview, on 07/26/19 at 1:44 PM, with the Accounts Receivable Coordinator (ARC) revealed Resident #91 and Resident #94 had personal fund accounts. The ARC further revealed the office was open every day of the week except weekends when it was closed. She revealed the Office Manager volunteered to come in and give residents their money on the weekend; however, she was on vacation this week. The ARC stated the residents should not have to wait more than an hour on the weekends to get their funds when requested and if no one could get a hold of the designated person then, she guessed the staff would call the administrator. Interview, on 07/26/19 at 2:59 PM, with Certified Nursing Assistant (CNA) #2 revealed the resident's normally asked for their funds ahead of time. She further stated the nurses on the unit could call the receptionist or find someone else who had access to the money when requested funds on the weekends. Interview, on 07/26/19 at 02:04 PM, with the Administrator revealed the business office was not open on weekends, and the facility no longer had a receptionist working on the weekends who could provide residents with their requested funds. The Administrator stated the residents knew they could go to the receptionist to get their money. He further revealed the residents, should now contact the nurses, who then contacted the weekend supervisor, who then contacted someone in the business office who had access to the money. The Administrator revealed the personal funds should be made available in a reasonable amount of time. When asked what a reasonable amount of time was the Administrator stated two (2) to four (4) hours was a reasonable amount of time for the facility to get the money to the resident. When asked how he would feel if he had to wait four hours to get his money from, for instance, an Automated Teller Machine (ATM) he stated I guess I should have planned better. Interview with the Administrator further revealed, according to the policy, there was a two (2) hour window on the weekend to request a withdrawal from the residents' personal funds.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective infection control program for the provision of a safe, sanitary, comfortable environment. Observation revealed clean resident clothing items transported on one (1) of two (2) units, Unit B, not covered to protect from dust and soil. In addition, one (1) of twenty-two (22) sampled resident's (Resident #79) nebulization mask was not stored in a sanitary manner, within a plastic covering. The findings include: 1. Review of the facility's policy, Laundry Guidelines, not dated, revealed clean linen would be transported to areas in a covered container, which was labeled and disinfected, inside and outside, on a regular basis. Moreover, clean linen would be kept separate from soiled laundry, only employees with clean hands may access clean linen, and clean linen would be held away from the employee's uniform. Review of the facility's in-service sign-in sheet, dated 04/03/18, revealed the Housekeeping Supervisor educated eight (8) housekeeping staff, including Housekeeper #1, on Laundry Guidelines - Infection Control. Observation during the lunch meal service, on 05/15/18 at 12:35 PM, revealed Housekeeper #1 transported clean resident clothing on Unit B. The cover of the clean linen cart was unzipped during transport, exposing clean resident clothing to dust and soil. Interview, on 05/15/18 at 12:36 PM, with Housekeeper #1 revealed she was delivering clothes to residents all over the facility and the clothes were exposed because the zipper would not go all of the way down. She stated the laundry policy stated to hold clean linen away from the body and cover all clothes until it reached the resident's room to prevent cross contamination. Housekeeper #1 stated infection control training was provided upon hire a year ago and in (MONTH) of this year. Interview with the Housekeeping Supervisor, on 05/15/18 at 12:45 PM, revealed the laundry policy stated to wash hands, to hold clean linens away from the body when transporting to resident's rooms and delivery had to be in a covered manner to protect linens from becoming soiled. The Supervisor stated training on infection control was conducted for employees upon hire, and last month. Additionally, the Supervisor monitored staff by making rounds all day and providing in-services on infection control. Observation of the laundry room, on 05/17/18 at 11:09 AM, revealed the clean linen cart's zipper was not damaged and zipped all of the way to the bottom of the cart. 2. Review of the facility's policy, Administering Medications through a Small Volume (Handheld) Nebulizer, revised (MONTH) 2010, revealed the purpose of the procedure was to safely and aseptically administer aerosolized particles of medication into the resident's airway. The subtitled section of the policy, Steps in the Procedure, revealed after the resident's medication had been delivered via the nebulizer mask, the nebulizer equipment was to be rinsed and disinfected according to facility protocol and then it was to be allowed to air dry on a paper towel. When the equipment was completely dry, it was stored in a plastic bag with the resident's name and date on it. Review of the clinical record for Resident #79 revealed the facility readmitted the resident on 04/23/18, after a hospital stay for treatment of [REDACTED]. Review of Resident #79's Medication Administration Record [REDACTED]. The resident had an additional physician's orders [REDACTED]. Observation, on 05/16/18 at 10:59 AM, of Resident #79's room revealed several tissues/napkins wadded up and on the resident's floor. There was a nebulization machine on a table near the bed and the mask was resting on top of the machine, not stored in the plastic bag that was near the machine. Certified Nursing Assistant (CNA) #5 was in the resident's room, changing the bed and tidying up the room. CNA #5 stated the resident had left for his/her [MEDICAL TREATMENT] treatment. Observation, on 05/16/18 at 12:31 PM, revealed Resident #79's breathing treatment mask remained open to air and not stored in the plastic bag. At 1:09 PM and 1:55 PM, the breathing treatment mask remained open to air and not stored in a plastic bag. Observation, on 05/17/18 at 8:15 AM, revealed Resident #79 sitting on the side of his/her bed, eating breakfast. The resident's nebulization mask was resting on top of the nebulization machine on a nearby table, and the mask was not covered. A bag was near the machine and available for covering the mask. Interview, on 05/17/18 at 8:38 AM, with CNA #3 revealed she was aware Resident #79 had a nebulizer in his/her room, but had never seen the resident use it. CNA #3 stated she had not paid much attention to the nebulizer, but stated she knew the plastic bag beside the mask was for storage of the mask when the equipment was not in use. Interview, on 05/17/18 at 8:42 AM, with Licensed Practical Nurse (LPN) #7 revealed Resident #79 received his/her breathing treatment twice daily, at 6:00 AM and again at 6:00 PM. LPN #7 stated the night shift nurse had already administered the resident's breathing treatment that morning by the time she arrived for her shift. She stated the mask was to remain bagged when not in use to prevent environmental contamination of the mask and to keep the mask uncovered was an infection control issue. According to the LPN, keeping the resident's breathing treatment mask bagged when not in use would be important especially because the mask could accidentally fall on the floor. Interview, on 05/17/18 at 10:00 AM, with the Unit Manager (UM) revealed Resident #79's nebulization mask should be stored in a plastic bag when not in use, so that if the mask fell to the floor it would be protected from direct contact with the floor. She stated bagging the mask was an infection control measure. The UM stated Resident #79 would sometimes turn off the breathing treatment, and might not bag the mask, but the nurse who administered the breathing treatment should observe the resident once the treatment was completed, and ensure the mask was properly cleaned and stored. Per interview, nurses administered the breathing treatments and should know the standards of practice for keeping the equipment stored to minimize contamination. The UM stated she made rounds through her unit at least two (2) times each day to ensure equipment was properly stored. The UM further stated Resident #79 tended to drop trash on the floor; therefore it was important the breathing treatment equipment was bagged to prevent direct contact with the floor should it fall from the top of the nebulizer. According to the UM, Resident #79 had a recent bout with Pneumonia, and also had [MEDICAL CONDITION], so it was very important to minimize the resident's risk of acquiring additional infections. Interview, on 05/17/18 at 2:09 PM, with the Director of Nursing (DON) revealed the best infection control measure would be to clean, dry, and place the face mask in the protective package after each use to maintain the cleanest possible environment for storage of the equipment and minimize the spread of infection to the resident. The DON stated if a CNA saw the mask uncovered, he or she should notify the nurse to ensure it was covered. She stated if the mask was found on the floor, the mask should be given to the nurse to throw away and a new one obtained. The assigned nurse should be looking at the mask each time he or she entered the resident's room to ensure proper storage. She stated it was the nurse's responsibility to ensure the breathing treatment equipment was properly stored, even if the resident took off the mask, the nurse who administered the treatment should ensure proper storage of any equipment used upon completion of the treatment. Interview with the Administrator, on 05/17/18 at 3:33 PM, revealed the Infection Preventionist and the DON oversaw the infection control program and monitored for patterns of breaks in infection control practices. He stated he was not sure if the facility currently had a Performance Improvement Plan in place for breeches in infection control practice.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the care plan with interventions to secure the indwelling urinary catheter for one (1) of twenty-two (22) sampled residents, Resident #7. Observations revealed the resident's indwelling urinary catheter was not secured to reduce friction and movement at the insertion site. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed a comprehensive, person centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. Interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The plan describe the services that were provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and reflected currently recognized standards of practice for problem areas or conditions. Additionally the policy stated the Interdisciplinary Team (IDT) must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment. Review of the facility's policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the facility was to ensure the catheter remained secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Review of Resident #7's clinical record revealed the facility readmitted the resident on 09/19/17, with multiple diagnoses, which included Neuromuscular Dysfunction of Bladder and [MEDICAL CONDITION] Bladder. Review of Resident #7's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. The facility assessed the resident had an indwelling urinary catheter. Review of the Physician order [REDACTED]. Observation of Resident #7's urinary catheter care with Certified Nursing Assistant (CNA) #1, on 05/16/18 at 2:00 PM, revealed the indwelling catheter was not secured to reduce friction and movement at the insertion site, as per facility policy. Interview with CNA #1 and CNA #4, on 05/16/18 at 2:00 PM, revealed indwelling urinary catheters were not secured, as it was not their routine. Review of Resident #7's Care Plan for Foley Catheter, initiated 08/15/17, and revised 02/02/18, revealed no interventions to ensure the catheter was secured. Observation of Resident #7's skin assessment with Registered Nurse (RN) #1, on 05/17/18 at 11:22 AM, revealed the indwelling catheter was not secured to the resident's leg. RN #1 completed the skin assessment and did not ensure the urinary catheter was secured after providing care. The resident did not have a leg strap to secure the catheter. Interview with RN #1, on 05/17/18 at 11:22 AM, revealed she would have to get a leg strap for the resident's indwelling catheter, as residents wear leg straps routinely. Interview with Resident #7, on 05/17/18 at 3:00 PM, revealed he/she did not use a leg strap to keep the catheter from pulling. He/she stated the catheter got tight when he/she was turned and it pulled at times. The resident stated he/she could feel the tugging and it was uncomfortable. Interview with the Director of Nursing (DON), on 05/17/18 at 1:30 PM, revealed she was not concerned Resident #7's indwelling catheter was not secured because he/she experienced [MEDICAL CONDITION] and had paresis and she did not think the resident could tell if the catheter was uncomfortable if it got tugged. The DON stated the facility did not have to include the intervention of applying the leg strap and securing the indwelling catheter tubing to the leg, since it was in their policy.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents, Resident #7, received appropriate treatment and services for an indwelling urinary catheter. Observation of urinary catheter care for Resident #7 revealed staff failed to secure the indwelling urinary catheter to prevent trauma as required by the facility's policy. The findings include: Review of the facility's policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the facility's policy was to ensure the catheter remained secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Review of Resident #7's clinical record revealed the facility admitted the resident originally on 03/27/17 and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Per the Quarterly Minimum Data Set, dated dated [DATE], the resident had an indwelling urinary catheter. In addition, the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Physician Orders, dated (MONTH) (YEAR), signed by the Advance Practice Registered Nurse (APRN) on 05/10/18, revealed a continued order of the Foley Catheter (urinary catheter) for [DIAGNOSES REDACTED]. Observation of catheter care with Certified Nursing Assistant (CNA) #1 for Resident #7, on 05/16/18 at 2:00 PM, revealed the indwelling catheter was not secured to his/her leg prior to the care being initiated. CNA #4 assisted with turning the resident during care. CNA #1 provided catheter care but did not ensure the indwelling catheter was secured to the resident's leg with a leg strap to reduce friction and movement at the insertion site after providing care. Interview with CNA #1 and CNA #4, on 05/16/18 at 2:00 PM, revealed indwelling catheters were not secured to residents' legs. They stated it was not their routine. Observation of the skin assessment with Registered Nurse (RN) #1 for Resident #7, on 05/17/18 at 11:22 AM, revealed the indwelling catheter was not secured to his/her leg. RN #1 completed the skin assessment but did not ensure the urinary catheter was secured after providing care. She did not have the leg strap to apply and did not mention the missing leg strap when the skin assessment began. Interview with RN #1, on 05/17/18 at 11:22 AM, revealed she would have to get a leg strap for the resident's indwelling catheter. She stated residents wore leg straps routinely. Continued interview at 2:22 PM revealed the facility utilized a leg securing device to secure indwelling urinary catheters. She stated Resident #7 normally wore a leg strap to secure his/her catheter. Interview with Resident #7, on 05/17/18 at 3:00 PM, revealed he/she was not using a leg strap to keep the catheter from pulling. He/she stated the catheter did get tight when turned and it pulled at times. He/she stated he/she could feel the tugging and it was uncomfortable. He/she stated the leg strap was on now and it felt much better. Interview with the Director of Nursing (DON), on 05/17/18 at 3:15 PM, revealed she was not concerned Resident #7 did not have an anchor to the tubing to ensure the indwelling catheter was secured. She stated Resident #7 experienced paresis and was a [DIAGNOSES REDACTED] and she did not believe he/she was able to feel any pain or discomfort and therefore did not require an anchor.

Based on observation and interview, it was determined the facility failed to post a notice of the availability of the most recent survey results in areas prominent and accessible to the public. The findings include: Interview during Resident Council Group, on 05/15/18 at 3:00 PM, revealed the residents were unaware they could view the latest survey inspection results. Additionally, they did not know where the results were kept for them to view. Observations, on 05/15/18, 05/16/18, and 05/17/18, during the survey revealed throughout the facility, there were no postings regarding the availability of the latest state survey results. The previous survey results were located in a binder labeled facility data, in the front lobby on the right wall table next to the reception desk. There was no sign posted in the area identifying where the survey results were located. Interview with the Activity Director, on 05/17/18 at 10:30 AM, revealed resident rights were reviewed during the monthly resident council meeting, and were on the monitor screens in the resident hallways. The Activity Director was not able to provide documentation of providing information to the residents regarding the right to review survey results. Interview with the Administrator, on 05/17/18 at 2:50 PM, revealed the survey results at the front desk did not have a sign revealing the availability of the state survey results; however, the information was included in the Resident Rights, which were given to the resident and their family upon admission.

Based on observation, interview, record review, and review of the facility's policy, investigation, and job descriptions, Interview and record review revealed on 09/30/14 at approximately 2:45 PM, a housekeeper observed two (2) Certified Nursing Assistants (CNA) use a mechanical lift to take Resident #1 to the bathroom. At approximately 3:10 PM, Resident #1 was found alone in the bathroom, on the toilet, asleep and slumped toward the right side. The resident was still attached to a sit to stand mechanical lift with the lift's sling still around the resident's waist. The resident was removed from the toilet and a complete skin assessment was conducted that found no injuries. The facility's failure to have an effective system to ensure residents were protected from neglect placed residents at risk in a situation that had caused or was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 10/22/14, and was determined to exist on 09/30/14. The facility was notified of the Immediate Jeopardy on 10/22/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 with the facility alleging removal of the Immediate Jeopardy on 10/24/14. The Immediate Jeopardy was verified to be removed on 10/24/14 as alleged. The scope and severity was lowered to a "D" while the facility monitors the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure necessary care and services are provided, and residents are protected from neglect. The findings include: Review of the facility's Abuse and Neglect Policy, revised 07/30/12, revealed abuse and neglect of residents was prohibited. The policy identified neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. In addition, the facility provided a document they used as a supplement to their Abuse/Neglect policy titled Recognizing Signs and Symptoms of Abuse/Neglect, revised June 2004, that revealed signs of neglect to include leaving someone unattended who needed supervision. Review of the facility's Job Description for the position of charge nurse, not dated, revealed licensed nursing personnel were to provide direct care to residents and to supervise the day-to-day nursing activities performed by nursing assistants. Review of the Job Description for a nursing assistant, not dated, revealed the CNA's essential duties and responsibilities included the provision of personal care required by residents daily in accordance with the resident's assessment and care plan. Review of the medical record for Resident #1 revealed the facility admitted the resident on 09/20/05 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 04/21/14, revealed the facility assessed Resident #1 to have a severe cognition impairment with memory loss and impaired decision making ability. Continued review of the MDS Assessment revealed the facility assessed Resident #1 as requiring physical assistance of two (2) staff for Activities of Daily Living (ADLs) such as bed mobility, transfers, and toileting. The facility assessed the resident to have a sitting balance deficit and required stabilization from staff when moving on and off the toilet and moving from seated to a standing position. The resident was assessed to rarely/never understand. Review of the most recent quarterly MDS assessment, completed on 10/09/14, revealed the resident had no changes in cognition or functional status since the last review. Review of the Comprehensive Care Plan revealed the facility initiated a care plan on 04/21/14 for risk of falling related to the resident's lack of awareness of safety needs, poor communication/comprehension, and vision/hearing problems. The care plan indicated the resident required total staff assistance with all care including transfers to and from the bed, wheelchair and toileting needs. The care plan interventions included a stand up lift as needed. However, the facility failed to develop interventions for staff to ensure the resident was not left alone during toileting as indicated through interviews. (Refer to F279) Review of Resident #1's daily care plan (what the nurse aides follow to care for each resident) revealed under the safety section there were instructions that the resident needed assistance of two persons with the Vera Lift for all transfers. In addition, the daily care plan indicated the resident was hard of hearing and had poor vision. Under the elimination section there was information that the resident was incontinent of bowel and bladder and needed assistance to be clean and dry. The daily care plan had no written instructions regarding toileting needs or supervision required. Review of the facility's investigation, revealed on 09/30/14 at approximately 3:10 PM, Housekeeper #1 reported she observed Resident #1 in the bathroom attached to a sit to stand lift with no one supervising the resident. She stated she observed CNA #2 and CNA #5 take the resident to the bathroom at approximately 2:45 PM, using the mechanical lift. At about 3:00 PM, the housekeeper took the trash outside and noticed CNA #2 was outside on a break, but did not know the location of the other CNA. The housekeeper took a short break then returned to the unit and checked the bathroom and found the resident on the toilet asleep at approximately 3:10 PM. The report indicated the housekeeper reported her findings to her supervisor immediately, who then reported to the Director of Nursing (DON). The facility's investigation revealed the facility substantiated neglect in the care for Resident #1 and appropriate actions were required. The facility indicated a plan of correction was implemented with re-education of staff. Interview, on 10/09/14 at 8:42 AM and 10/22/14 at 11:08 AM per telephone, with Housekeeper #1 revealed on 09/30/14 at approximately 3:10 PM, she observed Resident #1, in the bathroom, on the toilet, still attached to the lift. She stated the resident was alone in the bathroom with no staff supervising the resident. She stated she had observed CNA #2 and CNA #5 take the resident to the bathroom at approximately 2:45 PM, using the mechanical lift. At approximately 3:00 PM, the housekeeper said she took the trash outside and noticed CNA #2 on a break. She did not know the location of CNA #5 at that time, but later said she saw CNA #5 go down the 200 Hallway. The housekeeper said she became concerned and after a short break she returned to the unit and checked the bathroom. She found Resident #1 asleep on the toilet, still connected to the lift. She stated she reported the incident to her supervisor immediately, who then reported to the DON. She indicated she had not observed the two aides leave the bathroom. Interview with the DON, on 10/09/14 at 1:02 PM and on 10/21/14 at 11:30 AM, revealed the Housekeeping Supervisor reported to her, on 09/30/14 at around 3:10 PM, that Resident #1 was found by a housekeeper to be in the community bathroom (across from the nurses station) alone and still attached to the mechanical lift. She stated she immediately went to the bathroom and found the resident asleep and slumped over to the right side. The resident was still attached to the mechanical lift and the sling was around the resident's waist. She stated the resident was not to be left alone as the resident required total care for all needs, had a cognitive impairment, was non-verbal and could not call out for help, could not use the call light, and was unable to retain safety instructions. Interview with CNA #2, on 10/09/14 at 9:15 AM and a telephone interview on 10/22/14 at 10:46 AM, revealed she was one (1) of the CNA's involved in the incident with Resident #1. She stated she and CNA #5 took Resident #1 to the bathroom across from the nurse's station by the shower room. They had used the sit to stand lift. She stated the shower aide had pulled the emergency call light to get help with another resident who used a Hoyer lift and they went to help her. She stated both aides left Resident #1 alone in the bathroom to care for other residents. She stated Resident #1 should not be left alone in the bathroom because the resident could not pull the call light or call for help. She stated the 200 hall was very hectic and it was during shift change and she just forgot about Resident #1. She stated she still had four (4) or five (5) more residents to care for and when she completed those last checks, she went outside for a short break. The CNA stated the next thing she recalled was the DON calling over the intercom for all nursing staff to report to Unit A. When she came inside, the DON started yelling and screaming at her and CNA #5 telling them they had left Resident #1 on the toilet. She said the DON only asked who had put the resident on the toilet and screamed they were suspended and would never work as an aide again. The CNA said she assumed CNA #5 had assisted the resident from the toilet. It was a communication problem and she should not have left the resident alone unsupervised; however, it was not intentional. A telephone interview with CNA #5, on 10/14/14 at 2:05 PM and 10/21/14 at 3:58 PM, revealed she had only worked at the facility for about one month. She stated she helped CNA #2 place Resident #1 on the toilet on 09/30/14, using a mechanical lift. She stated she left before CNA #2 and she believed CNA #2 reported to the second shift staff that Resident #1 was in the bathroom, on the toilet. She stated walking rounds were conducted with the second shift aide (CNA #6) and she was told Resident #1 was in the bathroom before her and CNA #2 left to assist other residents to bed. She revealed she did not go back and check on the resident because she thought the second shift aide was with the resident. She revealed a short time later, the DON paged the nurse aides to Unit A's nurses' station. She stated the DON was very angry and yelled at them and wouldn't allow them to speak. She stated she tried to tell the DON it was reported to a second shift CNA, but the DON told her they (CNA #2 and #5) had left the resident in the bathroom alone. She continued to say she was sure the second shift CNA was informed of the resident being in the bathroom. She stated the resident should not be left alone on the toilet. A telephone interview with CNA #6, on 10/22/14 at 2:07 PM, revealed she did conduct walking rounds with CNA #2 and #5 the day of the incident. She stated the aides told her they had four (4) or five (5) residents left to complete last rounds on and she thought Resident #1 was included. She stated she was not aware Resident #1 was on the toilet. When she first arrived at work the resident was sitting in a wheelchair at the nurses' station. She recalled the DON paged all staff to the Unit's desk and told them Resident #1 was left on the toilet alone. Interview with CNA #4, on 10/21/14 at 3:07 PM, revealed she worked the second shift on 09/30/14. She stated she received report during walking rounds with CNA #2 and #5 that day. She was told by the two aides that they had several residents left to complete checks. They told her they were going to place Resident #1 on the toilet but she did not observe them take the resident to the bathroom. She stated Resident #1 was sitting in a wheelchair at the Nurses' station when she began her work shift at 2:30 PM. She revealed Resident #1 required supervision when on the toilet because the resident cannot call out for help and was unable to use the call light. She stated the resident doesn't have good sitting balance and fidgets and should not be left alone. Interview with Licensed Practical Nurse (LPN) #3, on 10/21/14 at 2:52 PM, revealed she was working the day the resident was left on the toilet unsupervised. She stated she was with another resident when the DON came and asked her if she knew Resident #1 had been left in the bathroom alone. She said she was unaware. She revealed it was facility policy for two (2) persons to transfer a resident in a mechanical lift. She revealed Resident #1 was total assist and dependent on staff for all ADL tasks. She stated the resident required supervision while on the toilet. She indicated the resident's sitting balance was not good and the resident would lean to the left side. She revealed walking rounds between the two shifts were to be conducted, but she was busy and could not validate if the rounds were conducted that day. She stated during the walking rounds, the staff was supposed to visualize each resident. She indicated the nurse aides had no scheduled breaks but took their breaks whenever they could. She said the nurse aides were supposed to tell the nurse when they were off the floor; however, she said CNA #2 and #5 had not informed her when they left for a break and did not tell her they had left Resident #1 on the toilet. Interview with LPN #1, on 10/09/14 at 10:45 AM, revealed Resident #1 was not to be left alone during any transfers or when on the toilet because she was totally depended on staff for all care needs and a fall risk. Interview with LPN #2, on 10/09/14 at 12:42 PM, revealed she was the manager for Unit A, the unit where Resident #1 resided. She revealed she was at the nurses' station during the time Resident #1 was left in the bathroom unsupervised. However, she stated she was unaware the resident was in the bathroom or for how long. LPN #2 stated the normal procedure for Resident #1 was for staff to take the resident to the bathroom and stay with the resident. She stated the resident was found asleep in the bathroom, slumped to the side, and the call light was not in the resident's hand. She stated the potential risk to the resident was a fall, and skin breakdown. Further interview with the Unit A Manager, on 10/29/14 at 2:35 PM, revealed when the DON came to her and asked if she knew anything about the resident left on the toilet alone, she went with the DON to the community bathroom and found the resident sitting on the toilet asleep. She said nobody was in the bathroom with the resident at that time. She stated she called all the nurses (for that unit) together and asked them if they knew the resident had been left in the bathroom alone and they did not. She said she paged over the intercom for all aides to report to the Unit A desk. She said both aides (CNA #2 and CNA #5) had been outside taking a break. She revealed when the aides came back inside, she took all the aides to the bathroom, opened the bathroom door and showed the aides (1st and 2nd shift) the resident sitting on the toilet. She said LPN #3 was with the resident at that time. She then instructed CNA #2 and CNA #5 to remove the resident from the toilet and place the resident in bed. LPN #3 conducted a skin assessment and found no marks on the resident's skin. Continued interview revealed the Unit Manager revealed supervision of the direct care staff was conducted throughout the day to ensure they were providing care for the residents. She stated the nurses were supposed to help the aides when needed and the staff nurses were supposed to check behind the aides to ensure the care was provided. Interview with the DON, on 10/09/14 at 1:02 PM and on 10/21/14 at 11:30 AM, revealed staff knew residents could not be left on a lift unsupervised and residents that required total care could not be left in the bathroom alone. Interview with the Administrator, on 10/21/14 at 1:40 PM and on 10/21/14 at 3:27 PM, revealed he had conducted an interview with CNA #2 when she acknowledged she had left the resident on the toilet alone. The CNA told him it was a communication problem because she thought CNA #5 had taken the resident off the toilet and CNA #5 had thought she had done it. He stated both aides apologized and told him they should not have left the resident alone. He determined it was a communication problem and not a purposeful act. However, he did substantiate neglect because the resident did not received the care he/she needed. Observation of Resident #1, on 10/21/14 at 11:58 PM, revealed the resident sitting in a wheelchair with arms crossed and eyes closed in the main dining room. The resident did not respond to conversation. At 12:52 PM, observation revealed the resident sitting in a shower chair after receiving a shower. Continued observation revealed CNA #7 and #8 used a mechanical lift (Vera sit to stand type) to transfer the resident from the shower chair to a wheelchair. The staff placed the resident's hands onto the lift's grab bars. The lift raised the resident to a standing position and the resident was able to hold onto the grab bars while the staff applied a brief and transported the resident into a wheelchair. The resident was observed to be non-verbal and required cues and reminders to hold onto the grab bars. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 that alleged removal of the Immediate Jeopardy on 10/24/14. Review of the AOC revealed the facility implemented the following: 1. On 09/30/14, Resident #1 was removed from the lift and a full body skin assessment was conducted. Additional skin assessments were conducted on 10/01/14 and 10/02/14. No injuries or harm was detected. 2. A re-investigation was conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14. A new checklist was developed for Abuse/Neglect investigations. 3. The Medical Director was notified of the incident and Immediate Jeopardy on 10/23/14. 4. A full audit and assessment of the nineteen (19) residents using a mechanical lift was conducted by the Director of Nursing on 10/23/14. Upon concluding the audit, the DON reviewed and did not identify any further concerns for resident safety or adequate supervision of residents who need assistance with the lifts. 5. On 10/23/14 the MDS nurse reviewed and completed care plans for those nineteen (19) residents. 6. On 10/23/14, the DON and QA nurse educated nursing staff (eighty) on lift assessments and policy and understanding, following, and updating care plans. Those employees on medical leave or works as needed will be trained prior to resuming normal working schedule. 7. On 10/23/14, the DON, Staff Development Nurse, and Department Heads conducted a training for all staff (nursing, housekeeping, dietary, maintenance, activities, and social services) on Abuse and Neglect. A total of one hundred and twenty-nine (129) employees attended. A written quiz was given to those in attendance. The Social Service Director updated the orientation quiz on 10/23/14. 8. On 10/23/14, the Regional Director of Operations reviewed the Abuse and Neglect procedures with the Administrator. The Administrator, DON, and Social Services Director participated in an in-service titled Hand-In-Hand V. 1, Module 2 as training to identify the items required when reporting abuse. 9. A new attendance system regarding breaks for nursing staff was implemented on 10/23/14. To improve communications between shift change a new shift change Huddle system was implement on 10/23/14. The DON, Unit Managers, and the QA Nurse educated all nursing staff on the new policy and Huddle system on 10/23/14. 10. A new Huddle system was implemented on 10/23/14 to improve communication between shifts. 11. The Administrator will convene an in-house QA committee weekly until full compliance is met and a lesser frequency is deemed appropriate. The Administrator will be ultimately responsible for compliance with stated plans. A QA meeting was held on 10/28/14 with the Medical Director in attendance. A new quality-assurance program was implemented to monitor nurse aides who are using the lifts to ensure residents are receiving care according to their individualized care plans. An audit will be conducted on each shift by a Nurse Manager and reviewed for proper supervision and lift procedures to ensure consistency with the care plans. Results of the audits will be accumulated by the DON and brought to the Quality Assurance (QA) committee. 12. The Administrator will conduct daily Grand Rounds to oversee the implementation of the AOC and review daily staffing and supervision. Trends will be reported to the QA. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducts the rounds daily and talks with staff and residents to ensure staffing is adequate and care is provided. Through observation, interview and record review the State Survey Agency validated the AOC as follows: 1. Review of the skin assessment conducted for Resident #1 on 10/01/14 and 10/02/14 revealed no injuries were found. Review of the Weekly skin assessments revealed the resident had no skin issues. 2. Review of the re-investigation, conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14, revealed a more thorough investigation. The new checklist for Abuse/Neglect investigations was used. 3. Interview with the Administrator, on 10/30/14 at 3:00 PM revealed the Medical Director had been contacted on 10/23/14 and notified of the incident and Immediate Jeopardy. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director. 4. Review of the audit forms for the lift assessments for the nineteen (19) residents, identified to be transferred with a mechanical lift, revealed all nineteen had been assessed for appropriate use of the lifts on 10/23/14. The staff was instructed to always use two persons for a transfer with a mechanical lift by the Director of Nursing on 10/13/14. Observation of the mechanical lift used for transfer with Resident #1 on 10/21/14 at 11:58 AM revealed two staff performed the transfer properly. Interview with Resident #6, on 10/29/14 at 4:55 and #7 on 10/30/14 at 9:02 AM, revealed two staff were present when the lift was used and staff stayed with Resident #6 when on the toilet. Resident #7 uses a bed pan. 5. Review of training records dated 10/23/14 revealed the MDS coordinator and staff were trained on completion of care plans. Review of the nineteen (19) residents that utilized the mechanical lifts revealed care plans were completed to include supervision during the use of the lifts and during toileting. 6. Review of the sign in sheet dated 10/23/14 revealed eighty (80) nursing staff received training on the new lift assessments and policy and updating care plans. Interview on 10/30/14 with CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on the lifts, care plans, scheduled breaks and new Huddle system. 7. Review of the training sign-in sheet titled Abuse & Neglect, dated 10/23/14, revealed one hundred twenty-nine (129) employees received the training. A post test was given and Review of the POS [REDACTED]. Review revealed the orientation Abuse & Neglect quiz was updated as stated on 10/23/14. Interview on 10/30/14 with Housekeeper #2 at 3:40 PM, CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on Abuse/Neglect. 8. Review of the sign in sheet dated 10/23/14 revealed the Regional Director of Operations conducted a training to review Abuse and Neglect procedures with the Administrator. The Administrator, Director of Nursing, and Social Services Director reviewed the Hand-In-Hand Module 2 as training to identify the items required when reporting abuse. This was completed on 10/23/14. 9. Review of the new break schedule for nursing staff on 10/30/14 revealed all nursing staff had scheduled break times and the Unit Managers provided oversight to ensure staff was compliant with those scheduled times. Interview with the Unit A Manager, on 10/29/14 at 2:35 PM and Unit B Manager, on 10/30/14 at 2:35 PM, revealed they monitor the scheduled breaks for compliance. They also conduct a random audit of the lift use to ensure the staff were using the lifts appropriately and supervision was provided as care planned. 10. Observation of a Huddle meeting between the first and second shift, on 10/29/14 at 3:05 PM, on the 200 hall, revealed the nurses and nurse aides did walking rounds and reported on each resident regarding any changes. 11. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director, Administrator, Director of Nursing Services, Staff Development, QA Nurse and Social Services Director to discuss current Immediate Jeopardy deficiencies and a Plan of Correction. Review of the audits conducted by the Unit Manager (each shift) to ensure staff was using the mechanical lifts and residents receiving care according to their care plan revealed the audits were conducted as stated on each shift since 10/23/14. Interview with the DON and the Administrator, on 10/30/14 at 3:00 PM, confirmed the QA Meeting was held on 10/28/14 with the Medical Director. They stated the incident on 09/30/14 was discussed as well as the Immediate Jeopardy deficiencies. There was discussion of the audits, interviews, and training that was being done related to the deficiencies. 12. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducted the Grand rounds daily and talked with staff and residents to ensure staffing was adequate and care was provided. He did not have documented forms, only verbal. Observation revealed the Regional Director of Operations was present at the facility throughout the survey until the Immediate Jeopardy was removed prior to exit on 10/30/14.

Based on interview, record review, review of the facility's policy and investigation report, it was determined the facility failed to have an effective system in place to ensure all allegations of abuse, including neglect, were investigated to ensure residents were protected from further neglect for one of seven (7) sampled residents, Residents #1. (Refer to F224) Interview and record review revealed on 09/30/14 at approximately 2:45 PM, a housekeeper observed two (2) Certified Nursing Assistants (CNA) use a mechanical lift to take Resident #1 to the bathroom. At approximately 3:10 PM, Resident #1 was found alone in the bathroom, on the toilet, asleep and slumped toward the right side. The resident was still attached to a sit to stand mechanical lift with the lift's sling still around the resident's waist. The resident was removed from the toilet and a complete skin assessment was conducted that found no injuries. The facility assessed Resident #1 at risk for falls, with severe cognition impairment, and non-verbal communication. Interviews with CNA #2 and #5 revealed the resident could not yell out for help, was unable to retain safety instructions, and could not use the call light due to the level of cognition impairment. CNA #4, Licensed Practical Nurse (LPN) #3 and LPN #1 stated the resident required supervision during toileting and should not be left alone. Review of the facility's investigation revealed only the first shift staff had been interviewed. The incident occurred during shift change but no evening shift staff were interviewed to determine if they had knowledge of the resident being left on the toilet unsupervised. Review of CNA #2's written statement revealed she indicated she had given report to the second shift staff informing them Resident #1 was on the toilet. The facility's investigation revealed only CNA #2 and #5, Housekeeper #1, and the Director of Nursing (DON) were interviewed. The Administrator made his decision on these interviews and failed to investigate further. Although the facility's investigation determined the two CNAs did not purposefully leave the resident on the toilet unsupervised, there was no documented evidence the facility investigated any contributing factors that caused the incident. The facility failed to assess other non-interviewable residents on the 200 Unit for possible neglect through skin assessments and failed to interview all staff who had knowledge of the practice. The facility's failure to have an effective system in place to ensure all allegations of abuse, including neglect were investigated by interviewing staff and to ensure residents were protected from further neglect placed residents at risk in a situation that caused or was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 10/22/14, and was determined to exist on 09/30/14. The facility was notified of the Immediate Jeopardy on 10/22/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 with the facility alleging removal of the Immediate Jeopardy on 10/24/14. The Immediate Jeopardy was verified to be removed on 10/24/14 as alleged, with remaining non-compliance at a Scope and Severity of a "D", while the facility monitors the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure an effective system is in place to ensure all allegations of abuse, including neglect are investigated thoroughly, and residents are protected from further neglect. The findings include: Review of the facility's Abuse and Neglect Policy, revised 07/30/12, revealed the Administrator would be responsible for ensuring the facility's compliance with all applicable provisions of 42 CFR 483.13. As soon as possible, all information related to a report of abuse/neglect, would be obtained in writing from all persons with knowledge of the reported incident. Pertinent interviews are conducted in a confidential, professional manner with "need to know" priority information. These interviews may include the resident, if possible, the individual reporting the event, all staff on duty at the time of the event with any probable first-hand information, and other individuals present in the area at the time of the reported incident. These interviews are put in writing and discussed only by those with responsibility for determining substantiation of the report. Review of the facility's investigation, revealed on 09/30/14 at approximately 3:10 PM, Housekeeper #1 reported she observed Resident #1 in the bathroom attached to a sit to stand lift with no one supervising the resident. She stated she observed CNA #2 and CNA #5 take the resident to the bathroom at approximately 2:45 PM, using the mechanical lift. At about 3:00 PM, the housekeeper took the trash outside and noticed CNA #2 was outside on a break, but did not know the location of the other CNA. The housekeeper took a short break then returned to the unit and checked the bathroom and found the resident on the toilet asleep at approximately 3:10 PM. She reported this to her supervisor immediately, who then reported to the Director of Nursing (DON). The facility's investigation results stated the facility substantiated neglect in the care for Resident #1 and appropriate actions were required. The facility indicated a plan of correction was implemented with re-education of staff. Continued review of the facility's investigation revealed the only written statements obtained during the investigation were Housekeeper #1, CNA #1, and the DON. In addition, CNA #2 indicated in her written statement, dated 10/03/14, that she had informed the second shift CNA that Resident #1 was on the toilet. However, there was no evidence the facility investigated further to determine if that was true. Interview with the DON, on 10/21/14 at 1:40 PM, revealed she had not interviewed any staff on the second shift. She did determine CNA #2 and CNA #5 had placed the resident on the toilet and was off the unit at the same time when the resident was found in the bathroom alone. However, she had not asked the aides if they left the bathroom together after putting Resident #1 on the toilet and did not interview any staff on the second shift to determine if they may have knowledge of the resident on the toilet. Another interview with the DON was conducted at 4:20 PM that revealed she was angry upon finding the resident in the bathroom alone and sent the aides home without getting their statements. Interview, on 10/21/14 at 1:40 PM and 3:27 PM, with the Administrator revealed he was aware of the facility's abuse policy; he had been involved in investigations, and was aware of the status of investigations. He stated he had conducted a telephone interview with CNA #2 and CNA #5 and determined it was a communication problem and not a purposeful act. He stated as Acting Administrator at that time he read the final investigation reports and substantiated neglect because the resident did not receive the care he/she needed. The Administrator revealed he had not interviewed any second shift staff and did not ask the two CNAs if they left the bathroom together. He stated he did not investigate any contributing factors that may have caused the incident. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 that alleged removal of the Immediate Jeopardy on 10/24/14. Review of the AOC revealed the facility implemented the following: 1. On 09/30/14, Resident #1 was removed from the lift and a full body skin assessment was conducted. Additional skin assessments were conducted on 10/01/14 and 10/02/14. No injuries or harm was detected. 2. A re-investigation was conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14. A new checklist was developed for Abuse/Neglect investigations. 3. The Medical Director was notified of the incident and Immediate Jeopardy on 10/23/14. 4. A full audit and assessment of the nineteen (19) residents using a mechanical lift was conducted by the Director of Nursing on 10/23/14. Upon concluding the audit, the DON reviewed and did not identify any further concerns for resident safety or adequate supervision of residents who need assistance with the lifts. 5. On 10/23/14 the MDS nurse reviewed and completed care plans for those nineteen (19) residents. 6. On 10/23/14, the DON and QA nurse educated nursing staff (eighty) on lift assessments and policy and understanding, following, and updating care plans. Those employees on medical leave or works as needed will be trained prior to resuming normal working schedule. 7. On 10/23/14, the DON, Staff Development Nurse, and Department Heads conducted a training for all staff (nursing, housekeeping, dietary, maintenance, activities, and social services) on Abuse and Neglect. A total of one hundred and twenty-nine (129) employees attended. A written quiz was given to those in attendance. The Social Service Director updated the orientation quiz on 10/23/14. 8. On 10/23/14, the Regional Director of Operations reviewed the Abuse and Neglect procedures with the Administrator. The Administrator, DON, and Social Services Director participated in an in-service titled Hand-In-Hand V. 1, Module 2 as training to identify the items required when reporting abuse. 9. A new attendance system regarding breaks for nursing staff was implemented on 10/23/14. To improve communications between shift change a new shift change Huddle system was implement on 10/23/14. The DON, Unit Managers, and the QA Nurse educated all nursing staff on the new policy and Huddle system on 10/23/14. 10. A new Huddle system was implemented on 10/23/14 to improve communication between shifts. 11. The Administrator will convene an in-house QA committee weekly until full compliance is met and a lesser frequency is deemed appropriate. The Administrator will be ultimately responsible for compliance with stated plans. A QA meeting was held on 10/28/14 with the Medical Director in attendance. A new quality-assurance program was implemented to monitor nurse aides who are using the lifts to ensure residents are receiving care according to their individualized care plans. An audit will be conducted on each shift by a Nurse Manager and reviewed for proper supervision and lift procedures to ensure consistency with the care plans. Results of the audits will be accumulated by the DON and brought to the Quality Assurance (QA) committee. 12. The Administrator will conduct daily Grand Rounds to oversee the implementation of the AOC and review daily staffing and supervision. Trends will be reported to the QA. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducts the rounds daily and talks with staff and residents to ensure staffing is adequate and care is provided. Through observation, interview and record review the State Survey Agency validated the AOC as follows: 1. Review of the skin assessment conducted for Resident #1 on 10/01/14 and 10/02/14 revealed no injuries were found. Review of the Weekly skin assessments revealed the resident had no skin issues. 2. Review of the re-investigation, conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14, revealed a more thorough investigation. The new checklist for Abuse/Neglect investigations was used. 3. Interview with the Administrator, on 10/30/14 at 3:00 PM revealed the Medical Director had been contacted on 10/23/14 and notified of the incident and Immediate Jeopardy. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director. 4. Review of the audit forms for the lift assessments for the nineteen (19) residents, identified to be transferred with a mechanical lift, revealed all nineteen had been assessed for appropriate use of the lifts on 10/23/14. The staff was instructed to always use two persons for a transfer with a mechanical lift by the Director of Nursing on 10/13/14. Observation of the mechanical lift used for transfer with Resident #1 on 10/21/14 at 11:58 AM revealed two staff performed the transfer properly. Interview with Resident #6, on 10/29/14 at 4:55 and #7 on 10/30/14 at 9:02 AM, revealed two staff were present when the lift was used and staff stayed with Resident #6 when on the toilet. Resident #7 uses a bed pan. 5. Review of training records dated 10/23/14 revealed the MDS coordinator and staff were trained on completion of care plans. Review of the nineteen (19) residents that utilized the mechanical lifts revealed care plans were completed to include supervision during the use of the lifts and during toileting. 6. Review of the sign in sheet dated 10/23/14 revealed eighty (80) nursing staff received training on the new lift assessments and policy and updating care plans. Interview on 10/30/14 with CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on the lifts, care plans, scheduled breaks and new Huddle system. 7. Review of the training sign-in sheet titled Abuse & Neglect, dated 10/23/14, revealed one hundred twenty-nine (129) employees received the training. A post test was given and Review of the POS [REDACTED]. Review revealed the orientation Abuse & Neglect quiz was updated as stated on 10/23/14. Interview on 10/30/14 with Housekeeper #2 at 3:40 PM, CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on Abuse/Neglect. 8. Review of the sign in sheet dated 10/23/14 revealed the Regional Director of Operations conducted a training to review Abuse and Neglect procedures with the Administrator. The Administrator, Director of Nursing, and Social Services Director reviewed the Hand-In-Hand Module 2 as training to identify the items required when reporting abuse. This was completed on 10/23/14. 9. Review of the new break schedule for nursing staff on 10/30/14 revealed all nursing staff had scheduled break times and the Unit Managers provided oversight to ensure staff was compliant with those scheduled times. Interview with the Unit A Manager, on 10/29/14 at 2:35 PM and Unit B Manager, on 10/30/14 at 2:35 PM, revealed they monitor the scheduled breaks for compliance. They also conduct a random audit of the lift use to ensure the staff were using the lifts appropriately and supervision was provided as care planned. 10. Observation of a Huddle meeting between the first and second shift, on 10/29/14 at 3:05 PM, on the 200 hall, revealed the nurses and nurse aides did walking rounds and reported on each resident regarding any changes. 11. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director, Administrator, Director of Nursing Services, Staff Development, QA Nurse and Social Services Director to discuss current Immediate Jeopardy deficiencies and a Plan of Correction. Review of the audits conducted by the Unit Manager (each shift) to ensure staff was using the mechanical lifts and residents receiving care according to their care plan revealed the audits were conducted as stated on each shift since 10/23/14. Interview with the DON and the Administrator, on 10/30/14 at 3:00 PM, confirmed the QA Meeting was held on 10/28/14 with the Medical Director. They stated the incident on 09/30/14 was discussed as well as the Immediate Jeopardy deficiencies. There was discussion of the audits, interviews, and training that was being done related to the deficiencies. 12. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducted the Grand rounds daily and talked with staff and residents to ensure staffing was adequate and care was provided. He did not have documented forms, only verbal. Observation revealed the Regional Director of Operations was present at the facility throughout the survey until the Immediate Jeopardy was removed prior to exit on 10/30/14.

Based on interview, record review, and review of the facility's investigation report and policy, it was determined the facility failed to have an effective system in place to ensure the facility's policies and procedures related to abuse/neglect were implemented for one (1) of seven (7) sampled residents, Resident #1. Interview and record review revealed on 09/30/14 at approximately 2:45 PM, a housekeeper observed two (2) Certified Nursing Assistants (CNA) use a mechanical lift to take Resident #1 to the bathroom. At approximately 3:10 PM, Resident #1 was found alone in the bathroom, on the toilet, asleep and slumped toward the right side. The resident was still attached to a sit to stand mechanical lift with the lift's sling still around the resident's waist. The resident was removed from the toilet and a complete skin assessment was conducted that found no injuries. The facility assessed Resident #1 at risk for falls, with severe cognition impairment, and non-verbal communication. Interviews with CNA #2 and #5 revealed the resident could not yell out for help, was unable to retain safety instructions, and could not use the call light due to the level of cognition impairment. CNA #4, Licensed Practical Nurse (LPN) #3 and LPN #1 stated the resident required supervision during toileting and should not be left alone. (Refer to F224, F225) Although the incident occurred during the shift change, the facility failed to interview any staff from the evening shift to determine their knowledge of the resident left in the bathroom alone. The facility's failure to have an effective system in place to ensure the implementation of abuse policies and procedures to prevent neglect placed residents at risk in a situation that caused or was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 10/22/14, and determined to exist on 09/30/14. The facility was notified of the Immediate Jeopardy on 10/22/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14, with the facility alleging removal of the Immediate Jeopardy on 10/24/14. The Immediate Jeopardy was verified to be removed on 10/24/14 as alleged, with remaining non-compliance at a Scope and Severity of a "D", while the facility monitors the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure an effective system is in place to ensure abuse policies and procedures are implemented to prevent neglect of residents. The findings include: Review of the facility's Abuse and Neglect Policy, revised 07/30/12, revealed "Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Administrator would be responsible for ensuring the facility's compliance with all applicable provisions of 42 CFR 483.13. As soon as possible, all information related to a report of abuse/neglect, would be obtained in writing from all persons with knowledge of the reported incident. Pertinent interviews were conducted in a confidential, professional manner with "need to know" priority information. These interviews may include the resident, if possible, the individual reporting the event, all staff on duty at the time of the event with any probable first-hand information, and other individuals present in the area at the time of the reported incident. These interviews are put in writing and discussed only by those with responsibility for determining substantiation of the report. Review of the facility's investigation, revealed on 09/30/14 at approximately 3:10 PM, Housekeeper #1 reported she observed Resident #1 in the bathroom attached to a sit to stand lift with no one supervising the resident. She stated she observed CNA #2 and CNA #5 take the resident to the bathroom at approximately 2:45 PM, using the mechanical lift. At approximately 3:10 PM, the incident was reported to the Director of Nursing (DON). The investigation indicated the DON went immediately and found the resident sitting on the toilet with no staff in the bathroom. The facility's investigation results stated the facility substantiated neglect in the care for Resident #1 and appropriate actions were required. The facility indicated a plan of correction was implemented with re-education of staff. Continued review of the facility's investigation report revealed only three (3) written statements were obtained: CNA #2, Housekeeper #1, and the DON. In addition, CNA #2's written statement indicated she had informed the second shift nurse aide during shift report. However, there was no documented evidence CNA #6 was interviewed regarding her knowledge of the incident according to the facility's abuse policy. Interview with the Administrator, on 10/21/14 at 1:40 PM and 3:27 PM, revealed he had not interviewed any staff from the second shift and did not investigate any other factors that may have contributed to the incident. The Administrator said he called and interviewed both aides (two days after the incident) and said they both thought the other person was going to take the resident off the toilet. He said both aides apologized and told him they should not have left the resident alone. He determined it was a communication problem and not a purposeful act. However, he did substantiated neglect because the resident did not receive the care he/she needed. The Administrator stated he was aware of the facility's abuse policy and was involved in the investigation. He revealed the investigation findings were discussed with the DON and they were in agreement that neglect of Resident #1 had occurred. He stated as Administrator he determined the final investigation report and findings. Interview, on 10/21/14 at 4:20 PM, with the Director of Nursing (DON) revealed the investigation conducted on 09/30/14 had been "focused" on the two CNAs. The DON revealed she had not interviewed anyone on the second shift. Further interview revealed she had failed to obtain pertinent information from the two CNAs before suspending them and did not ask them if they both left together. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 that alleged removal of the Immediate Jeopardy on 10/24/14. Review of the AOC revealed the facility implemented the following: 1. On 09/30/14, Resident #1 was removed from the lift and a full body skin assessment was conducted. Additional skin assessments were conducted on 10/01/14 and 10/02/14. No injuries or harm was detected. 2. A re-investigation was conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14. A new checklist was developed for Abuse/Neglect investigations. 3. The Medical Director was notified of the incident and Immediate Jeopardy on 10/23/14. 4. A full audit and assessment of the nineteen (19) residents using a mechanical lift was conducted by the Director of Nursing on 10/23/14. Upon concluding the audit, the DON reviewed and did not identify any further concerns for resident safety or adequate supervision of residents who need assistance with the lifts. 5. On 10/23/14 the MDS nurse reviewed and completed care plans for those nineteen (19) residents. 6. On 10/23/14, the DON and QA nurse educated nursing staff (eighty) on lift assessments and policy and understanding, following, and updating care plans. Those employees on medical leave or works as needed will be trained prior to resuming normal working schedule. 7. On 10/23/14, the DON, Staff Development Nurse, and Department Heads conducted a training for all staff (nursing, housekeeping, dietary, maintenance, activities, and social services) on Abuse and Neglect. A total of one hundred and twenty-nine (129) employees attended. A written quiz was given to those in attendance. The Social Service Director updated the orientation quiz on 10/23/14. 8. On 10/23/14, the Regional Director of Operations reviewed the Abuse and Neglect procedures with the Administrator. The Administrator, DON, and Social Services Director participated in an in-service titled Hand-In-Hand V. 1, Module 2 as training to identify the items required when reporting abuse. 9. A new attendance system regarding breaks for nursing staff was implemented on 10/23/14. To improve communications between shift change a new shift change Huddle system was implement on 10/23/14. The DON, Unit Managers, and the QA Nurse educated all nursing staff on the new policy and Huddle system on 10/23/14. 10. A new Huddle system was implemented on 10/23/14 to improve communication between shifts. 11. The Administrator will convene an in-house QA committee weekly until full compliance is met and a lesser frequency is deemed appropriate. The Administrator will be ultimately responsible for compliance with stated plans. A QA meeting was held on 10/28/14 with the Medical Director in attendance. A new quality-assurance program was implemented to monitor nurse aides who are using the lifts to ensure residents are receiving care according to their individualized care plans. An audit will be conducted on each shift by a Nurse Manager and reviewed for proper supervision and lift procedures to ensure consistency with the care plans. Results of the audits will be accumulated by the DON and brought to the Quality Assurance (QA) committee. 12. The Administrator will conduct daily Grand Rounds to oversee the implementation of the AOC and review daily staffing and supervision. Trends will be reported to the QA. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducts the rounds daily and talks with staff and residents to ensure staffing is adequate and care is provided. Through observation, interview and record review the State Survey Agency validated the AOC as follows: 1. Review of the skin assessment conducted for Resident #1 on 10/01/14 and 10/02/14 revealed no injuries were found. Review of the Weekly skin assessments revealed the resident had no skin issues. 2. Review of the re-investigation, conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14, revealed a more thorough investigation. The new checklist for Abuse/Neglect investigations was used. 3. Interview with the Administrator, on 10/30/14 at 3:00 PM revealed the Medical Director had been contacted on 10/23/14 and notified of the incident and Immediate Jeopardy. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director. 4. Review of the audit forms for the lift assessments for the nineteen (19) residents, identified to be transferred with a mechanical lift, revealed all nineteen had been assessed for appropriate use of the lifts on 10/23/14. The staff was instructed to always use two persons for a transfer with a mechanical lift by the Director of Nursing on 10/13/14. Observation of the mechanical lift used for transfer with Resident #1 on 10/21/14 at 11:58 AM revealed two staff performed the transfer properly. Interview with Resident #6, on 10/29/14 at 4:55 and #7 on 10/30/14 at 9:02 AM, revealed two staff were present when the lift was used and staff stayed with Resident #6 when on the toilet. Resident #7 uses a bed pan. 5. Review of training records dated 10/23/14 revealed the MDS coordinator and staff were trained on completion of care plans. Review of the nineteen (19) residents that utilized the mechanical lifts revealed care plans were completed to include supervision during the use of the lifts and during toileting. 6. Review of the sign in sheet dated 10/23/14 revealed eighty (80) nursing staff received training on the new lift assessments and policy and updating care plans. Interview on 10/30/14 with CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on the lifts, care plans, scheduled breaks and new Huddle system. 7. Review of the training sign-in sheet titled Abuse & Neglect, dated 10/23/14, revealed one hundred twenty-nine (129) employees received the training. A post test was given and Review of the POS [REDACTED]. Review revealed the orientation Abuse & Neglect quiz was updated as stated on 10/23/14. Interview on 10/30/14 with Housekeeper #2 at 3:40 PM, CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on Abuse/Neglect. 8. Review of the sign in sheet dated 10/23/14 revealed the Regional Director of Operations conducted a training to review Abuse and Neglect procedures with the Administrator. The Administrator, Director of Nursing, and Social Services Director reviewed the Hand-In-Hand Module 2 as training to identify the items required when reporting abuse. This was completed on 10/23/14. 9. Review of the new break schedule for nursing staff on 10/30/14 revealed all nursing staff had scheduled break times and the Unit Managers provided oversight to ensure staff was compliant with those scheduled times. Interview with the Unit A Manager, on 10/29/14 at 2:35 PM and Unit B Manager, on 10/30/14 at 2:35 PM, revealed they monitor the scheduled breaks for compliance. They also conduct a random audit of the lift use to ensure the staff were using the lifts appropriately and supervision was provided as care planned. 10. Observation of a Huddle meeting between the first and second shift, on 10/29/14 at 3:05 PM, on the 200 hall, revealed the nurses and nurse aides did walking rounds and reported on each resident regarding any changes. 11. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director, Administrator, Director of Nursing Services, Staff Development, QA Nurse and Social Services Director to discuss current Immediate Jeopardy deficiencies and a Plan of Correction. Review of the audits conducted by the Unit Manager (each shift) to ensure staff was using the mechanical lifts and residents receiving care according to their care plan revealed the audits were conducted as stated on each shift since 10/23/14. Interview with the DON and the Administrator, on 10/30/14 at 3:00 PM, confirmed the QA Meeting was held on 10/28/14 with the Medical Director. They stated the incident on 09/30/14 was discussed as well as the Immediate Jeopardy deficiencies. There was discussion of the audits, interviews, and training that was being done related to the deficiencies. 12. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducted the Grand rounds daily and talked with staff and residents to ensure staffing was adequate and care was provided. He did not have documented forms, only verbal. Observation revealed the Regional Director of Operations was present at the facility throughout the survey until the Immediate Jeopardy was removed prior to exit on 10/30/14.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop a comprehensive plan of care for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for one (1) of seven (7) sampled residents, Resident #1. On 09/30/14 at approximately 3:10 PM, Resident #1 was found alone in a bathroom, on the toilet, asleep and slumped toward the right side. The resident was still attached to a mechanical lift with the lift's sling around the resident's waist. The facility assessed the resident to have a severe cognition impairment and to be non-verbal. Interviews with Certified Nursing Assistant (CNA) #2 and #5 revealed the resident could not yell out for help, was unable to retain safety instructions, and could not use the call light due to the cognition loss. CNA #4, Licensed Practical Nurse (LPN) #3 and LPN #1 stated the resident required supervision during toileting and should not have been left alone. The facility assessed the resident to be at risk for falls due to the cognitive loss, vision deficit, and total staff assistance for all care including transfers to and from bed and wheelchair, locomotion, and toileting needs. However, the facility failed to develop interventions to ensure the resident's safety on the toilet. The facility's failure to ensure it's policy was followed and a care plan related to supervision of a cognitively impaired resident during toileting was developed placed residents at risk in a situation that caused or was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 10/22/14, and was determined to exist on 09/30/14. The facility was notified of the Immediate Jeopardy on 10/22/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 with the facility alleging removal of the Immediate Jeopardy on 10/24/14. The Immediate Jeopardy was verified to be removed on 10/24/14 as alleged with the scope and severity was lowered to a "D" while the facility monitors the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure necessary care and services are provided, and residents are protected from neglect. The findings include: Review of the facility's Care Plan policy, revised 03/01/13, revealed the comprehensive care plan must include review of the Care Area Assessments (CAA's) as identified through completion of the Minimum Data Set (MDS). The comprehensive care plan will be updated as needed based upon a change in the existing treatment plan. Review of the medical record for Resident #1 revealed the facility admitted the resident on 09/20/05 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 04/21/14, revealed the facility assessed Resident #1 to have a severe cognitive impairment with memory loss and impaired decision making ability. Continued review of the MDS Assessment revealed the facility assessed Resident #1 as requiring total physical assistance of two (2) staff for Activities of Daily Living (ADLs) such as bed mobility, transfers, and toileting. The facility assessed the resident to be unable to walk. The facility assessed the resident to have a sitting balance deficit and was unsteady and required stabilization from staff when moving on and off the toilet and moving from seated to a standing position. The resident was assessed to rarely/never understand. Review of the most recent quarterly MDS assessment, completed on 10/09/14 revealed the resident had no changes in cognition or functional status. Review of the CAA worksheet for ADLs function, dated 04/22/14, revealed the resident was at risk for functional decline in regard to toileting related to physical weakness, limited range of motion, poor coordination, poor balance, pain, and visual impairment. The facility indicated they would proceed to care plan to prevent loss. The CAA worksheet for falls, completed on 04/22/14, revealed the resident required total staff assistance and the use of a mechanical lift for transfers to and from the bed and toileting. The resident was assessed to be non-ambulatory. The falls worksheet identified the resident to be a fall risk related to difficulty maintaining sitting balance, impaired balance during transitions, cognitive impairment, incontinence, and visual impairment. The facility indicated the fall risk would be addressed in the care plan. Review of the comprehensive care plan revealed the facility initiated a care plan on 04/21/14 for risk of falling related to the resident's lack of awareness of safety needs, poor communication/comprehension, and vision/hearing problems. The care plan indicated the resident required total staff assistance with all care including transfers to and from the bed, wheelchair and toileting needs. The care plan interventions included a stand up lift as needed. However, the facility failed to develop interventions to address the resident's sitting balance deficit and the need for supervision during toileting according to staff interviews. Review of the daily care plan (what the nurse aides follow to care for each resident) revealed under the safety section there were instructions that Resident #1 needed assistance of two (2) persons with the Vera Lift (sit to stand) for all transfers. In addition, the daily care plan indicated the resident was hard of hearing and had poor vision. Under the elimination section there was information that the resident was incontinent of bowel and bladder and needed assistance to be clean and dry. The daily care plan had no written instructions regarding the resident's toileting needs or supervision required. Review of the facility's investigation, revealed on 09/30/14 at approximately 3:10 PM, Housekeeper #1 reported she observed Resident #1 in the bathroom attached to a sit to stand lift with no one supervising the resident. She reported this to her supervisor immediately, who then reported to the Director of Nursing (DON). The facility's investigation findings on 10/03/14 stated the facility substantiated neglect in the care for Resident #1 and appropriate actions were required. The facility indicated a plan of correction was implemented with re-education of staff. (Refer to F224) Interview with the DON, on 10/21/14 at 11:30 AM, revealed Resident #1 should not have been left alone in the bathroom. She stated the resident's cognitive impairment, the inability to retain safety instructions or use the call light, and the resident's inability to yell out for help placed the resident at risk for injury. Interview with LPN #3, on 10/21/14 at 2:52 PM, revealed Resident #1 was a total assist with all ADLs and needed supervision when on the toilet. She stated the resident's sitting balance was not good and the resident leaned toward the left side. Interview with CNA #4, on 10/21/14 at 3:07 PM, revealed Resident #1 should not be left alone in the bathroom because the resident cannot use the call light and was non-verbal so he/she could not call out for help. She continued to say the resident did not have good sitting balance and would fidget at times. She stated she would follow the care plan instructions. Interview with the Unit A Manager, on 10/29/14 at 2:35 PM revealed Resident #1 required supervision and needed someone to stay with the resident when in the bathroom toileting. She revealed she was responsible for the creation and revision of the daily care plan the nurse aides utilize to provide care for residents. She stated Resident #1's daily care plan was not specific before the incident but she thought everyone understood the resident could not be left alone during toileting. Interview with the MDS nurse, on 10/22/14 at 2:45 PM, revealed the comprehensive care plan did not include the required supervision during toileting. She revealed she had reviewed the care plan on 10/03/14 (the same day the DON had issued a memo stating all residents who used the mechanical lifts were not to be left unattended while being toileted) but did not make any changes to include that intervention. She stated she had knowledge of the incident on 09/30/14, but failed to developed any new interventions. She stated she should have developed a care plan to include the required supervision of Resident #1 when the resident was in the bathroom toileting. She said she was focused on ensuring the method of transfer (lifts) was on the care plan and did not think to put the required supervision. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 that alleged removal of the Immediate Jeopardy on 10/24/14. Review of the AOC revealed the facility implemented the following: 1. On 09/30/14, Resident #1 was removed from the lift and a full body skin assessment was conducted. Additional skin assessments were conducted on 10/01/14 and 10/02/14. No injuries or harm was detected. 2. A re-investigation was conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14. A new checklist was developed for Abuse/Neglect investigations. 3. The Medical Director was notified of the incident and Immediate Jeopardy on 10/23/14. 4. A full audit and assessment of the nineteen (19) residents using a mechanical lift was conducted by the Director of Nursing on 10/23/14. Upon concluding the audit, the DON reviewed and did not identify any further concerns for resident safety or adequate supervision of residents who need assistance with the lifts. 5. On 10/23/14 the MDS nurse reviewed and completed care plans for those nineteen (19) residents. 6. On 10/23/14, the DON and QA nurse educated nursing staff (eighty) on lift assessments and policy and understanding, following, and updating care plans. Those employees on medical leave or works as needed will be trained prior to resuming normal working schedule. 7. On 10/23/14, the DON, Staff Development Nurse, and Department Heads conducted a training for all staff (nursing, housekeeping, dietary, maintenance, activities, and social services) on Abuse and Neglect. A total of one hundred and twenty-nine (129) employees attended. A written quiz was given to those in attendance. The Social Service Director updated the orientation quiz on 10/23/14. 8. On 10/23/14, the Regional Director of Operations reviewed the Abuse and Neglect procedures with the Administrator. The Administrator, DON, and Social Services Director participated in an in-service titled Hand-In-Hand V. 1, Module 2 as training to identify the items required when reporting abuse. 9. A new attendance system regarding breaks for nursing staff was implemented on 10/23/14. To improve communications between shift change a new shift change Huddle system was implement on 10/23/14. The DON, Unit Managers, and the QA Nurse educated all nursing staff on the new policy and Huddle system on 10/23/14. 10. A new Huddle system was implemented on 10/23/14 to improve communication between shifts. 11. The Administrator will convene an in-house QA committee weekly until full compliance is met and a lesser frequency is deemed appropriate. The Administrator will be ultimately responsible for compliance with stated plans. A QA meeting was held on 10/28/14 with the Medical Director in attendance. A new quality-assurance program was implemented to monitor nurse aides who are using the lifts to ensure residents are receiving care according to their individualized care plans. An audit will be conducted on each shift by a Nurse Manager and reviewed for proper supervision and lift procedures to ensure consistency with the care plans. Results of the audits will be accumulated by the DON and brought to the Quality Assurance (QA) committee. 12. The Administrator will conduct daily Grand Rounds to oversee the implementation of the AOC and review daily staffing and supervision. Trends will be reported to the QA. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducts the rounds daily and talks with staff and residents to ensure staffing is adequate and care is provided. Through observation, interview and record review the State Survey Agency validated the AOC as follows: 1. Review of the skin assessment conducted for Resident #1 on 10/01/14 and 10/02/14 revealed no injuries were found. Review of the Weekly skin assessments revealed the resident had no skin issues. 2. Review of the re-investigation, conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14, revealed a more thorough investigation. The new checklist for Abuse/Neglect investigations was used. 3. Interview with the Administrator, on 10/30/14 at 3:00 PM revealed the Medical Director had been contacted on 10/23/14 and notified of the incident and Immediate Jeopardy. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director. 4. Review of the audit forms for the lift assessments for the nineteen (19) residents, identified to be transferred with a mechanical lift, revealed all nineteen had been assessed for appropriate use of the lifts on 10/23/14. The staff was instructed to always use two persons for a transfer with a mechanical lift by the Director of Nursing on 10/13/14. Observation of the mechanical lift used for transfer with Resident #1 on 10/21/14 at 11:58 AM revealed two staff performed the transfer properly. Interview with Resident #6, on 10/29/14 at 4:55 and #7 on 10/30/14 at 9:02 AM, revealed two staff were present when the lift was used and staff stayed with Resident #6 when on the toilet. Resident #7 uses a bed pan. 5. Review of training records dated 10/23/14 revealed the MDS coordinator and staff were trained on completion of care plans. Review of the nineteen (19) residents that utilized the mechanical lifts revealed care plans were completed to include supervision during the use of the lifts and during toileting. 6. Review of the sign in sheet dated 10/23/14 revealed eighty (80) nursing staff received training on the new lift assessments and policy and updating care plans. Interview on 10/30/14 with CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on the lifts, care plans, scheduled breaks and new Huddle system. 7. Review of the training sign-in sheet titled Abuse & Neglect, dated 10/23/14, revealed one hundred twenty-nine (129) employees received the training. A post test was given and Review of the POS [REDACTED]. Review revealed the orientation Abuse & Neglect quiz was updated as stated on 10/23/14. Interview on 10/30/14 with Housekeeper #2 at 3:40 PM, CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on Abuse/Neglect. 8. Review of the sign in sheet dated 10/23/14 revealed the Regional Director of Operations conducted a training to review Abuse and Neglect procedures with the Administrator. The Administrator, Director of Nursing, and Social Services Director reviewed the Hand-In-Hand Module 2 as training to identify the items required when reporting abuse. This was completed on 10/23/14. 9. Review of the new break schedule for nursing staff on 10/30/14 revealed all nursing staff had scheduled break times and the Unit Managers provided oversight to ensure staff was compliant with those scheduled times. Interview with the Unit A Manager, on 10/29/14 at 2:35 PM and Unit B Manager, on 10/30/14 at 2:35 PM, revealed they monitor the scheduled breaks for compliance. They also conduct a random audit of the lift use to ensure the staff were using the lifts appropriately and supervision was provided as care planned. 10. Observation of a Huddle meeting between the first and second shift, on 10/29/14 at 3:05 PM, on the 200 hall, revealed the nurses and nurse aides did walking rounds and reported on each resident regarding any changes. 11. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director, Administrator, Director of Nursing Services, Staff Development, QA Nurse and Social Services Director to discuss current Immediate Jeopardy deficiencies and a Plan of Correction. Review of the audits conducted by the Unit Manager (each shift) to ensure staff was using the mechanical lifts and residents receiving care according to their care plan revealed the audits were conducted as stated on each shift since 10/23/14. Interview with the DON and the Administrator, on 10/30/14 at 3:00 PM, confirmed the QA Meeting was held on 10/28/14 with the Medical Director. They stated the incident on 09/30/14 was discussed as well as the Immediate Jeopardy deficiencies. There was discussion of the audits, interviews, and training that was being done related to the deficiencies. 12. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducted the Grand rounds daily and talked with staff and residents to ensure staffing was adequate and care was provided. He did not have documented forms, only verbal. Observation revealed the Regional Director of Operations was present at the facility throughout the survey until the Immediate Jeopardy was removed prior to exit on 10/30/14.

Based on interview, record review and review of the facility's policies, it was determined the facility's Administrator failed to ensure an effective system was in place to utilize available resources, including policies related to abuse/neglect and care plans, were used effectively and efficiently to ensure each resident was free from neglect and received appropriate care and services in regard to toileting needs for one (1) of seven (7) sampled residents. Resident #1. Interview and record review revealed on 09/30/14 at approximately 2:45 PM, a housekeeper observed two (2) Certified Nursing Assistants (CNA) use a mechanical lift to take Resident #1 to the bathroom. At approximately 3:10 PM, Resident #1 was found alone in the bathroom, on the toilet, asleep and slumped toward the right side. The resident was still attached to a sit to stand mechanical lift with the lift's sling still around the resident's waist. The resident was removed from the toilet and a complete skin assessment was conducted that found no injuries. The facility assessed Resident #1 at risk for falls, with severe cognition impairment, and non-verbal communication. Interviews with CNA #2 and #5 revealed the resident could not yell out for help, was unable to retain safety instructions, and could not use the call light due to the level of cognition impairment. CNA #4, Licensed Practical Nurse (LPN) #3 and LPN #1 stated the resident required supervision during toileting and should not be left alone. (Refer to F224, F225, F226) The Administrator's failure to have an effective system in place to ensure policy and procedures were implemented to protect from neglect placed residents at risk in a situation that caused or was likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 10/22/14 and determined to exit on 09/30/14. The facility was notified of the Immediate Jeopardy on 10/22/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 with the facility alleging removal of the Immediate Jeopardy on 10/24/14. The Immediate Jeopardy was verified to be removed on 10/24/14 as alleged, with the scope and severity was lowered to a "D" while the facility monitors the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure necessary care and services are provided, and residents are protected from neglect. The findings include: Review of the facility's Abuse and Neglect Policy, revised 07/30/12, revealed "Neglect" meant failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Administrator would be responsible for ensuring the facility's compliance with all applicable provisions of 42 CFR 483.13. As soon as possible, all information related to a report of abuse/neglect, would be obtained in writing from all persons with knowledge of the reported incident. Pertinent interviews are conducted in a confidential, professional manner with "need to know" priority information. These interviews may include the resident, if possible, the individual reporting the event, all staff on duty at the time of the event with any probable first-hand information, and other individuals present in the area at the time of the reported incident. These interviews are put in writing and discussed only by those with responsibility for determining substantiation of the report. In addition, the facility provided a document they used as a supplement to their Abuse and Neglect policy titled Recognizing Signs and Symptoms of Abuse and Neglect, revised dated of June 2004, which revealed signs of neglect to include leaving someone unattended who needed supervision. Interview and record review revealed the Administrator failed to ensure policy and procedures were implemented related to abuse and neglect. Review of the facility's investigation revealed pertinent interviews were not conducted per the facility's policy. The facility only interviewed first shift staff even though it was determined the incident occurred during shift change. No evening shift staff was interviewed to determine if they had knowledge of the resident being left on the toilet unsupervised. In addition, the Administrator failed to ensure other non-interviewable residents on the 200 Unit were assessed for possible neglect through skin assessments and failed to investigated any contributing factors that may have caused the incident. Interview, on 10/21/14 at 1:40 PM and 3:27 PM, with the Administrator revealed he was aware of the facility's abuse policy. He stated he had conducted a telephone interview with the two CNAs involved, CNA #2 and CNA #5, and based on their interviews he had determined it was a communication problem between the CNAs. He stated both aides apologized and told him they should not have left the resident alone. Per interview, he did not interview any second shift staff and did not investigate other contributing factors which may have caused the incident because he had determined the incident was caused by lack of communication. He stated as Acting Administrator at that time of the incident, he substantiated neglect because the resident did not receive the care he/she needed. The facility provided an acceptable Allegation of Compliance (AOC) on 10/29/14 that alleged removal of the Immediate Jeopardy on 10/24/14. Review of the AOC revealed the facility implemented the following: 1. On 09/30/14, Resident #1 was removed from the lift and a full body skin assessment was conducted. Additional skin assessments were conducted on 10/01/14 and 10/02/14. No injuries or harm was detected. 2. A re-investigation was conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14. A new checklist was developed for Abuse/Neglect investigations. 3. The Medical Director was notified of the incident and Immediate Jeopardy on 10/23/14. 4. A full audit and assessment of the nineteen (19) residents using a mechanical lift was conducted by the Director of Nursing on 10/23/14. Upon concluding the audit, the DON reviewed and did not identify any further concerns for resident safety or adequate supervision of residents who need assistance with the lifts. 5. On 10/23/14 the MDS nurse reviewed and completed care plans for those nineteen (19) residents. 6. On 10/23/14, the DON and QA nurse educated nursing staff (eighty) on lift assessments and policy and understanding, following, and updating care plans. Those employees on medical leave or works as needed will be trained prior to resuming normal working schedule. 7. On 10/23/14, the DON, Staff Development Nurse, and Department Heads conducted a training for all staff (nursing, housekeeping, dietary, maintenance, activities, and social services) on Abuse and Neglect. A total of one hundred and twenty-nine (129) employees attended. A written quiz was given to those in attendance. The Social Service Director updated the orientation quiz on 10/23/14. 8. On 10/23/14, the Regional Director of Operations reviewed the Abuse and Neglect procedures with the Administrator. The Administrator, DON, and Social Services Director participated in an in-service titled Hand-In-Hand V. 1, Module 2 as training to identify the items required when reporting abuse. 9. A new attendance system regarding breaks for nursing staff was implemented on 10/23/14. To improve communications between shift change a new shift change Huddle system was implement on 10/23/14. The DON, Unit Managers, and the QA Nurse educated all nursing staff on the new policy and Huddle system on 10/23/14. 10. A new Huddle system was implemented on 10/23/14 to improve communication between shifts. 11. The Administrator will convene an in-house QA committee weekly until full compliance is met and a lesser frequency is deemed appropriate. The Administrator will be ultimately responsible for compliance with stated plans. A QA meeting was held on 10/28/14 with the Medical Director in attendance. A new quality-assurance program was implemented to monitor nurse aides who are using the lifts to ensure residents are receiving care according to their individualized care plans. An audit will be conducted on each shift by a Nurse Manager and reviewed for proper supervision and lift procedures to ensure consistency with the care plans. Results of the audits will be accumulated by the DON and brought to the Quality Assurance (QA) committee. 12. The Administrator will conduct daily Grand Rounds to oversee the implementation of the AOC and review daily staffing and supervision. Trends will be reported to the QA. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducts the rounds daily and talks with staff and residents to ensure staffing is adequate and care is provided. Through observation, interview and record review the State Survey Agency validated the AOC as follows: 1. Review of the skin assessment conducted for Resident #1 on 10/01/14 and 10/02/14 revealed no injuries were found. Review of the Weekly skin assessments revealed the resident had no skin issues. 2. Review of the re-investigation, conducted by the Owner and former Administrator on 10/27/14 and faxed to the State Survey Agency on 10/29/14, revealed a more thorough investigation. The new checklist for Abuse/Neglect investigations was used. 3. Interview with the Administrator, on 10/30/14 at 3:00 PM revealed the Medical Director had been contacted on 10/23/14 and notified of the incident and Immediate Jeopardy. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director. 4. Review of the audit forms for the lift assessments for the nineteen (19) residents, identified to be transferred with a mechanical lift, revealed all nineteen had been assessed for appropriate use of the lifts on 10/23/14. The staff was instructed to always use two persons for a transfer with a mechanical lift by the Director of Nursing on 10/13/14. Observation of the mechanical lift used for transfer with Resident #1 on 10/21/14 at 11:58 AM revealed two staff performed the transfer properly. Interview with Resident #6, on 10/29/14 at 4:55 and #7 on 10/30/14 at 9:02 AM, revealed two staff were present when the lift was used and staff stayed with Resident #6 when on the toilet. Resident #7 uses a bed pan. 5. Review of training records dated 10/23/14 revealed the MDS coordinator and staff were trained on completion of care plans. Review of the nineteen (19) residents that utilized the mechanical lifts revealed care plans were completed to include supervision during the use of the lifts and during toileting. 6. Review of the sign in sheet dated 10/23/14 revealed eighty (80) nursing staff received training on the new lift assessments and policy and updating care plans. Interview on 10/30/14 with CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on the lifts, care plans, scheduled breaks and new Huddle system. 7. Review of the training sign-in sheet titled Abuse & Neglect, dated 10/23/14, revealed one hundred twenty-nine (129) employees received the training. A post test was given and Review of the POS [REDACTED]. Review revealed the orientation Abuse & Neglect quiz was updated as stated on 10/23/14. Interview on 10/30/14 with Housekeeper #2 at 3:40 PM, CNA #13 at 3:47 PM, CNA #14 at 3:56 PM, CNA #15 at 4:02 PM, LPN # 8 at 4:05 PM, and the MDS Coordinator at 4:10 PM revealed they all had received inservice training on Abuse/Neglect. 8. Review of the sign in sheet dated 10/23/14 revealed the Regional Director of Operations conducted a training to review Abuse and Neglect procedures with the Administrator. The Administrator, Director of Nursing, and Social Services Director reviewed the Hand-In-Hand Module 2 as training to identify the items required when reporting abuse. This was completed on 10/23/14. 9. Review of the new break schedule for nursing staff on 10/30/14 revealed all nursing staff had scheduled break times and the Unit Managers provided oversight to ensure staff was compliant with those scheduled times. Interview with the Unit A Manager, on 10/29/14 at 2:35 PM and Unit B Manager, on 10/30/14 at 2:35 PM, revealed they monitor the scheduled breaks for compliance. They also conduct a random audit of the lift use to ensure the staff were using the lifts appropriately and supervision was provided as care planned. 10. Observation of a Huddle meeting between the first and second shift, on 10/29/14 at 3:05 PM, on the 200 hall, revealed the nurses and nurse aides did walking rounds and reported on each resident regarding any changes. 11. Review of the Quality Assurance (QA) Signature Sheet revealed a QA meeting was held on 10/28/14 with the Medical Director, Administrator, Director of Nursing Services, Staff Development, QA Nurse and Social Services Director to discuss current Immediate Jeopardy deficiencies and a Plan of Correction. Review of the audits conducted by the Unit Manager (each shift) to ensure staff was using the mechanical lifts and residents receiving care according to their care plan revealed the audits were conducted as stated on each shift since 10/23/14. Interview with the DON and the Administrator, on 10/30/14 at 3:00 PM, confirmed the QA Meeting was held on 10/28/14 with the Medical Director. They stated the incident on 09/30/14 was discussed as well as the Immediate Jeopardy deficiencies. There was discussion of the audits, interviews, and training that was being done related to the deficiencies. 12. Interview with the Administrator, on 10/30/14 at 3 PM revealed he conducted the Grand rounds daily and talked with staff and residents to ensure staffing was adequate and care was provided. He did not have documented forms, only verbal. Observation revealed the Regional Director of Operations was present at the facility throughout the survey until the Immediate Jeopardy was removed prior to exit on 10/30/14.