Every finding on record at Ridgeway Nursing & Rehabilitation Facility

The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 7 of 40 sampled residents (Resident (R) 16, R32, R40, R50, R78, R82, and R88). The findings include: Review of the facility's policy titled, Infection Prevention Manual for Long Term Care, undated, revealed gowns should be worn when there is potential for soiling clothing with blood/body fluids; the type of personal protective equipment [PPE] should be appropriate for the procedure being performed and the type of exposure anticipated. Review of the facility's policy titled, Medication Administration, dated 07/01/2024, revealed the facility will ensure medications are administered in accordance with manufacturers' specifications and good nursing principles and practices. Further review revealed gloves should be applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications; and hands are washed with soap and water or sanitized after administration and with any resident contact. Review of the glucometer manufacturer's cleaning instructions titled, Assure Prism Multi Blood Glucose Monitoring, revealed to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions. Further review revealed the meter should be cleaned and disinfected after use on each patient. Continued review revealed the cleaning procedure needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. Review of the facility's policy titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention, dated 12/29/2021, revealed the purpose is to ensure appropriate technique in the care and maintenance of foley catheters; secure catheter properly to prevent movement; and keep the collection bag and the tube off the floor. 1. Review of R16's admission Record revealed the facility admitted the resident on 01/03/2024 with diagnoses including type 2 diabetes and Parkinson's disease. Review of R16's Care Plan Report revealed an intervention was initiated on 03/02/2026 for enhanced barrier precautions (EBP) related to a wound. Observation on 06/02/2026 at 12:09 PM revealed Licensed Practical Nurse (LPN) 1 entered the room of R16, who was on EBP, as indicated by signage posted on the resident's door. LPN1 administered an insulin injection to R16 but failed to don a gown prior to providing direct resident care. In an interview with LPN1 on 06/04/2026 at 10:04 AM, she stated EBP was not like standard precautions or contact precautions, PPE had to be worn if there was direct resident contact. She further stated it was important to wear PPE for residents on EBP if direct contact was made to help prevent cross contamination and the spread of infection. LPN1 stated she did not realize she failed to gown up before she administered insulin to R16; she stated she normally wore her PPE when she gave insulin to R16 and that she was just nervous. In an interview with the Infection Preventionist (IP) on 06/04/2026 at 3:26 PM, she stated the facility's resident population was vulnerable and compliance with policies was important, so residents were kept safe. She further stated it was her expectation that staff wore appropriate PPE for administration of an insulin injection for a resident on EBP. In an interview with the Director of Nursing (DON) on 06/04/2026 at 10:28 AM, she stated it was her expectation staff followed infection control policies when medications were passed. She further stated she expected that staff performed hand hygiene and changed gloves if the resident's medications contained more than one route of administration. When asked about EBP, the DON stated residents with any type of open portal were placed on EBP to help protect them and other residents. She further stated, she anticipated if staff administered insulin to a resident on EBP, both gloves and a gown should be donned prior to administration. In an interview with the Administrator on 06/04/2026 at 3:06 PM, he stated he expected staff always followed the facility's infection control policies and procedures and that included during medication administration times. He further stated he expected that staff donned the appropriate PPE at the appropriate times. 2. Review of R78's admission Record revealed the facility admitted the resident on 03/27/2026 with diagnoses including type 2 diabetes and dementia. Observation on 06/02/2026 at 12:12 PM revealed LPN1 reviewed the Medication Administration Record (MAR) for R78 and removed eye drops from the medication cart. After entering R78's room and performing hand hygiene, one glove fell onto the floor while LPN1 was preparing to administer the medication. LPN1 picked up the glove from the floor, donned both gloves, and administered the eye drops to R78. In further interview with LPN1 on 06/04/2026 at 10:04 AM, when asked about the observation of the contaminated glove on the floor, LPN1 again stated she was nervous and simply did not realize she picked it up and donned a dirty glove. LPN1 stated the gloves should have been discarded, hand hygiene should have been performed, and clean gloves should have been donned. She stated it was important for staff to follow infection control protocols during medication pass and at all times, so residents were protected. In further interview with the IP on 06/04/2026 at 3:26 PM, she stated if, during medication administration, staff dropped a glove on the ground, it was her expectation that staff discarded the gloves, performed hand hygiene, and donned clean gloves. In further interview with the DON on 06/04/2026 at 10:28 AM, she stated it was her expectation if, during medication pass, staff dropped a glove on the floor, both gloves were removed and thrown away, hand hygiene was performed, and the staff or staff members donned new gloves prior to administration of any medication. In further interview with the Administrator on 06/04/2026 at 3:06 PM, he stated it was important staff followed the facility's infection prevention and control policies, so residents were properly cared for and kept safe. 3. Observation on 06/03/2026 at 8:21 AM revealed LPN3 obtained R50's blood pressure using a shared blood pressure cuff. After use, LPN3 removed the cuff and placed it on the medication cart without cleaning or disinfecting it. Further observation at 9:04 AM revealed LPN3 used the same shared blood pressure cuff to obtain R88's blood pressure. Following use, the cuff was again placed on the medication cart without being cleaned or disinfected. During the same observation, LPN3 used R88's personal glucometer to obtain a blood glucose reading and placed the glucometer on the medication cart before administering medications. After medication administration, LPN3 stated, I'm going to put this back in his [R88] room, without cleaning or disinfecting the glucometer. During an additional observation on 06/03/2026 at 9:05 AM, LPN4 used her personal electronic wrist blood pressure cuff on R40 and then went to use it on R82 without cleaning the equipment between residents. During an immediate interview, LPN4 stated she thought she only had to clean the one on wheels. She further stated there was a risk of spreading germs if equipment was not cleaned between residents. In an interview with LPN3 on 06/03/2026 at 9:13 AM, she stated that the glucometer should be cleaned after each use, and the blood pressure cuff should be disinfected after use with each resident using purple wipes. LPN3 stated that purple wipes were not on her cart, and she obtained blue-top Clorox disinfecting wipes to clean the equipment. LPN3 stated that it was important to clean and disinfect equipment after each use to prevent the spread of germs and bacteria. In an interview with the IP on 06/04/2026 at 9:27 AM, she stated we don't like them to use the wrist cuffs, but indicated that the expectation was for all blood pressure cuffs to be cleaned and disinfected between each resident use. She stated the wrist blood pressure cuffs were not provided by the facility and were purchased by the nursing staff, on their own. She further stated the facility provides nurse on a stick blood pressure equipment for staff to use. The IP stated the residents' personal glucometers were to be cleaned and sanitized after each use and to be treated as a shared device. She further stated that cleaning and disinfecting equipment after each use was important to prevent the spread of infection. In an interview with the DON on 06/04/2026 at 8:35 AM, she stated the facility categorized infection control risks as low, medium, and high. She stated that shared blood pressure cuffs were considered low risk equipment and were expected to be cleaned between residents with the facility's blue top Clorox disinfectant wipes. The DON stated it was important to clean shared blood pressure cuffs between each resident to prevent the spread of infection and limit potential exposure to infections. She further stated that although the residents have their own individual glucometers, staff were still expected to clean and disinfect the device after each use, the same as they would for shared equipment. The DON stated that proper cleaning and disinfection was important to prevent the potential transmission of infections. In an interview with the Administrator on 06/04/2026 at 1:13PM, he stated the shared wrist cuffs had all been removed from the units. He further stated the staff were expected to clean equipment, including blood pressure cuffs and glucometers, in between each resident and in between use as it was important to prevent infections. 4. Observation on 06/03/2026 at 9:49 AM revealed R32 was lying in bed with the catheter bag located on the left side of the bed frame. The bed was in a lowered position, and the catheter bag was touching the floor. During an interview with LPN6 on 06/04/2026 at 10:46 AM, she stated the catheter bag should not hang on the floor because the floor was dirty. During an interview with the IP on 06/04/2026 at 3:24 PM, she stated the catheter bag should not be on the floor due to infection control concerns. During an interview with the DON on 06/04/2026 at 4:07 PM, she stated the catheter bag should be hung from the bed frame and not in the bend of the frame. During an interview with the Administrator on 06/04/2026 at 4:39 PM, he stated the catheter bag should not touch the floor due to infection control.

Based on interview and record review, the facility failed to provide documentation of residents' advance directive information for 2 of 12 sampled residents, Resident (R) 22 and R53. The findings include: Review of the facility's policy titled, Advance Directives, dated 08/08/2024, revealed the resident has the right to formulate an advance directive defined as a written instruction such as a living will, or durable power of attorney for healthcare recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Further review revealed during the admission process the facility will attempt to determine whether the resident has an advance directive and, if not, determine whether the resident wishes to formulate an advance directive. 1. Review of R22's Face Sheet revealed the facility admitted the resident on 10/10/2013 with diagnoses to include dementia, type 2 diabetes, and chronic kidney disease (CKD). Review of R22's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/25/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired. Review of R22's Advance Directive Acknowledgement (ADA), dated 03/17/2017, indicated the resident had executed an advance directive. Review of R22's Power of Attorney (POA) documentation scanned into the Electronic Medical Record (EMR) under the Advance Directive tab revealed a general POA document that addressed financial decisions only. The facility was unable to provide medical POA documentation for R22. 2. Review of R53's Face Sheet revealed the facility admitted the resident on 11/15/2023 with diagnoses to include type 2 diabetes, cerebral infarction, and interstitial pulmonary disease. Review of R53's quarterly MDS, with an ARD of 03/25/2025, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R53's ADA, dated 11/26/2023, indicated the resident had executed an advance directive, however there was no documentation of that advance directive in the resident's EMR. Further review of R53's ADA revealed a notation that stated, Family never provided. When requested from the facility on 05/07/25 at 10:35 AM, a copy of R53's advance directive was not provided. In an interview with R53's daughter on 05/07/25 at 12:23 PM, she stated she was the resident's POA and provided a copy of the POA documents to the facility when the resident was admitted . In an interview on 05/08/2025 at 11:57 AM, the Admissions Coordinator/Business Director Developer stated she addressed advance directives with residents and their families during the admission process. She stated she asked the resident and/or family if there was an advance directive in place, and if so, she requested a copy at that time. She further stated, if a copy was not received within 24 hours, she contacted the family again and made an additonal request. The Admissions Coordinator/Business Developer stated advance directives were addressed again if the resident had a change in condition and the Social Service Director (SSD) usually followed up with the resident and/or their representative regarding changes. She further stated it was important the facility had current advance directive information, so that the right person could make decisions on the resident's behalf, and the facility wanted to ensure a resident's wishes were honored. In an interview with the SSD on 05/08/2025 at 12:07 PM, she stated advance directives were addressed at admission and again after admission during quarterly meetings. The SSD stated it was important to have a resident's current advance directive information because a resident's wishes should be supported by the facility. She further stated a resident's wishes could not be honored if the facility did not know what the wishes were or who the designated responsible party was. In an interview with the Director of Nursing (DON) on 05/08/2025 at 2:42 PM, she stated advance directives were typically addressed during the admission process, but nurses addressed them if needed. The DON stated if a resident had executed an advance directive, a copy of the directive should be in the resident's EMR, and that documentation was requested at the time of admission. She further stated if the advance directive information was not provided at the time of admission, the facility should not wait long to get that POA paperwork; however, she was unable to provide a time frame for what too long meant. The DON stated it was important the facility knew who to call when medical decisions must be made for the resident. In an interview with the Administrator on 05/08/2025 at 2:52 PM, she stated advance directives were addressed at the time of admission and a copy of any advance directive information was also requested at that time. She further stated it was her expectation if a copy was not given to the facility at admission, the facility followed up with the family until a copy was obtained and placed in the resident's EMR.

Based on interview, record review, and review of the facility's policy, the facility failed to protect 1 of 11 sampled residents from physical abuse involving a resident to resident altercation, Resident (R) 21. On 01/13/2024 at 1:20 PM, State Registered Nurse Aide (SRNA) 7 witnessed R72 smack R21 in the face for taking R72's teddy bear away from her. Per review of the progress notes, R21 stated she thought her nose had been broken after the incident. The findings include: Review of the facility's policy titled, Abuse, Neglect, Protection, Prevention, and Reporting Policy, dated 08/04/2024, revealed the facility will conduct screenings and trainings to prevent and identify instances of abuse. Further review of the policy revealed that all reports of abuse will be investigated, ensuring the protection of victims and the reporting of all instances of abuse. Review of the facility's policy titled, Resident Rights Policy, dated of 08/13/2024, revealed all residents have the right to be treated with respect, dignity, and in a manner and environment that promotes maintenance or enhancement of their quality of life. Review of the Long-Term Care Facility-Initial Self-Reported Incident Form, dated 01/13/2024 at 3:03 PM, revealed the incident occurred on 01/13/2024 on A hall next to the nurses' station at 1:20 PM. Further review revealed R21, R72, and R240 were sitting near the nurses' station and SRNA7 witnessed R72 slap R21 in the face when R72 thought R21 had taken her stuffed teddy bear. While Licensed Practical Nurse (LPN) 4 was on the phone reporting the incident to the Administrator, she heard R240 yell out oh that hurt, and then R240 reported to LPN4 that R72 hit her on the right shoulder, which was not witnessed. Review of a witness statement from SRNA7, dated 01/13/2024, revealed SRNA7 stated that R72 was showing R21 her teddy bear when R21 took the bear to look at it and R72 got mad. R72 then leaned over and swatted R21 in the face on her nose twice. Review of R21's Face Sheet revealed the facility admitted the resident on 08/25/2022 with diagnoses to include acute kidney failure, anxiety, hypertension, and malignant of neoplasm of the upper lobe of the right lung. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident was severely cognitively impaired. Review of R21's Progress Notes, dated 01/13/2024 at 2:58 PM, revealed she had an acute change in condition that detailed the incident, and the nurse practioner (NP) made no recommendations for follow up care. Review of R21's Progress Notes, dated 01/13/2024 at 3:18 PM, revealed in an acute monitoring note that she was hit by R72 when she took R72's teddy bear and R21 stated she felt like her nose was broken. An attempt was made by the State Survey Agency (SSA) Surveyor to interview R21, on 05/05/2025 at 2:33 PM, but she was unable to answer questions due to a low BIMS score. Review of R72's Face Sheet revealed the facility admitted the resident on 11/22/2023 with diagnoses to include cerebral ischemia, hypertension, heart failure, and cognitive social/emotional deficit related to cerebrovascular disease. Review of R72's quarterly MDS, with an ARD of 01/05/2025, revealed the resident had a BIMS score of 4 out of 15, which indicated the resident was severely cognitively impaired. Review of R72's quarterly Minimum Data Set (MDS), dated 01/05/2024, revealed R72 was assessed as having physical and verbal behaviors directed toward others, 4 to 6 days but not daily. She was also assessed as having behavior symptoms not directed toward others, 1 to 3 days. Review of R72's Comprehensive Care Plan (CCP) from before the incident, dated 11/24/2023, and after the incident, dated 01/17/2024, revealed she was care planned for the focus of behaviors: yelling and cursing at staff and residents; agitation and aggression; combative with staff; exit seeking; refusing to put on clothes; looking in other residents' rooms; attempting to take other residents' items; raising fist at staff; hitting residents; using foul language; taking brief and pants off; and refusing skin checks. The goal was that R72 would have a reduction in these behavioral episodes. Further review of R72's CCP revealed the following interventions were in place: allow space; reapproach later if resident was resistive to care; ask for help if R72 was demonstrating abusive/resistive symptoms; convey acceptance during periods of inappropriate behaviors; encourage diversional activities that include providing art materials; communication of staff with R72 as tolerated; keeping environment as calm as possible; redirecting R72 as needed by all staff; removing R72 from public areas when behaviors posed a risk for harm; and when resident became agitated/had aggressive behaviors provide a quiet, calm setting. Review of R72's Progress Notes, dated 01/13/2024 at 2:58 PM, revealed in an acute monitoring note that she slapped her roommate in the face because she took her teddy bear and then moved to another resident and hit her while the nurse was making a phone call to report the abuse. R204 stated to LPN4 that R72 smacked her. Review of R72's Progress Notes, dated 01/13/2024 at 4:36 PM, revealed in a change in condition note that the NP made a recommendation for close monitoring. Review of R72's Progress Notes, dated 01/13/2024 through 01/21/2024, revealed she had acute monitoring notes for being on 1:1 supervision. An attempt was made by the SSA Surveyor to interview R72, on 05/05/2025 at 1:43 PM, but she was unable to answer questions due to a low BIMS score. Attempts were made by the SSA Surveyor on 05/06/2025 at 6:23 PM and 05/07/2025 at 12:13 PM to call SRNA7 for an interview, and she did not answer. A request was made for SRNA7 to return a call but she did not. In an interview on 05/06/2025 at 6:26 PM with Family Member (F) 12, the daugher of R72, she stated that she was never told that her mother had hit other residents in 2024. F12 stated she did not know if the facility had the psychiatry provider treat R72 or if they had changed her medications to help with her aggressive behaviors after the incidents. In an interview on 05/06/2025 at 6:32 PM with F13, the daughter of R21, she stated she remembered the facility telling her about another resident hitting her mother. She stated she did not remember the specific details of the incident but that her mother was not injured and had no changes in her mood. She further stated she thought it was an argument that precipitated the incident, and it was over something silly. In an interview with SRNA1 on 05/07/2025 at 9:01AM, she stated she remembered the incident when R72 smacked R21. SRNA1 stated staff no longer allow R72 to sit close enough to other residents to hit them. In an interview with LPN4 on 05/07/2025 at 12:26 PM, she stated she did not remember the exact instance of R72 hitting R21 because R72 had in the past frequently hit other residents. In an interview with LPN2 on 05/07/2025 at 8:50 AM, she stated R72 had a rough voice and said what she thought, and can be rude. She stated R72 was combative with staff but she never knew her to be that way with other residents. In an interview with the Psychiatric Nurse Practitioner (PNP) on 05/07/2025 at 1:27 PM, he stated R72 had a medication adjustment adjustment after the incident. Her Celexa (ordered for depression) was increased from 10 milligrams (mg) to 20 mg and he made other recommendations to the Medical Director for things to order if they did not see a decrease in R72's aggressive behaviors. In a concurrent interview with the Assistant Director of Nursing (ADON) 1, ADON2, and the Director of Nursing (DON) on 05/08/2025 at 7:59 AM, all stated that abuse should be reported immediately. In an interview with the Administrator on 05/08/2025 at 8:18 AM, she stated it was her expectation that staff report any incident that they feel could be abuse immediately to her, as she was the abuse coordinator, and the facility had been doing a lot of education about abuse. She stated signs were posted at the nurses' station with her phone number listed on them so that staff could contact her.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 4 sampled residents, Resident (R) 51. The findings include: Review of the facility's policy titled, Medication Administration, dated 08/04/2024, revealed the person who prepares the dose for administration is the person who administers the dose and the individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) which would show that the medication has been given. Review of the facility's policy titled, Preparation and General Guidelines; IIA7: Controlled Substances, dated 11/2021, revealed accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: date and time of administration; amount administered; remaining quantity; initials of the nurse administering the dose; and completed after the medication is administered. Review of R51's admission Record revealed the facility admitted the resident on 11/22/2022 with diagnoses to include chronic obstructive pulmonary disease (COPD) and pain due to internal orthopedic devices, implants, and grafts. Review of R51's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R51's Physician Orders revealed an order was in place for a scheduled oxycodone (related to pain) 5 milligram (mg) tablet four times a day. Review of R51's Controlled Drug Record for 09/25/2025 revealed an oxycodone 5 mg tablet was signed out by Licensed Practical Nurse (LPN) 14 the following four times during her shift: 8:00 AM, 12:00 PM, and twice at 5:00 PM. Review of R51's electronic MAR revealed an oxycodone 5 mg tablet was only administered twice on 09/25/2025 by LPN14 at 12:00 PM and 6:00 PM. Review of a Medication Error Report, dated 09/26/2024, revealed one extra dose of oxycodone 5 mg was administered to R51 on 09/25/2024 at 8:00 AM by LPN14. A request was made on 05/09/2025 at 7:30 AM and again at 10:15 AM for shift change controlled substance count sheets for all medication carts for 09/26/2024, 09/28/2024, and 10/22/2024, but none of the requested documentation was received. LPN14 no longer worked at the facility at the time of survey and the State Survey Agency (SSA) Surveyor was unable to contact her for an interview. In an interview with LPN4 on 05/07/2025 8:44 AM, she stated controlled substances were locked in a box on the medication cart and when she pulled a medication from the box, she signed it out immediately on the controlled substance log. She further stated a complete controlled substance count was performed at shift change with the oncoming nurse. LPN4 stated if any discrepancies were found after the count, they were reported immediately to the Director of Nursing (DON). In an interview with LPN8 on 05/07/2025 at 9:18 AM, she stated when she started her shift on 09/25/2024, she completed a controlled substance count of the medication cart with LPN14, who had worked the previous shift with no issues found. LPN8 stated when she started her medication pass on B hall, several residents complained of pain and asked for pain medication, but when she checked the log, medications were signed out and could not be dispensed again. LPN8 stated she attempted numerous times to contact the previous administrator; when she finally reached him and the DON, she was asked to send copies of the controlled substance logs, which she did. LPN8 stated ultimately the facility completed a medication error report for R51 that stated an extra dose of medication was administered by LPN14 to R51. LPN8 stated the facility policy for controlled medication administration was order checked, medication pulled from the cart, signed off on the logbook, administered to resident, and then signed off on the MAR. In an interview with the DON on 05/07/2025 at 2:21 PM, she stated she received a phone call from LPN8 on 09/25/2024 that some residents complained pain medication was not given by the previous nurse. The DON stated she went to the facility and immediately initiated an investigation that included a complete full house narcotic count audit and a review of resident MARs. The DON stated nothing was found with the audit, but she continued her investigation, and it was ultimately determined LPN14 administered an extra dose of oxycodone 5 mg to R51, so a medication error report was completed. She further stated the resident was assessed and there were no signs of an adverse reaction. In an additional interview with the DON on 05/08/2025 at 7:39 AM, she stated it was her expectation nurses signed controlled substances out of the logbook immediately when pulled from the cart and signed out on the MAR immediately after the medication was administered. The DON stated all scheduled pain medications appeared with a red bar on the MAR as a reminder for staff to follow up, but the medications administered on an as needed basis were white, so sometimes the nurses signed them out of the logbook but forgot the MAR. She further stated she had provided reeducation to all nursing staff on this matter. In an interview with the Administrator on 05/08/2025 at 2:52 PM, she stated it was her expectation the controlled substance log and the MAR for each resident matched every time a controlled medication was pulled from the cart because all medications had to be accounted for. When asked if R51 was charged for the two unaccounted for oxycodone 5 mg tablets, she stated that was a good question, but never supplied a definitive answer. Additionally, the Administrator stated a situation such as this would be presented and discussed at a Quality Assurance Process Improvement (QAPI) meeting.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a the resident's medical and nursing needs for 1 of 1 sampled residents, Resident (R) 47. The findings include: Review of the facility's policy titled, Care Plan Policy, dated 08/04/2024, revealed the Comprehensive Care Plan (CCP) is based on a thorough assessment that includes but is not limited to, the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) Assessments; and is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and be revised as necessary with changes. Further review revealed the CCP will be person-centered for each resident. Review of the facility's policy titled, Medication Administration, dated 08/04/2024, revealed the facility will ensure medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Further review revealed long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Observation on 05/06/2025 at 8:09 AM revealed Kentucky Medication Aide (KMA) 2 crushed all medications for R47 except for an esomeprazole (used to reduce stomach acid production) capsule. KMA2 placed the crushed medications in chocolate pudding, opened the capsule and emptied it into chocolate pudding, and administered all the medications to R47. Review of R47's Admission Record revealed the facility admitted the resident on 06/02/2020 with diagnoses to include chronic kidney disease (CKD), stroke, and dementia. Review of R47's quarterly MDS, with an Assessment Reference Date (ARD) of 02/14/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 9 out of 15, which indicated the resident was moderately cognitively impaired. Review of R47's CCP, with a revision date of 04/23/2025, revealed a focus on routine care needs with an intervention that included medications may be crushed when appropriate. Review of R47's Physician Orders revealed an active order for potassium chloride 10 milliequivalent (mEq) tablet extended release (ER) one time a day. Review of R47's Electronic Medication Administration Record (eMAR) revealed a potassium chloride 10 mEq tablet ER was administered by KMA2 on 05/06/2025 during morning medication pass. Further review revealed a potassium chloride 10 mEq tablet ER was administered by KMA14 on 05/07/2025 during morning medication pass. Review of the facility document titled, Medications Not To Be Crushed, dated 07/2019, revealed potassium chloride (used to manage and treat hypokalemia) ER tablet was listed as a medication not to be crushed because of its time release formulation. In an interview with KMA2 on 05/06/2025 at 9:15 AM, she stated she usually crushed all R47's medication except for an esomeprazole capsule because it was not supposed to be crushed. In an interview with KMA14 on 05/07/2025 at 8:53 AM, she stated she passed medications to R47 earlier that morning. She further stated she crushed R47's medications except for a capsule and administered them to her in applesauce. In an interview with the pharmacist on 05/06/2025 at 12:22 PM, she stated potassium ER was not a medication that should be crushed, but some potassium ER tablets could be dissolved in water prior to administration. While on the phone with the pharmacist, she reviewed the type of potassium that was sent to the facility for R47 and stated it could not be crushed or dissolved and should be administered whole. In an interview with the Director of Nursing (DON) on 05/08/2025 at 2:42 PM, she stated she expected that staff utilized available resources if unsure whether a medication could be crushed or not. She further stated numerous resources were available such as Do Not Crush lists, more experienced KMAs or nurses, pharmacy, or they knew she could be contacted anytime with questions. The DON stated she thought the need for crushed medications was not typically placed on a resident's care plan, but it should be. She further stated if a resident's medications were crushed, that was a special instruction, and special instructions were placed on care plans. In an interview with the Administrator on 05/08/2025 at 2:52 PM, she stated it was important to follow proper administration instructions for crushed medications so residents were not adversely affected. The Administrator further stated special instructions, such as crushed medications, should be a part of the resident's care plan and should be followed by staff so resident needs were met.

The facility failed to review and revise the Comprehensive Care Plan (CCP) for 1 of 34 sampled residents, Resident (R) 43. Review of R43's CCP revealed the facility failed to revise the care plan for placing his catheter bag on the floor, despite an interview with the resident stating that he liked to do so and observations of the catheter bag lying on the floor. The findings include: Review of the facility's policy titled, Care Plan Policy, dated 08/04/2024, revealed that the facility would develop and implement a person-centered care plan for each resident that is designed to incorporate identified problem areas, risk factors associated with the identified problems and should be revised as necessary with changes. Review of the facility's policy titled, Resident Rights Policy, dated 08/13/2024, revealed that residents have the right to see their care plan and to participate in decisions and care planning. Review of the facility's policy titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention, not dated, revealed that the purpose of the policy was to ensure the appropriate technique in the care and maintenance of Foley catheters. Further review of the policy stated that the collection bag and tubing should be kept off the floor. Review of R43's Face Sheet revealed that he was admitted to the facility on [DATE] with the diagnoses of benign prostatic hyperplasia (BPH), peripheral vascular disease (PVD), hypertension, and chronic kidney disease (CKD). Review of R43's Quarterly Minimum Data Set (MDS) dated [DATE], revealed that he was assessed as a Brief Interview for Mental Status (BIMS) of 14, cognitively intact. Further review of R43's Quarterly MDS revealed that he was assessed as having an indwelling catheter. Review of R43's Comprehensive Care Plan (CCP) dated 01/23/2025 revealed that he was care planned for the focus of urinary catheterization Foley catheter 16 French with a balloon related to BPH, obstructive and reflux uropathy, noncompliance with catheter securement, removal of catheter bag cover on his own, and masturbation with the Foley catheter present causing bleeding and displacement. The goals for this focus were that he would show no signs and symptoms of a urinary tract infection (UTI) and would not masturbate with the catheter in place. The interventions placed for this focus were to secure the catheter in place as tolerated, perform catheter care each shift and pro re nata (PRN), change the catheter and catheter bag per orders and PRN, position the catheter bag and tubing below the level of the bladder and away from the entrance of the door to the room, check tubing for kinks each shift and PRN, educate R43 on the dangers of masturbating with an indwelling Foley catheter, observe and document intake and output per facility policy, observe for pain or discomfort due to the catheter, observe for signs and symptoms of discomfort on urination and of frequency, observe for signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns and report findings to the Medical Director (MD). Further review of the care plan revealed that he was not care planned for placing his catheter bag on the floor. Observation on 05/05/2025 at 12:47 PM revealed R43's catheter bag was lying on the floor beside his recliner without a dignity bag. Observation on 05/06/2025 at 8:30 AM revealed R43's catheter bag on the floor without a dignity bag. Observation on 05/07/2025 at 8:18 AM revealed R43's catheter bag was in the floor and had no dignity bag. In an interview with R43 on 05/06/2025 at 8:30 AM he stated he did not like the paper cover (dignity cover) on his catheter bag because it covered the bag, and he could not see the urine. He also stated that he wanted his catheter bag on the floor beside of his chair and that was where he always put it when he was sitting in his recliner. Review of R43's Electronic Medical Record revealed no notes, point of care behavior monitoring, or orders detailing education provided to R43 about the importance of not placing his catheter bag on the floor. In an interview with State Registered Nurse Aide (SRNA) 8 on 05/07/2025 at 8:19 AM, she stated that R43 was able to ambulate independently and he placed his catheter bag on the floor when he sat down in his chair. SRNA8 stated that the catheter bag should not be on the floor because it was unsanitary, and it should be hanging on the side of R43's bed with the bag below R43 to allow it to drain. In a dual interview with Unit Manager (UM)1 and Licensed Practical Nurse (LPN)1 on 05/07/2025 at 8:28 AM, both stated that R43 would repeatedly place his catheter bag on the floor. Nursing staff educated him on the importance of leaving the catheter bag hanging on his bed (off the floor) but he would not listen to them and still placed it on the floor. They further stated the CCP should have been revised to reflect the resident putting the bag on the floor and the education that should be done when found that way. In a group interview with Assistant Director of Nursing (ADON)1, ADON2, and the Director of Nursing (DON) on 05/08/2025 at 7:59 AM, all stated that it was an ongoing issue with R43 placing his catheter bag on the floor. They stated that when staff saw the bag on the floor, they should re-hang it on his bed and educate him as to the importance of not placing the catheter bag on the floor. They stated this should be included on the resident's CCP. All stated that the Foley catheter bag should not be on the floor for infection purposes and should be hung so that the bag and tubing were both below the level of R43's bladder.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 sampled residents, Resident (R) 47. The findings include: Review of the facility's policy titled, Medication Administration, dated 08/04/2024, revealed the facility will ensure medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Further review revealed long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Observation on 05/06/2025 at 8:09 AM revealed Kentucky Medication Aide (KMA) 2 crushed all medications for R47 except for an esomeprazole (used to reduce stomach acid production) capsule. KMA2 placed the crushed medications in chocolate pudding, opened the capsule and emptied it into chocolate pudding, and administered all the medications to R47. Review of R47's Admission Record revealed the facility admitted the resident on 06/02/2020 with diagnoses to include chronic kidney disease (CKD), stroke, and dementia. Review of R47's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 9 out of 15, which indicated the resident was moderately cognitively impaired. Review of R47's Comprehensive Care Plan (CCP), with a revision date of 04/23/2025, revealed a focus on routine care needs with an intervention that included medications may be crushed when appropriate. Review of R47's Physician Orders revealed an active order for potassium chloride 10 milliequivalent (mEq) tablet extended release (ER) one time a day. Review of R47's Electronic Medication Administration Record (eMAR) revealed a potassium chloride 10 mEq tablet ER was administered by KMA2 on 05/06/2025 during morning medication pass. Further review revealed a potassium chloride 10 mEq tablet ER was administered by KMA14 on 05/07/2025 during morning medication pass. Review of the facility document titled, Medications Not To Be Crushed, dated 07/2019, revealed potassium chloride (used to manage and treat hypokalemia) ER tablet was listed as a medication not to be crushed because of its time release formulation. In an interview with KMA2 on 05/06/2025 at 9:15 AM, she stated she usually crushed all R47's medication except for an esomeprazole capsule because it was not supposed to be crushed. KMA2 stated the resident's potassium was crushed and placed into pudding prior to administration. KMA2 further stated she was not aware of a list on the medication cart that showed medications that were not supposed to be crushed. Observation of KMA2 at that time revealed she looked through a binder on the medication cart that contained the controlled substance log and other resources, but a Do Not Crush List was not located. In an interview with the pharmacist on 05/06/2025 at 12:22 PM, she stated potassium ER was not a medication that should be crushed, but some potassium ER tablets could be dissolved in water prior to administration. While on the phone with the pharmacist, she reviewed the type of potassium that was sent to the facility for R47 and stated it could not be crushed or dissolved and should be administered whole. The pharmacist stated when ER medications were crushed, large doses of the medication could be released, which were potentially harmful to the resident. She further stated there were other options for this medication such as liquid or a capsule. In an interview with Licensed Practical Nurse (LPN) 2 on 05/06/2025 at 12:31 PM, she stated KMAs trained with nurses or more experienced KMAs before they were allowed to administer medications on their own. LPN2 stated if a medication was not supposed to be crushed, sometimes it was listed on the order. She further stated ER and enteric coated medications were not crushed because they could potentially be absorbed too quickly in the body. In an interview with LPN3 on 05/06/2025 at 12:39 PM, who also served as Unit Manager (UM) for side 1, she stated KMAs trained with either a nurse or another experienced KMA before they passed medications on their own. LPN3 stated there was a nursing drug reference book located at the nurse's station, as well as a list of Do Not Crush medications located on the medication carts. In an interview with KMA14 on 05/07/2025 at 8:53 AM, she stated she passed medications to R47 earlier that morning. She further stated she crushed R47's medications except for a capsule and administered them to her in applesauce. KMA14 stated capsules and ER medications were not crushed, but some ER medications were dissolvable in water. KMA14 stated R47 did not have any ER medications. When asked if R47 received a potassium 10 mEq ER tablet, KMA14 stated she did not think so. In an interview with the Director of Nursing (DON) on 05/08/2025 at 2:42 PM, she stated she was the overseer of every nurse in the building which meant she ensured medication was properly administered and jobs were accurately completed. The DON stated it was important the staff that passed medications knew which were crushable and which were not. She further stated if a resident was given a crushed ER potassium tablet, it had the potential to be released too quickly into the resident's system and potassium levels could be elevated. The DON stated she expected that staff utilized available resources if unsure whether a medication could be crushed or not. She further stated numerous resources were available such as Do Not Crush lists, more experienced KMAs or nurses, pharmacy, or they knew she could be contacted anytime with questions. In an interview with the Administrator on 05/08/2025 at 2:52 PM, she stated it was important to follow proper administration instructions for crushed medications so residents were not adversely affected.

Based on observations, interviews, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 34 sampled residents, R36, R43 and R390. Observations revealed R390 and R36 did not have the proper signage or proper precautions in place. Observations revealed R43's catheter was observed on the floor on multiple observations. The findings include: Review of the facility's policy titled Infection Prevention Program Overview, no date given, revealed the goals of the program are to decrease risk of infection, implement appropriate control measures, and to identify and correct problems relating to infection prevention practices. Added review of goals revealed facility is to maintain compliance with state and federal regulations related to infection prevention. Continued review revealed major activities of the program are to practice proper hand hygiene, standard precautions and other barriers to prevent the spread of infections. Review of the facility's signage for Enhanced Barrier Precautions (EBP), (procedure to be used) revealed providers and staff must wear gloves and a gown for high contact resident care activities to include dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care of any skin opening requiring a dressing. 1. Review of R390's face sheet revealed the facility admitted the resident on 04/30/2025 with diagnoses to include liver disease, defects in the complement system (part of the immune system), and high blood pressure. Review of R390's Comprehensive Care Plan (CCP) dated 04/30/2025 with revision date of 05/01/2025, revealed R390 had an actual skin impairment related to unstageable pressure ulcer to lateral left ankle. Added review of CCP dated 05/01/2025 with revision date of 05/01/12025 revealed R390 was at risk for infection related to wounds, and defects in complement system. However, added review of CCP revealed interventions did not include any isolation precautions. Review of R390's orders dated 04/30/2025 revealed wound management orders to include daily cleansing of wound, applying ointments, and dressing to lateral left ankle. Continued review of R390's orders revealed telephone order dated 05/06/2025 for EBP related to wound. Review of R390's admission nursing assessment dated [DATE] at 3:38 PM, revealed skin assessment identified left ankle (outer) alteration as unstageable with measurements to have a length of 1.5 centimeters (cm) by width of 2.2 cm, and depth of 0.1 cm skin alterations. Continued review of facility document revealed an unstageable wound is described as full thickness tissue loss in which the base of the ulcer is covered by slough (tan, gray, green or brown and or eschar (tan, brown, or black) in the wound bed. Review of R390's Wound Assessment Report with date of service to be 05/05/2025 revealed the wound was located to left lateral ankle, was present upon admission, and staged as unstageable. Added review of assessment revealed there was a moderate amount of serosanguinous (light pink thin fluid with small amounts of blood) drainage and an enzymatic (form of enzyme debridement of necrotic tissue) debridement was performed. On 05/05/2025 at 1:00 PM observation revealed no isolation signage on R390's room door and no Personal Protective Equiptment (PPE) in place at the door. Further observation revealed staff entering and exiting the room with no PPE be utilized. During an interview with Registered Nurse (RN)2 on 05/06/2025 at 12:45 PM, she stated residents were placed in EBP to protect them from getting infections. In an interview with Infection Preventionist (IP) during rounding/tour of isolation rooms, on 05/08/2025 at 8:30 AM, she stated R390 was admitted with an open wound to his ankle and should have been placed in EBP isolation. When IP was informed there was no isolation signage during the initial tour on Monday 05/05/2025, she stated R390 should have been placed on EBP when first admitted preventing infection spreading and the order was placed Tuesday. During an interview with the Wound Care Nurse on 05/08/2025 at 1:15 PM, she stated to best of memory R390's wound to ankle was an open area when admitted and should have been placed on precautions to prevent infection from spreading. During an interview with the Director of Nursing (DON) on 05/08/2025 at 2:47 PM, she stated her tasks as the DON are to assure staff are performing their jobs adequately for resident safety. When asked which residents are placed in EBP, she stated they could include residents who have catheters, g-tubes, Peripherally Inserted Central Catheter (PICC) (a thin tube inserted into a large vein for administration of medications and blood draws), and wounds. She continued in interview and stated if a resident has a wound upon admission, they should be placed in EBP. When asked about R390 having a wound upon admission on 04/30/2025, she stated the resident should probably been placed in EBP. She added when the wound nurse practitioner rounded on Monday, 05/05/2025, she had discovered drainage from R390 rubbing ankles together. She stated he should have been placed in EBP then and it was unacceptable to have waited until 05/06/2025 since he could have been infected with other bacteria. During an interview with the Medical Director on 05/08/2025 at 9:50 AM, he stated his expectations of facility staff is to follow infection control policies and procedures, and to go by isolation signage to prevent infection from spreading to vulnerable residents. The facility Administrator stated in an interview on 05/08/2025 at 3:16 PM, she expected the staff to abide by infection control policies and procedures and signage to protect the residents. When asked if staff are not abiding by these policies, trainings and procedures what is her concern, she stated infection could spread and wounds could potentially worsen. 50442 2. Review of the facility's policy titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention, not dated, revealed that the purpose of the policy was to ensure the appropriate technique in the care and maintenance of Foley catheters. Further review of the policy stated that the collection bag and tubing should be kept off the floor. Review of R43's Face Sheet revealed that he was admitted to the facility on [DATE] with the diagnoses of benign prostatic hyperplasia (BPH), peripheral vascular disease (PVD), hypertension, and chronic kidney disease (CKD). Review of R43's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed him as having a Brief Interview for Mental Status (BIMS) of 14, cognitively intact. Further review of R43's Quarterly MDS revealed that he was assessed as having an indwelling catheter. Review of R43's Comprehensive Care Plan (CCP) dated 01/23/2025 revealed that he was care planned for the focus of urinary catheterization Foley catheter due to obstructive and reflux uropathy, noncompliance with catheter securement, removal of catheter bag cover on his own, and masturbation with the Foley catheter present causing bleeding and displacement. The goals for this focus were that he would show no signs and symptoms of a urinary tract infection (UTI) and would not masturbate with the catheter in place. The interventions placed for this focus were to secure the catheter in place as tolerated, perform catheter care each shift and pro re nata (PRN), change the catheter and catheter bag per orders and PRN, position the catheter bag and tubing below the level of the bladder and away from the entrance of the door to the room, check tubing for kinks each shift and PRN, educate R43 on the dangers of masturbating with an indwelling Foley catheter, observe and document intake and output per facility policy, observe for pain or discomfort due to the catheter, observe for signs and symptoms of discomfort on urination and of frequency, observe for signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns and report findings to the Medical Director (MD). Further review of the care plan revealed no documented evidence he was care planned for placing his catheter bag on the floor. Observation on 05/05/2025 at 12:47 PM revealed R43's catheter bag was lying on the floor beside his recliner without a dignity bag. Observation on 05/06/2025 at 8:30 AM revealed R43's catheter bag on the floor without a dignity bag. Observation on 05/07/2025 at 8:18 AM revealed R43's catheter bag was in the floor and had no dignity bag. In an interview with R43 on 05/06/2025 at 8:30 AM he stated he did not like the paper cover (dignity cover) on his catheter bag because it covered the bag, and he could not see the urine. R43 stated that he was not embarrassed about having the cover off where others could see his urine. He also stated that he wanted his catheter bag on the floor beside of his chair and that was where he always put it when he was sitting in his recliner. In an interview with State Registered Nurse Aide (SRNA)8 on 05/07/2025 at 8:19 AM, she stated that R43 was able to ambulate unaided and he placed his catheter bag on the floor when he sat down in his chair. SRNA8 stated that the catheter bag should not be on the floor because it was unsanitary, and it should be hanging on the side of R43's bed with the bag below R43 to allow it to drain. In a dual interview with Unit Manager (UM)1 and Licensed Practical Nurse (LPN)1 on 05/07/2025 at 8:28 AM, both stated that R43 would repeatedly place his catheter bag on the floor. Nursing staff educated him on the importance of leaving the catheter bag hanging on his bed (off the floor) but he would not listen to them and still placed it on the floor. In a group interview with Assistant Director of Nursing (ADON)1, ADON2, and the Director of Nursing (DON) on 05/08/2025 at 7:59 AM, all stated that it was an ongoing issue with R43 placing his catheter bag on the floor. They stated that when they saw the bag on the floor, they would re-hang it on his bed and educate him as to the importance of not placing the catheter bag on the floor. They stated they had no documented proof of this education being performed. All stated that the Foley catheter bag should not be on the floor for infection purposes and should be hung so that the bag and tubing were both below the level of R43's bladder. In an interview with the Administrator (ADM) on 05/08/2025 at 8:18 AM she stated she could not answer about whether R43 should be placing his Foley catheter bag on the floor and if he should be care planned to do so. She stated her nursing staff were the ones that looked at things like that. Review of R43's Electronic Medical Record revealed no notes, point of care behavior monitoring, or orders detailing education provided to R43 about the importance of not placing his catheter bag on the floor. 51155 3. Observation on 05/05/2025 at 1:00 PM revealed no evidence of EBP signage on R36's room. Further observation on 05/05/2025 at 2:00 PM revealed staff in the hall actively hanging EBP signage and placing PPE by the door. Review of R36's Face sheet revealed R36 was admitted to facility on 04/03/2024 with a diagnosis of Congestive Heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus. Review of R36's MDS, dated [DATE], revealed R36 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Indicating R36 was cognitively intact. Review of R36's Order revealed an order was entered on 05/07/2025 for EBP related to a wound. Review of R36's Wound Assessment Report revealed on 04/07/2025 they documented a Deep Tissue Injury (DTI) to left heel. On 04/14/2025, they documented an unstageable wound to left heel. On 04/21/2025, 04/28/2025, and 05/05/2025, they documented a Stage 3 wound to left heel. During an interview on 05/08/2025 at 12:06 PM with the Infection Preventionist (IP), she stated R36 was placed in EBP because due to the DTI opened. She stated she placed R36 in EBP when the Wound Nurse Practitioner made her aware that the wound was now open. She stated that R36 should have been placed in EBP on 04/21/2025, when the wound opened. During an interview on 05/08/2025 at 2:40 PM with the DON, she stated that R36 should have been placed in EBP when the wound was found to be opened. She stated that the responsibility depended on who found it but that it should have been reported appropriately. She stated that it was her expectation that it would not take more than a 24 hour period to place the precautions once the need was identified. She stated this was important to prevent the Resident from getting any infections. Continued interview on 05/08/2025 at 3:09 PM, she stated that it was her expectation that staff follow the rules and the proper signage. She stated that infection control was discussed in the daily morning meetings, and it was important to have the proper signage and PPE in place to decrease the potential for the wound to get worse.

Based on observation, interview, record review, review of food product package instructions, and review of the facility's policies, and the www.website it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety to prevent cross contamination of foods. The facility failed to ensure food was prepared and served at the proper temperature to prevent residents from receiving potentially hazardous food which could cause food-borne illness. This deficient practice had the potential to affect eighty-two (82) of eighty-four (84) current residents, as two (2) residents received tube feedings and not a meal tray. 1. Observations, on [DATE] at 9:20 AM and 4:22 PM, revealed meat thawing without a drip pan underneath it, stored on the middle shelf of the walk-in refrigerator dripping red liquid on or near raw foods. Also, an observation, on [DATE], revealed a whole, plastic wrapped pre-cooked ham, on the middle rack of the walk-in refrigerator, above a shelf containing individual [NAME]. The observation revealed liquid was noted to drip from the packaging when the DM moved the ham to the bottom rack. 2. Interviews with residents/family members and staff revealed, for the evening meal on [DATE], undercooked chicken nuggets and waffle fries were served to residents. The facility's failure to ensure food served to residents was not contaminated by incorrect storage or prepared undercooked has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE]. 3. Additional observations revealed other improperly stored food items, expired food items, food items undated, and food items opened with no opened date. 4. Interviews with staff and the facility's failure to produce documentation of dietary staff's training records revealed there was not a process in place to ensure adequate training of dietary staff for safe practice. The findings include: Review of the facility's policy titled, Food Storage, not dated, revealed the facility was to store raw animal foods separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) in drip proof containers. Further review revealed food would be stored at a minimum of six (6) inches above the floor. Review of the facility's policy titled, General Hazard Analysis Critical Control Point (HACCP) Guidelines for Food Safety, dated 2019 revealed to thaw meat, fish, and/or poultry in a refrigerator in a drip proof container and in a way that prevented cross contamination (the transfer of harmful substances or disease-causing microorganisms to food). The food should be stored on a lower shelf with nothing underneath or near it. Review of the facility's policy titled, Floor Stock, dated 2019, revealed limited supplies of food and drink items would be available around the clock from the nursing unit, refrigerator, kitchenette, and/or food storage areas. It stated dietary staff would rotate stock and remove outdated items. Review of the facility's policy titled, Accurate Temperature Policy, not dated, revealed temperatures of foods should be taken to ensure foods stayed at proper temperatures. 1. Observation, of the walk-in refrigerator, on [DATE] at 9:20 AM, during the initial kitchen tour, revealed on the middle shelf, three (3) five (5) pound rolls of ground beef, in packaging, thawing, with no drip pan underneath. Red liquid was dripping down onto a box of whole raw potatoes sitting on the bottom shelf. In addition, shredded lettuce was sitting beside the ground beef. Further observation revealed, above the ground beef, there was a bag of opened lettuce, one-half full, with an opened date of [DATE] and an expiration date of [DATE]. Observation, of the walk-in refrigerator, on [DATE] at 4:22 PM, with the DM and the Corporate Certified Dietary Manager (CCDM) revealed the ground beef rolls were still thawing on the middle shelf, dripping onto the raw potatoes. Observation, on [DATE] at 4:41 PM, with the DM and the CCDM, of the kitchen walk-in refrigerator, revealed a whole, plastic wrapped pre-cooked ham, not in a drip proof pan, on the middle shelf, above a shelf containing individual [NAME]. There was also yogurt in containers beside the ham. Observation revealed liquid was noted to drip from the packaging when the DM moved the ham to the bottom rack. The DM stated she felt this was okay since the ham was pre-cooked. The CCDM stated it was unacceptable to have any meat product on the middle shelf and not in a drip proof pan. 2. Review of the product packaging revealed the chicken nuggets that were served to residents on Sunday, [DATE], were to be deep-fried at 350 degrees Fahrenheit for three (3) to four (4) minutes to ensure an internal temperature of 165 degrees Fahrenheit was obtained by a calibrated thermometer. Interview with Resident #62, on [DATE] at 4:25 PM, revealed that the supper meal on Sunday night, [DATE], contained frozen chicken nuggets. The resident stated the chicken nuggets were raw in the middle, so he/she did not eat it. Further interview revealed the supper menu was chicken nuggets and french fries; however, the fries were still frozen. In addition, the resident stated an aide came into the room and advised him/her to not eat the food, and retrieved the supper tray. Interview with Resident #5, on [DATE] at 4:08 PM, revealed, on Sunday, [DATE], supper was two (2) hours late, it was served around 7:00 PM. The resident stated the waffle fries were cold. Also, the resident stated he/she had only three (3) chicken nuggets and they were ice cold and he/she did not eat them. The resident stated that the fried potatoes served were barely warm. Resident #5 stated the potatoes were unappetizing, chunked, white, and did not look like they had been fried. Interview with Resident #49's Power of Attorney (POA), on [DATE] at 9:30 AM, revealed she was at the facility for supper on [DATE]. She stated Resident #49 received undercooked chicken nuggets and waffle fries that were cold and had the appearance of not being cooked. Interview with Cook #1, on [DATE] at 11:33 AM, revealed he checked the temperature of the nuggets to be 180 to 185 degrees Fahrenheit before they left the kitchen. After the first two (2) meal carts went out, he stated Dietary Aide (DA) #2 came back and said the chicken nuggets were raw. Cook #1 stated he was instructed by the Dietary Manager (DM), when he called her, to throw away the nuggets on the trays and re-bake the nuggets that were left in the kitchen. Cook #1 stated he put the nuggets back in the oven for about thirty (30) minutes. He stated the DM came to the facility after he called her and prepared two (2) or three (3) Philly cheesesteak sandwiches for some of the residents. Cook #1 stated he was trained on the job by Cook #2 for about two (2) days. Additional telephone interview with Cook #1, on [DATE] at 1:39 PM, revealed he put the nuggets from the meal carts that had not been sent out of the kitchen, and the nuggets from the steam table back in the oven for about (30) more minutes. He stated when he checked the temperature of the nuggets again, he checked the centers of several nuggets. He stated he had not received training on how to calibrate a food thermometer. Interview with Dietary Aide (DA) #2, on [DATE] at 11:47 AM, revealed that she had resigned and that Sunday, [DATE], was the day that caused her to quit. She stated there was only one (1) other staff working in the kitchen that day, the cook. She stated she helped the cook prepare the food: chicken nuggets, waffle fries, and coleslaw. She stated she had already served A Hall, and she was on her way to take 100 and 200 Hall trays, when at least ten (10) nurses came up and were almost yelling that they could not serve the food because it was frozen. However, she stated all the food, when checked for temperature was in the correct range, but she thought the steam table had quit working. She stated dietary staff called the DM, who instructed them to make a new meal. She stated dietary staff made Philly steak sandwiches and tried again to prepare the rest of the nuggets; it was a big ordeal. DA #2 stated the DM came to the facility. Cook #1, stated she took the temperature of the steam table, and it would only get to 175 degrees Fahrenheit. DA #2 stated when the trays came back from the first delivery, the chicken nuggets that were returned had a temperature of 153 degrees Fahrenheit, and they felt like they were slightly more than room temperature. DA #2 stated Cook #1 had heated the remainder of nuggets that had not been sent out in the oven because the steam table apparently was not working. However, observation, on [DATE] at 5:11 PM, while foods temperatures were being checked, revealed the steam table appeared hot, and food temperatures were being maintained appropriately. Interview with State Registered Nurse Aide (SRNA) #24, on [DATE] at 3:38 PM, revealed she was working, on [DATE], and dinner trays were late from the kitchen. She stated the chicken nuggets that were served looked doughy on the outside, the fries looked frozen, and the residents were complaining about the food. Interview with SRNA #11, on [DATE] at 10:49 AM, revealed she was working on Sunday night on [DATE], on the A Hall The SRNA stated the first supper cart did not come to the floor until approximately 6:00 PM. She stated residents then complained of the food not being cooked and being cold. SRNA #11 stated the chicken nuggets did not look browned. She stated she touched the waffle fries on a returned tray, and they were frozen. She stated the waffle fries were returned to the kitchen for reheating; but, when trays came back within thirty (30) minutes, the potatoes still looked white, but were a little warmer. Interview with SRNA #22, on [DATE] at 6:11 PM, revealed she and other aides reported the undercooked food to the kitchen staff, and she was told, Don't come in here [OBSCENITY] ing to us, it is not our fault. SRNA #22 stated she informed nursing staff on her halls and was told, There is not a damn thing I can do. She stated that she and other SRNA's tried to heat the chicken nuggets and potatoes in the microwave for as many residents as they could, but they could not get to all the trays. She stated some residents ate some of the undercooked chicken nuggets. Interview with the DM, on [DATE] at 4:56 PM, revealed she was called back to the facility on Sunday night, on [DATE], due to the report from the cook that nursing staff had reported the evening meal had chicken nuggets that were cold and not done. She stated she instructed dietary staff to put what was on the steam table back in the oven and that she was coming back to the facility to help with alternative foods to be served. She stated she instructed dietary staff to dispose of the food that had already been sent out and had been returned to the kitchen. She also stated she called the Administrator and the CCDM to let them know what was happening. Further interview revealed the Administrator told her those instructions were correct. The DM stated the outcome of residents eating raw chicken was that it could have made them sick. Additional interview with the DM, on [DATE], at 10:22 AM, revealed she departed the facility around 2:00 PM or 2:30 PM on Sunday, [DATE]. She stated the evening cooks were there already, as they worked 12:00 PM to 8:00 PM. She stated that delivery of the supper trays was supposed to start at 5:00 PM, so plating began around 4:50 PM. The DM stated her instructions to the cook, via phone, while on her way to facility, was to be sure the chicken nuggets had a temperature of 190 degrees Fahrenheit before they were served. When she arrived, she stated dietary staff were placing the second service in the meal cart. The DM stated the chicken nugget she observed upon return to the kitchen, appeared to have a tendon in it that looked pink. In addition, the DM stated that she ensured that food was cooked correctly and appeared palatable by her own observation and by reviewing food temperature logs. She stated she felt comfortable that the Sunday evening kitchen staff were sufficiently trained and prepared to leave alone to prepare a meal without oversight. Additional interview with the DM, on [DATE] at 4:37 PM, revealed the instructions on the chicken nuggets box stated their internal temperature must reach 165 degrees Fahrenheit, but there were no baking instructions on the box. Again, she stated she knew the potential outcome of eating undercooked poultry was illness from food poisoning. Interview with the Consulting Dietician, on [DATE] at 11:42 AM, revealed his concern for the undercooked food presented by a resident's family from Sunday night's tray, on [DATE], would be illness. Interview with the Administrator, on [DATE] at 5:30 PM, revealed she was notified, on [DATE], of problems with chicken nuggets on the evening meal tray. She stated she was not aware of the waffle fries being cold. Additional interview with the Administrator, on [DATE] at 9:35 AM, revealed the chicken nuggets box was labeled as partially cooked. She stated the nuggets temperature was checked at 175 degrees Fahrenheit per report and record. She stated food thermometers should be calibrated before each meal, but she would check the policy. She stated Cook #1 would have been responsible for checking the temperature of the chicken nuggets on Sunday. The food distributor was contacted, after the [DATE] incident, and told her baking was an acceptable method of preparing the chicken nuggets. She stated she reviewed the instructions on the actual packaging from the chicken nuggets that were prepared for the Sunday evening meal. The Administrator stated the package instruction stated the nuggets were uncooked, ice glazed battered chicken breast nuggets. Interview with the Customer Relations Administrator of Food Quality and Safety for the chicken nugget production company, via telephone, on [DATE] at 2:47 PM, revealed the item (chicken nuggets) was frozen, un-cooked, and needed to be cooked per packaging instructions for safe consuming. 3. Observation, on [DATE] at 9:20 AM, during the initial kitchen tour, of the walk-in refrigerator revealed pork tenderloin in a box on the middle shelf, thawing, without a drip pan underneath it. The Dietary Manager (DM) picked up the box of pork, put it on the bottom shelf, and stated, Someone accidentally left that there while getting something else. There were two (2) pork tenderloin boxes on the bottom shelf with for ,d+[DATE] written on the boxes. One package of pork had been removed from one of the boxes, and the box had been lined with foil, with pork put on top of the foil and the box closed. Interview with the DM, on [DATE] at 9:20 AM, revealed the thawed pork tenderloin was intended for use on [DATE], but there was not enough. She stated they should be able to be used on [DATE], when the other pork tenderloins that were ordered arrived. Observation, on [DATE] at 9:25 AM, of the walk-in freezer revealed twelve (12) boxes of bulk food sitting on the floor. The DM stated there had been a delivery of food, and dietary staff did not have time to put the boxes on the shelves. However, the boxes were labeled with the received date of [DATE]. Observation, on [DATE] at 9:30 AM, of the reach-in refrigerator, revealed the middle shelf had a butt end of ham in a plastic baggie, with no date noted, next to an open flat containing raw eggs. There were other prepared foods, on the shelf, such as jello cups made by the facility covered with plastic lids. On the top shelf, there was a gallon of honey mustard dressing, with an expiration date of [DATE], and no opened date; and, a gallon of ranch dressing, three-quarters (,d+[DATE]) empty, with no expiration dated noted, and no opened date. On the bottom shelf, there was a tray with juice cups prepared by the facility with plastic lids on them, undated, with spillage all in the tray. The DM stated the juice cups were to be thrown away, but she had not gotten to that yet. Also on the bottom shelf, there was a container of potato salad covered with foil, dated ,d+[DATE], located below and to the side of the open flat of eggs on the middle shelf. Observation revealed cooked sausage links and biscuits in a plastic bag, dated ,d+[DATE], stored directly below the open flat of raw eggs. Observation, of Nourishment Room #1, on [DATE] at 4:40 PM, with the DM, revealed the freezer section, in refrigerator #1 on A Hall contained popsicles and frozen rice dinners, which had no name and were undated. Observation, on [DATE] at 4:50 PM, with the DM, of Nourishment Room #2, located in the front of the building, revealed a small refrigerator which contained a chicken sandwich on a bun in a plastic bag, not dated, no name. Interview with the DM, on [DATE] at 4:45 PM, revealed staff members often used this nourishment refrigerator to store their personal food items. Observation, on [DATE] at 12:30 PM, of Resident #49's room, after the SSA (State Survey Agency) Surveyor received several complaints of uncooked steak fries from residents, revealed the resident sitting at the bedside with the lunch meal tray and a family member in the room. Further observation revealed the lunch meal consisted of fish, steak fries, hushpuppies, and coleslaw. The steak fries were white in color and appeared uncooked. Interview with the family member revealed most of the time the food was served warm, not hot. The family member also stated, I bring food as often as I can because (he/she) can't eat the food here most of the time. Interview with the Consulting Registered Dietician, on [DATE] at 1:10 PM, revealed he thought the reason for the uncooked appearance of the steak fries was because the facility had no deep fryer, and everything was baked. He also reported if food temperatures were good, the food was ok. Observation, on [DATE] at 1:17 PM, of the reach-in refrigerator in the kitchen, revealed a container of ranch dressing that was not dated when opened. In addition, the refrigerator contained a tray full of sandwiches, they were not dated or the dates had been rubbed off. Observation, on [DATE] at 4:15 PM, of the kitchen, revealed a dirty trash can with no lid sitting next to prepared food, cheese, bologna, and bread that was on the counter. 4. Record review revealed there was no documentation of competency evaluations sheets to show the Dietary employees had received in-services and education to safely prepare and serve food that included the proper process to take temperatures of food, how to calibrate the thermometer, or that they had received food handler cards that were required by the local health department. This requirement was verified on the web site https://courseforfoodsafety.com/states/KY. In addition, review of the web site https://www.efoodhandlers.com/Food-Handlers, an on-line program approved to meet the requirement, revealed it contained training on: The Importance of Food Safety; Health and Hygiene; Temperature Control; Avoiding Cross Contamination; and Cleaning and Sanitizing. Interview with the DM, on [DATE] at 4:20 PM, revealed the older cooks educated the new cooks on how to prepare meals. She stated there were no training logs available and no formal dietary training for dietary staff. Interview with DA #3, on [DATE] at 8:43 AM, revealed she had worked at the facility since [DATE], but was not working on Sunday, [DATE]. She stated training was from co-workers; she had never had a skills check off; and, there was a lot she did not know until the CCDM came last week. She stated, for example, she never got training on renal diets, and the staff was giving [CONDITION(S)] residents foods that they should not have received. She stated the issues with under cooking or over cooking was not Cook #1's fault because he had not been trained. DA #3 stated the DM spent little time in the kitchen, took a lot of smoke breaks, and got distracted when she said she was going to see/talk to residents. Continued interview with DA #2, on [DATE] at 11:47 AM, revealed she had literally three (3) days of training, from the previous cook, who quit, showing her the basics of the job. Interview with the DM, on [DATE] at 10:22 AM, revealed she started at the facility on [DATE]. She stated the CCDM had provided her with the specific DM orientation for two (2) to three (3) days straight, then they had been at the facility other times to work on different things. She stated she did not use skill check off sheets when orienting new employees, and the skills sheets only verified general and basic kitchen skills, such as handwashing and scoop size. Interview with the DM, on [DATE] at 4:37 PM, revealed the Administrator was her direct supervisor. She stated she had dietary policies in the kitchen, as far as she knew. She stated she was educated that the policies were in the kitchen; and, if asked for a specific policy, she would go through the manual to find or call for help in locating it. Further interview revealed she was responsible to her staff to keep track of training, to access needed policies, to ensure dietary staff knew what they were doing, and if she did not know an answer, to seek it out. Per the interview, she stated the process for maintaining records, such as food handler's permits, was in her office. She stated she had been working on establishing this protocol. Continued interview with the DM, on [DATE] at 4:37 PM, revealed if she observed work outside of accepted dietary standards, she would provide intervention/education to remedy the practice. She stated she provided verbal education on the job, but had no documentation of it. The DM stated she had a current food handler's permit, but was not a Certified Dietary Manager. However, she stated she was enrolled online to get her certification, and the plan was to take one (1) lesson per week. State Survey Agency (SSA) Surveyors requested to the DM and the Administrator to provide them with the food handler cards of all dietary staff for review. Both stated they were unaware if their local health department required food handler cards (they did) and would investigate and get back to the SSA Surveyors with an answer. Review of the required food handler cards revealed Cook #3 had a current card, the DM's card was expired, and the remaining dietary staff did not have a card. Interview with the Consulting RD, on [DATE] at 11:42 AM, revealed his responsibilities included audits of test trays. He stated these documents were maintained at the corporate level and were done monthly or as needed. He stated the process for reviewing a test tray was that he would go to a unit and wait for a tray to be delivered, take the top off the plate for ten (10) minutes before checking and documenting the temperature. He stated food temperatures were taken at the point of service, when preparing to take a bite. Per the interview, he stated he began covering this facility in [DATE], and the facility had been through several DM's. He stated his responsibility for training was on clinical aspects. Interview with the CCDM, on [DATE] at 3:30 PM, revealed she was not aware of any problems with the steam table, but a new plate warmer had been ordered. She stated she expected that she would have been notified of problems at the facility, especially from a newer DM. Per the interview, she stated the local health department did require food handler permits, so the dietary staff was working to obtain the permits. Interview with the Administrator, on [DATE] at 5:30 PM, revealed she had contacted the CCDM for the DM's orientation because she had the qualifications and knowledge to do it. She stated she had also considered sending the DM to a sister facility for training with a DM onsite there. Additional interview with the Administrator, on [DATE] at 9:35 AM, revealed she had never seen any foods undercooked on residents' meal trays. She stated she had talked to the DM about timing of cooking and preparation, in order to have meals at the right time and the right temperature. She stated she was ultimately responsible to ensure policies were followed. She stated she was not aware that the local health department required food handler's permits for kitchen staff. Continued interview revealed she did not know the DM's food handler permit had expired, but she thought that the CCDM's training covered that information. She explained she was unsure of whether there were competencies documented on kitchen staff. Per the interview, she stated older employees trained newer employees as a preceptorship, and these preceptors should have documented the content of the training and that it had been done. She stated part of her oversight included ensuring new employees received proper training. She stated that dietary staff was responsible for checking and removing expired and unlabeled food items. Interview with the Regional Director of Operations (RDO), on [DATE] at 2:39 PM, revealed the CCDM had been working to train the new DM. In addition, the RDO stated he had not been aware of the areas of concern identified in the Dietary department. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on [DATE] by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on [DATE]. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on [DATE], to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on [DATE], revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective [DATE]. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since [DATE] to determine if the residents' belongings were moved with the resident to their new room on [DATE] and [DATE]. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on [DATE], to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on [DATE], regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on [DATE], on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On [DATE], the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on [DATE] and [DATE]. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available [DATE] days a year and can be used anonymously; the hotline number was posted throughout the facility on [DATE]. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on [DATE] in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. <br [TRUNCATED]

Based on observation, interview, record review, review of the facility's Administrator's Job Description, and review of the facility's policies, it was determined the Administrator failed to administer the facility in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The following deficiencies were identified: 1. The Administrator failed to ensure that food leaving the kitchen was stored, prepared, distributed and served in accordance with professional standards for food service safety; and that dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Observations, during the initial kitchen tour, on [DATE] at 9:20 AM and 4:22 PM, and on [DATE] at 4:41 PM, revealed uncooked meats, not stored on the bottom shelf, which had juice dripping on raw vegetables or butter packets. Resident and staff interviews revealed, on [DATE] at the supper meal, undercooked chicken nuggets and waffle fries were served to the residents. This deficient practice had the potential to affect eighty-two (82) of eighty-four (84) current residents. Two (2) residents received only tube feedings. 2. The Administrator failed to ensure that Resident #6, one (1) of fifty-three (53) sampled residents, was not a victim of abuse and neglect, violating the resident's rights, and failed to ensure this abuse and neglect was reported immediately. Resident #6 revealed, on [DATE], his/her personal belongings were deliberately taken from him/her, without his/her consent, because he/she refused a room transfer. Per the resident, these personal belonging were not returned until [DATE], and the absence of them caused him/her great emotional distress. Interview with the Housekeeping Supervisor and other staff revealed, even though they believed this deliberate action, directed by the Administrator, was abuse, they failed to report it because they were afraid of being fired by the Administrator. 3. The Administrator failed to ensure written notice of a room change was provided to residents, including the reason for the change, before the resident's room or roommate was changed. Resident interviews and record reviews revealed eight (8) of fifty-three (53) sampled residents were transferred without notice or choice, Residents #3, #6, #40, #49, #50, #60, #72, and #82. Also, after these room transfers, the Administrator failed to ensure that medically related social services was provided to these eight (8) residents. 4. The Administrator failed to ensure the facility implemented the comprehensive person-centered care plans for Residents #6 and #50, consistent with the residents' rights, including psychosocial and/or physical needs. This deficient practice affected two (2) of fifty-three (53) sampled residents. The facility's failure to be administered in a manner that enabled the effective use of its resources has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE]. Refer to F-557, F-559, F-600, F-609, F-656, F-745, and F-812. The findings include: Review of the facility's policy titled, Food Storage, not dated, revealed the facility was to store raw animal foods separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) in drip proof containers. Review of the facility's policy titled, General Hazard Analysis Critical Control Point (HACCP) Guidelines for Food Safety, dated 2019, revealed to thaw meat, fish, and/or poultry in a refrigerator in a drip proof container and in a way that prevented cross contamination (the transfer of harmful substances or disease-causing microorganisms to food). The food should be stored on a lower shelf with nothing underneath or near it. Review of the facility's policy titled, Resident Rights H5MAPL0768, undated, and the facility's document Residents' Rights for Residents in Kentucky Long-Term Care Facilities, undated, revealed the resident's right to retain and use personal possessions to the maximum extent that space and safety permitted, unless it would infringe upon the right of others. In addition, the facility's policy revealed residents had the right to refuse a transfer from a distinct part within the institution. Continued review revealed the facility would make every effort to assist each resident in exercising his/her rights to assure that the resident was always treated with respect, kindness, and dignity. Review of the facility's policy titled, Transfers: Room to Room H5MAPL0792, dated [DATE], revealed unless medically necessary or for the safety and well-being of the resident(s), a resident would be provided with an advance notice of the room transfer. Such notice would include the reason(s) why the move was recommended. This right to be notified was also in the facility's Admission Agreement, under Patient Rights, undated. Per the policy, documentation of a room transfer would be recorded in the resident's medical record. Review of the facility's policy titled, Reporting Abuse to Facility Management, dated [DATE], revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by the individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental or emotional anguish. Review of the policy also revealed it was the responsibility of employees to promptly report any incident or suspected incident of neglect or resident abuse to facility management. Review of the facility's policy titled, Prevention - Reporting of Concerns, Incidents, and Grievances, dated ,d+[DATE], revealed it was the facility's policy for personnel to immediately report, without the fear of retribution, any signs or suspected incidents of abuse to facility management. Review of the facility's job description for the Administrator, undated, revealed the Administrator's functions included: Plan, develop, organize, implement, evaluate, and direct all aspects of the facility's operations. The Administrator had, as the principal concern, the delivery of quality care to all residents of the facility. The Administrator was to ensure that all residents were given the freedom of self-determination and individuality, and the respect for privacy, property, and civil rights. The Administrator was responsible for staffing, training and supervision. Continued review revealed the Administrator was to communicate with co-workers at all levels to adequately meet the needs of the residents. 1. Observation, of the walk-in refrigerator, on [DATE] at 9:20 AM, during the initial kitchen tour, revealed on the middle shelf, three (3) five (5) pound rolls of ground beef, in packaging, thawing, with no drip pan underneath. Red liquid was dripping down onto a box of whole raw potatoes sitting on the bottom shelf. In addition, shredded lettuce was sitting beside the ground beef. Further observation revealed, above the ground beef, there was a bag of opened lettuce, one-half full, with an opened date of [DATE] and an expiration date of [DATE]. Observation, of the walk-in refrigerator, on [DATE] at 4:22 PM, with the DM and the Corporate Certified Dietary Manager (CCDM) revealed the ground beef rolls were still thawing on the middle shelf, dripping onto the raw potatoes. Observation, on [DATE] at 4:41 PM, with the DM and the CCDM, of the kitchen walk-in refrigerator, revealed a whole, plastic wrapped pre-cooked ham, not in a drip proof pan, on the middle shelf, above a shelf containing individual [NAME]. Observation revealed liquid was noted to drip from the packaging when the DM moved the ham to the bottom rack. The CCDM stated it was unacceptable to have any meat product on the middle shelf and not in a drip proof pan. Interviews with Cook #2 and Cook #1, on [DATE] and [DATE] at 1:25 PM and 4:55 PM, respectfully, revealed they did not have formalized kitchen education, and there were no competency check offs or training logs. Both stated the older cooks trained the newer cooks. Both were unaware if their local health department required food handler cards. The DM stated that Cook #3 was the only Dietary employee with a current food handler card, that her card was expired, and none of the remaining dietary staff had a food handler card. 2. Interview with the Housekeeping Supervisor, on [DATE] at 1:45 PM, revealed she talked with Resident #6 when informed the resident did not want to be transferred to another room. The Housekeeping Supervisor stated she informed the Administrator of Resident #6's refusal to be transferred. The Housekeeping Supervisor stated the Administrator stated to go ahead and move Resident #6's belongings to the new room and the resident could go and get his/her items if he/she wanted them. She stated she felt it was abusive of the Administrator to take Resident #6's personal belongings and not return them to the resident. The Housekeeping Supervisor stated she would have been fired if she reported the abuse. Interview with State Registered Nursing Assistant (SRNA) #18, on [DATE] at 2:25 PM, revealed she was unable to provide any care to Resident #6 nor was she able to help the resident to change clothes since the resident's personal belongings were taken from the resident's room. SRNA #18 stated she felt this was abuse, but she was afraid to report the abuse. SRNA #18 stated other staff had been fired for reporting things. Interview with SRNA #14, on [DATE] at 4:00 PM, revealed she felt it was abusive of the Administrator to remove Resident #6's personal belongings. SRNA #14 stated Resident #6 told her it was abuse to take his/her belongings and not return them. SRNA #14 stated she was afraid to report the abuse due to being fired. Interview with SRNA #7, on [DATE] at 9:00 AM, revealed she felt this situation was abuse. She stated Resident #6 was very upset and cried repeatedly. But SRNA #7 stated she was afraid she would have been fired if she had reported the abuse. Interview with Licensed Practical Nurse #2, on [DATE] at 5:38 PM, revealed that the day of the decision to transfer Resident #6 to another room, the Administrator stated, in her presence and at least one (1) other staff member, the reason for the move was that a resident was being admitted who was a private pay/cash pay, and she wanted to place him/her in a nicer room. Further interview revealed that the Administrator had stated that Resident #6 did not pay his/her bill, so he/she did not deserve the nicer room. Per the interview, LPN #2 stated the Administrator had told staff members that if Resident #6 wanted his/her belongings, he/she would have to walk to the other room to get them. Interview with LPN #3, on [DATE] at 6:15 PM, revealed she stated she felt this was abuse. LPN #3 stated staff were afraid to report anything due to the risk of being fired. Interview with SRNA #11 and SRNA #16, on [DATE] at 7:47 AM and 10:49 AM respectively, revealed they felt taking a resident's belongings and not returning them would be considered abuse. However, the SRNAs did not report this allegation of abuse for fear of being fired. Interview with the Administrator, on [DATE] at 11:05 AM, revealed she was informed Resident #6 was refusing the room transfer and she was going to talk to Resident #6 on [DATE] but she forgot 3. Interview with Resident #6, on [DATE] at 10:30 AM, revealed he/she did not receive any written notice prior to the facility's attempt to transfer him/her to another room. Resident #6 stated he had been very upset about the possible transfer and removal of his/her personal belongings from [DATE] until [DATE]. Interview with Resident #49's Power of Attorney (POA)/Next of Kin (NOK), on [DATE] at 10:47 AM, revealed the resident had Alzheimer's Disease, and the room transfers confused the resident and increased the resident's agitation. The POA/NOK stated he/she had never received a written notice nor the reason for the room transfers for Resident #49. Interview with Resident #3, on [DATE] at 1:10 PM, revealed he/she was moved from his/her room five (5) times in a period of five (5) months. Resident #3 stated he/she was notified right before the moves occurred, and he/she was pissed off because the resident should get to one place and stay. Interview with Resident #40's Spouse, on [DATE] at 11:25 AM, revealed he/she had never received a written notice for room transfers. The spouse stated Resident #40 had Alzheimer's Disease, and he/she felt the moves were harmful for the resident. Interview with Resident #50, on [DATE] at 11:50 AM, revealed he/ Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse who died in the room. Continued review of Resident #50's medical record, in the Social Service notes, revealed no documentation of the SSD's assessment of the resident's psychosocial needs related to the room transfer. Interview with Resident #60, on [DATE] at 11:30 AM, revealed he/she never received any written transfer notices and was not happy about all the moves. Resident #60 was moved to a smaller room which made it hard for the resident to perform most of his/her personal hygiene independently. It also affected the resident's independent with mobility. Continued review of Resident #60's medical record, in the Social Service note, revealed no Social Service documentation related to the transfers, and no documented evidence the SSD addressed Resident #60's needs. Interview with Resident #72's POA/NOK, on [DATE] at 10:10 AM, revealed he/she had never received any type of notice of the resident's eight (8) transfers. The POA/NOK stated the resident had [CONDITION(S)] which caused sight limitations and would have to be re-oriented to the new rooms after transfers. Interview with Resident #82's POA/NOK, on [DATE] at 3:45 PM, revealed the facility called him/her to inform of the transfer to another room, on [DATE], to be able to provide more monitoring of the resident since the room was across from the nurse's station. Interview with the Administrator, on [DATE] at 1:45 PM, revealed it was the responsibility of the Social Service Director to inform the residents and/or their POA/NOK (Power of Attorney/Next of Kin) when a transfer was warranted. The Administrator stated the Social Services Director (SSD) was responsible for documentation in the medical record when the notification of a transfer was given. It was the responsibility of the Social Service Director to follow up with the resident(s) after a transfer and document their emotional well-being after the transfer. However, review of Residents #6, #49, #3 #40,#50, #60, #72's and #82's records revealed no documentation of an evaluation of the residents' psychosocial needs related to the residents' room transfers. Interview with the former Social Services Director, on [DATE] at 4:00 PM, revealed she did rounded on the residents after the transfers, but was directed by the Administrator not to put any documentation in the residents' medical records. She stated she told the Administrator the residents were unhappy and upset with the transfers, but the Administrator took no action regarding these concerns. 4. Review of Resident #50's Care Plan, revealed it included a psychosocial element for Anxiety and Depression. However, the resident's care plan was not updated, on [DATE], to reflect an increase in his/her anxiety and depression related to moving to a different room. Review of Resident #6's Care Plan, dated [DATE], revealed it included elements addressing Activities of Daily Living (ADL), including personal hygiene tasks, which could not be carried out due to his/her tools/supplies being removed and taken to another room across the facility from where he/she was located, on [DATE]. Resident #6's care plan included a psychosocial element that addressed his/her anxiety. However, the care plan was not updated to reflect the residents psychosocial needs related to increased anxiety with having his her belonging taken from him/her for an extended period of time, from [DATE] to [DATE]. Interview with the Director of Nursing (DON), on [DATE] at 11:59 AM, revealed she was notified of the incident with Resident #6 on Friday morning, the day after the personal belongings were moved. She stated removing Resident #6's belongings resulted in the resident not being able to perform routine ADL's, which were on his/her care plan. Interview with the Administrator, on [DATE] at 9:35 AM, revealed she She did not recall why some residents were being moved. She stated she had never seen any foods undercooked, and she had talked to the DM about timing of cooking and food preparation, so that food would be served at the right temperature. Continued interview with the Administrator, on [DATE] at 9:35 AM, revealed she was not aware the local health department required food handler permits for kitchen staff, prior to the survey, and she did not know the DM's food handler permit was expired. She stated part of her oversight included ensuring that new employees received proper training. She stated she could not think of a reason why staff would fear retaliation from her. She stated she did not know why staff would not have called her or made the decision to return Residents #6's items sooner. The Administrator reported she had signed inservice sheets where staff was instructed on reporting abuse. She explained she had told staff to hold off on returning Residents #6's belongings until she could talk to him/her, and then forgot, which was a mistake. However, she stated she did see how it could be considered abuse or neglect. The Administrator stated she was ultimately responsible to ensure policies were followed. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on [DATE] by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on [DATE]. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on [DATE], to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on [DATE], revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective [DATE]. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since [DATE] to determine if the residents' belongings were moved with the resident to their new room on [DATE] and [DATE]. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on [DATE], to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on [DATE], regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on [DATE], on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On [DATE], the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on [DATE] and [DATE]. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available [DATE] days a year and can be used anonymously; the hotline number was posted throughout the facility on [DATE]. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on [DATE] in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on [DATE]. The facility contracted with a dietary consulting company, on [DATE] to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on [DATE] and completion by [DATE]. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on [DATE], with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on [DATE] and [DATE] to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on [DATE]. Review of Resident #6's medical record, on [DATE], revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on [DATE] at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on [DATE] at 2:53 PM, revealed the previous Administrator was terminated on [DATE]. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on [DATE] at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on [DATE] at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on [DATE] at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on [DATE] at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on [DATE], revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since [DATE]. Interview with the

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents received written notice, including the reason for the room change/transfer, for eight (8) of fifty-three (53) sampled residents (Residents #6, #50, #72, #49, #3, #40, #60, and #82. The facility transferred Resident #6's personal belongings to another room, but when Resident #6 refused the transfer, the facility did not return the belongings for four (4) days. Resident #6 was upset and cried for four (4) days. The facility transferred Resident #50 out of a room the resident had shared with his/her spouse who had died in the room. The facility transferred Resident #72 several times who is a fall risk and has limited vision. The facility transferred Resident #49 who has Alzheimer's; the transfers caused confusion and behaviors. The facility transferred Resident #3 to another room. The move resulted in the resident having no social interactions with a roommate. The facility attempted to transfer Resident #40, who has Alzheimer's Disease, and felt his/her current room was his/her home. The facility transferred Resident #60 into a smaller room where the resident was more dependent on staff for ADL care and limited mobility to walk in the room. The facility transferred Resident #82, who has Alzheimer's Disease, to another room which caused increased behaviors. The facility's failure to ensure staff followed the facility's policy for transfers as well as Resident Rights, has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE]. The findings include: Review of the facility's policy titled, Resident Rights H5MAPL0768, undated, revealed the resident had the right to refuse a transfer from a distinct part within the institution. Continued review revealed the facility would make every effort to assist each resident in exercising his/her rights to assure that the resident was always treated with respect, kindness, and dignity. Review of the facility's policy titled, Transfers: Room to Room H5MAPL0792, dated [DATE], revealed where feasible the facility would make room to room transfers when requested by the resident or as could become necessary to meet the resident's medical and nursing needs. Continued review revealed unless medically necessary or for the safety and well-being of the resident(s), a resident would be provided with an advance notice of the room transfer. Such notice would include the reason(s) why the move was recommended. It also stated the residents had a right to refuse a transfer from a distinct part within the facility. In addition, documentation of a room transfer would be recorded in the resident's medical record. Review of the facility's Admission Agreement, under Patient Rights, undated, revealed the resident had the right to receive written notice, including the reason for the change, before the resident's room or roommate was changed. 1. Review of Resident #6's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on [DATE] at 10:30 AM, revealed he/she did not receive a written notice prior to the facility's attempt to transfer him/her to another room. Resident #6 stated he/she refused to be transferred. The resident stated housekeeping staff removed all of his/her personal belongings from the current room and moved them to the room the facility intended to transfer Resident #6. Resident #6 stated he/she asked repeatedly for his/her belonging to be returned, from [DATE] until [DATE] when the personal belongings were returned. Resident #6 stated he/she told staff this was abusive, and the resident was distraught and cried daily. 2. Review of Resident #50's medical record revealed the facility originally admitted Resident #50, on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #50's Quarterly MDS, dated [DATE], revealed the resident's BIMS score of fifteen (15) of fifteen, which indicated intact cognition. Interview with Resident #50, on [DATE] at 11:00 AM, revealed he/she did not receive any notice of a transfer on [DATE]. Resident #50 stated housekeeping staff came in and informed him/her of the transfer and started taking items off the walls and packing up his/her personal belongings. Resident #50 stated he/she became very upset and cried all day long. Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse who died in the room. 3. Review of Resident #72's medical record revealed the facility admitted the resident, originally on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #72's Quarterly MDS, dated [DATE], revealed a BIMS' score of five (5), which indicated severe cognitive impairment. Interview with Resident #72's POA/NOK, on [DATE] at 10:10 AM, revealed he/she had never received any type of notice of the resident's transfers. The POA/NOK stated the resident had [CONDITION(S)] which caused sight limitations and would have to be re-oriented to the new rooms after the transfers. Review of the facility's Action Summary, dated [DATE], revealed Resident #72 was transferred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 4. Review of Resident #49's medical record revealed the facility originally admitted Resident #49, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #49's POA (Power of Attorney)/Next of Kin (NOK), on [DATE] at 11:10 AM, revealed the resident had Alzheimer's Disease, and the room transfers confused the resident and increased the resident's agitation. The POA/NOK stated he/she had never received a written notice nor, the reason for the transfers for Resident #49. 5. Review of Resident #3's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS' score was fifteen (15) of fifteen, which indicated intact cognition. Interview with Resident #3, on [DATE] at 9:50 AM, revealed he/she was moved from his/her room five (5) times in a period of five (5) months. Resident #3 stated he/she was notified right before the moves occurred, and he/she was pissed off because he/she should have gotten to one place and stayed. The resident stated COVID was the reason given for one (1) of the moves, but the resident could not recall the reasons for the other four (4) times he/she was moved. 6. Review of Resident #40's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #40's Quarterly MDS, dated [DATE], revealed under Section C - Cognition, severely impaired cognition. Interview with Resident #40's Spouse, on [DATE] at 11:25 AM, revealed he/she had visited the resident on [DATE]. The following week, when he/she visited, the facility was in the process of transferring the resident to another room. The spouse stated he/she was not notified of the transfer and felt the Administrator was retaliating against the resident since he/she had complained, on [DATE], about the resident being in soiled clothes and wearing the same clothes for two (2) days. The spouse stated Resident #40 had Alzheimer's Disease and was confused with room changes. 7. Review of Resident #60's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #60, on [DATE] at 1:50 PM, revealed he/she never received any written notice or an explanation for the room transfers. Resident #60 stated his/her current room was smaller than his/her previous room. The resident stated this made self-ambulation harder to perform. The resident stated the bathroom was smaller, so staff had to take him/her to the shower room to provide personal hygiene. Resident #60 was moved three (3) times. Review of the facility's Action Summary, dated [DATE], revealed Resident #60 was transferred to another room on [DATE], [DATE], and [DATE]. 8. Review of Resident #82's medical record revealed the facility admitted the resident, on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's Quarterly MDS, dated [DATE], revealed the resident's BIMS score of nine (9) of fifteen (15), which indicated moderate cognitive impairment. Interview with Resident #82's POA/NOK, on [DATE] at 3:45 PM, revealed the facility called him/her to inform him/her of the transfer of the resident to another room, on [DATE]. The POA/NOK stated the reason given was to be able to provide more monitoring of the resident since the room was across from the nurse's station. However, review of Resident #82's Psychiatric Nurse Practitioner's Note, from [DATE], revealed the resident stated that he/she was stressed from just being there and in a bad mood due to having to change rooms. Record review revealed the resident required increased supervision for behaviors and suicidal ideation (sad and wanted to go home) during this period. Interview with the Administrator, on [DATE] at 1:45 PM, revealed she was unaware of the regulation to give a resident a written notice prior to room transfer. The Administrator stated many of the transfers were to move residents onto the COVID unit after a breakout as well as moving residents off of the COVID unit. The Administrator also stated transfers were needed on the COVID unit since two (2) resident rooms shared a joint bathroom, and the transfers were needed to ensure the residents of the same sex were sharing a bathroom. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on [DATE] by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on [DATE]. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on [DATE], to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on [DATE], revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective [DATE]. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since [DATE] to determine if the residents' belongings were moved with the resident to their new room on [DATE] and [DATE]. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on [DATE], to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on [DATE], regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on [DATE], on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On [DATE], the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on [DATE] and [DATE]. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available [DATE] days a year and can be used anonymously; the hotline number was posted throughout the facility on [DATE]. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on [DATE] in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on [DATE]. The facility contracted with a dietary consulting company, on [DATE] to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on [DATE] and completion by [DATE]. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on [DATE], with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on [DATE] and [DATE] to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on [DATE]. Review of Resident #6's medical record, on [DATE], revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on [DATE] at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on [DATE] at 2:53 PM, revealed the previous Administrator was terminated on [DATE]. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on [DATE] at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on [DATE] at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on [DATE] at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on [DATE] at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on [DATE], revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since [DATE]. Interview with the MDS Support Nurse, on [DATE] at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since [DATE] until the present on [DATE]. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on [DATE] at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on [DATE]. Interview with the DON, on [DATE] at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on [DATE] and [DATE] with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on [DATE] with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on [DATE] at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on [DATE] at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on [DATE] at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on [DATE] at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on [DATE] at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on [DATE] at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on [DATE] at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on [DATE] at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on [DATE] at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on [DATE] at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on [DATE] with Cook #2 at 10:10 AM; Cook #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated th [TRUNCATED]

Based on interview, record review, and the facility's Social Services Director job description, it was determined the facility failed to provide medically-related social services related to the failure to advocate for residents and to assist them in the assertion of their rights. Residents were not assisted by the Social Services Director in voicing and obtaining resolution to grievances about treatment, living conditions, and accommodation of needs. Also, the Social Services Director did not provide services to meet the needs of residents who were coping with stressful events. This deficient practice affected eight (8) of fifty-three (53) sampled residents (Residents #3, #6, #40, #49, #50, #60, #72, and #82). The facility's failure to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident has caused or is likely to cause serious injury, serious harm, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE]. The findings include: Review of the facility's job description, Social Services Director, undated, revealed the essential functions included: to ensure that all residents were given fair and equitable treatment, the freedom of self-determination and individuality, and the respect for privacy, property, and civil rights. Review of the facility's Admission Agreement, Resident Rights, undated, revealed the resident(s) had the right to be free from mental and physical abuse. In addition, the resident had the right to retain and use personal possessions, including furniture, and clothing, as space permitted. Further, the resident had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Interview with the Administrator, on [DATE] at 11:05 AM, revealed it was the responsibility of the Social Services Director to inform the residents and/or their POA/NOK (Power of Attorney/Next of Kin) when a room transfer was warranted. The Administrator stated the Social Services Director (SSD) was responsible for documentation in the medical record when the notification of a room transfer was given. Also, she stated it was the responsibility of the SSD to follow up with the resident(s) after a transfer and document their emotional well-being after the transfer. 1. Review of Resident #6's medical record revealed the facility admitted the resident, on [DATE], with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on [DATE] at 10:30 AM, revealed he/she did not receive any written notice prior to the facility's attempt to transfer him/her to another room. Resident #6 stated he/she refused to be transferred. The resident stated housekeeping staff removed all of his/her personal belongings from the current room and moved them to the room the facility intended to transfer Resident #6. Resident #6 stated he/she asked repeatedly for his/her belongings to be returned, from [DATE] until [DATE] when the personal belongings were returned. Resident #6 stated he/she told staff this was abusive, and he/she was distraught and cried daily. Continued review of Resident #6's medical record, in the Social Service Notes, revealed no documentation related to the resident being without his/her belongings from [DATE] to [DATE]. Additionally, there were no interventions by Social Services to address Resident #6's psychosocial needs. 2. Review of Resident #49's medical record revealed the facility originally admitted Resident #49, on [DATE], with diagnoses which included Hypertension, Anxiety, and Dementia. Review of Resident #49's Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be five (5) of fifteen, which indicated severe cognitive impairment. Interview with Resident #49's POA (Power of Attorney)/Next of Kin (NOK), on [DATE] at 11:10 AM, revealed the resident had Alzheimer's Disease, and the three (3) room transfers confused the resident and increased the resident's agitation. The POA/NOK stated he/she had never received a written notice, or the reason for the transfers for Resident #49. Continued review of Resident #49's medical record, in the Social Service notes, revealed no documentation that the SSD assessed the resident's psychosocial needs related to the resident's three (3) room transfers. 3. Review of Resident #40's medical record revealed the facility admitted the resident, on [DATE], with diagnoses which included Alzheimer's Disease, Assistance with Personal Care, [CONDITION(S)] Disease, [CONDITION(S)], and Depression. Review of Resident #40's Quarterly MDS, dated [DATE], revealed under Section C - Cognition, severely impaired cognition. Interview with Resident #40's Spouse, on [DATE] at 11:25 AM, revealed he/she had visited the resident on [DATE]. The following week, when he/she visited, the facility was in the process of transferring the resident to another room. The spouse stated he/she felt the moves were harmful for the resident because he/she had Alzheimer's Disease and was confused with room changes. Continued review of Resident #40's medical record revealed there was no documentation in the Social Service notes that the SSD assessed the resident's psychosocial needs related to the move. 4. Review of Resident #3's medical record revealed the facility admitted the resident, on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Hypertension, and [CONDITION(S)]. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #3's BIMS score as fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #3, on [DATE] at 9:50 AM, revealed he/she was moved from his/her room five (5) times in a period of five (5) months. Resident #3 stated he/she was notified right before the moves occurred, and he/she was pissed off because he/she should have gotten to one place and stayed. Resident #3 stated he/she was angry about the move and lacked the social interaction he/she had in his/her previous room. Resident #3 stated he/she wanted to return to his/her original room. Continued review of Resident #3's medical record revealed there was no documentation in the Social Service Notes following the transfers, and no documentation that the SSD assessed the resident's psychosocial needs. 5. Review of Resident #72's medical record revealed the facility admitted the resident, originally on [DATE], with diagnoses which included Chronic Respiratory Failure, [CONDITION(S)], Dementia, Congestive Heart Failure, Depression, Anxiety, and [CONDITION(S)]. Review of Resident #72's Quarterly MDS, dated [DATE], revealed a BIMS' score of five (5), which indicated severe cognitive impairment. Interview with Resident #72's POA/NOK, on [DATE] at 10:10 AM, revealed the resident had [CONDITION(S)] which caused sight limitations and made him/her at risk for falls. The POA/NOK stated the risk for falls and injuries increased because he/she would have to be re-oriented to the new room after each transfer. The POA/NOK stated the resident had been moved numerous times. Review of the facility's Action Summary, dated [DATE], revealed Resident #72 was transferred to another room on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Continued review of Resident #72's medical record, in the Social Service notes, revealed no documentation that the SSD assessed the resident's psychosocial needs following the resident's numerous transfers. 6. Review of Resident #60's medical record revealed the facility admitted the resident, on [DATE], with diagnoses which included [CONDITION(S)], Congestive Heart Failure, Chest Pain, [CONDITION(S)], and Hypertension. Review of Resident #60's Quarterly MDS, dated [DATE], revealed the facility assess the resident to have a BIMS' score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #60, on [DATE] at 1:50 PM, revealed he/she never received any written notice or the explanation for the several room transfers and was not happy about the moves. Resident #60 stated his/her current room was smaller than his/her previous room. The resident stated this made self-ambulation harder to perform. The resident stated the bathroom was smaller, so staff had to take him/her to the shower room to provide personal hygiene. Review of the facility's Action Summary, dated [DATE], revealed Resident #60 was transferred three (3) times; [DATE], [DATE], and [DATE]. Continued review of Resident #60's medical record, in the Social Service note, revealed no Social Service documentation related to the transfers, and no documented evidence the SSD addressed Resident #60's needs. 7. Review of Resident #50's medical record revealed the facility originally admitted Resident #50, on [DATE], with diagnoses which included Nightmare Disorder, [CONDITION(S)], Hypertension, Depression, Anxiety, and Chronic Pain. Review of Resident #50's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #50, on [DATE] at 11:00 AM, revealed he/she did not receive any notice of a transfer on [DATE]. Resident #50 stated housekeeping staff came in and informed him/her of the transfer and started taking items off the walls and packing up his/her personal belongings. Resident #50 stated he/she became very upset and cried all day long, increasing the resident's anxiety and depression due to the transfer. Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse who died in the room. Continued review of Resident #50's medical record, in the Social Service notes, revealed no documentation of the SSD's assessment of the resident's psychosocial needs related to the room transfer. 8. Review of Resident #82's medical record revealed the facility admitted the resident, on [DATE], with diagnoses which included Diabetes, Hypertension, Repeated Falls, Dementia, Depression, and Anxiety. Review of Resident #82's Quarterly MDS, dated [DATE], revealed the resident had a BIMS' score of nine (9) of fifteen (15), which indicated moderate cognitive impairment. Interview with Resident #82's POA/NOK, on [DATE] at 3:45 PM, revealed the facility called him/her to inform him/her of Resident #82's transfer to another room, on [DATE]. The POA/NOK was told the transfer was to provide more monitoring of the resident since the room was across from the nurse's station. However, additional review of Resident #82's medical record revealed the Psychiatric Nurse Practitioner's Note, from [DATE]. Further review of the Note revealed the resident stated that he/she was stressed from just being there and in a bad mood due to having to change rooms. Record review revealed the resident required increased supervision for behaviors and suicidal ideation during this period. Continued review of Resident #82's medical record, in the Social Service notes, revealed no SSD documentation of an assessment following the resident's transfers. Interview with the former Social Services Director, on [DATE] at 9:35 AM, revealed she did rounds of the residents after the transfers, but she was directed by the Administrator not to put any documentation in the residents' medical records. The former Social Services Director stated she told the Administrator many of the residents were unhappy and upset with the transfers, but the Administrator took no action regarding these concerns. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on [DATE] by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on [DATE]. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on [DATE], to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on [DATE], revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective [DATE]. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since [DATE] to determine if the residents' belongings were moved with the resident to their new room on [DATE] and [DATE]. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on [DATE], to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on [DATE], regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on [DATE], on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On [DATE], the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on [DATE] and [DATE]. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available [DATE] days a year and can be used anonymously; the hotline number was posted throughout the facility on [DATE]. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on [DATE] in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on [DATE]. The facility contracted with a dietary consulting company, on [DATE] to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on [DATE] and completion by [DATE]. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on [DATE], with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on [DATE] and [DATE] to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on [DATE]. Review of Resident #6's medical record, on [DATE], revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on [DATE] at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on [DATE] at 2:53 PM, revealed the previous Administrator was terminated on [DATE]. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on [DATE] at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on [DATE] at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on [DATE] at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on [DATE] at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on [DATE], revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since [DATE]. Interview with the MDS Support Nurse, on [DATE] at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since [DATE] until the present on [DATE]. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on [DATE] at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on [DATE]. Interview with the DON, on [DATE] at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on [DATE] and [DATE] with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on [DATE] with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on [DATE] at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on [DATE] at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on [DATE] at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on [DATE] at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on [DATE] at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on [DATE] at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on [DATE] at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on [DATE] at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on [DATE] at 4:50 PM, revealed multiple residents had reported the meals were better. <br [TRUNCATED]

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of fifty-three (53) sampled residents (Resident #6) was treated with respect and dignity and failed to ensure the resident's right to retain and use personal possessions, including clothing. According to Resident #6, facility staff came into his/her room on 02/24/2022 and took all of his/her personal belongings to another room. Resident #6 stated he/she told staff to leave the belongings alone, and the resident refused the transfer. Resident #6 stated he/she cried and asked for his/her belongings from 02/24/2022 to 02/28/2022 until they were returned on 02/28/2022. The facility's failure to ensure staff treated residents with dignity and respect and failure to ensure a resident's right to retain and use personal belongings has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Resident Rights H5MAPL0768, undated, revealed the resident's right to retain and use personal possessions to the maximum extent that space and safety permit. Review of the facility's document, Residents' Rights for Residents in Kentucky Long-Term Care Facilities, undated, revealed residents could retain the use of their personal clothing unless it would infringe upon the right of others. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Continued review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed he/she told staff not to take his/her belongings on 02/24/2022. However, the facility removed the resident's personal possessions in an attempt to move him/her to another room against his/her wishes. The staff would not return the resident's personal belongings which resulted in the resident not being able to perform routine Activities of Daily Living (ADL). Resident #6 stated he/she was not able to change his/her clothing or perform dental care until his/her belongings were returned on 02/28/2022. Resident #6 stated he/she cried and asked for his/her belongings, from the time they were taken until they were returned. Resident #6 stated he/she was told it was the Administrator's instruction to move his/her belongings to another room. Interview with Housekeeping Staff #1, on 03/11/2022 at 9:30 AM, revealed she was told to pack Resident #6's belongings and move them to another room in the facility, on 02/24/2022. Housekeeping Staff #1 stated Resident #6 told the staff not to touch his/her belongings and stated he/she was not going to be transferred to the other room. Further interview revealed Housekeeping Staff #1 stated she informed her supervisor of the situation. Interview with the Housekeeping Supervisor, on 03/11/2022 at 10:00 AM, revealed she talked with Resident #6 the same day she was informed the resident did not want to be transferred. The Housekeeping Supervisor stated she informed the Administrator of Resident #6's refusal to be transferred. Continued interview revealed the Administrator stated to go ahead and move Resident #6's belongings to the new room, and the resident could go and get his/her items if he/she wanted them. Interview with SRNA (State Registered Nurse Aide) #7, on 03/15/2022 at 2:50 PM, revealed she worked with Resident #6 during the time the resident did not have his/her personal belongings. SRNA #7 stated the resident was tearful and kept asking for his/her belongings to be returned. Interview with LPN (Licensed Practical Nurse) #2, on 03/15/2022 at 3:05 PM, revealed she worked with Resident #6 on 02/24/2022. LPN #2 stated Resident #6 was very upset about his/her belongings being taken. She stated she talked with the Administrator who stated not to return Resident #6's belongings. LPN #2 stated she informed the Administrator that Resident #6 wanted to speak to her. The LPN stated the Administrator never talked to Resident #6 during this timeframe. Interview with SRNA #18, on 03/15/2022 at 2:25 PM, revealed she was unable to provide any care to Resident #6, nor was she able to help the resident change clothes since the resident's personal belongings were taken from the resident's room. SRNA #18 stated Resident #6 was very upset and crying, asking for his/her belongings to be returned. Interview with SRNA #14, on 03/17/2022 at 4:00 PM, revealed Resident #6 stated it was abuse to take his/her belongings and not return them to him/her. SRNA #14 stated Resident #6 was anger and upset regarding the Administrator taking his/her personal belongings. Interview with LPN #3, on 03/17/2022 at 6:15 PM, revealed she did not provide direct care to Resident #6. She stated she heard that the Administrator had taken Resident #6's personal belongings and did not return them to the resident and the resident was very upset. Interview with SRNA #26, on 03/16/2022 at 4:00 PM, revealed she had just started working at the facility on 02/21/2022. SRNA #26 stated towards the end of the week, either 02/24/2022 or 02/25/2022 (Thursday or Friday), she remembered Resident #6 was supposed to be transferred to another room, but the resident refused. Interview with SRNA #16, on 03/18/2022 at 7:47 AM, revealed she worked on Thursday and Friday nights. Review of the staffing record confirmed SRNA #16 worked on the 300 Hall on 02/24/2022. Further interview revealed that she had administered medications to Resident #6 on that night. The SRNA stated that Resident #6 was very upset about his/her belongings being moved. Interview with Maintenance Technician #1, on 03/30/2022 at 4:13 PM, revealed it was one of his first days at the facility when Resident #6's belongings were moved from his/her room. He stated he had gone to the room to install a television for Resident #6's roommate, and Resident #6 was not in a good place. He stated Resident #6 was very angry and distressed. Continued interview revealed Resident #6 did not know who he was (the Maintenance Technician), but the resident just needed to tell somebody about the situation. He stated Resident #6 told him that he/she did not have any of his/her belongings, had not been able to brush his/her teeth or wash, and did not have his/her cell phone because they had been moved to another room by staff. Maintenance Technician #1 stated he went to the Social Services Director to get help for Resident #6. He stated the Social Services Director did go talk to the resident. Interview with the Director of Nursing (DON), on 03/17/2022 at 4:10 PM, revealed she was unaware of Resident #6 being without his/her belongings over the weekend. She stated at the morning meeting the next day, Friday, 02/25/2022, the topic was brought up that Resident #6 had refused to be transferred from Unit 2, but his/her belongings had already been taken to another room on Unit 1. The DON stated the Administrator stated she was going to talk to Resident #6 before having his/her belongings returned. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed she was informed Resident #6 was refusing the room transfer. She stated she was going to talk to Resident #6, on 02/24/2022, but she forgot, and when she remembered, on 02/28/2022, she had the resident's belongings returned to him/her The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with Cook #2 at 10:10 AM; Cook #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated they had training on calibrating thermometers every morning; training on the food temperatures including being sure not to touch the bottom of the pan because it was hotter than the food; and more education on the dishwasher and sanitizer. Interview with the Regional Dietary Manager (RDM), on 03/31/2022 at 10:28 AM, revealed he had been in this position just this week since Monday and had been in the kitchen daily since Friday. He stated he had provided trainings on the issues, every staff member now had their food handler permits as required. He further stated every kitchen employee had been provided job descriptions, so they knew what they were responsible for. He stated training was provided on food storage, temperatures, dating foods, use by dates for foods, temps required for cooking, and providing snacks. He further stated he would be checking in daily and be at the facility at least 2-3 days per week for the time being. 9. Observations beginning on 03/30/2022, revealed food being stored correctly in the coolers. Observations on 03/31/2022 at 11:30 AM, revealed staff recording temperatures correctly and recording them on temperature log sheets. Review of the log sheets revealed daily recording of all meals being documented. 10. Review of the facility's audit sheets, on 03/30/2022, revealed documentation of audits being performed daily. The sheets were turned into the Quality Assurance and Performance Improvement (QAPI) Committee. Interview with the Regional Director of Operations (RDO)/Interim Administrator, Admissions Coordinator (AC), Regional Nurse Consultant (RNC), and the Director of Nursing (DON), on 03/31/2022 at 9:50 AM, revealed they were meeting daily to review the audits being performed. The Department Directors/Managers were going around to perform the various audits to ensure staff compliance with the recent reeducation and training. Observations of rounds, on 03/31/2022 at 11:01 AM, with SRNA Supervisor and scheduler, revealed they audited for care needs such: as care plans being implemented; residents being treated with dignity and respect; abuse and reporting it; as well, as rounding to ensure care needs were being met. 11. Interview with the Regional Director of Operations (RDO)/Interim Administrator and the Regional Clinical Operations Consultant, on 03/31/2022 at 9:30 AM, revealed they were in daily contact with the Medical Director who was coming weekly to the facility to discuss corrective action. Interview with the Medical Director, on 03/31/2022 at 3:03 PM, revealed he was on conference call with lawyers about corrections and met with the QA Committee with plans. The Medical Director stated he was curious about why people didn't pursue resolution at lower level first. He stated, It is a work in progress. He also stated he was going to stay on the QA Committee, coming weekly from 3:00 PM on that day for however long it was necessary. Continued interview revealed he was in daily contact with the RDO. The Medical Director stated he would review applicant names for the new Administrator.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to protect residents from abuse and neglect for one (1) of fifty-three (53) sampled residents (Resident #6). The facility willfully deprived Resident #6 of his/her personal belongings, from 02/24/2022 to 02/28/2022. These belongings were necessary to attain or maintain his/her mental and psychosocial well-being necessary to avoid mental anguish or emotional distress. Resident #6 stated he/she felt this behavior was abuse, as well as staff, who described this behavior as abusive. Staff were aware Resident #6 was upset and cried during this time. However, the resident's belongings were not returned until 02/28/2022. The facility's failure to provide Resident #6 with his/her personal belongings and failure to follow their policy to ensure all residents were free from abuse and neglect has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Identification (of Abuse), dated 11/03/2017, revealed the facility identified the potential for abuse, neglect, misappropriation of property and exploitation by reviewing the daily nursing report forms, conducting nursing rounds, and routine observations. Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by the individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental, or emotional anguish. Review of the facility's document, Abuse Policy Definitions, dated 11/02/2017, revealed willful was defined as an individual acting in a deliberate way; not that the individual must have intended to inflict injury or harm. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed facility staff removed his/her belongings, including clothing, grooming/hygiene and dental supplies, on Thursday, 02/24/2022, and did not return them until the following Monday, 02/28/2022. Resident #6 stated this was done in an attempt to make him/her move to another room. The resident stated that he/she was not able to change clothes, to perform personal hygiene, and was unable to perform oral care. Resident #6 stated he/she was very upset and hurt by the facility's actions and cried the entire weekend. The resident stated he/she told the housekeeping staff not to touch his/her belongings. Resident #6 stated he/she asked repeatedly to speak to the Administrator, as well as asked daily to have his/her personal belongings returned. Resident #6 stated he/she felt this was abuse. Interview with the Housekeeping Supervisor, on 03/11/2022 at 10:00 AM, revealed she felt it was abusive of the Administrator to take Resident #6's personal belongings and not return them to the resident. Interview with State Registered Nurse Aide (SRNA) #7, on 03/15/2022 at 2:50 PM, revealed she worked with Resident #6 during the time the resident did not have his/her personal belongings. SRNA #7 stated she felt this situation was abuse by taking the resident's personal belongings. The SRNA stated Resident #6 was very upset and cried repeatedly. But SRNA #7 stated she was afraid she would have been fired if she reported the abuse. Interview with Licensed Practical Nurse (LPN) #2, on 03/15/2022 at 3:05 PM, revealed she worked with Resident #6 on 02/24/2022. LPN #2 stated Resident #6 was very upset about his/her belongings being taken. LPN #2 stated she talked with the Administrator, who stated not to return Resident #6's belongings. LPN #2 stated she informed the Administrator Resident #6 wanted to speak to her. However, the Administrator never talked to Resident #6 during this time. Interview with SRNA #18, on 03/15/2022 at 2:25 PM, revealed she was unable to provide any care to Resident #6 nor, was she able to help the resident to change clothes since the resident's personal belongings were taken from the resident's room. SRNA #18 stated she felt this was abuse, but she was afraid to report the abuse. SRNA #18 stated other staff have been fired for reporting things. Interview with SRNA #14, on 03/17/2022 at 4:00 PM, felt it was abusive of the Administrator to remove Resident #6's personal belongings and told staff not to return them. SRNA #14 stated Resident #6 stated it was abuse to take his/her belongings and not return them to him/her. SRNA #14 stated she was afraid to report the abuse due to being fired. Interview with LPN #3, on 03/17/2022 at 6:15 PM, revealed she felt this was abuse and that she was aware of what constituted abuse. Interview with SRNA #11, on 03/18/2022 at 10:50 AM, and SNRA #16, on 03/18/2022 at 7:45 AM, revealed they felt taking a resident's belongings and not returning them would be considered abuse. LPN #3 stated staff were afraid to report anything due to the risk of being fired. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed she was informed Resident #6 was refusing the room transfer and was going to talk to Resident #6 on 02/24/2022 but she forgot, and when she remembered, on 02/28/2022, she had the resident's belongings returned. Further interview revealed the Adminstrator stated she had meant to go and talk to the resident on Friday, 02/25/2022, and if the resident still refused the transfer, she would have returned the resident's belongings then. When interviewed regarding Resident #6 having to go all weekend without his/her personal belongings, including hygiene and clean clothing, the Administrator then stated it would be considered abuse. When interviewed why she did not report the abuse, the Administrator stated she did not know. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with Cook #2 at 10:10 AM; Cook #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated they had training on calibrating thermometers every morning; training on the food temperatures including being sure not to touch the bottom of the pan because it was hotter than the food; and more education on the dishwasher and sanitizer. Interview with the Regional Dietary Manager (RDM), on 03/31/2022 at 10:28 AM, revealed he had been in this position just this week since Monday and had been in the kitchen daily since Friday. He stated he had provided trainings on the issues, every staff member now had their food handler permits as required. He further stated every kitchen employee had been provided job descriptions, so they knew what they were responsible for. He stated training was provided on food storage, temperatures, dating foods, use by dates for foods, temps required for cooking, and providing snacks. He further stated he would be checking in daily and be at the facility at least 2-3 days per week for the time being. 9. Observations beginning on 03/30/2022, revealed food being stored correctly in the coolers. Observations on 03/31/2022 at 11:30 AM, revealed staff recording temperatures correctly and recording them on temperature log sheets. Review of the log sheets revealed daily recording of all meals being documented. 10. Review of the facility's audit sheets, on 03/30/2022, revealed documentation of audits being performed daily. The sheets were turned into the Quality Assurance and Performance Improvement (QAPI) Committee. Interview with the Regional Director of Operations (RDO)/Interim Administrator, Admissions Coordinator (AC), Regional Nurse Consultant (RNC), and the Director of Nursing (DON), on 03/31/2022 at 9:50 AM, revealed they were meeting daily to review the audits being performed. The Department Directors/Managers were going around to perform the various audits to ensure staff compliance with the recent reeducation and training. Observations of rounds, on 03/31/2022 at 11:01 AM, with SRNA Supervisor and scheduler, revealed they audited for care needs such: as care plans being implemented; residents being treated with dignity and respect; abuse and reporting it; as well, as rounding to ensure care needs were being met. 11. Interview with the Regional Director of Operations (RDO)/Interim Administrator and the Regional Clinical Operations Consultant, on 03/31/2022 at 9:30 AM, revealed they were in daily contact with the Medical Director who was coming weekly to the facility to discuss corrective action. Interview with the Medical Director, on 03/31/2022 at 3:03 PM, revealed he was on conference call with lawyers about corrections and met with the QA Committee with plans. The Medical Director stated he was curious about why people didn't pursue resolution at lower level first. He stated, It is a work in progress. He also stated he was going to stay on the QA Committee, coming weekly from 3:00 PM on that day for however long it was necessary. Continued interview revealed he was in daily contact with the RDO. The Medical Director stated he would review applicant names for the new Administrator.

Based on interview, record review, review of job descriptions, and review of the facility's policies, it was determined the facility failed to report allegations of abuse and neglect for one (1) of fifty-three (53) sampled residents (Resident #6), whose personal belongings were removed from his/her room for four (4) days causing him/her psychosocial harm. Resident #6 cried and was upset from Thursday to Monday. Staff wasn't able to provide the necessary care for the resident. The resident asked for his/her belongings to be given back. However, no one would give him/her his/her belongings. Although the resident felt this behavior was abusive and staff thought it was abuse, no one reported this as an allegation of abuse. The facility's failure to ensure staff followed the facility's policy for reporting abuse, has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Prevention - Reporting of Concerns, Incidents, and Grievances, dated 02/2004, revealed it was the policy of the facility to encourage residents, families, and staff to report concerns, incidents, and grievances without the fear of retribution. Continued review revealed the policy encouraged all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed it was the responsibility of the facility's employees, the facility's consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility's management. Review of the facility's policy titled, Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/03/2017, revealed it was the policy of the facility that all suspected violations of abuse, neglect, exploitation, or mistreatment would be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Review of the facility's policy titled, Policy for Adult Protection, undated, revealed it was a policy of the facility that any employee who had reasonable cause to believe or even suspect that a resident or child had suffered abuse or neglect must report the incident immediately. Continued review revealed abuse or suspicion of abuse included rough physical treatment, abusive or disrespectful language, neglect or failure to respond to a resident's needs, or misappropriation of property. Further review revealed this reported incident must be given immediately to his/her supervisor and the Administrator or his/her designee. Review of the facility's job descriptions for Nursing Assistant, Licensed Practical Nurse, Director of Nursing, Social Services Director, and Administrator, all undated, revealed under Resident Rights, the Essential Functions were to ensure all residents were given fair and equitable treatment, the freedom of self-determination, individuality, and the respect for privacy, property, and civil rights. Review of the facility's document, In-Service Training, undated, revealed all employees received periodic in-service training relative to resident rights and the facility's abuse prevention program's policies and procedures. Continued review revealed all employees were required to attend the facility's resident rights and abuse prevention program in-service training sessions prior to having any resident contact. Further review revealed annual resident rights in-service training programs were conducted, and it was mandatory that all personnel attend such training programs. Review of the facility's inservice sign-in sheets compared to the employee roster revealed all current staff had received abuse training, at the last annual training. Further review revealed all new hires had received abuse training upon hire. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed facility staff removed his/her belongings, including clothing, grooming/hygiene and dental supplies, on Thursday, 02/24/2022, in an attempt to force him/her to move to another room. The resident's belongings were not returned until the following Monday, 02/28/2022. Resident #6 stated he/she was not able to change clothes or to perform personal hygiene, including oral care. Resident #6 stated he/she was very upset and hurt by the facility's actions and cried throughout the four (4) days. The resident stated he/she told the housekeeping staff not to touch his/her belongings. Resident #6 stated he/she asked staff repeatedly to speak to the Administrator and also asked daily to have his/her personal belongings returned. Resident #6 stated he/she felt this was abuse. Interview with the Housekeeping Supervisor, on 03/11/2022 at 10:00 AM, revealed she felt it was abusive of the Administrator to take Resident #6's personal belongings and not return them to the resident. The Housekeeping Supervisor stated she would have been fired if she had reported the abuse. Interview with State Registered Nurse Aide (SRNA) #7, on 03/15/2022 at 2:50 PM, revealed she worked with Resident #6 during the time the resident did not have his/her personal belongings. SRNA #7 stated she felt this situation was abuse by taking the resident's personal belongings. But SRNA #7 stated she was afraid she would have been fired if she reported the abuse. Interview with Licensed Practical Nurse (LPN) #2, on 03/15/2022 at 3:05 PM, revealed she worked with Resident #6 on 02/24/2022. LPN #2 stated Resident #6 was very upset about his/her belongings being taken. She stated she talked with the Administrator, who stated not to return Resident #6's belongings. LPN #2 stated she informed the Administrator that Resident #6 wanted to speak to her. However, she stated the Administrator never talked to Resident #6 during this time. Interview with SRNA #18, on 03/15/2022 at 2:25 PM, revealed she was unable to provide any care to Resident #6, nor was she able to help the resident to change clothes since the resident's personal belongings were taken from the resident's room. She stated she felt this was abuse, but she was afraid to report the abuse. SRNA #18 stated other staff had been fired for reporting things. Interview with SRNA #14, on 03/17/2022 at 4:00 PM, revealed it was abusive to remove Resident #6's personal belongings. She stated the Administrator told staff not to return them. The SRNA stated Resident #6 stated it was abuse to take his/her belongings and not return them to him/her. SRNA #14 stated she was afraid to report the abuse due to being fired. Interview with LPN #3, on 03/17/2022 at 6:15 PM, revealed she did not provide direct care to Resident #6, but had heard the Administrator had taken Resident #6's personal belongings and did not return them to the resident. LPN #3 stated she felt this was abuse. LPN #3 stated staff were afraid to report anything due to the risk of being fired. Interview with SRNA #11 and SRNA #16, on 03/18/2022 at 7:47 AM and 10:49 AM, revealed they felt taking a resident's belongings and not returning them would be considered abuse. SRNA #16 stated she was going to write her concerns regarding Resident #6 on the 24-hour nursing report, but she was afraid to report the abuse due to fear of being fired. SRNA #11 stated she did not report the abuse due to the fear of being fired. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed she was informed that Resident #6 refused the room transfer and she was going to talk to Resident #6 on 02/24/2022. Continued interview revealed she forgot to talk to the resident, and when she remembered, on 02/28/2022, she had the resident's belongings returned. When interviewed whether it was abuse or not, the Administrator stated she had meant to go and talk to the resident on Friday, 02/25/2022, and if the resident still refused the transfer, she would have returned the resident's belongings then. When interviewed regarding Resident #6 having to go all weekend without his/her personal belongings, including hygiene and clean clothing, the Administrator stated it would be considered abuse. When interviewed why she did not report the abuse, the Administrator stated, I don't know. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with Cook #2 at 10:10 AM; Cook #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated they had training on calibrating thermometers every morning; training on the food temperatures including being sure not to touch the bottom of the pan because it was hotter than the food; and more education on the dishwasher and sanitizer. Interview with the Regional Dietary Manager (RDM), on 03/31/2022 at 10:28 AM, revealed he had been in this position just this week since Monday and had been in the kitchen daily since Friday. He stated he had provided trainings on the issues, every staff member now had their food handler permits as required. He further stated every kitchen employee had been provided job descriptions, so they knew what they were responsible for. He stated training was provided on food storage, temperatures, dating foods, use by dates for foods, temps required for cooking, and providing snacks. He further stated he would be checking in daily and be at the facility at least 2-3 days per week for the time being. 9. Observations beginning on 03/30/2022, revealed food being stored correctly in the coolers. Observations on 03/31/2022 at 11:30 AM, revealed staff recording temperatures correctly and recording them on temperature log sheets. Review of the log sheets revealed daily recording of all meals being documented. 10. Review of the facility's audit sheets, on 03/30/2022, revealed documentation of audits being performed daily. The sheets were turned into the Quality Assurance and Performance Improvement (QAPI) Committee. Interview with the Regional Director of Operations (RDO)/Interim Administrator, Admissions Coordinator (AC), Regional Nurse Consultant (RNC), and the Director of Nursing (DON), on 03/31/2022 at 9:50 AM, revealed they were meeting daily to review the audits being performed. The Department Directors/Managers were going around to perform the various audits to ensure staff compliance with the recent reeducation and training. Observations of rounds, on 03/31/2022 at 11:01 AM, with SRNA Supervisor and scheduler, revealed they audited for care needs such: as care plans being implemented; residents being treated with dignity and respect; abuse and reporting it; as well, as rounding to ensure

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, to meet the resident's highest practicable quality of life, specifically nursing and psychosocial needs, that were identified in the comprehensive assessment for two (2) of fifty-three (53) sampled residents (Residents #6 and #50). The facility deprived Resident #6 and Resident #50 of goods or services that were necessary to attain or maintain his/her highest level of practicable physical, mental, and psychosocial well-being. Review of Resident #6's care plan, dated [DATE], revealed a focus of psychosocial wellbeing risk related to a new environment. Goals included the resident would have care needs met daily as measured by the resident being clean, well-groomed, and odor free. Interventions included staff assistance with dressing, hygiene, and oral and denture care daily and, as needed. However, Resident #6 stated his/her personal belongings were removed from his/her room and held without consent from [DATE] through [DATE]. Staff was not able to provide Resident #6's daily hygiene and oral care due to lack of supplies and clean clothing. Review of Resident #50's care plan, dated [DATE], revealed a goal of being free from signs and symptoms of mood decline. Interview with the resident revealed, on [DATE], Resident #50 was transferred to another room without prior notification or consent. Staff removed everything off the resident's walls and his/her other belongings. Resident #50 stated that he/she felt very distraught, cried everyday, and was emotionally distressed. Continued interview revealed his/her attachment to the original room was due to having resided there with his/her spouse, who was now deceased . The facility's failure to implement the comprehensive person-centered care plans for Residents #6 and #50, consistent with their rights and psychosocial needs, has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE]. Refer to F-557, F-559, F-600, and F-745. The findings include: Review of the facility's policy titled, Care Plans - Comprehensive, dated [DATE], revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Per the policy, the Care Planning/Interdisciplinary Team developed and maintained a comprehensive care plan for each resident, in coordination with the resident, and his/her family or representative, that identified the highest level of functioning the resident could be expected to attain. Continued review revealed that the comprehensive care plan was based on a thorough assessment that included, but was not limited to, the Minimum Data Set (MDS) Assessments. Further review revealed the care plan would aid in preventing or reducing a decline in the resident's functional status and/or functional levels and would reflect currently recognized standards of practice for problem areas and conditions. Review of care plan interventions revealed they were implemented after consideration of the resident's problem areas and their causes. Additional review revealed the care plans were ongoing and revised as information about the resident and the resident's condition changed. Review of the facility's policy titled, Using the Care Plan, dated [DATE], revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who had responsibility for providing care or services to the resident. Further review revealed that completed care plans were available to authorized personnel. Continued review revealed the nurse aide was responsible for reporting to the nurse or charge nurse any change in the resident's condition. Additional review revealed that changes in the resident's condition must be reported to the Nurse Assessment Coordinator, so that a review of the resident's assessment and care plan could be made. 1. Review of Resident #6's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a fifteen (15) of fifteen (15), which indicated intact cognition. Review of Resident #6's care plan, dated [DATE], revealed a focus of psychosocial wellbeing risk related to new environment with interventions utilizing psychiatric services when needed and per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included staff assistance with dressing, hygiene, and oral and denture care daily and as needed. Interview with Resident #6, on [DATE], revealed he/she did not receive any written notice prior to the facility's attempt to transfer him/her to another room. Further interview revealed Resident #6 refused to be transferred. The resident stated that housekeeping staff removed all of his/her personal belongings from the current room and moved them to the room the facility intended to transfer Resident #6 to. According to Resident #6, he/she asked repeatedly for his/her belongings to be returned from [DATE] until [DATE], when the personal belongings were returned. Resident #6 stated he/she told staff this was abusive, and he/she was distraught and cried daily. Further interview revealed Resident #6 stated, because his/her personal belongings had been taken away, he/she could not perform oral hygiene or change clothes from [DATE] through [DATE]. Interview with State Registered Nurse Aide (SRNA) #18, on [DATE] at 2:26 PM, revealed she worked the weekend Resident #6's belongings were removed. She stated staff could not provide care because the resident could not get a bath or change of clothes due to his/her hygiene supplies and clothing had been moved. Continued interview revealed staff members were informed they were not allowed to get Resident #6's belongings. Further interview revealed the staff determined the reason was that the Administrator was trying to get the resident to move to the other side of the building. She stated Resident #6 expressed sadness about the situation. Interview with SRNA #7, on [DATE] at 2:50 PM, revealed she did not give care during the five (5) day time period. She stated staff was not allowed to get the resident's belongings from the other room. SRNA #7 stated the instruction, not to get the resident's belongings, came from the Administrator. Interview with SRNA #16, on [DATE] at 7:47 AM, revealed she worked on the night shift of [DATE]. She stated that Resident #6 asked for his/her belongings, particularly pajamas. She stated the resident declined the offer of a hospital gown, and remained in his/her old clothing. Further review of Resident #6's medical record revealed there was no documented evidence his/her comprehensive care plan was implemented during [DATE] through [DATE]. 2. Review of Resident #50's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed, in the Cognitive Patterns section, a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating intact cognition. Review of Resident #50's comprehensive care plan, dated [DATE], revealed a focus for potential for grieving related to the death of a spouse, with interventions including staff to observe for causative and contributing factors that may delay the grief process and reduce or eliminate causative or contributing factors that may delay grieving, if possible. Further review revealed a focus for a potential problem with the resident's psychosocial well-being related to anxiety, depression, and pain. Continued review revealed to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Additional review of Resident #50's comprehensive care plan, dated [DATE], revealed to increase communication between resident/family/caregivers about care and living environment: explain all changes, rules, and options. Also, to provide assistance/supervision/support to identify precipitating factor(s)/stressors, to reduce or eliminate causative and contributing factors, and to identify potential solutions to present problems. Continued review revealed focus for potential for mood problem related to depression, anxiety, and [CONDITION(S)] with interventions. Further review revealed to observe for the following: episode feelings or sadness. Observe for mood patterns, signs and symptoms of depression, anxiety, sad mood as per the facility's behavior monitoring protocols; observe mood to determine if problems seemed to be related to external causes, and provide encouragement/assistance/support to maintain as much independence and control as possible. Interview with Resident #50, on [DATE] at 11:00 AM, revealed he/she did not receive any notice of a transfer on [DATE]. Resident #50 stated housekeeping staff came in and informed him/her of the transfer, and started taking items off the walls and packing up his/her personal belongings. Resident #50 stated he/she became very upset and cried all day long. Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse, who died in the room. Further review of Resident #50's medical record revealed there was no documentation that his/her comprehensive care plan was implemented, beginning with the room transfer on [DATE]. Interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 2:45 PM, revealed when residents had dementia, they needed consistency and moving to another part of the facility could really disorient them. She stated increased behaviors and confusion could result from the disruption of routines. Interview with the Director of Nursing (DON), on [DATE] at 11:59 AM, revealed she was told by the Housekeeping Supervisor that the Administrator told staff to leave Resident #6's personal belongings in the new room where he/she was supposed to be transferred. She stated this prevented Resident #6 from receiving daily hygiene and oral care due to lack of supplies and clean clothing. She stated charting on Resident #6 for Activities of Daily Living (ADL) indicated he/she refused a shower during the time of [DATE] to [DATE]. She stated the resident might not have wanted to shower only to put the same clothes back on. The DON stated that this situation could be psychosocial harm, and she would be upset if it had happened to her. She stated her expectation was nurses and SRNA's would follow care plans, no matter what the circumstances. Interview with the Administrator, on [DATE] at 9:35 AM, revealed she did forget about returning Resident #6's belongings to him/her, but staff could have retrieved his/her belongings. She further stated the goal was to keep residents safe and happy in their home. Further interview revealed she did not know whether anyone else followed up on the psychosocial impact of Resident #6 being without his/her belongings from [DATE] to [DATE]. She stated she was unsure if the DON did or not and she did not remember if she talked to the APRN about harm or follow-up for Resident #6. The Administrator stated she was ultimately responsible to ensure policies, including residents' care plans, were followed. Interview with the Regional Clinical Operations Consultant, on [DATE] 11:21 AM, revealed her expectation was that clinical staff should be following residents' care plans, regardless of the circumstances. The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on [DATE] by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on [DATE]. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on [DATE], to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on [DATE], revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective [DATE]. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since [DATE] to determine if the residents' belongings were moved with the resident to their new room on [DATE] and [DATE]. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on [DATE], to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on [DATE], regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on [DATE], on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On [DATE], the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on [DATE] and [DATE]. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available [DATE] days a year and can be used anonymously; the hotline number was posted throughout the facility on [DATE]. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on [DATE] in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or Admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the Admission Director. If the IDT approves, the Admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on [DATE]. The facility contracted with a dietary consulting company, on [DATE] to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on [DATE] and completion by [DATE]. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on [DATE], with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on [DATE] and [DATE] to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on [DATE]. Review of Resident #6's medical record, on [DATE], revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on [DATE] at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on [DATE] at 2:53 PM, revealed the previous Administrator was terminated on [DATE]. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on [DATE] at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on [DATE] at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on [DATE] at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on [DATE] at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on [DATE] at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on [DATE], revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since [DATE]. Interview with the MDS Support Nurse, on [DATE] at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since [DATE] until the present on [DATE]. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on [DATE] at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on [DATE]. Interview with the DON, on [DATE] at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on [DATE] and [DATE] with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on [DATE] with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on [DATE] at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on [DATE] at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on [DATE] at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on [DATE] at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on [DATE] at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on [DATE] at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on [DATE] at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on [DATE] at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on [DATE] at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on [DATE] at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on [DATE] at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on [DATE] at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 [TRUNCATED]

Based on observation, interview and record review, and the website it was determined the facility failed to ensure there was sufficient dietary staff with necessary skill sets to safely and adequately prepare and serve meals three (3) times a day. This lack of sufficient dietary staff had the potential to affect eighty-two (82) of eighty-four (84) current residents. Two (2) residents received tube feedings. The findings include: Interview and observations of Cook #1 taking food temperatures, on [DATE] at 5:11 PM, during the supper meal service, revealed he was resting the thermometer on the bottom of the steam table pan. Cook #1 stated he did not know how to take food temperatures nor, did he know how to calibrate a thermometer. Observations of various meal preparation/service times, primarily evening shift, during [DATE] through [DATE], revealed staffing was a cook and a dietary aide (DA) to cook, plate, and deliver meal carts for eighty-two (82) residents. Review of the Dietary Work Schedules, dated [DATE] through [DATE], revealed there was not a time when the dietary shifts had one (1) cook and two (2) DA's. Interview with DA #2, via telephone, on [DATE] at 11:47 AM, revealed she no longer worked at the facility. She stated on [DATE], she and Cook #1 were alone on evening shift to prepare chicken nuggets, waffle fries, and Cole slaw. DA #2 stated she had literally three (3) days of training, from the previous cook, who quit, showing her the basics of the job. Interview with the DM, on [DATE] at 4:37 PM, revealed if there was a cook and two (2) DA's for each shift, meal preparation and service ran well. Interview with the Administrator, on [DATE] at 5:30 PM, revealed the DM brought staffing concerns to her, and she had worked on that concern. She stated regardless of the building size, the dietary department would need to be staffed with at least a cook and two (2) DA's for any meal service. Interview with the DM, on [DATE] at 10:22 AM, revealed she started at the facility on [DATE]. She stated the CCDM had provided her with the specific DM orientation for two (2) to three (3) days straight, then they had been at the facility other times to work on different things. The DM referred to a notebook in front of her, but stated she did not know the details of what it contained. She stated she did not use skill check off sheets when orienting new employees, and these skills sheets only verified general and basic kitchen skills, such as handwashing and scoop size. Interview with the CCDM, on [DATE] at 4:22 PM, revealed she had completed and documented two (2) to three (3) days of education with the DM. Record review revealed there was no documentation, such as competency sheets to show the dietary employees had received in-services and education to safely prepare and serve food that included the proper process to take temperatures of food; how to calibrate the thermometer; or, that they had obtained food handler cards that were required by the local health department. This requirement was verified on the web site https://courseforfoodsafety.com/states/KY. In addition, review of the web site https://www.efoodhandlers.com/Food-Handlers, an on-line program approved to meet the requirement, revealed it contained training on: The Importance of Food Safety; Health and Hygiene; Temperature Control; Avoiding Cross Contamination; and Cleaning and Sanitizing. State Survey Agency (SSA) Surveyors requested the DM and the Administrator to provide the food handler cards of all dietary staff for review. They stated they were unaware if their local health department required food handler cards and would investigate and get back to the SSA Surveyors with an answer. Review of the required food handler cards revealed Cook #3 had a current card, the DM's card was expired, and the remaining dietary staff did not have a card. Interviews with Cook #2, on [DATE] at 1:25 PM and Cook #1, on [DATE] at 4:55 PM, revealed they did not have formalized kitchen education, and there were no competency check offs or training logs. Both stated the older cooks trained the newer cooks. Continued interview revealed they were unaware if their local health department required a food handler card or, what a food handler card was. They both stated that needing a card had never been mentioned to them. Additional interview with the DM, on [DATE] at 4:20 PM, revealed the older cooks trained the newer cooks. The DM stated there were no available formal training or education logs. Additional interview with the DM, on [DATE] at 4:37 PM, revealed she had identified short staffing to be a concern and had brought that to the attention of the Administrator. She stated ads had been placed. Also, she stated there was no documentation that dietary staff had been screened regarding existing dietary knowledge or current education to work in the kitchen and handle food. Interview with the CCDM, on [DATE] at 3:30 PM, revealed short staffing was a concern. She stated ads had been placed for dietary staff. The CCDM stated there were no formalized training records available, and older staff trained newer staff while on the job. Interview with the Administrator, on [DATE] at 5:30 PM, revealed her responsibility, as the Administrator, included ensuring new staff had education provided to them to be able to correctly perform the job duties for their department. In the case of the new DM, a CCDM was brought in for a few days to assist with the DM's orientation and training. Then, she stated the DM should educate the dietary staff, and she trusted the DM and CCDM to do their jobs. When the Administrator was interviewed as to why she had not ensured this had happened, she was unable to give a specific answer. The Administrator also stated she was aware that ultimately she was responsible to ensure staff followed all policies and procedures and to oversee the day to day happenings in the facility.

Based on observation, interview, review of the Dietary Manager's (DM) job description, and review of the facility's policy, it was determined the facility failed to distribute food that was palatable. Interviews with residents and staff revealed meals served on 03/09/2022 and 03/10/2022, were not palatable. On 03/09/2022, residents received overcooked and tough breaded pork tenderloin. On 03/10/2022, residents received steak fries that were white in color and did not appear to have been cooked. Interviews from numerous residents/family members and staff revealed, on 03/13/2022, at the dinner meal, residents were served cold, undercooked chicken nuggets and waffle fries, with the appearance of not being cooked. Eighty-two (82) of the eighty-four (84) current residents had the potential to be affected by the meals. Two (2) residents received tube feedings. The findings include: Review of the facility's policy titled, Food Production and Food Safety 3-39, dated 02/2019, found in the Dietary Policy and Procedure Manual, Chapter 3, revealed the cook was responsible to taste all food before the meal service with the DM in attendance. Additionally, the policy stated all food that did not pass the taste test due to seasoning, toughness, color, or other negative factors would not be served until or unless the problem was corrected. Further review revealed it was the DM's responsibility to ensure that food served was attractive and palatable. 1. Observations, on 03/09/2022 at 12:00 PM, revealed several residents on the 300 Hall complained of overcooked pork tenderloin served on their lunch trays. The State Survey Agency (SSA) Surveyor observed several residents' lunch trays which contained what appeared to be breaded pork tenderloin that was dark brown in color. Further observation, on 03/09/2022 at 1:40 PM, with two (2) SSA Surveyors, the DM, and the Corporate Certified Dietary Manager (CCDM), revealed the DM and the CCDM were both unable to cut the pork tenderloin that was served for the lunch meal. The CCDM stated, We have lots of education to do with staff. Observation, on 03/10/2022 at 12:30 PM, of Resident #49's room, after the SSA Surveyor received several complaints of uncooked steak fries from residents, revealed the resident sitting at the bedside with the lunch meal tray and a family member in the room. Further observation revealed the lunch meal contained steak fries which were white in color as if they had been put on the steam table to thaw and were uncooked. Interview with the CCDM, on 03/10/2022 at 1:10 PM, revealed she thought the reason for the uncooked appearance of the steak fries was because the facility had no deep fryer, and everything was baked. However, observation on 03/10/2022 at 12:30 PM, revealed there was no color on the bottoms or around the edges of the steak fries that one would expect to see from items baked in the oven. The CCDM stated if food temperatures were good, the food was ok to serve, no matter what the appearance. 2. Interview with Resident #5, on 03/15/2022 at 4:08 PM, revealed the food was hardly ever served warm, often cold; the fried potatoes were white, not browned, barely warm and looked unappetizing. Continued interview revealed the supper meal on Sunday (03/13/2022) was served about 7:00 PM, the waffle fries were cold, and he/she only had three (3) nuggets. Review of the chicken nugget packaging revealed six (6) nuggets was a serving. Interview with Resident #62, on 03/15/2022 at 4:25 PM, revealed supper on 03/13/2022 was cold and frozen. Resident #5 stated the waffle fries were frozen and the chicken nuggets were pink and cold in the middle. Interview with Resident #49's Power-of-Attorney (POA), on 03/15/2022 at 9:30 AM, revealed she was at the facility for supper on 03/13/2022. She stated Resident #49 received undercooked chicken nuggets and waffle fries that were cold and had the appearance of not being cooked because there was no color noted on them at all. Interview with State Registered Nurse Aide (SRNA) #24, on 03/15/2022 at 3:38 PM, revealed she was working on 03/13/2022, and the dinner trays were late from the kitchen. She stated the chicken nuggets that were served looked doughy on the outside, and the steak fries looked frozen. She stated the residents complained about the food. Interview with Cook #1, on 03/16/2022 at 11:33 AM, revealed he checked the temperature of the nuggets to be 180 to 185 degrees Fahrenheit before they left the kitchen. After the first two (2) meal carts went out, he stated Dietary Aide (DA) #2 came back and said the chicken nuggets were raw. Cook #1 stated he was instructed by the Dietary Manager (DM), when he called her, to throw away the nuggets on the trays and re-bake the nuggets that were left in the kitchen. Telephone interview with Cook #1, on 03/18/2022 at 1:39 PM, revealed he put the nuggets from the meal carts that had not been sent out of the kitchen and the nuggets from the steam table back in the oven for about (30) more minutes. Cook #1 stated when he checked the temperature of the nuggets again, he checked the centers of several nuggets. He stated he had not received training on how to calibrate a food thermometer. Cook #1 stated he was trained on the job by Cook #2 for about two (2) days. He stated the DM came to the facility after he called her and prepared two (2) or three (3) Philly cheesesteak sandwiches for some of the residents. Interview with the DM, on 03/18/2022 at 4:37 PM, revealed she thought the chicken nuggets could be baked and that the instructions directed the internal temperature of the nuggets must reach 165 degrees Fahrenheit. Also, she stated there were no baking instructions on the package. The DM stated she knew the potential outcome of eating undercooked poultry was illness from food poisoning. Interview with the Administrator on 03/18/2022, at 5:30 PM, revealed she had been notified about the chicken nugget concerns, but she was unaware of the waffle fries concerns. Additional interview with the Administrator, on 03/19/2022 at 9:35 AM, revealed she had researched the chicken nuggets product labeling, and the Food and Drug Administration (FDA) required accurate labeling. She stated, based on the labeling on the package of nuggets that stated, partially cooked product would allow finishing touches to be added in a timely manner, it was her interpretation that the product was pre-cooked and baking was an acceptable cooking method. She further stated the facility's food distributor had expressed to her that baking the chicken nuggets was an acceptable cooking method. However, review of the product packaging revealed the chicken nuggets were to be deep-fried at 350 degrees Fahrenheit for three (3) to four (4) minutes to ensure an internal temperature of 165 degrees Fahrenheit was obtained by a calibrated thermometer. Interview with the Customer Relations Administrator of Food Quality and Safety for the chicken nugget production company, via telephone, on 03/28/2021 at 2:47 PM, revealed the item (chicken nuggets) was frozen, un-cooked, and needed to be cooked per packaging instructions for safe consuming. Interview with the Administrator, on 03/18/2022 at 5:30 PM, revealed she was aware that ultimately she was responsible to ensure staff followed all policies and procedures and to oversee the day-to-day operation of the facility.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to routinely offer snacks for all residents, excluding those that received tube feedings and received no snacks. In addition, meal service was delayed on 03/08/2022, 03/11/2022, and 03/13/2022. These deficient practices affected eighty-two (82) of eighty-four (84) current residents. The findings include: Review of the facility's policy titled, Process for Snacks in the Hydration Rooms, undated, revealed the Dietary Manager (DM) or designee checked the hydration rooms twice daily, Monday through Friday. This included checks for the number of snacks available, the dates on snacks and disposing of any that were out of date, and to restock, as needed. Also, the policy stated that on the Friday evening checks, the hydration rooms were stocked to provide snacks throughout the weekend. In addition, the policy stated the meal schedule was breakfast at 7:00 AM, lunch at 12:00 PM, and supper at 5:00 PM. State Survey Agency (SSA) Surveyor, on 03/10/2022 at 4:20 PM, requested a snack policy related to the times of snacks, content of snacks, etc. This request was made to the Administrator and the Regional Nurse Consultant (RNC). They reported the facility currently had no snack policy. 1. Observation, on 03/08/2022 at 12:40 PM, revealed the noon lunch service was beginning at this time, forty (40) minutes late. The last tray was delivered thirty (30) minutes later at 1:10 PM. Interview with State Registered Nurse Aide (SRNA) #7, on 03/15/2022 at 2:50 PM, revealed the residents were lucky when they received meals on time. Interview with Resident #5, on 03/15/2022 at 4:08 PM, revealed the 03/13/2022 Sunday night supper was two (2) hours late, being served at 7:00 PM. The resident stated that he/she did not eat the meal because the food was cold. Resident #5 stated around 9:00 PM, he/she was offered a hot hamburger. Interview with Resident #62, on 03/15/2022 at 4:25 PM, revealed that supper on Sunday night, 03/13/2022, was late because it was not cooked completely. The resident stated he/she was given a hamburger later, after 8:00 PM. Interview with Family Member #10, on 03/15/2022 at 4:40 PM, revealed that on Friday night (03/11/2022), Resident #64 ate ice cream and chips because the supper tray arrived so late. Further interview revealed that it was apparent the tray had been out for an extended time, as there was so much condensation in the cover lid; and the food and coffee were cold. Family Member #10 stated the grilled cheese sandwich was delivered late and it had been out for so long it was too tough to chew, and this was typical. Interview with SRNA #10, on 03/16/2022 at 12:19 PM, revealed she was working on Sunday (03/13/2022) when supper was served late. She stated second shift came (6:30 PM) before the second round of trays were out to replace the undercooked meal. Interview with SRNA #20, on 03/16/2022 at 2:30 PM, revealed that the evening meal on Sunday (03/13/2022) was late and arrived at 5:30 PM; then it was delayed for another hour after the food was noted to be undercooked. 2. Observation, of the reach in refrigerator in the kitchen, on 03/13/2022 at 1:20 PM, revealed that morning snacks, dated 03/13/2022, had not been distributed. Observation, on 03/14/2022 at 4:15 PM, of the reach in refrigerator in the kitchen revealed the morning snacks, dated 03/13/2022, still had not been distributed and were in the refrigerator. Interview with Resident #2, on 03/09/2022 at 3:45 PM, revealed the residents did not get snacks regularly. Interview with Resident #75, on 03/11/2022 at 11:10 AM, revealed residents just started getting snacks recently. The resident stated he/she currently had a tuna sandwich and had cookies yesterday as a snack. Interview with Environmental Services Employee (ES) #4, on 03/13/2022 at 12:42 PM, revealed the facility had not passed snacks for two (2) years until this week. She stated she knew this was correct because she had worked in the kitchen and knew what occurred. Interview with SRNA #9, on 03/15/2022 at 9:46 AM, revealed when the SSA Surveyors were not in the facility, residents did not get snacks distributed routinely. However, the SRNA stated when residents asked for snacks, they could obtain them from the hydration room. Interview with SRNA #7, on 03/15/2022 at 2:50 PM, revealed the facility had never passed out snacks until the SSA Surveyors entered. The SRNA stated she had worked at the facility for five (5) months and had never passed snacks before now. Interview with Dietary Aide (DA) #1, on 03/16/2022 at 11:16 AM, revealed snacks had not normally been given out on a regular basis until the SSA Surveyors arrived. Interview with SRNA #10, on 03/16/2022 at 12:19 PM, revealed the current snack distribution was not being done until the SSA Surveyors arrived. The SRNA stated no one got snacks during day shift unless they requested them, not even diabetic residents. Interview with DA #3, on 03/17/2022 at 8:43 AM, revealed that prior to the arrival of the SSA Surveyors, no snacks were prepared during day shift, but there had been 8:00 PM snacks. DA #3 stated, since the new DM started, there had been more of a struggle to have the items/foods needed for snacks. She stated dietary staff often did not have supplies for sandwiches, and staff asked the DM, on a weekly basis, to order chicken salad or something for sandwiches, but the supplies were not received. DA #3 stated snacks had been a piece of fruit or a small amount of applesauce. She stated, for the 8:00 PM snacks, residents that received thickened liquids should receive a drink, and for the rest, a sandwich or chips for those who had an order for a night time snack. Interview with the Consulting Registered Dietician (RD), on 03/15/2022 at 11:42 AM, revealed that a substantial evening snack would include a protein, but snack requirements varied. In general, he stated a ¼ cup of applesauce would not meet criteria for a substantial snack for diabetic residents. Interview with the Advanced Practice Registered Nurse, Family Nurse Practitioner-Certified, on 03/16/2022 at 2:45 PM, revealed a substantial snack for a diabetic resident would be a half sandwich of peanut butter and a piece of fruit or graham crackers and peanut butter and a piece of fruit. Interview with the DM, on 03/17/2022 at 10:22 AM, revealed the snack policy was that snacks were distributed at 10:00 AM, 2:00 PM, and 8:00 PM. However, she stated snacks had been on hold since before she started as the DM, and the facility had only provided 8:00 PM snacks before her arrival. The DM stated she had a list of the residents with specific orders for bedtime snacks, as well as snacks available in the nourishment rooms. She stated she got other snacks up and running after she started as the DM and kept peanut butter and crackers, milk, sometimes cookies, and fruit for snacks in the nourishment rooms. The DM stated a substantial snack for a diabetic resident would include peanut butter or items that were sugar free. She then stated a sugar free cookie or ½ cup of applesauce was not a substantial snack, and a protein would be needed for a snack to be substantial. Interview with the Administrator, on 03/19/2022 at 9:35 AM, revealed snacks had been ongoing since she learned they were not being distributed on a regular basis. She stated if a delivered snack was seen as not substantial, there were always snacks available that the nurses could obtain for the residents. She stated as soon as she found out there were no consistent snack times, she ensured snacks would be distributed routinely. In addition, she stated to her knowledge there were never occasions of being out of snack items or supplies for making sandwiches. The Administrator stated the process was that the dietary staff was responsible for checking the snack stock in the nourishment rooms every day.

Based on observations, interviews, and record review, it was determined the facility failed to ensure menus were posted and/or followed as posted. Review of the menus posted for 03/14/2022, lunch and dinner, and 03/17/2022, dinner only, did not match the foods observed to be served to the residents. This deficiency affected eighty-two (82) of eighty-four (84) current residents; two (2) residents were receiving tube feedings and did not receive meal trays. The findings include: The facility did not provide a policy for following menus. Review of the Resident Council meeting minutes, dated 01/14/2022, revealed the Administrator's signature was not dated. Further review revealed residents voiced concerns related to mealtimes and menus not being posted. The resolution listed was to start posting mealtimes and menus. The minutes also stated the current menu would be changing from the Fall/Winter menu to the Spring/Summer Menu very soon. 1. Review of the lunch meal menu posted, for 03/14/2022, revealed the foods to be served included: pot roast, mashed potatoes, mixed vegetables, choice of roll, and red gel cake. Further review revealed there were no alternative foods listed. Observation, on 03/14/2022 at 4:15 PM, revealed a pot of Ravioli (type of pasta) sitting on the three (3) bay sink in the kitchen. Interview with the DM (Dietary Manager) revealed cheese ravioli with sauce, broccoli, garlic toast, and grapes were the foods served for lunch, and the pot of ravioli sitting on the sink was to be thrown out. Review of the dinner menu posted, for 03/14/2022, revealed the foods to be served were cheese ravioli with sauce, broccoli, garlic toast, and grapes. Observation, on 03/14/2022 at 4:20 PM, of the dinner meal being prepared in the kitchen, revealed the foods being prepared included: chili with beans, grilled cheese sandwiches, tossed salad, and ice cream. Interview with the Dietary Manager (DM), on 03/14/2022 at 4:20 PM, revealed the menu changes on 03/14/2022 were due to the roast beef not having time to thaw to prepare for lunch. She stated the residents had cheese ravioli for lunch that was originally scheduled for dinner, which necessitated also changing the dinner menu. Interview with the Corporate Certified Dietary Manager (CCDM), on 03/14/2022 at 4:40 PM, revealed she was informed of the menu change due to the beef not being thawed timely. She stated she was working on a plan to correct this from happening. 2. Review of the Fall/Winter 2021-2022 dinner menu, on 03/17/2022 at 4:30 PM, revealed ham/potato augratin, tossed salad, roll, and fruit crisp were to be served to the residents for dinner. However, observation of the tray line, on 03/17/2022 at 4:30 PM, revealed the residents' dinner being prepared was pinto beans, mashed potatoes, greens, cornbread, and succotash, which was the only alternative food offered. Interview with the DM, on 03/17/2022 at 4:30 PM, revealed the menu change today was due to having to re-vamp the menu earlier in the week, on 03/14/2022. Interview and observation of the kitchen, on 03/17/2022 at 4:30 PM, revealed Cook #1 preparing deep fried cubed potatoes in a large pot of oil on the gas stove. At 4:40 PM, during the observation, the DM told the State Survey Agency (SSA) Surveyors that the fried potatoes were not going to be done in time for dinner. The posted menu was changed from fried potatoes to mashed potatoes at this point. Interview with the Administrator, on 03/18/2022 at 5:30 PM, revealed she only recently received the Resident Council minutes for the past few months because the previous Activities Director had not provided them as required. She stated she reviewed the minutes from the January 2022 meeting last week and signed off on them. She also stated one of her responsibilities was to be a patient (resident) advocate and to address concerns presented to her by the Resident Council.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of four (4) sampled residents (Resident #1). Resident #1's Comprehensive Care Plan, undated, with target date of 10/17/18, revealed an intervention dated 05/29/18 which stated, may use Mechanical Lift for transfers. Staff interviews revealed the resident would fidget or move about while being transferred with the Hoyer Lift (Mechanical Lift); however, record review revealed there was no documented evidence the resident's Comprehensive Care Plan was revised with interventions for safety related to this behavior during transfers. On 09/04/18, Resident #1 was being transferred from the wheelchair to the bed per the Hoyer Lift with the assistance of State Registered Nurse Aide (SRNA) #1 and SRNA #2. Per staff interview, the resident was moving around and squirming during this transfer, one (1) of the sling straps to the Hoyer Lift became disconnected from the sling attachment point on the sling bar, and the resident fell . Resident #1 suffered an Acute Closed Comminuted Left Distal Femur Fracture and a Right Distal Comminuted Femur Fracture requiring hospitalization . (Refer to F-689) The findings include: Interview with the Director of Nursing (DON), on 09/13/18 at 12:20 PM, revealed there was no facility Policy related to revising the Comprehensive Care Plan. The DON further stated the facility utilized the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0 as a reference for revising Care Plans. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #1's medical record revealed the facility admitted the resident on 05/09/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring total physical assistance of two (2) persons for transfers; and as having no falls since the prior Assessment. Review of the Comprehensive Care Plan, undated, revealed Resident #1 was at risk for falls related to impaired mobility secondary to late effects of Polio. The goal stated the resident would be free of falls with the target date of 10/17/18. There were several interventions which included anticipate and meet the resident's needs; call light in reach; dycem to wheelchair; and attempt to determine cause of falls and remove any potential causes if possible. Continued review of the Comprehensive Care Plan, undated, revealed the resident had limited mobility related to late effects of Polio, and declined therapy interventions for contractures. The goal stated the resident would be free from complications related to immobility with the target date of 10/17/18. There were several interventions which included wheelchair for locomotion, staff assist with mobility, and an intervention dated 05/29/18, stating, may use Mechanical Lift for transfers. Review of Resident #1's Progress Note, dated 09/04/18 at 8:09 PM, signed by LPN #1, revealed during transfer via Hoyer Lift, one (1) hook of the sling became unattached from the Hoyer lift and the resident fell to the floor. Per the Note, the resident stated he/she hit his/her head on the wheelchair and landed on his/her right side. The Note revealed Resident #1 was complaining of right sided pain and hurting all over. Further review of the Note, revealed the resident was kept immobile until Emergency Medical Technicians arrived. The Note further stated, the resident's sister was notified, and report was called to the Hospital Emergency Department. Continued review of the Note, revealed the resident was transported via Emergency Medical Services (EMS) to the Hospital. Review of the Hospital Discharge Summary, dated 09/07/18, revealed the patient was admitted on [DATE] after falling out of the Hoyer Lift at the Nursing Home landing on his/her Left Hip. X-Ray revealed a Closed Left Midshaft Femur Fracture. Orthopedics was consulted and did not think the resident was a surgical candidate as he/she had not mobilized in several months and a knee Immobilizer was recommended. However, a knee immobilizer could not be placed due to contracture. A (CT) Scan (computed tomography scan) of the left thigh on 09/07/18, demonstrated active hemorrhage from the superficial femoral artery (SFA) at the level of the adductor canal. Per the Summary, the resident was transferred to a University Hospital. Review of the University Hospital History and Physical dated 09/08/18, revealed the reason for visit was Bilateral Femur Fractures. Radiology studies dated 09/07/18, revealed a Comminuted Obliquely Oriented [MEDICAL CONDITION] Third of the Femur with overriding at the fracture site and Moderate Apex Posterior Angulation and Comminuted [MEDICAL CONDITION] Right Femur Extending Intercondylar and a [MEDICAL CONDITION] Condyle. Orthopedics consulted but likely non-operative given age and immobility. Interview on 09/11/18 at 2:43 PM, with Resident #1 during the resident's hospitalization , revealed he/she was hospitalized following a fall from a lift at the facility, which he/she stated was a result of the lift not getting fastened on one side. Resident #1 revealed both his/her legs were broken. Interview with SRNA #1, on 09/12/18 at 12:43 PM, revealed she was assigned to Resident #1's hall the evening of 09/04/18. She stated she asked SRNA #2 to come assist her with transferring the resident per the Hoyer lift. SRNA #1 further stated she made sure everything was secure, and was next to the resident, holding on to him/her while moving the wheelchair out of the way. Per interview, SRNA #2 was manning the Hoyer Lift controls. SRNA #1 stated Resident #1 started moving around, and SRNA #2 asked the resident to sit still; however, before the sentence was out of her mouth, the left lower sling strap had come unhooked and Resident #1 fell . SRNA #1 further stated she was unable to determine how the sling strap had come loose from the sling bar, and was unable to recall where Resident #1's hands or legs were at the time of the fall, as she (SRNA) #1, was moving the wheelchair out of the way. Per interview, prior to the fall, Resident #1 had been placed in the sling appropriately and the sling straps had been secured to the sling bar of the Hoyer lift. Continued interview revealed Resident #1 would move around or try to sit up while in the lift sling while being transferred despite staff reminding him/her to sit still. SRNA #1 stated when a resident moved around while in a Hoyer Lift sling while being transferred, she would attempt to lower the resident to the closest bed or chair, but during this incident Resident #1 fell so suddenly, there was not enough time to do that. Interview with SRNA #2, on 09/12/18 at 1:15 PM, revealed she was working on Resident #1's hall on 09/04/18, when she was asked to assist SRNA #1 in transferring Resident #1 from his/her wheelchair to bed. SRNA #2 stated she and SRNA #1 checked out the Hoyer Lift, making sure everything was in proper order, and all the straps to the sling were properly connected before attempting the transfer with the Hoyer Lift. She further stated Resident #1 began squirming, and as she was asking Resident #1 to stop, the resident fell . Per interview, prior to the fall, the resident had been positioned appropriately on the sling, and the sling straps had been secured appropriately. Per interview, the sling had no rips or tears when it was examined after the fall. SRNA #2 stated she was unable to determine how the left lower sling strap had come loose. Further interview revealed Resident #2 had squirmed around in the lift on previous occasions, and would say the pad (sling pad) was killing him/her and she (SRNA #2) would explain to the resident, the Hoyer Lift had to be used. SRNA #2 stated the nurses were aware of how the resident acted when being transferred with the Lift. Additional interview revealed normally when a resident moved around while being transferred with a Hoyer Lift, the resident was lowered to the nearest bed or chair, but in this instance there wasn't time. Additional review of Resident #1's Comprehensive Care Plan, revealed there was no documented evidence the Care Plan was revised related to the resident's behaviors of squirming, moving around, or reaching for sling straps during Hoyer Lift transfers, with interventions to address these behaviors for the resident's safety, prior to the fall on 09/04/18. Interview with Licensed Practical Nurse (LPN) #1, on 09/13/18 at 9:23 AM, revealed she was passing medications on 09/04/18, when SRNA #2 informed her Resident #1 fell from the lift. She stated SRNA #1 and SRNA #2 informed her Resident #1 started fidgeting, moving his/her arms and moving around, and somehow the sling strap came loose. She further stated she examined Resident #1 to the extent possible without moving him/her, and due to complaints of pain the resident was transported by Emergency Medical Services (EMS) to the local hospital. LPN #1 stated she was aware Resident #1 squirmed a lot when transferred, and attributed it to the lift being uncomfortable for him/her; however, she did not ask the MDS Nurse to Care Plan this issue, nor did she Care Plan this issue prior to the resident's fall on 09/04/18. Interview with SRNA #3, on 09/12/18 at 4:04 PM, revealed Resident #1 did not like the Hoyer Lift, and would attempt to move around while in the Lift sling. He stated whenever that was the case, he would lower Resident #1 to whatever was closer, the chair or the bed. Interview with SRNA #4, on 09/13/18 at 10:25 AM, revealed Resident #1 would try to turn from side to side and reach out for the leg straps, while in the Hoyer Lift sling during transfers. She stated she would remind Resident #1 of the need to keep his/her hands inside the sling and stay still, and if the resident persisted with the same behavior, she would put him/her back down in the bed or the chair, and readjust the sling. Interview with SRNA #5, on 09/13/18 at 10:45 AM, revealed Resident #1 constantly complained when in the Hoyer Lift sling of it hurting him/her and would sometimes fidget or lean to the side while in the sling during transfer. She stated Resident #1 would also reach out and grab anything hanging down, such as sling loops, or the sling bar. She further stated she had alerted nurses that Resident #1 threw a fit, when being transferred with the Hoyer Lift. Interview with Registered Nurse (RN) #1 on 09/13/18 at 12:44 PM revealed she had never been informed Resident #1 was restless or fidgety while on the lift. Interview on 09/13/18 at 1:50 PM with MDS Nurse #2, revealed she revised Resident #1's Comprehensive Care Plan after the Quarterly MDS assessment dated [DATE]. She stated although she was aware Resident #1 exhibited behaviors directed towards nurse aides, she was not aware of behaviors such as fidgeting or moving around while being transferred with the Hoyer lift. She further stated although she didn't believe it would have prevented this fall incident, she did feel the resident's behaviors while being transferred per the Hoyer Lift should have been care planned, with safety interventions related to this behavior. Interview with the Director of Nursing (DON), on 09/12/18 at 8:58 AM, and on 09/12/18 at 4:36 PM, revealed Resident #1's fall on 09/04/18 was discussed during the investigation with the interdisciplinary team and the facility identified the sling strap came loose from the sling bar of the Hoyer lift; however, they were unable to determine how the sling straps could come loose from the sling if correctly secured. Additional interview revealed she was unaware prior to Resident #1's fall on 09/04/18, that the resident was being restless or fidgety in the sling during Hoyer Lift transfers. She stated if this concern had been communicated the issue could have been brought up to the resident in the care plan meetings, and the Care Plan could have been revised related to this behavior for the resident's safety. Phone interview with the Administrator, on 09/13/18 at 9:37 AM, revealed she received a call on 09/04/18 after Resident #1's fall and came in to initiate the investigation. She stated the Hoyer Lift was checked by Maintenance after the fall and was found to be in good working order, and her inspection of the sling pad used during Resident #1's transfer determined it was in good working order. The Administrator stated both SRNA #1 or SRNA #2 were able to effectively demonstrate proper procedure for use of the Hoyer lift after the incident and she was unable to determine the cause of the fall. This Administrator was unable to be interviewed related to Resident #1's Care Plan on a later date during the Survey as she was off work on emergency leave. Interview with the Acting Administrator, on 09/13/18 at 2:25 PM, who was Acting during the Survey, revealed behaviors such as fidgeting in a Hoyer Lift should be communicated in order for the Care Plan to be revised for resident safety.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of four (4) sampled residents (Resident #1). Resident #1 was assessed by the facility to required total assistance of two (2) persons for transfers per the Minimum Data Set (MDS) Assessment, dated 06/29/18. Per the Comprehensive Care Plan, undated, there was an intervention which stated, may use Mechanical Lift for transfers. Although staff interviews revealed the resident would fidget or move about while being transferred with the Hoyer Lift (Mechanical Lift), record review revealed there was no documented evidence the resident's Comprehensive Care Plan was revised with interventions for safety related to this behavior during transfers. On 09/04/18, Resident #1 was being transferred per the Hoyer Lift from the wheelchair to the bed with the assistance of State Registered Nurse Aide (SRNA) #1 and SRNA #2. Staff interviews revealed the resident was moving around and squirming during this transfer, and one (1) of the sling straps to the Hoyer Lift became disconnected from the sling attachment point on the sling bar, resulting in the resident sustaining a fall. Resident #1 suffered an Acute Closed Comminuted Left Distal Femur Fracture and a Right Distal Comminuted Femur Fracture requiring hospitalization . (Refer to F-657) The findings include: Review of the facility Accidents/Incidents Policy, dated 08/01/13, revealed it was facility policy to provide a safe and healthful work environment. The section titled, Investigative Action, revealed the charge nurse or the department supervisor shall conduct an immediate investigation of an accident or incident to include names of witnesses and their accounts of the incident/accident; the injured persons account of the accident/incident; corrective action taken; and other pertinent data. Review of Resident #1's medical record revealed the facility admitted the resident on 05/09/13 with [DIAGNOSES REDACTED]. The facility assessed Resident #1 in a Quarterly Minimum Data Set ((MDS) dated [DATE], as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident as requiring total physical assistance of two (2) persons for transfers; and as having no falls since the prior Assessment. Review of Resident #1's Comprehensive Care Plan, undated, revealed the resident was at risk for falls related to impaired mobility secondary to late effects of Polio. The goal stated the resident would be free of falls with a target date of 10/17/18. There were several interventions including anticipate and meet the resident's needs; call light in reach; dycem to wheelchair; and attempt to determine cause of falls and remove any potential causes if possible. Further review of the Comprehensive Care Plan, undated, revealed the resident had limited mobility related to late effects of Polio. The goal stated the resident would be free from complications related to immobility with a target date of 10/17/18. There were several interventions including wheelchair for locomotion, staff assist with mobility, and an intervention dated 05/29/18 which stated, may use Mechanical Lift for transfers. Review of Resident #1's Fall Risk Assessment, dated 07/12/18, revealed the resident scored an eight (8). According to the Assessment, if the score was ten (10) or greater, the resident would be considered high risk for falls. Review of the Monthly September 2018 physician's orders [REDACTED]. Review of the Resident Incident/Accident Follow Up Assessment Form, dated 09/04/18, completed by Licensed Practical Nurse (LPN) #1, revealed Resident #1 sustained a fall on 09/04/18 at 7:45 PM, and the resident complained of right hip and left hip and leg pain. Vital Signs were documented as Temperature 96.8, Pulse 48, respirations 20, and Blood Pressure 134/48. Under the section titled, Ask resident what precipitated the Fall, there was a comment stating, I was being put to bed and fell out of the lift. Under the section titled Causative Factor, documentation revealed the lift strap slid off the lift hook while resident was moving around in lift (fidgety). Resident assisted to floor. Sling was noted to be intact with no fraying or tears noted. Under the section titled Action Taken, documentation revealed the lift was taken out of service and evaluated by maintenance with no problems noted. Review of Resident #1's Progress Notes dated 09/04/18 at 8:09 PM, completed by LPN #1, revealed during transfer via Hoyer Lift, one (1) hook of the sling became unattached from the Hoyer lift and the resident fell to the floor. Upon assessment the resident stated he/she hit his/her head on the wheelchair and landed on his/her right side. The Note further stated Resident #1 was complaining of right sided pain and hurting all over. Continued review of the Note, revealed the resident was kept immobile until Emergency Medical Technicians arrived. Per the Note, the resident's sister was notified, and report was called to the Hospital Emergency Department. Further review of the Note, revealed the resident was transported via Emergency Medical Services (EMS) to the Hospital. Review of the Hospital Discharge Summary, dated 09/07/18, revealed the patient was admitted on [DATE] after falling out of the Hoyer Lift at the Nursing Home landing on his/her Left Hip. X-Ray revealed a Closed Left Midshaft Femur Fracture. Orthopedics was consulted and did not think the resident was a surgical candidate as he/she had not mobilized in several months and a knee Immobilizer was recommended. However, a knee immobilizer could not be placed due to contracture. A (CT) Scan (computed tomography scan) of the left thigh on 09/07/18, demonstrated active hemorrhage from the superficial femoral artery (SFA) at the level of the adductor canal. Per the Summary, the resident was transferred to a University Hospital. Review of the University Hospital History and Physical dated 09/08/18, revealed the reason for visit was Bilateral Femur Fractures. Radiology studies dated 09/07/18, revealed a Comminuted Obliquely Oriented [MEDICAL CONDITION] Third of the Femur with overriding at the fracture site and Moderate Apex Posterior Angulation and Comminuted [MEDICAL CONDITION] Right Femur Extending Intercondylar and a [MEDICAL CONDITION] Condyle. Orthopedics consulted but likely non-operative given age and immobility. Interview with Resident #1, on 09/11/18 at 2:43 PM, while hospitalized , revealed he/she had been hospitalized following a fall from a lift at the facility, which he/she stated was a result of the Lift not getting fastened on one side. Resident #1 revealed both his/her legs were broken. Review of SRNA #1's Statement, dated 09/04/18, revealed Resident #1 was in his/her wheelchair sitting on the lift pad (sling). SRNA #1 hooked the resident up and SRNA #2 was standing behind the lift ready to lift with the remote. SRNA #2 began to lift him/her, the resident cleared the chair, and SRNA #1 pushed the wheelchair out of the way. SRNA #1 heard SRNA #2 tell the resident to sit still. SRNA #1 turned around and saw the resident sliding from the lift, hitting his/her head on the cushion of the wheelchair. SRNA #1 noticed the hook was unhooked on the left lower side. Further review of the Statement, revealed the nurse was immediately called and came to see about the resident. Interview with SRNA #1, on 09/12/18 at 12:43 PM, revealed she was assigned to Resident #1's hall on 09/04/18, and responded to his/her call light that evening. She stated Resident #1 wanted to go to bed, so she asked SRNA #2 to come assist her with the Hoyer lift. SRNA #1 further stated she made sure everything was secure, and was next to Resident #1, holding on to him/her while moving the wheelchair out of the way. Per interview, SRNA #2 was manning the lift controls. SRNA #1 stated Resident #1 started moving around, and SRNA #2 asked the resident to sit still, but before the sentence was out of her mouth, the left lower sling strap had come unhooked and Resident #1 fell . SRNA #1 further stated she was unable to determine how the sling strap had come loose from the sling bar, and was unable to say where Resident #1's hands or legs were at the time of the fall, as she (SRNA) #1, was moving the wheelchair out of the way. SRNA #1 stated, prior to the fall, Resident #1 had been placed in the sling appropriately and the sling straps had been secured to the sling bar of the Hoyer lift. Further interview revealed Resident #1 would move around or try to sit up while in the lift sling while being transferred despite staff reminding him/her to sit still. SRNA #1 stated when a resident moved around while in a Hoyer Lift sling while being transferred, they would attempt to lower the resident to the closest bed or chair, but during this incident Resident #1 fell so suddenly, there was not enough time. Review of SRNA #2's Statement, dated 09/04/18, revealed Resident #1 was in the wheelchair sitting on the lift pad (sling). SRNA #1 made sure the lift pad was in place before hooking up the sling. SRNA #2 hooked the top part of the lift on green hooks and the bottom part on purple. SRNA #1 and SRNA #2 checked that loops were in place on the lift. Started to raise the lift pad and {the resident} started squirming around and kept saying the lift was killing {him/her}, it rips my butt off. SRNA #1 moved the wheelchair back after we stated lifting the resident. All of the sudden his/her left leg was hanging so we stopped and observed the left hook was unhooked. SRNA #1 tried to grab him/her and the resident rolled out of the lift pad. We were able to keep his/her upper body from hitting the floor. Further review of the Statement, revealed the resident's head hit the cushion of the wheelchair and the resident landed on her right side. Per the Statement, the nurse was immediately called and came to assess the resident. Interview with SRNA #2, on 09/12/18 at 1:15 PM, revealed she was working on Resident #1's hall on 09/04/18, when she was called to assist SRNA #1 in transferring Resident #1 from his/her wheelchair to bed. SRNA #2 stated she and SRNA #1 checked out the Hoyer Lift, making sure everything was in proper order, and all the straps to the sling were properly connected before attempting the transfer per the Hoyer Lift. She further stated Resident #1 began squirming, and as she was asking Resident #1 to stop, Resident #1 fell . Per interview, prior to the fall, Resident #1 had been positioned appropriately on the sling, and the sling straps had been secured appropriately. She stated the sling had no rips or tears when examined after the fall. SRNA #2 further stated she was unable to determine how the left lower sling strap had come loose. Additional interview revealed Resident #2 had squirmed around in the lift on previous occasions, and would say the pad (sling pad) was killing him/her and she (SRNA #2) would explain to the resident, the Hoyer Lift had to be used. Per interview, the nurses were aware of how the resident acted when being transferred with the Lift. Further interview revealed normally when a resident moved around while being transferred with a Hoyer Lift, the resident was lowered to the nearest bed or chair, but in this instance there wasn't time. Further review of Resident #1's Comprehensive Care Plan, revealed there was no documented evidence the Care Plan was revised related to the resident's behaviors of squirming, moving around, or reaching for sling straps during Hoyer Lift transfers, with interventions to address these behaviors for the resident's safety, prior to the fall on 09/04/18. Interview with Licensed Practical Nurse (LPN) #1, on 09/13/18 at 9:23 AM, revealed she was passing medications on 09/04/18 when SRNA #2 came out into the hall and informed her Resident #1 fell from the lift. She stated SRNA #1 and SRNA #2 informed her Resident #1 started fidgeting, moving his/her arms and moving around, and somehow the strap came loose. She further stated she examined Resident #1 to the extent possible without moving him/her, and was unable to visualize any apparent injury, although he/she complained of non-centralized pain. Further interview revealed she made the appropriate calls, and Resident #1 was transported by Emergency Medical Services (EMS) to the local hospital. LPN #1 revealed she was aware Resident #1 squirmed a lot when transferred, and attributed it to the Lift being uncomfortable for him/her; however, she did not ask the MDS Nurse to Care Plan this issue, nor did she Care Plan this issue prior to the resident's fall on 09/04/18. Interview with SRNA #3, on 09/12/18 at 4:04 PM, revealed Resident #1 did not like the Hoyer lift, and would attempt to move around while in the Lift sling during transfers. He further stated whenever that was the case, he would lower Resident #1 to whatever was closer, the chair or the bed. Interview with SRNA #4, on 09/13/18 at 10:25 AM, revealed Resident #1 would try to turn from side to side and would reach out for the leg straps while in the Hoyer Lift sling during transfers. SRNA #4 stated she would remind Resident #1 of the need to keep his/her hands inside the sling and stay still, and if the resident persisted with the same behavior, she would put him/her back down in the bed or the chair, and readjust the sling. Interview with SRNA #5, on 09/13/18 at 10:45 AM, revealed Resident #1 constantly complained when in the Hoyer Lift sling of it hurting him/her and would sometimes fidget or lean to the side while in the sling during Hoyer Lift transfers. SRNA #5 stated Resident #1 would also reach out and grab anything hanging down, such as sling loops, or the sling bar. Per interview, she had alerted nurses that Resident #1 threw a fit, when being transferred with the Hoyer Lift. Interview with the Staff Development Nurse (SDN), on 09/12/18 at 11:15 AM, revealed she was not present when the accident occurred, and did not know how Resident #1 fell from the Hoyer lift. She stated it was hard for her to fathom how a sling strap could come loose from a sling bar if properly attached. She further stated the Administrator immediately had the Hoyer lift pulled from the floor for it to be examined by maintenance, after the resident sustained [REDACTED]. Interview with the Maintenance Director, on 09/13/18 at 2:42 PM, revealed he was called into the facility on the evening of 09/04/18, after Resident #1 sustained the fall, and examined the Hoyer lift involved in the incident. He stated the lift was in good shape with no issues identified. Further interview revealed he checked the lifts monthly and if there was a problem they were pulled out of operation until repaired. Interview on 09/13/18 at 1:50 PM with MDS Nurse #2, revealed she revised Resident #1's Comprehensive Care Plan after the 06/29/18 Quarterly MDS Assessment. Per interview, although she was aware Resident #1 exhibited behaviors directed towards nurse aides, she was not aware of any behaviors such as fidgeting or moving around while on the Hoyer lift. She stated she didn't believe it would have prevented this fall incident, but did feel it was important information that should have been included in Resident #1's care plan, with safety interventions related to this behavior. Interview with the Director of Nursing (DON), on 09/12/18 at 8:58 AM, and on 09/12/18 at 4:36 PM, revealed falls were discussed the following work day in the Morning Meetings with the interdisciplinary team which included the DON, Unit Managers, MDS Coordinators, and applicable department heads to analyze the root cause of the falls as a team. She stated Resident #1's fall on 09/04/18 was discussed during the investigation and the facility identified the sling strap came loose from the sling bar of the Hoyer lift; however, they were unable to determine how the sling straps could come loose from the sling if correctly secured. She further stated maintenance examined the lifts monthly, and had also done so following the incident, and there were no issues with the lift. Per interview, the slings were examined every time they went through the wash by housekeeping staff and by SRNAs prior to use, and no concerns had been identified with the slings. Further interview revealed she was unaware prior to Resident #1's fall on 09/04/18 that the resident was being restless or fidgety in the sling during Hoyer Lift transfers. She stated if this concern had been communicated, the issue could have been brought up to the resident in the care plan meetings, and the Care Plan could have been revised related to this behavior for the resident's safety. Phone interview with the Administrator, on 09/13/18 at 9:37 AM, revealed she received a call on 09/04/18 following Resident #1's fall and came in to initiate the investigation. She stated upon her arrival, Resident #1 was already out of the facility. She further the Hoyer Lift used for Resident #1's transfer was put out of order until checked by Maintenance, and when checked it was found to be in good working order. She further revealed per her inspection the sling pad used during Resident #1's transfer was determined to be in good working order as well. Per interview, both SRNA #1 or SRNA #2 were able to effectively demonstrate proper procedure for use of the Hoyer lift several times after the incident. Further interview revealed she was unable to determine the cause of the fall. This Administrator was unable to be interviewed for more information on a later date during the Survey, as she was off work on emergency leave. Interview with the Acting Administrator, on 09/13/18 at 2:25 PM, who was Acting during the Survey, revealed the incident had been thoroughly investigated, and they had not been able to recreate the accident or determine how the Resident #1's fall could have occurred. Further interview revealed behaviors which could be a safety problem should be care planned.

Based on observation, interview, record review, and review of facility's policy, it was determined the facility failed to ensure the Comprehensive Plan of Care/Acute Care Plan was evaluated and revised to accurately reflected the resident's status and needs related to Pressure Ulcers. The Care Plans were not being revised when new Pressure Ulcers were identified and were not being revised as Pressure Ulcers improved or deteriorated. This failure affected nine (9) of fourteen (14) sampled residents (Resident's #1, #2, #4, #5, #7, #8, #10, #11, #12). (Refer to F314) The findings include: Review of the facility Care Plan Goal and Objectives Policy, dated 08/01/13, revealed care plans should incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were defined as the desired outcome for a specific resident problem. Goals and objectives were entered on the resident's care plan so that all disciplines had access to such information and were able to report whether or not the desired outcomes were achieved. Goals and objectives were reviewed and revised when there was a significant change in the resident's condition, and when the resident had been readmitted from a hospital stay. Review of the Resident Assessment Instrument Version 3.0 Manual, (section 4.1) revealed the results of the assessment which must accurately reflect the resident's status and needs, were to be used to review and revise each resident's Comprehensive Plan of Care. Section 4.7 revealed the Care Plan must be reviewed and revised periodically and services provided or arranged must be consistent with each resident's written plan of care. Interview on 08/19/15 at 12:30 PM, with MDS Coordinator #1 who was over the other MDS Nurses, revealed there were three (3) MDS Nurses in the facility who all completed MDSs and developed/revised care plans. She revealed acute care plans would be done for each wound for the date the wound was identified. Per interview, when the next MDS assessment was completed, if the wound was still there, the comprehensive care plan would include the wound. She further stated the care plan did not need to specify the site of the wound or the stage of the wound because the nurses could look at the Treatment Administration Record (TAR) for treatments and look at the skin assessments for stages of the wound to see if the wound was healing or deteriorating. Continued interview revealed the care plan could state the resident had impaired skin integrity, and did not have to specify the resident had a pressure ulcer. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 03/11/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring the extensive assist of two (2) for bed mobility, transfers and toileting. Continued review of the MDS, revealed the facility assessed the resident as always incontinent of urine, frequently incontinent of bowel, and as having no pressure ulcers. Review of the Significant Change MDS dated [DATE] revealed the facility assessed Resident #1 as having both short and long term memory impairment, as requiring extensive assist of two (2) for bed mobility, transfers, and toileting and as always incontinent of bowel and bladder. Further review of the MDS revealed the facility assessed the resident as having one (1) Stage II pressure ulcer and having one (1) unstageable pressure ulcer. Review of the Comprehensive Plan of Care, dated 03/23/15, revealed Resident #1 had the potential for impaired skin integrity related to immobility. The goal stated the resident would not develop pressure ulcers. The interventions included monitoring for skin intolerance to two (2) hour turning schedule, reposition in wheelchair frequently, turn and reposition every two (2) hours, nursing staff to monitor for indication of skin impairment during daily care, report any red or open areas, and weekly skin assessments by the licensed staff to monitor for any indication of skin breakdown. Review of the Nurse's Note dated 04/06/15 at 1545 (3:45 PM), revealed Resident #1 was identified to have a Stage II pressure ulcer measuring two (2) centimeters (cm) length by one (1) cm width with yellow slough noted extending for an undetermined amount into the rectum. Review of the Wound Care Summary (WCS) dated 04/06/15 revealed the resident had a wound to the left buttock. The Acute Care Plan initiated 04/06/15 revealed the resident had a pressure ulcer related to decreased mobility; however, the care plan did not specify the site or the stage of the pressure ulcer. Review of the WCS dated 04/09/15 revealed the resident's left buttock pressure ulcer measured 1.5 cm by 3.0 cm and there was an open wound with gray/pale slough, slight odor, and purulent drainage. The WCS dated 04/21/15 revealed the resident's left buttock pressure ulcer measured 1.0 cm by 3 cm by 0.3 cm and was an open wound that extended into the rectum with decreased slough, slight odor and purulent drainage. Further review of the WCS dated 04/21/15 revealed the resident had a new pressure ulcer to the coccyx described as Stage II measuring 0.6 cm by 0.4 cm, with red surrounding skin with blanching discoloration, no odor, and scant serosanguinous drainage. Further review of the clinical record revealed no documented evidence the resident's care plan was revised until 05/23/15, approximately four (4) weeks after the new area was identified. Review of the Acute Care Plan initiated on 05/23/15 revealed the care plan did not specify the stage of the pressure ulcers. Review of the Resident Data Collection (RDC) dated 05/12/15, revealed Resident #1 was readmitted to the facility and the resident was assessed to have a Sacral Stage II pressure ulcer, and a right heel Suspected Deep Tissue Injury (SDTI). However, the care plan was not revised related to the new SDTI of the right heel. Review of the weekly Skin Report dated 05/28/15 revealed Resident #1 had a sacral wound, Stage II 2 cm by 3 cm x 1 cm depth with eschar noted in the wound bed, fluid filled blister on the right side of the wound, a right heel SDTI 2 cm by 2 cm which was dark purple, and an open are to the left buttock measuring 3 cm by 1 cm which was not staged. Review of the Wound Care Clinic Note dated 06/04/15, revealed the decubitus (sacral and buttock) was now one (1) big ulcer, gray wound bed to 80%, red granulation to 20%, measures 10 cm by 6 cm by unknown depth. Although the sacral/left buttock continued to deteriorate, there was no documented evidence the care plan was evaluated and revised in order to assess the effectiveness of the interventions. Interview on 08/10/15 at 5:45 PM with MDS Coordinator #1, revealed she reviewed the care plans for Resident #1 and stated the care plan related to the resident's left buttock wound on 04/06/15 should have revealed the site and stage of the wound and she did not know why resolved was written at the top of the care plan since the wound had not resolved. Continued interview revealed the care plan related to the resident's coccyx wound dated 04/21/15 should have revealed the stage of the pressure ulcer. In addition, MDS Coordinator #1 stated the care plan should have been updated related to the resident's SDTI to the right heel when the resident was readmitted from the hospital on [DATE]. Further interview revealed it would be important to be specific on the wound care plans to be able to show the tracking and trending and evaluate the effectiveness of the interventions. 2. Review of Resident #10's medical record revealed the facility admitted the resident on 02/02/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], revealed the facility assessed Resident #10 as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15). Further review revealed the facility assessed Resident #1 as requiring extensive assistance of two (2) for bed mobility, transfers, toilet use, as not rated for urinary incontinence, as always incontinent of bowel and as having one (1) unstageable pressure ulcer. Review of the Comprehensive Plan of Care, undated, revealed Resident #10 had potential impairment/actual impairment to skin integrity due to impaired mobility and multiple pressure sores. The goal stated the resident would have no complications related to skin injury. The interventions included pressure relieving cushion to wheelchair, follow skin care protocol, observe location, size and treatment of [REDACTED]. There was a new intervention added on 05/04/15 to see TAR for treatments of skin tears and pressure areas and a new intervention added on 07/15/15 for gel boots. Review of the Nurse's Notes dated 02/16/15 on re-admission to the facility after hospitalization , revealed Resident #10 had a 1.3 cm by 1.0 cm open area to the left sacrum, a 1.7 cm by 0.8 cm open area to the right sacrum, and a 4.4 cm by 3.8 cm fluid filled purple area to the right heel. However, there was no documented evidence the Care Plan was revised related to the right and left sacrum and right heel pressure ulcers. The pressure ulcer to the right heel continued to deteriorate. The WCS dated 02/23/15 described the resident's right heel ulcer measured 5.0 cm by 4.0 cm red purple blister. However, there was no documented evidence the Care Plan was revised related to the the resident's right heel ulcer. The WCS dated 03/12/15 described the right heel as unstageable and measured 6.0 cm by 5.0 cm with eschar and brown drainage indicating the wound was deteriorating. However, there was no documented evidence the Care Plan was revised. The WCS dated 04/09/15 described the right heel ulcer as 75% eschar, measuring 6.5 cm by 7.5 cm wound bed with serosanguinous drainage. Further review revealed on 04/09/15 the WCS revealed the resident had a SDTI measuring 1.0 cm by 1.0 cm purple area to the left coccyx; however, the care plan was not revised related to this new area. The WCS dated 04/14/15 revealed the resident's SDTI to the left coccyx measured 3.0 cm by 3.0 cm's and was purple maroon in color, and the right heel wound measured 5.0 cm by 6.5 cm with 75% eschar and 25% red wound bed, brown drainage with odor. However, there was no documented evidence the Care Plan was revised. The WCS dated 04/21/15 revealed the resident's left coccyx SDTI was now unstageable and measured 2.0 cm by 3.5 cm with 100% slough, and serosanguinous drainage with nonblanchable skin surrounding the ulcer. Further review of the WCS dated 04/21/15 revealed the resident's right heel ulcer measured 5.0 cm by 6.5 cm with greater than 75% eschar and brown drainage. Additionally, the WCS dated 04/21/15 revealed the resident had a new SDTI measuring 1.0 cm by 1.0 cm non blanching purple maroon in color to the right coccyx. However, again the care plan was not revised related to this new pressure ulcer to the coccyx. On 05/14/15 a WCS was initiated related to a SDTI on the left lower inner buttocks measuring 1.0 cm x 0.5 cm. However, there was no care plan initiated for this pressure ulcer. On 06/02/15 a weekly Skin Assessment described the resident's left coccyx wound as unstageable measuring 6.0 cm by 3.0 cm by 0.5 cm; the resident's right coccyx as a SDTI measuring 1.0 cm by 1.0 cm; and, the resident's right heel wound as unstageable measuring 6 cm by 8 cm with eschar. Also, on the 06/02/15 weekly Skin Assessment, it was noted Resident #10 had a SDTI to the left inner buttock which was red and non blanchable measuring 6.0 cm by 5.0 cm. However, on the same date, 06/02/15, physician's orders [REDACTED]. There was no indication the care plan was revised related to the area on the left inner buttock. The weekly Skin assessment dated [DATE] described the resident as having fluid filled blisters to the bilateral upper thighs and a left buttock SDTI measuring 3.0 cm by 1.0 cm. However, there was no indication the Physician was notified of the blisters to the resident's bilateral upper thighs and the left buttock SDTI, even though there was no treatment ordered for these areas. Also, there was no revision of the care plan related to these areas. The weekly Skin assessment dated [DATE] did not mention the resident's right coccyx wound. The resident's unstageable right heel ulcer was measured at 6.0 cm by 8.0 cm with eschar. The resident's left coccyx ulcer was described as Stage II measuring 4 cm x 2.2 cm x 1.5 cm with a 2 cm tunnel to 12 o'clock and the wound bed had 25% eschar. The resident's left lower coccyx was mentioned separately as 1.2 cm x 1 cm stage II. The resident's left inner buttock area was not mentioned in this assessment. Additionally, the resident's posterior left thigh area was described as 6.0 cm by 2.5 cm stage II and there was dried blood blisters to the right thigh. However, there was no documented evidence the Care Plan was revised. The weekly Skin Report dated 06/23/15 also revealed the an unstageable area to the left posterior thigh and measured 4.5 cm x 2.8 cm but did not mention the left lower coccyx wound. There was no revision of the care plan related to the areas to the thighs or the left lower coccyx. Review of the Wound Care Clinic Note dated 06/22/15, described the resident's coccyx decubitus as measuring 4.0 by 2.0 by 2.0 with pink granulation tissue and loose gray slough in the wound bed. Further review, revealed the resident's right heel had a large black eschar 5.5 cm x 9.5 cm with the odor of gangrene with some purulent drainage. Additionally, the Note stated the resident had a decubitus ulcer to the left ischium with thin eschar which measured 4.0 cm x 2.5 cm x unknown depth. However, there was no care plan initiated for the ischium pressure ulcer. Further review of the record revealed the resident was followed in the Wound Care Clinic on 07/06/15, 07/13/15, and 07/20/15 related to the decubitus ulcers on the right heel, coccyx and left ischium. Review of the 07/20/15 Wound Care Clinic Note, revealed there was more necrosis in the resident's coccyx wound and ischial wound and bone was exposed in the right heel and would consult with General surgery for [REDACTED]. However, there was no documented evidence the Care Plan was revised. The WCS on 08/14/15 revealed the resident's coccyx wound had deteriorated, was unstageable and measured 5.0 cm by 3.0 cm by 1.0 cm with tunneling from 9 o'clock to 3 o'clock measuring 1.9 cm with the wound bed described as 25% slough, and wound edges with maceration, purulent drainage. Further review revealed the WCS dated 08/14/15 related to the resident's left ischium revealed the area was unstageable measuring 6.0 cm by 3.4 cm by 4.8 cm, wound bed with slough present and purulent drainage. Further review of the WCS dated 08/14/15 revealed the right heel wound was described as a Stage IV measuring 7.0 cm by 7.0 cm by 1.3 cm, with eschar noted along the 6 o'clock side of the wound and bone visible, white maceration to the wound edges and purulent drainage. Although the resident's pressure ulcers continued to deteriorate, there was no documented evidence of the facility utilizing the care plan to evaluate the effectiveness of the treatments or follow the progression of the wounds. 3. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/09/14 with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed Resident #2 as requiring extensive assistance of two (2) persons for bed mobility, dressing, toilet use and personal hygiene. Further review of the MDS revealed the facility assessed the resident as being at risk for developing pressure ulcers with a history of pressure ulcers noted during the last MDS assessment. Review of Resident #2's Comprehensive Care Plan, dated 04/21/14, revealed the resident had a problem of skin integrity, impaired: potential related to impaired mobility, Diabetes, Arthritis, chronic pain, incontinence, and declined to turn and reposition in the bed or wheelchair. The goal stated Resident #2 would have intact skin. The interventions included weekly skin assessments by licensed staff/ monitor for any indication of skin breakdown, RD consult, gel cushion to wheelchair, reposition in wheelchair and chair frequently, treatments per orders-see TAR, turn and reposition every two (2) hours, and bilateral heel protectors to feet when in bed. Further review of Resident #2's record revealed Nurse's Notes dated 08/04/15, which stated there was three (3) stage II's ulcers noted to the resident's coccyx. Review of the Acute Care Plan dated 08/05/15, revealed the resident had a Stage II Pressure Ulcer to the coccyx; however, did not indicate there was three (3) Stage II areas to the coccyx. Review of Resident #2's weekly Skin Assessment revealed an entry on 08/06/15 which described the Stage II ulcer to the left upper buttock as 0.5 cm x 1 cm with 100% granulation with 1 cm x 1 cm purple discoloration surrounding the area, dry peeling skin to the surrounding tissue and serosanguinous drainage. Review of the resident's care plan revealed the care plan had not been revised to indicate the resident had a Stage II ulcer to the left upper buttock. Interview with MDS Coordinator #4, on 08/12/15 at 9:15 AM, revealed the wounds changed daily so wound sites and stages did not have to be on the care plan. Continued interview revealed nurses could look at the skin assessment book to see all wound progress. 4. Review of Resident #4's clinical record revealed the facility admitted the resident on 04/20/10 with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS assessment dated [DATE], revealed the facility assessed Resident #4 as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15). Continued review of the MDS revealed the facility assessed the resident as requiring extensive assistance of one (1) for bed mobility, dressing and personal hygiene and and as requiring extensive assistance of two (2) for transfers, and toilet use. Per the MDS, the facility further assessed the resident to be frequently incontinent of urine and occasionally incontinent of bowel, and as having two (2) Stage II Pressure Ulcers at the time of the assessment which had not been present on the prior assessment. Review of Resident #4's Comprehensive Care Plan, dated 06/04/12, revealed the resident had a skin integrity problem related to a history of recurrent skin tears on the buttocks that develop into ulcers and immobility. The goal stated Resident #4 would have intact skin. The interventions included; assess wound healing by a licensed nurse, measure length, width and depth where possible and assess and document status of wound perimeter, wound bed and healing progress, assist to turn and reposition at least every two (2) hours, and follow the facility protocol for the prevention/treatment of [REDACTED]. Review of Resident #4's Nurses Notes dated 04/28/15 revealed a new Stage II area to right buttock measuring 0.8 cm x 0.8 cm, red, no odor and a scant amount of serosanguinous drainage. However, there was no care plan initiated related to the Stage II pressure ulcer to the right buttock. Further review of Resident #4's Nurse's Notes dated 05/06/15, revealed the resident had a new Stage II ulcer to the right upper posterior thigh measuring 1.5 cm x 0.5 cm, red, no odor with serosanguinous drainage. However, there was no care plan initiated for the Stage II pressure ulcer to the right upper posterior thigh. Further review revealed an Acute Care Plan was initiated 06/24/15 which stated the resident had a pressure ulcer. The goal stated the pressure ulcer would decrease in size. There were several interventions including keep skin clean, warm, and dry, promote nutritional status, assess for signs and symptoms of worsening, of infections or complications daily, treatments as ordered, assess skin daily during care for changes and report to nurse supervisor, Registered Dietician (RD) to evaluate and assess per policy, and staff to assist with mobility needs of transfers and bed mobility as needed to promote pressure relief. There was a new intervention, undated which stated prostat and zinc per orders. However, this care plan did not specify the sites or stages of the wounds, or indicate if the wounds were healing or deteriorating. 5. Review of Resident #8's clinical record revealed the facility admitted the resident on 05/02/14 with [DIAGNOSES REDACTED]. Review of Resident #8's Significant Change MDS assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of 15 indicating severe cognitive impairment. Further review revealed the facility assessed the resident to require extensive assist of two (2) persons for bed mobility, transfer, toilet use, personal hygiene and bathing. Further review revealed the facility assessed Resident #8 as having a indwelling urinary catheter, as occasionally incontinent of bowel and as having two (2) stage II pressure ulcers. Review of Resident #8's Care Plan, undated, revealed a problem of impaired skin integrity due to immobility. The goal stated Resident #8 would not develop complications related to pressure ulcers. The interventions included weekly skin assessments by licensed staff to monitor for any indication of skin breakdown, turn and reposition every two (2) hours, report any red or open areas, and float heels in bed, and reposition in wheelchair/chair frequently. Review of Resident #8's Nurse's Notes dated 05/06/15 revealed the resident was observed to have a 0.8 cm x 0.9 cm Stage II to the posterior upper left thigh with a 3 cm x 2 cm SDTI (Suspected Deep Tissue Injury) purple/maroon area to the distal end of the Stage II, no odor or drainage. Further review of the Note, revealed the coccyx had a 0.5 cm x 0.3 cm Stage II which was red, no odor or drainage. However, there was no care plan initiated for the Stage II pressure ulcer to the posterior upper left thigh and the Stage II pressure ulcer to the coccyx. Further review of the weekly Skin Assessment revealed on 07/04/15 the resident's right upper thigh healed and there were two (2) areas to the coccyx, with no measurements or staging of the areas, and there was no care plan initiated again for the coccyx areas. The weekly Skin assessment dated [DATE] revealed a Stage II to the left medial buttocks measured at 1 cm x 0.6 cm and the coccyx had blanchable redness. An Acute care plan was initiated for the left medial buttock on 07/11/15; however, there was no stage of the ulcer noted. 6. Review of Resident #12's clinical record revealed the facility admitted the resident on 01/26/15 with [DIAGNOSES REDACTED]. Review of Resident #12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having both short and long term memory loss. Continued review revealed the facility assessed Resident #12 as requiring extensive assistance of one (1) person for bed mobility, and personal hygiene, and as requiring extensive assistance of two (2) persons for transfer, toilet use and bathing. Further review revealed the facility assessed the resident as incontinent of urine and occasionally incontinent of bowel, and as having one (1) stage II pressure ulcer. Review of Resident #12's Care Plan, undated, revealed the resident had impaired; potential for impaired skin integrity related to mobility, and incontinence. The goal stated Resident #12 would not develop pressure ulcers. The interventions included nursing staff to monitor for indication of skin impairment during ADL care, report any red or open area, weekly skin assessment by licensed staff to monitor for any indications of skin breakdown. Review of the WCS dated 04/08/15 revealed the resident had a Stage III pressure ulcer to the posterior left thigh measuring 1.8 cm x 1.9 cm x 0.4 cm with tunneling from 12 o'clock to 2 o'clock (the wound was discovered on 02/04/15, according to the WCS dated 04/08/15). However, there was no documented evidence the care plan was revised related to this pressure ulcer. Further review of Resident #12's Wound Care Summary dated 04/08/15, revealed a lower right buttock SDTI (discovered on 02/04/15) which was described as unstageable and measured 1.2 cm x 2 cm with yellow slough in the wound bed, purulent drainage and odor. There was no documented evidence the care plan was revised related to this pressure ulcer. 7. Review of Resident #5's medical record revealed the resident was initially admitted by the facility on 02/14/13 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Comprehensive Care Plan revealed a Skin Integrity Care Plan which included interventions: float heels in bed, gel boots as tolerated, pressure reducing mattress, turn and reposition every two (2) hours, and weekly skin assessments. Further review revealed a Pressure Ulcer Care Plan related to Multiple Pressure Areas and referred to the TAR/Skin Assessments and included interventions to keep the skin warm and dry, supplements as ordered, treatments as ordered, assess for signs and symptoms of worsening of infection daily. Record review revealed Resident #5 had an Unstageable Sacral/Coccyx Wound developed/discovered 03/08/15. In August a weekly progress noted the Sacral / Coccyx wound was noted to be a Stage IV pressure ulcer and no longer an unstageable wound. However, review of the Pressure Ulcer Care Plan revealed the care plan was not updated to indicate the unstageable wound or the change in wound status to a Stage IV pressure ulcer. Record review revealed a Stage II pressure ulcer on right lower buttock identified on 05/23/15 and review of the May 2015 TAR revealed a treatment order for an [MEDICATION NAME] foam dressing to the Stage II pressure ulcer on the right lower buttock to change every three (3) days. However, review of the Pressure Ulcer Care Plan revealed the care plan was not updated to indicate the new Stage II pressure ulcer or when the wound was healed. Record review revealed a Suspected Deep Tissue Injury (SDTI) to Resident #5's left great toe knuckle area identified on the 06/16/15 re-admission note and review of Admission Physician orders, dated 06/16/15 revealed skin prep was to be applied to the left great toe site each shift. However, review of the Skin Integrity Care Plan and Pressure Ulcer Care Plan related to Multiple Pressure Areas revealed the care plan was not updated to include the newly identified SDTI or when it was healed. Record review revealed Resident #5 had a newly identified a partially open SDTI to the lower right buttock on a Wound Care Summary Document, dated 07/03/15, which was later identified on 08/14/15 as an unstageable wound. However, review of the Pressure Ulcer Care Plan revealed the care plan was not updated to indicate the newly identified wounds. Record review of the Monthly Physician Orders, August 2015, revealed Resident #5 had an order, dated 07/27/15, to have a pressure reduction foam mattress to the bed. Observation of a skin assessment, on 08/11/15 at 5:50 PM, revealed the resident had a low air loss mattress. Interview, on 08/21/15 at 5:50 PM, with LPN #4 revealed Resident #5 had pressure ulcers and interventions included an air loss mattress. Interview, on 08/10/15 at 6:35 PM, with MDS Coordinator #1 revealed they get a yellow copy of orders every morning and update the care plan as soon as they see the orders. However, Resident #5's care plan was not updated for the pressure reduction mattress ordered on [DATE]. 8. Review of Resident #7's medical record revealed the resident was admitted by the facility on 07/13/15 with [DIAGNOSES REDACTED]. Review of the facility's Admission Minimum Data Set, dated dated [DATE], revealed the resident was admitted with no pressure sores, but was at risk. Review of Resident #7's Comprehensive Care Plan revealed a Skin Integrity care plan, undated, with interventions which included monitor indication of skin impairment during daily care, use a turn sheet, weekly skin assessment. Observation of skin assessment performed by Licensed Practical Nurses (LPN) # 1 and #2, on 08/11/15 at 6:25 PM, revealed two open wounds on Resident #7's left buttock and no open wound on the resident's right buttock. However, review of Resident #7's Wound Care Summary documents revealed the resident developed facility acquired pressure ulcers listed on the WCS forms as developed/was discovered 08/04/15. One WCS had a Stage II pressure ulcer to the left medial buttock, which on the 08/08/15 weekly progress note described two (2) Stage II wounds to the left buttock, and one WCS had a Stage II pressure ulcer to the right medial buttock. Review of an acute care plan for Pressure Ulcer, dated 08/04/15, revealed interventions which included keep skin clean warm and dry, assess for signs and symptoms of worsening, treatments as ordered, and see treatment sheet. Further review of the Pressure Ulcer care plan revealed it was revised to include a proximal left mid-buttock- Stage II pressure ulcer and a distal mid-back Stage II pressure ulcer. However, record review revealed the resident had no distal mid-back Stage II pressure ulcer identified on any other record, but had another Stage II PU to the left buttock. In addition, the Pressure Ulcer Care Plan was revised to include a surgical incision wound which was not a pressure ulcer wound and was not revised for the Stage II pressure ulcer to the right buttock, identified on 08/04/15 through the Wound Care Summary. 9. Review of Resident #11's medical record revealed the facility admitted the resident on 01/07/05 with [DIAGNOSES REDACTED]. Review of the Quarterly (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of a three (3) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident to require limi

Based on observation, interview, record review and policy review, it was determined the facility failed to have an effective system in place to ensure services were provided in accordance with each resident's written plan of care. There was no documented evidence the residents' care plans were implemented to ensure the facility's wound care protocol was implemented and/or weekly skin assessments were conducted for ten (10) of fourteen (14) sampled residents (Resident's #1, #2, #4, #5, #6, #7, #8, #9, #10 and #12). In addition, Resident #2's care plan was not followed related to wearing heel protectors in bed and the resident was observed to have a boggy left heel. (Refer to F314) The findings include: Interview, on 08/25/15 at 9:55 AM, with the Administrator revealed the facility had no policy which addressed following the care plan; however, it was her expectation staff followed residents' care plan. Interview, on 08/20/15 at 11:54 AM, with Minimum Data Set (MDS) Coordinator #1 revealed the purpose of the care plan was to identify care needs and communicate to staff what interventions needed to be provided to meet the care needs. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 03/11/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) indicating severe cognitive impairment. Further review revealed the facility assessed Resident #1 as requiring extensive assist of two (2) for bed mobility, transfers and toileting, always incontinent of urine, frequently incontinent of bowel, and as having no pressure ulcers. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring the extensive assist of two (2) for bed mobility, transfers and toileting. Continued review of the MDS, revealed the facility assessed the resident as always incontinent of urine, frequently incontinent of bowel, and as having no pressure ulcers. Review of the Comprehensive Care Plan, dated 03/23/15 revealed Resident #1 had the potential for impaired skin integrity related to immobility with a goal stating the resident would not develop pressure ulcers. The interventions included monitor for skin intolerance to two (2) hour turning schedule, reposition in wheelchair frequently, turn and reposition every two (2) hours, nursing staff to monitor for indication of skin impairment during daily care, report any red or open areas, and weekly skin assessments by the licensed staff in order to monitor for any indication of skin breakdown. Review of the Significant Change MDS dated [DATE] revealed the facility assessed Resident #1 as having both short and long term memory impairment, as requiring extensive assist of two (2) for bed mobility, transfers, and toileting and as always incontinent of bowel and bladder. Further review of the MDS revealed the facility assessed the resident as having one (1) Stage II pressure ulcer and having one (1) unstageable pressure ulcer. Review of the Nurse's Note dated 04/06/15 at 1545 (3:45 PM), revealed Resident #1 had a Stage II area measuring 2 centimeters (cm) length x 1 cm width with yellow slough noted and the ulcer extended for an undetermined amount into the rectum. Review of the Wound Care Summary (WCS) dated 04/06/15 revealed Resident #1 had a wound to the left buttock. Review of the WCS dated 04/09/15 revealed Resident #1's left buttock pressure ulcer measured 1.5 cm x 3.0 cm and there was an open wound with gray/pale slough, slight odor, and purulent drainage. The WCS dated 04/14/15 revealed the resident's left buttock had an open wound measuring 1.5 cm x 3.0 cm x 0.3 cm and was red with less than twenty-five percent (25%) slough in the wound bed and purulent drainage with slight odor. The WCS dated 04/21/15 revealed the resident's left buttock wound measured 1.0 cm x 3 cm x 0.3 cm and was an open wound that extended into the rectum with decreased slough, slight odor and purulent drainage. Further review of the WCS dated 04/21/15 revealed Resident #1 had a new area to the coccyx described as a Stage II pressure ulcer measuring 0.6 cm by 0.4 cm, with red surrounding skin with blanching discoloration, no odor, and scant serosanguinous drainage. Review of the Resident Data Collection (RDC) dated 05/12/15, revealed Resident #1 was readmitted to the facility from the hospital with a sacral Stage II, and right heel Suspected Deep Tissue Injury (SDTI). Continued review of Resident #1's clinical record revealed there was no documented evidence Resident #1 received another skin assessment to include all the resident's wounds from 04/21/15 until 05/26/15, more than five (5) weeks later, even though the resident's care plan stated weekly skin assessments would be completed. Interview with Licensed Practical Nurse (LPN) #6 on 08/11/15 at 5:00 PM, on 08/12/15 at 10:51 AM, and on 08/20/15 at 4:00 PM, revealed she had completed the weekly Nurses Notes for Resident #1 on 04/28/15, 05/05/15, 05/19/15, and 06/02/15 and should have completed the weekly Skin Assessments, Wound Care Summaries, and weekly Skin Reports when she did the weekly Nurses Notes. However, she stated at the time she did not understand she needed to do this. Further review revealed there were no more weekly Skin Assessments completed for this resident after 05/28/15. However, review of the Weekly Skin Report (document which was to be completed weekly for all residents with wounds to take to the weekly Quality of Care (QOC) Meeting), dated 06/04/15, revealed the resident had a sacral/left buttock wound which measured 9.5 cm x 6 cm by 0.5 cm with seventy five percent (75%) eschar and twenty-five percent (25%) red/purple wound bed with purulent drainage and the Report indicated this wound had worsened. Interview with LPN #7 on 08/10/15 at 7:00 PM, revealed she had documented the measurements on the weekly Skin Report dated 06/04/15, and the measurement and assessment performed was for the sacral ulcer only. She stated she had measured the right heel and had documented the right heel wound on 06/04/15 as a SDTI 2 cm x 2.8 cm purple on the weekly Skin Report, which was not dated. However, LPN #7 stated she had failed to document the ulcer to the left buttock. Further interview revealed she had not followed through with documenting the wounds on the Wound Care Summary as per protocol or on the weekly Skin Assessment per the resident's care plan. 2. Review of Resident #10's medical record revealed the facility admitted the Resident #10 on 02/02/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], revealed the facility assessed Resident #10 as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15). Further review revealed the facility assessed the resident as requiring the extensive assistance of two (2) for bed mobility, transfers, toilet use, as not rated for urinary incontinence, as always incontinent of bowel and as having one (1) unstageable pressure ulcer. Review of the Quarterly MDS dated [DATE], revealed the facility assessed Resident #10 as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15). Further review revealed the facility assessed Resident #1 as requiring extensive assistance of two (2) for bed mobility, transfers, toilet use, as not rated for urinary incontinence, as always incontinent of bowel and as having one (1) unstageable pressure ulcer. Review of the Comprehensive Plan of Care, undated, revealed Resident #10 had potential impairment/actual impairment to skin integrity related to impaired mobility and multiple pressure sores. The goal stated the resident would have no complications related to the skin injury. There were several interventions including pressure relieving cushion to wheelchair, follow skin care protocol, observe location, size and treatment of [REDACTED]. There was a new intervention added on 05/04/15 to see TAR for treatments of skin tears and pressure areas and a new intervention added 07/15/15 for gel boots. Review of the Nurse's Note on 02/02/15, the date of the resident's admission to the facility, revealed the resident had scabs noted to left check, left ear and right ear, left fourth finger left hand, and second finger right hand. However, there was no indication of pressure ulcers. Review of the Nurse's Notes dated 02/16/15 on re-admission to the facility after hospitalization , revealed Resident #10 had a 1.3 centimeter (cm) x 1 cm open area to the left sacrum, a 1.7 cm x 0.8 cm open area to the right sacrum, and a 4.4 cm x 3.8 cm fluid filled purple area to the right heel. The WCS dated 02/23/15 described the right heel ulcer as 5 cm x 4 cm red purple blister, and the WCS dated 03/02/15 described the right heel ulcer as 5 cm x 4 cm purple blister. The WCS dated 03/12/15 described the right heel as an unstageable pressure ulcer measuring 6 cm x 5 cm with eschar and brown drainage indicating the wound was deteriorating. The WCS dated 03/16/15 revealed the resident's right heel unstageable pressure ulcer measured 5.5 cm x 4.5 cm with greater than twenty-five (25%) eschar. The WCS dated 03/22/15 revealed the right heel ulcer measured 5 cm x 4 cm with eschar, slough and serosanguinous drainage. The WCS dated 03/30/15 described the right heel ulcer as 4 cm x 4 cm with seventy-five (75%) red wound bed and with twenty-five (25%) deep purple red wound bed, and serosanguinous drainage. The WCS dated 04/09/15 described the right heel ulcer as seventy-five percent (75%) eschar, 6.5 cm x 7.5 cm wound bed with serosanguinous drainage. Continued review revealed on 04/09/15 the WCS revealed Resident #10 had a SDTI measuring 1 cm x 1 cm purple area to the left coccyx. The WCS dated 04/14/15 revealed the SDTI to the resident's left coccyx measured 3 cm x 3 cm and was purple maroon in color, and the right heel wound measured 5 cm x 6.5 cm with seventy-five (75%) eschar and twenty-five percent (25%) red wound bed, brown drainage with odor. The WCS dated 04/21/15 revealed the resident's left coccyx SDTI was now unstageable and measured 2 cm x 3.5 cm with one hundred percent (100%) slough, and serosanguinous drainage with nonblanchable skin surrounding the ulcer. Further review of the WCS dated 04/21/15 revealed the resident's right heel ulcer measured 5 cm x 6.5 cm with greater than seventy-five percent (75%) eschar and brown drainage. Additionally, the WCS dated 04/21/15 revealed Resident #10 had a new SDTI measuring 1 cm x 1 cm non blanching purple maroon in color to the right coccyx. There was no further documented evidence of a WCS for the left coccyx pressure ulcer, the right coccyx pressure ulcer, or the right heel ulcer from 04/21/15 until 08/14/15 (over three (3) months) as per the facility's wound care protocol. Additionally, these areas were not documented on the Weekly Skin Report from 04/29/15 until 06/09/15 (over five (5) weeks) and there was no Weekly Skin Assessments noted from 04/14/15 until 06/02/15 (seven (7) weeks). The facility failed to implement the skin care protocol per the resident's plan of care. 3. Review of Resident #7's medical record revealed the resident was admitted by the facility on 07/13/15 with [DIAGNOSES REDACTED]. Review of the facility's Admission Minimum Data Set, dated dated [DATE], revealed the resident was admitted with no pressure sores, but was at risk. Review of the medical record revealed Resident #7 had Physician admission orders [REDACTED]. Further review of Physician order [REDACTED]. Review of the Medical Record revealed a Comprehensive Care Plan: MRSA to surgical wound plan of care, undated, which included an intervention for open wounds to be covered, and not open to air. Further review of the care plans revealed a Pressure Ulcer Care Plan, dated 08/04/15, which included an intervention for treatments as ordered by the Physician to the wound care area and see treatment sheet. Observation of a skin assessment performed by LPNs # 1 and #2 on 08/11/15 at 6:25 PM, revealed two (2), open to the air wounds on Resident #7's left buttock, and the ordered wound dressing was not in place. The wounds were measured by LPN #1 as being 1.0 cm in length x 0.4 cm in width (distal wound) and 0.4 cm length x 0.6 cm width (proximal wound). Interview, on 08/11/15 at 7:00 PM, with LPN #1 revealed wounds on the left buttock had no dressing in place and were open to air. LPN #1 reported the ordered wound treatment was not in place, as per the care plan, and there was a potential risk of the wounds worsening or becoming infected, because the resident had [MEDICAL CONDITION] infection. Interview, on 8/11/15 at 7:10 PM, with LPN #2 revealed Resident #7 had an infection [MEDICAL CONDITION] to the abdominal surgical wound site and the open wounds on the left buttock were at risk of potential infection without the dressing in place. Interview, on 08/20/15 at 3:05 PM, with LPN #3 revealed she routinely cared for Resident #7 and the open wounds to the left buttock, observed on 08/11/15, were supposed to be covered. The LPN revealed the resident [MEDICAL CONDITION] and was care planned to cover open wounds; however, the care plan was not followed if the wound treatment was not in place and the wounds were open to air. Interview, on 08/24/15 at 4:09 PM, with the Director of Nursing (DON) revealed she had no explanation why Resident #7's left buttock wound treatment was not in place as ordered. The DON reported the resident'[MEDICAL CONDITION] care plan was not followed because wounds were open to air and not covered and the wound treatment was not followed because the wound treatment was scheduled every three (3) days and was last done on 08/07/15, was not performed on 08/10/15, and the dressing was not in place on 08/11/15. Interview, on 08/25/15 at 9:55 AM, with the Administrator revealed [MEDICAL CONDITION] Care plan intervention was not followed by staff, because wounds, to the left buttock, were not covered and the scheduled treatment was not performed on 08/10/15 as ordered. 4. Review of Resident #6's medical record revealed the resident was admitted by the facility on 07/09/15 with [DIAGNOSES REDACTED]. Review of the facility's Admission Nurse Note dated 07/09/15, revealed Resident #6 was admitted to the facility with a Stage II Pressure Ulcer on the Left Buttock which was measured to be 0.5 cm in length by 0.4 cm in width, but no depth measurement. Review of the Admission MDS Assessment, dated 07/20/15, revealed Resident #6 mental status was assessed as severely impaired. Review of the MDS section for Skin Conditions revealed the resident was at risk of developing pressure ulcers and had a Stage II pressure ulcer, not measured on MDS, with granulation tissue. Review of physician's orders [REDACTED]. Review of Resident #6's Comprehensive Care Plan revealed a skin integrity problem care plan, undated, with interventions which included assess wound healing: measure the wound's length, width, depth, and to assess/document the status of the wound perimeter, wound bed and healing progress. Review of the Treatment Administration Record (TAR) revealed the wound treatment was changed on: 07/12/15, 07/15/15, 07/18/15, 07/21/15, 07/24/15, 07/27/15, 07/30/15, 08/02/15, 08/05/15, 08/08/15, and 08/10/15. Review of the Nurse's Notes, on dates the wound treatment was changed revealed the Nurse's Note dated 07/12/15 at 5:20 AM, documented the dressing change was performed and there was no open areas, no bleeding or drainage, and no signs/symptoms of infection. However, the dressing changes continued and review of Nurse's Notes on treatment change dates: 07/15/15, 07/18/15, 07/21/15, 07/24/15, and 07/27/15 revealed no wound measurements, assessment of the wound bed or perineal wound and healing process as per the care plan intervention. Continued interview, on 08/20/15 at 11:54 AM, with MDS Coordinator #1 revealed Resident #6's skin integrity care plan included documenting the status of the wound bed/perimeter and healing process and the care plan was not followed if the nurses who provided wound treatments did not document the information. Further interview revealed if the resident had a skin integrity problem, the nurses were to measure the wound per the care plan intervention. Review of the facility's WCSs for Resident #6, revealed no documentation after 07/09/15. Review of the Weekly Skin Assessments done on 07/10/15, 07/17/15, 07/24/15, 07/31/15, and 08/07/15 revealed no measurements, assessment of the wound bed or perineal wound and healing process as per the care plan intervention. Interview, on 08/21/15 at 3:15 PM, with LPN # 4 revealed Resident #6 had a skin impairment care plan which included an intervention to measure and assess wounds. The LPN reported, after review of available nursing notes/skin assessments/wound summary documents (dates from 07/09/15 to 08/07/15), the wound's progress was not monitored according to the care plan because there were no wound measurements or documentation of the wound site. The LPN further reported the documentation was confusing and she was unable to tell if the wound improved. In addition, she reported the Suspected Deep Tissue Injury (SDTI) reported on the 07/31/15 and 08/07/15 skin assessments was not measured per the care plan. Interview, on 08/21/15 at 6:20 PM, with the DON, Administrator, Interim Administrator/Nurse Consultant revealed care plan interventions were individualized and to be followed by staff. If the care plan intervention included documentation of wound measurements/site/progress they had not followed the intervention process of documentation. 5. Review of Resident #5's medical record revealed the resident was initially admitted by the facility on 02/14/13 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 02/21/13, revealed the facility assessed the resident to be at risk for pressure ulcers only and no pressure ulcers were identified. Continued review of the MDS revealed the resident was assessed as moderately cognitively impaired. Review of Resident #5's Comprehensive Care Plan revealed a Skin Integrity Care Plan, undated, with an intervention to complete a weekly skin assessment for any indication of skin breakdown. Review of Resident #5's Weekly Skin Assessment documents, requested from April 2015 through 08/11/15, revealed documentation of weekly skin assessments on 07/10/15, 07/17/15, 07/31/15, and 08/07/15 only. Record review of nursing notes, for the same period, revealed no documentation a head to toe skin assessment was performed weekly per the care plan intervention. Interview, on 08/2/15 at 3:05 PM, with LPN # 4, who cared for Resident #6 revealed resident skin assessments were supposed to be documented on the weekly Skin Assessment form and were to include any area of abnormal skin identified on the weekly head to toe skin assessment. The LPN revealed the form was supposed to be completed each week. Further review of Resident #5's Comprehensive Care Plan revealed an individual care plan on Pressure Ulcer related to immobility, Multiple Pressure Areas with an intervention to assess for signs and symptoms of worsening, of infection, or complications daily. Review of Nurse's Notes revealed a Note dated 07/19/15 at 4:30 PM and 5:30 PM which revealed Resident #5 had a temperature of 101 degrees and was assessed to have increased drainage and odor when a dressing change was performed. The Note indicated the Physician had been notified and a wound culture was ordered. However, further review of the Nurse's Notes revealed no documented assessment of a worsening wound infection with wound care treatments. The next Nurse's Note documentation was 07/23/15 at 4:54 AM which revealed a new order was received to refer the resident to wound care and at 10:00 AM which indicated the Physician was notified of the wound culture results and antibiotics medications were ordered (Linezolid and [MEDICATION NAME]). Further interview with LPN #4, on 08/21/15 at 5:50 PM, after review of the 07/19/15 4:30 PM Nurse's Note, revealed there was supposed to be follow-up charting and wound assessments when the wound condition change was identified. The LPN revealed the resident should have been placed on seventy-two (72) hour charting and monitored more closely. Interview, on 08/21/15 at 6:20 PM, with the DON, Administrator, Interim Administrator/Nurse Consultant revealed they had no standard process for monitoring of residents when a condition change was identified, it was nursing judgement to determine if closer monitoring was needed and they charted by exception. 6. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/09/14 with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out fifteen (15), which indicated Resident #2 was cognitively intact. Further review revealed the facility assessed the resident as requiring the extensive assistance of two (2) persons for bed mobility, dressing, toilet use and personal hygiene. Continued review of the MDS revealed the facility assessed the resident as being at risk for developing pressure ulcers. Review of Resident #2's Comprehensive Care Plan, initiated 04/21/14, revealed the resident had a problem of skin integrity, impaired: potential related to: impaired mobility, Diabetes, Arthritis, chronic pain, incontinence, and declined to turn and reposition in bed/wheelchair. The goal stated Resident #2 would have intact skin. The interventions included: weekly skin assessments by licensed staff and monitor for any indication of skin breakdown, RD consult, gel cushion to the wheelchair, reposition in wheelchair and chair frequently, treatments per orders-see TAR, turn and reposition every two (2) hours, and bilateral heel protectors to feet when in bed. Review of Resident #2's Physician order [REDACTED]. Observation of Resident #2, during a skin assessment on 08/06/15 at 11:10 AM, revealed the bilateral heel protectors were not on the resident's feet as per the care plan, and Resident #2 had a soft boggy left heel. Interview, on 08/06/15 at 1:50 PM, with CNA #9 revealed she was assigned to Resident #2 and she carried a pocket flow sheet as a reference for care for the resident. However, after review of the flow sheet, she stated she did not see the intervention for the heel protectors on the flow sheet, even though, review of the current Nurse Aide Care Plan revealed Resident #2 was to have heel protectors in bed. CNA #9 then stated she was aware the resident was to have heel protectors; however, the resident refused to wear them. Continued interview revealed the CNAs were to inform the nurses if a resident refused an intervention; however, she did not remember telling the nurses about the resident refusing heel protectors. Interview, on 08/06/15 at 2:10 PM, with LPN #12, revealed she was assigned to Resident #2 and she did rounds during medication pass and while performing treatments to ensure safety devices and skin devices were in place and she used the Treatment Administration Record (TAR) as a reference. She further stated she was aware the resident was to wear heel protectors and the CNAs would sometimes tell her he/she refused to wear them; however, she was not told the resident refused them today. Review of the TAR for Resident #2 revealed during the month of July 2015, the intervention for bilateral heel protectors while in bed was circled nine (9) times without any notes documented on the back of the TAR as an explanation as to why the resident was not wearing the heel protectors. Observation, on 08/10/15 at 7:00 PM revealed Resident #2 was in bed with the bilateral heel protectors in place. Resident #2 stated he/she wore the heel boots night and day. Interview with Resident #2, on 08/11/15 at 12:00 PM, revealed, I always have them (heel protectors) on sometimes they fall off but I don't take them off. Interview, on 8/10/15 at 5:30 PM, 8/11/15 at 2:50 PM, and 08/12/15 at 9:15 AM with the DON revealed if a resident refused care on a regular basis the nurses should document a Nurses Note, notify the physician, circle their initials on the Medication Administration Record [REDACTED]. The DON further revealed the facility had no policy on refusal of care from residents. The DON stated, if a resident is well known to refuse, then nursing should contact the doctor and get new interventions in place is what should happen. She further stated the goal of the intervention of the heel protectors for he/she was prevention, and if there were problems with that intervention than an alternate intervention needed to be put in place. She further stated that if there was a care plan intervention for the heel protectors and the resident was not wearing them, the care plan was not followed. Further review of Resident #2's record revealed Nurse's Notes dated 08/04/15, which stated there was three (3) Stage II ulcers noted to the resident's coccyx. Review of the Nurse's Notes dated 08/06/15, revealed a new area was noted to the left upper buttock. Review of Resident #2's Weekly Skin Assessments revealed there was an entry on 08/06/15 which described the Stage II ulcer to the resident's left upper buttock as measuring 0.5 cm x 1 cm with one hundred percent (100%) granulation with one (1) x 1 cm purple discoloration surrounding the area, dry peeling skin to the surrounding tissue and slight serosanguinous drainage. However, there was no entry related to the three (3) Stage II areas which were noted to the resident's coccyx on the Nurse's Note dated 08/04/15, or on the weekly Skin assessment dated [DATE]. Review of Resident #2's WCS's revealed a WCS was initiated on 08/06/15 for the Stage II ulcer to the resident's left upper buttock which measured 0.5 cm x 1 cm with one hundred percent (100%) granulation with a 1 cm x 1 cm purple discoloration surrounding the area, dry peeling skin to the surrounding tissue and slight serosanguinous drainage. However, there was no documented evidence a WCS was initiated for the three (3) Stage II wounds to the resident's Coccyx, as per the care plan. Interview on 08/10/2015 at 6:45 PM with the DON in regards to Resident #2, revealed it would be hard to determine if the wounds were getting better or worse if the WCS's weren't completed accurately. 7. Review of Resident #4's clinical record revealed the facility admitted the Resident on 04/20/10 with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15). Further review of the MDS revealed the facility assessed Resident #4 as requiring extensive assistance of one (1) for bed mobility, dressing and personal hygiene and and as requiring extensive assistance of two (2) for transfers, and toilet use. Per the MDS, the facility further assessed the resident to be frequently incontinent of urine and occasionally incontinent of bowel, and as having two (2) Stage II Pressure Ulcers at the time of the assessment which had not been present on the prior assessment. Review of Resident #4's Comprehensive Care Plan, initiated 06/04/12, revealed the resident had a skin integrity problem related to a history of recurrent skin tears on the buttocks which developed into ulcers and immobility. The goal stated Resident #4 would have intact skin. The interventions included; assess wound healing by a licensed nurse, measure length, width and depth where possible and assess and document status of wound perimeter, wound bed and healing progress, assist to turn and reposition at least every two (2) hours, and follow facility protocol for the prevention/treatment of [REDACTED]. Review of Resident #4's Nurses Notes dated 04/28/15 revealed the resident had a new Stage II area to right buttock measuring 0.8 cm x 0.8 cm, red, no odor and a scant amount of serosanguinous drainage. However, further review revealed there was no WCS initiated for the new Stage II area to the resident's right buttock identified on 04/28/15. There was a WCS dated 07/17/15 which described a right buttock wound with no date the wound was discovered, and a WCS dated 08/07/15 related to the right buttock wound. However, there was no tracking of the wound weekly from 04/28/15, as per the care plan, and it could not be determined if this was the same wound on all these dates. Also, there was no weekly Skin Assessments completed related to this wound until 05/08/15. The weekly Skin assessment dated [DATE] revealed Resident #4 had a stage II ulcer to the buttocks; however, did not indicate which buttock or the measurement. The weekly Skin assessment dated [DATE] had no documentation related to the wound to the buttocks. The weekly Skin Assessments afterward were done weekly for the area to the right buttocks; however, many of the assessments did not indicate measurements and descriptions of the wound, as per the care plan interventions. Further review of Resident #4's Nurse's Notes dated 05/06/15, revealed the resident had a new Stage II ulcer to the right upper posterior thigh measuring 1.5 cm x 0.5 cm, red, no odor with serosanguinous drainage. However, further review revealed there was no WCS initiated for the new wound identified on 05/06/15 to the resident's right upper posterior thigh. There was a WCS initiated on 07/17/15 related to an ulcer to the right posterior t

Based on observation, interview, record review, and review of facility's policy and protocol, it was determined the facility failed to have an effective system in place to ensure the facility's protocol was implemented related to pressure ulcers to ensure a resident at risk for pressure ulcers or a resident with pressure ulcers, received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for eleven (11) of fourteen (14) sampled residents (Resident #1, #2, #4, #5, #6, #7, #8, #9, #10, #11, and #12). Interview and record review revealed on 04/24/15, the facility reassigned the facility's Wound Care Nurse to the position of a staff nurse and delegated all wound care assessments and treatments to the staff nurses. Interview revealed training was not provided related to measuring and staging of wounds and nurses were not comfortable completing this type of wound assessment. In addition, interview revealed the nurses were not educated on the types of forms, related to pressure ulcers, utilized by the facility. Review of the facility's Wound Care Protocol revealed Wound Care Summaries would be updated weekly and weekly Skin Assessments would be completed. However, record review revealed these assessments were not consistently completed and there was no documented evidence of consistent monitoring of the progress of the residents' wounds. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. The findings include: Review of the facility's Wound Protocol document, undated, revealed on any resident who is assessed to be at risk for skin breakdown, the protocol for early intervention should be implemented. Continued review revealed the Wound Care Summary should be initiated for any resident who was assessed to have a wound and continued with weekly updates until the wound was healed, with the Summary to be reviewed weekly in the Quality of Care (QOC) meetings for each resident who was identified as having a wound. Further review of the Summary revealed the weekly Skin Report should provide a summary of all wounds in the facility and progression of those wounds. Continued review revealed the weekly Skin Report should be copied for members of the Quality of Care Committee to review each week. Review of the facility Wound Care Documentation Protocol, undated, revealed if a wound exists on admission, re-entry or discharge, a photo of the wound was to be taken of the area. A narrative description of all bony prominences was to be recorded in the medical record if photographs were unable to be taken or if nothing existed on that bony prominence that justified taking a photograph. Upon admission or re-entry, if a resident had a wound present of any type, the Wound Care Summary Sheet was to be started. Each wound was to have its own sheet and there could not be multiple wound sites listed on any one (1) wound care summary sheet. The Wound Care Summary was to be completed at a minimum of weekly by a licensed nurse and the assessment was to include measurements and a narrative wound description as directed on the sheet. Interview with the Director of Nursing (DON) on 08/12/15 at 1240 PM, on 08/13/15 at 5:30 PM, and on 08/19/15 at 5:30 PM, revealed Licensed Practical Nurse (LPN) #7 had completed the skin assessments, Wound Care Summaries, and weekly Skin Reports for at least two (2) years. She stated toward the end of April, LPN #7 was needed to work the floor and was no longer in charge of the skin assessments, and the staff nurses were to do their own skin assessments, Wound Care Summaries and weekly Skin Reports. She stated the nurses were informed of this during a staff meeting, but she was unsure who informed the nurses. Interview with LPN #7 on 08/20/15 at 10:00 AM, revealed she was the previous skin nurse in the building which meant she did head to toe skin assessments on every resident in the building each week and documented this on the weekly Skin Assessment. Further interview revealed she also measured, staged and described each wound in the building each week and documented this on the Wound Care Summary and the weekly Skin Report when she was the skin nurse. However, sometime in April, she was moved to a floor nurse position and all nurses were responsible for conducting skin assessments. Interview with the former Interim Administrator/Nurse Consultant on 08/10/15 at 3:50 PM and on 08/12/15 at 3:00 PM revealed the DON was going on leave starting 05/01/15 and they realized they needed additional nursing staff. She stated the facility decided to let the staff nurses do their own skin assessments, leaving LPN #7 who was the skin nurse, to be free to function as a staff nurse. Further interview revealed on 04/24/15 it was explained to the nurses during a staff meeting that they would be doing the staging, measuring and description of wounds with their head to toe skin assessments weekly. She stated she was unsure who communicated this to the nurses and was unsure of exactly what information was conveyed to the nurses. Interview revealed she was unaware of any nurses voicing concerns or wanting training related to completing skin assessments. Continued interview revealed the weekly Skin Reports was a form that went to the weekly Quality of Care (QOC) Meeting and this form was to list all the wounds in the building with measurements and descriptions of the wounds. However, on 05/07/15 and the following week, she realized she had not received the weekly Skin Report. Further interview revealed she, the Assistant DON, and the current Administrator audited every chart in the building from 05/07/15 through 05/18/15. The audit consisted of a review of the Nurse's Notes and the completion of the skin assessments. However, they did not do a skin sweep or look at residents' skin because they felt it was just a documentation problem. Per interview, after the process change took place where the staff nurses were to do their own skin assessments to include measuring and staging the wounds, there was no immediate monitoring to ensure the facility wound protocol was followed. However, monitoring should have been implemented. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 03/11/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a three (3) indicating cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) for bed mobility, transfers and toileting, always incontinent of urine, frequently incontinent of bowel, and as having no pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 03/12/15 revealed the facility assessed the resident as being mild risk for pressure sores related to slightly limited sensory perception, often moist, chairfast, slightly limited mobility, adequate nutrition, and potential for friction and shear. A score of fifteen (15) was given and according to the Scale, fifteen (15) to eighteen (18) was considered to be mild risk. Review of the Comprehensive Plan of Care dated 03/23/15 revealed Resident #1 had the potential for impaired skin integrity related to immobility with a goal stating the resident would not develop pressure ulcers. The interventions included; monitor for skin intolerance to two (2) hour turning schedule, reposition in wheelchair frequently, turn and reposition every two (2) hours, nursing staff to monitor for indication of skin impairment during daily care, report any red or open areas, and weekly skin assessments by the licensed staff to monitor for any indication of skin breakdown. Review of the Nurse's Note dated 04/06/15 at 1545 (3:45 PM), revealed Resident #1 had a Stage II area measuring two (2) centimeters (cm) length by one (1) cm width with yellow slough noted extending for an undetermined amount into the rectum and the Physician was notified. Review of the physician's orders [REDACTED]. Review of the Wound Care Summary (WCS) dated 04/06/15 revealed Resident #1 had a wound to the left buttock. The Acute Care Plan dated 04/06/15 revealed the resident had a pressure ulcer related to decreased mobility; however the care plan did not specify the site or the stage of the pressure ulcer. The goal stated the pressure ulcer would decrease in size and the interventions included; keep skin clean warm and dry, promote nutritional status, assess for signs and symptoms of worsening of infection or complications daily, treatments as ordered, assess skin daily during care for changes and report to nurse supervisor, Registered Dietitian (RD) to evaluate and assess per policy, and staff to assist with mobility needs of transfers and bed mobility. Review of the WCS dated 04/09/15 revealed the resident's left buttock pressure ulcer measured 1.5 cm by 3.0 cm and there was an open wound with gray/pale slough, slight odor, and purulent drainage. The WCS dated 04/14/15 revealed the left buttock had an open wound measuring 1.5 cm by 3.0 cm by 0.3 cm and was red with less than twenty-five percent (25%) slough in the wound bed and purulent drainage with slight odor. The WCS dated 04/21/15 revealed the left buttock wound measured 1.0 cm by 3 cm by 0.3 cm and was an open wound that extended into the rectum with decreased slough, slight odor and purulent drainage. Further review of the WCS dated 04/21/15 revealed the resident had a new area to the coccyx described as a Stage II pressure ulcer measuring 0.6 cm by 0.4 cm, with red surrounding skin with blanching discoloration, no odor, and scant serosanguinous drainage. Review of the physician's orders [REDACTED]. Review of the resident's care plan revealed no Acute Care Plan was developed for the pressure ulcer identified on 04/21/15. Review of the Wound Care Clinic Note dated 04/23/15, revealed the resident had a superficial sacral decubitus ulcer and to continue with a [MEDICATION NAME], change every three (3) days. However, review of the physician's orders [REDACTED]. Review of the Wound Care Clinic Note, dated 05/07/15, revealed the resident's superficial sacral [MEDICAL CONDITION] had improved, and the resident had a small fissure at eleven (11) o'clock, continue with [MEDICATION NAME]es and [MEDICATION NAME] HC suppository three (3) times a day prn for anal fissure and return in three (3) weeks. However, review of physician's orders [REDACTED]. Review of the Nurse's Notes dated 05/10/15 at 0355 (3:55 AM) revealed Resident #1's oxygen saturation was seventy-three percent (73%) on room air, the physician was notified and the resident was sent to the hospital emergency room . Review of the Resident Data Collection (RDC) dated 05/12/15, revealed Resident #1 was readmitted to the facility and the skin condition was as follows; sacral Stage II, right heel Suspected Deep Tissue Injury (SDTI), and Stage II to sacral area. There was no documented measurements or a description of the ulcers. In addition, the care plan was not revised related to the new SDTI of the right heel. Review of the physician's orders [REDACTED]. Interview with LPN #6, on 08/20/15 at 4:00 PM, revealed she had readmitted Resident #1 on 05/12/15 and had completed the RDC. She stated she normally would measure the wounds for a re-admission, and she was not sure why she had not done this on 05/12/15. She stated she did check the resident's skin that day and the resident only had the SDTI to the right heel and the Stage II ulcer to the sacrum, and the resident did not have a wound to the left buttock. Continued interview revealed she had not photographed the wounds and only learned last week that she needed to photograph a resident's wounds when they returned to the facility after a hospitalization . Interview with the DON on 08/19/15 at 5:30 PM, revealed in reference to Resident #1, LPN #6 should have measured and taken photographs of the resident's wounds when the resident was re-admitted to the facility on [DATE] because it was policy to take pictures of wounds before a emergency room or hospital visit, if there was time and not a true emergency, and on return from the emergency room or hospital. In addition, she stated all the resident's wounds should have been measured on return from the hospital on [DATE]. Interview with LPN #13 on 08/11/15 at 6:15 PM and 08/12/15 at 7:00 PM and review of the Treatment Administration Record (TAR) dated May 2015, revealed LPN #13 did the resident's wound treatments on 05/15/15. She stated, she did not remember if the resident had an area on the left buttock on return from the hospital on [DATE]; however, stated if there was an area there when she did the treatment on 05/15/15, she would have notified the Physician. Review of a Nurse's Note dated 05/23/15 at 0200 (2:00 AM), revealed there was increased drainage to the Stage II pressure ulcer on the resident's sacrum and new orders were received. Review of the physician's orders [REDACTED]. Review of the Acute Care Plan dated 05/23/15, revealed the resident had a pressure ulcer to the coccyx related to immobility and incontinence with a goal stating the resident's pressure ulcer would decrease in size. The interventions included; keep skin clean warm and dry, promote nutritional status, assess for signs and symptoms of worsening of infection or complications daily, treatments as ordered, assess skin daily during care for changes and report to nurse supervisor, RD to evaluate and assess per policy, and staff to assist with mobility needs of transfers and bed mobility. Continued review of Resident #1's clinical record revealed there was no documented evidence of a Wound Care Summary to include staging, measurements, and descriptions of the wounds after 04/21/15 and no documented evidence Resident #1 received a weekly Skin Assessment to from 04/14/15 until 05/26/15, more than five (5) weeks later, even though the facility's Wound Protocol stated the Wound Care Summaries would be updated weekly and the resident's care plan stated weekly skin assessments would be completed. Also, there was no documented evidence Resident #1's wounds were transcribed to the weekly Skin Report to be taken to the weekly QOC meeting from 04/21/15 until 05/28/15. Interview with LPN #6 on 08/11/15 at 5:00 PM, on 08/12/15 at 10:51 AM, and on 08/20/15 at 4:00 PM, revealed LPN #7 had been completing the weekly Skin Assessment for the facility and she (LPN #6) would complete the weekly Nurses Notes, check the skin and only complete a weekly Skin Assessment if she found a new area of skin breakdown. However, she stated there was a staff meeting in April and the staff nurses were told they would be doing their own skin assessments weekly, but were not told which forms to use. She said it was not an in-service where they had to sign and she did not receive full instructions on what to do related to skin assessments. Further interview revealed she had completed the weekly Nurses Notes for Resident #1 on 04/28/15, 05/05/15, 05/19/15, and 06/02/15 and was supposed to have completed the weekly Skin Assessments, Wound Care Summaries, and weekly Skin Reports when she did the weekly Nurses Notes. However, she stated she was a lost ball in high weeds in May and did not understand she was to do this. In addition, she stated, in May she was not comfortable with staging and measuring wounds. Review of the weekly Skin Assessment, dated 05/26/15 and completed by LPN #10, revealed the resident was assessed as having a small healing area to the right heel area; however, there was no documentation related to the coccyx ulcer. Interview with LPN #10 on 08/11/15 at 7:00 PM, revealed she started at the facility in May or June 2015 and was told the nurses were to do their own skin assessments when they did the weekly Nurses Notes; however, she was unaware she was to do the Wound Care Summary or weekly Skin Report for residents with wounds when she did the weekly Skin Assessments. Further interview revealed she was not sure why she did not include all the resident's wounds on the weekly Skin Assessment she completed on 05/26/15; however, stated she did not receive any in-service when hired related to how to do the skin assessments. Review of the next weekly Skin Assessment completed by LPN #13, dated 05/28/15, revealed the resident had a Stage II pressure ulcer to the sacrum which measured 2 cm by 3 cm by 1 cm depth with eschar (dead tissue) noted in the wound and a fluid filled blister on the right side of the wound; a SDTI to the right heel which measured 2 cm by 2 cm and was dark purple. However, review of the weekly Skin Report completed by LPN #13, dated 05/28/15 revealed the resident had an open area to the left buttock measuring 3 cm by 1 cm which was not staged. Interview with LPN #13 on 08/11/15 at 6:15 PM and 08/12/15 at 7:00 PM revealed when she completed the Skin Assessment on 05/28/15, the resident was noted to have a Stage II to the left buttock and she should have documented the stage of the ulcer on the weekly Skin Report and should have documented this area on the weekly Skin Assessment. She stated she did not consistently work the same unit and most nurses at the facility floated to different units. Further interview revealed they had a nursing meeting which was not an in-service and were told they would be doing their own skin assessments sometime several months ago. She stated there was no in-service given related to how to measure and stage wounds and she was not comfortable staging wounds. Review of the Wound Care Clinic Note dated 05/28/15, revealed the wound status had declined for the sacral decubitus which measured 2.0 by 2.0 by 0.5 with stringy gray tissue to the wound bed, the left buttock measured 3.5 by 4.0 by 0.1 cm with yellow and dry red tissue to the wound bed with a superficial ulcer in area. The recommendations revealed apply Santyl Ointment to sacral decubitus, cover with NS wet to dry and cover site daily and NS wet to dry and cover site daily to the left buttock. New physician's orders [REDACTED]. Refer to Occupational Therapy for wedge for positioning off buttocks. Further review revealed there was no more weekly Skin Assessments completed for this resident after 05/28/15. However, review of the weekly Skin Report dated 06/04/15 (document which was to be completed weekly for all residents with wounds to take to the weekly Quality of Care (QOC) Meeting), revealed the resident had a sacral/left buttock wound which measured 9.5 cm by 6 cm by 0.5 cm with 75% eschar and 25% red/purple wound bed with purulent drainage and the Report indicated this wound had worsened. Interview with LPN #7 on 08/10/15 at 7:00 PM, revealed she had documented the weekly Skin Report dated 06/04/15 and the measurement performed was for the sacral area only. She stated she had measured the right heel and had documented the right heel wound on 06/04/15 as SDTI 2 cm by 2.8 cm purple on the weekly Skin Report, which was not dated. However, she had forgotten to document the area to the left buttock. Further interview revealed she had not followed through with documenting the wounds on the Wound Care Summary as per protocol or on the weekly Skin Assessments. She stated she noted the sacral/buttocks wound had worsened but she did not feel the need to notify the Physician because it was not an emergency such as a cardiac concern. Per interview, the resident would be going to the wound clinic later that day and she decided to pass the information on in report. Review of the Wound Care Clinic Note dated 06/04/15, revealed the decubitus was now one (1) big ulcer, gray wound bed to 80%, red granulation to 20%, measures 10 by 6 by unknown depth. The recommendations were to apply Santyl to wound bed twice a day, cover with NS wet to dry and foam dressing to secure today, evaluate nutritional status, and evaluate for Foley catheter. New physician's orders [REDACTED]. Continued record review, revealed Resident #1 experienced a fever starting on 06/06/15 at 00:10 (12:10) AM and the physician was not notified of the fevers until 06/07/15 at 3:50 PM, over thirty-nine (39) hours later, although the fever continued. Review of the Nurse's Notes dated 06/06/15 at 2410 (12:10 AM), completed by LPN #11, revealed Resident #1 was very hot to touch and her/his face was flushed and the resident's temperature was checked which was up to 102.4 degrees, Tylenol 500 milligrams (mg's) (medication for pain relief and fever reducer) was administered and the nurse would continue to monitor. Review of the Medication Administration Record (MAR) dated June 2015, revealed the Tylenol 500 mg was administered on 06/06/15 at 2410; however, there was no documentation on the MAR or further documentation in the Nurse's Notes to indicate if the medication was effective. Interview with LPN #11 on 08/20/15 at 9:30 AM, revealed at the time she wrote the Note on 06/06/15 she obtained a full set of vital signs, but did not document them. She further stated she did the wound dressing that shift and although she could not remember what the wound looked like, she would have notified the Physician if she had noted a change in the wound. Further interview revealed she did not notify the Physician of the temperature because the resident had a standing order for Tylenol for temperature. Continued interview revealed she always followed up with taking another temperature after she had given Tylenol for a fever, and just failed to document the effectiveness of the medication. There was no Nurse's Note on the subsequent shift (day shift for 06/06/15) and no documented evidence the nurse on the day shift 06/06/15 assessed this resident except for obtaining a temperature which was recorded on the MAR. Review of the June 2015 MAR revealed on 06/06/15 at 1430 (2:30 PM) Tylenol 500 mg was administered for a temperature of 101.6 and the resident's temperature decreased to 97.0 at 1730 (5:30 PM). Interview with LPN #9 on 08/21/15 at 2:10 PM, revealed she would normally assess the resident if the resident had a temperature from the shift before and in this case it would include assessing the resident's wound and obtaining vital signs. She stated she checked the resident's wound when she did the dressing on that shift and there was no redness or induration around the wounds and the wounds did not look infected. Continued interview revealed a temperature was a change in condition for the resident; however, she did not notify the Physician because the resident's temperature came down with Tylenol. Further interview revealed she failed to write a note related to her assessment of the resident. Continued review of the June 2015 MAR revealed LPN #8 had documented on 06/07/15 at 1045 (10:45 AM) Tylenol (no dosage noted) was administered for a temperature of 101.6 and the resident's temperature came down to 99.2 at (1200) 12:00 PM. Review of the physician's orders [REDACTED].#8 revealed orders for a culture of the sacral wound with the next dressing change due to odor, temperature, and drainage. After culture obtained start [MEDICATION NAME] (antibiotic medication) 750 milligrams every day for seven (7) days until the wound culture was received. Further review of the June 2015 MAR revealed the resident again received Tylenol on 06/07/15 at 1650 (4:50 PM), for a temperature of 102 degrees, and there was no notation on the MAR to indicate if the medication was effective for the temperature. Although the physician was notified of a change in the sacral wound and the resident having a temperature on 06/07/15 at 1550 (3:50 PM), there was no documentation in the Nurse's Notes of an assessment of the resident related to the wound and the temperature on that shift by LPN #8. Interview with LPN #8 on 08/11/15 at 7:00 PM revealed she had looked at the wound on 06/07/15 and it looked bad so she called the Physician for orders. She said the skin around the wound was red and inflamed and the wound looked infected but there was no drainage. Further interview revealed she did not usually take care of the resident so she did not know if the wound was worse because she had no comparison. Continued interview revealed she forgot to chart on the resident and talked to LPN #7 later that evening and asked LPN #7 to chart for her related to notification to the Physician and the orders received. Further interview revealed during her conversation with LPN #7, she was told the resident's wound was having a lot of drainage and she told LPN #7 there was no drainage from the wound during her shift. There was no subsequent Nurse's Note related to an assessment of the resident after the 06/06/15 at 2410 (12:10 AM) notation until 06/07/15 at 2200 (10:00 PM), over forty-six (46) hours, even though the resident was running a temperature during this time period. On 06/07/15 at 2200 (10:00 PM), LPN #7 documented the Physician was notified by LPN #8 about the increased temperature and increased redness around the sacral wound and a new order was received to culture the wound and then start the [MEDICATION NAME] 750 mg every day for seven (7) days until the culture report returned. Per the Note, the sacral wound was cleaned and a culture was obtained and antibiotics were started as ordered. Further review revealed the resident had a 1 cm open area approximately 2 cm from the rectum on the left lower buttock with a copious amount of drainage noted, temperature 99.4, pulse 113, respirations 20, and blood pressure 118/74. Interview with LPN #7 on 08/07/15 at 10:00 AM, revealed on 06/07/15 it was reported to her by LPN #8 that she had called the physician related to the wound change and temperature. She stated on her shift on 06/07/15 the resident was having a copious amount of drainage which was serosanguinous, and possibly some brown drainage but she could not remember if there was odor. She stated there was no redness, open areas or drainage from the vagina. However, she stated there was redness surrounding the sacral wound bed. She stated she did not call the Physician related to the wound having a lot of drainage because the Physician had been informed on the previous shift of the wound change and had ordered a culture and antibiotics. Interview on 08/07/15 at 8:40 AM with Certified Nursing Assistant (CNA) #5, revealed she was assigned to the resident from 06/07/15 at 10:30 PM until 06/08/15 at 7:00 AM. She stated on that shift the wound looked worse than before, and she had reported it to LPN #7. She stated the sacral wound had brown drainage and black eschar and a foul smell and LPN #7 assessed the resident. Further interview revealed this was a big change from the previous night when she was also assigned to the resident. Interview on 08/10/15 at 1:30 PM with CNA #8, revealed she was assigned to the resident on day shift on 06/08/15 and she had noted the resident had a hard area which was pink in color on the resident's labia/ vagina which she had noticed when she completed the resident's bed bath but she could not see the sacral wound due to a dressing over the area. She said there was a foul odor coming from the wound and she had notified LPN #9 to check the resident. She stated the resident was then sent out to the emergency room that morning. The subsequent Nurse's Notes dated 06/08/15 at 10:50 (10:50 AM) completed by LPN #9, revealed the physician was notified of a sacral wound with redness and induration surrounding the wound spreading down the left buttock and up the left labia and there was a 1 cm open area on the left buttock producing copious amount of gray/red purulent drainage, malodorous. Per the Note, new orders were received to send the resident to the hospital emergency room , temperature 97.8, pulse 118, respirations 20, blood pressure 98/60. Further interview with LPN #9 on 08/10/15 at 1:45 PM, revealed she had received report from LPN #7 the morning of 06/08/15 and was told the resident's wounds looked worse and the resident needed to be sent to the hospital to have the wounds assessed. She stated she checked the resident's wounds with LPN #7 that morning and they noted redness around the sacral wound bed, redness to the labia, and the buttock ulcer was having gray/red malodorous drainage. Review of the physician's orders [REDACTED]. Interview with the Attending Physician/Medical Director on 08/11/15 at 9:30 AM, revealed sometime between the wound clinic appointment on 06/04/15 and 06/08/15 the wound got infected because there was no mention in the wound clinic note on 06/04/15 of the need for hospitalization related to the wounds. Continued interview revealed he did not look at documentation of each wound but depended on the nursing staff to notify him when wounds were changing. He stated the nurses should have been doing weekly skin assessments to monitor the effectiveness of the treatments because he relied on them to tell him of changes in the wounds. The Attending Physician/Medical Director further stated he had deferred this resident to the Wound Care Clinic for their expertise because these wounds needed to be watched closely. However, he stated he did not always follow the Wound Care Clinic recommendations such as for the [MEDICATION NAME] dressing because this resident's skin was friable, and he did not want a Foley catheter because the resident had a history of [REDACTED]. Review of the hospital emergency room note dated 06/08/15, revealed the resident presented to the emergency room with a 12 cm by 10 cm necrotic sacral decubitus which was unstageable due to dead tissue over the surface, with brown foul smelling drainage coming from the wound. Review of the hospital Operative Report revealed on 06/08/15 eschar was removed from the sacral decubitus ulcer. The resident was noted to have gross stool within the wound bed itself, concerning for anocutaneous fistula (an abnormal connection that develops between the intestinal tract or stomach and the skin, as a result contents of the stomach or intestines leak through the skin). The ulcer was debrided down to the sacrum and there was significant tracking down into the pubic region and superiorly into the back with continued [DIAGNOSES REDACTED] in those

br>Based on interview, record review, review of in-service documentation, and review of the facility's policy, it was determined the facility's Administration failed to develop and implement an effective plan of action to ensure skin assessments were accurate, detailed and completed weekly, and to ensure wound assessments and wound monitoring were completed weekly after Administration made a decision to re-assign those duties from a designated staff person to the floor nursing staff at the end of April 2015. Survey findings revealed floor nursing staff failed to perform weekly Skin Assessments, failed to complete Wound Care Summary forms, and failed to complete weekly Skin Reports per the facility's Wound Protocol. Interview and record review revealed these assessments were not consistently completed and there was no documented evidence of consistent monitoring of the progress of the residents' wounds. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. This failure affected eleven (11) of fourteen (14) sampled residents (Resident #1, #2, #4, #5, #6, #7, #8, #9, #10, #11, and #12). (Refer to F314 and F520) The findings include: Record review of the facility's policy: Administrator, dated 08/01/13, revealed a licensed Administrator was responsible for the day-to-day functions of the facility. Further policy review revealed the Administrator was responsible to evaluate and implement recommendations from the facility's committees, including Quality Assurance. Review of the facility's Wound Protocol document, undated, revealed on any resident who is assessed to be at risk for skin breakdown, the protocol for early intervention should be implemented. Continued review revealed the Wound Care Summary should be initiated for any resident who was assessed to have a wound and continued with weekly updates until the wound was healed, with the Summary to be reviewed weekly in the Quality of Care (QOC) meetings for each resident who was identified as having a wound. Further review of the Summary revealed the Weekly Skin Report should provide a summary of all wounds in the facility and progression of those wounds. Continued review revealed the Weekly Skin Report should be copied for members of the Quality of Care Committee to review each week. Interview, on 08/10/15 at 3:50 PM and on 08/12/15 at 3:00 PM, with the facility's Nurse Consultant, who was also the Interim Administrator in charge of the facility until 07/24/15, revealed in April 2015 the designated wound nurse was re-assigned to the floor and the facility made a procedural change to assign floor nursing staff the responsibility to perform weekly skin/wound assessments and document observations on the designated forms. Per interview, Skin Assessments were to be documented on the weekly Skin Assessment document and, when applicable, wounds were assessed weekly and documented on the Wound Care Summary and also the QA's weekly Skin Report form. The Nurse Consultant revealed nurses were informed they were responsible to perform the weekly skin/wound assessments and complete the forms utilized be the facility on 04/24/15, but it was not a formal in-service and no signatures were required. She further revealed she was not sure exactly what information was communicated, or who communicated this to the nurses, but stated the nurses voiced no concerns or wanted re-training on skin assessments. She further reported nurses were trained in school and at orientation on how to properly perform a skin assessment. Per interview, no monitoring was conducted at the time of the process change; however, she stated they should have ensured a monitoring process was initiated and it would have been her responsibility to ensure the monitoring was done. Record review revealed the facility provided no documentation of the April 2015 meeting with the floor nurses which discussed the change in responsibility on the weekly performance of skin/wound assessments and the related forms. Interview with Licensed Practical Nurse (LPN) #13, on 08/11/15 at 6:15 PM and 08/12/15 at 7:00 PM, revealed they had a nurses meeting which was not an in-service and were told they would be doing their own skin assessments sometime several months ago. She stated there was no in-service given related to how to measure and stage wounds and she was not comfortable staging wounds. In addition, she revealed she did not consistently work the same unit and most nurses at the facility floated to different units. Interview with LPN #9, on 08/21/15 at 9:45 AM, revealed during an in-service in May 2015 the nurses were told all assessments related to skin and wounds were now their responsibility and she didn't understand what forms they were to use at that time. In addition, the LPN also revealed it was difficult to follow a wound if there was missing information from the previous assessment. Interview with LPN #6, on 08/11/15 at 5:00 PM, 08/12/15 at 10:51 AM, and 08/20/15 at 4:00 PM, revealed there was a staff meeting in April and the staff nurses were told they would be doing their own skin assessments weekly, but were not told which forms to use. She said it was not an in-service where they had to sign and she did not receive full instructions on what to do related to skin assessments. Continued interview, on 08/10/15 at 3:50 PM and 08/12/15 at 11:15 AM, and 3:00 PM, with the Nurse Consultant revealed she became aware of a problem, on 05/07/15, when she identified the weekly Skin Report was not being completed. She further revealed based the identified problem, an action plan was put in place which included an audit of every chart in the building for current weekly wound documentation. After the audit was completed, an in-service with nursing staff was conducted on 05/22/15 to discuss skin/wound assessments and which forms were to be used. Record review revealed a nurse's meeting took place on 05/22/15, and the topics included wounds, schedule of weekly skin assessments, and sign-in sheet, but no content of the education was provided other then the forms. Interview, on 08/12/15 at 11:30 AM, with the Assistant Director of Nursing (ADON) revealed she in-serviced nurses, on 05/22/15, and discussed skin assessments, the wound care documentation protocol and forms, and also discussed wound measurements, staging, and description. Interview with LPN #10, on 08/11/15 at 7:00 PM, revealed she started at the facility in May or June 2015 and was told the nurses were to do their own skin assessments when they did the Weekly Nurses Notes; however, she was unaware she was to do the Wound Care Summary or weekly Skin Report for residents with wounds when she did the weekly Skin Assessments. Further interview revealed she did not receive any in-service when hired related to how to do the skin assessments. Interview, on 08/21/15 at 6:20 PM, with current Administrator and the Nurse Consultant revealed the Administrator was unaware there was were still concerns with the completion of the Wound Care Summaries, Skin Assessments and the weekly Skin Report. The Nurse Consultant revealed after the State Survey Agency's findings more follow-up was needed.

Based on interview, record review, and review of facility's policy and protocol revealed the facility failed to have an effective system to ensure clinical records were maintained in accordance with accepted professional standards and practices which were complete and accurately documented, for eleven (11) of fourteen (14) sampled residents (Resident #1, #2, #4, #5, #6, #7, #8, #9, #10, #11, and #12). (Refer to F314) Interview with staff and record review revealed on 04/24/15, the facility delegated all wound care assessments and treatments to the staff nurses and the Wound Care Nurse was reassigned as a staff nurse. However, record review revealed there was no documented evidence these assessments were consistent, complete and accurately documented. Additionally, staff failed to document the treatment orders for Resident #5's right upper thigh wound. In addition, review of Resident #1's clinical record revealed staff failed document related to the resident's elevated temperature and the effectiveness of the medication that was administered. The findings include: Review of the facility's Wound Protocol document, undated, revealed the Wound Care Summary should be initiated for any resident who was assessed to have a wound and continued with weekly updates until the wound was healed. Further review revealed the Summary to be reviewed weekly in the Quality of Care (QOC) meetings for each resident who was identified as having a wound. Continued review revealed the weekly Skin Report should provide a summary of all wounds in the facility and progression of those wounds and the weekly Skin Report should be copied for members of the Quality of Care Committee to review each week. Review of the facility Wound Care Documentation Protocol, undated, revealed upon admission or re-entry, if a resident had a wound present of any type, the Wound Care Summary Sheet was to be started. Further review, revealed each wound was to have its own sheet and there could not be multiple wound sites listed on any one (1) wound care summary sheet. The Protocol stated, the Wound Care Summary was to be completed at a minimum of weekly by a licensed nurse and the assessment was to include measurements and a narrative wound description as directed on the sheet. Review of the Change in a Resident's Condition Policy, dated 08/01/13, revealed the Nurse Supervisor/Charge Nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 03/11/15 with [DIAGNOSES REDACTED]. Record review revealed Resident #1 developed a Stage II area measuring two (2) centimeters (cm) length by one (1) cm width with yellow slough noted extending for an undetermined amount into the rectum identified on 04/06/15. On 04/09/15 the resident's left buttock pressure ulcer measured 1.5 cm by 3.0 cm and there was an open wound with gray/pale slough, slight odor, and purulent drainage. On 04/14/15 the resident's left buttock had an open wound measuring 1.5 cm by 3.0 cm by 0.3 cm and was red with less than twenty-five percent (25%) slough in the wound bed and purulent drainage with slight odor. On 04/21/15 the resident's left buttock wound measured 1.0 cm by 3 cm by 0.3 cm and was an open wound that extended into the rectum with decreased slough, slight odor and purulent drainage. On 04/21/15 Resident #1 had a new area to the coccyx described as a Stage II pressure ulcer measuring 0.6 cm by 0.4 cm, with red surrounding skin with blanching discoloration, no odor, and scant serosanguinous drainage. Further review of Resident #1's clinical record revealed there was no documented evidence of a Wound Care Summary to include staging, measurements, and descriptions of the wounds after 04/21/15 and no documented evidence Resident #1 received a weekly Skin Assessment from 04/14/15 until 05/26/15, more than five (5) weeks later, even though the facility's Wound Protocol stated the Wound Care Summaries would be updated weekly. In addition, there was no documented evidence Resident #1's wounds were transcribed to the weekly Skin Report to be taken to the weekly QOC meeting from 04/21/15 until 05/28/15. Interview with Licensed Practical Nurse (LPN) #6 on 08/11/15 at 5:00 PM, on 08/12/15 at 10:51 AM, and on 08/20/15 at 4:00 PM, revealed she had completed the weekly Nurses Notes for Resident #1 for 04/28/15, 05/05/15, 05/19/15, and 06/02/15 and was to have completed the weekly Skin Assessments, Wound Care Summaries, and weekly Skin Reports when she did the weekly Nurses Notes. However, she revealed she was a lost ball in high weeds in May and did not understand she was to do this. Review of the weekly Skin Assessment, dated 05/26/15 and completed by LPN #10, revealed the resident was assessed as having a small healing area to the right heel area; however, there was no documentation related to the coccyx pressure ulcer and therefore no documented evidence the coccyx ulcer was assessed. Interview with LPN #10 on 08/11/15 at 7:00 PM, revealed she did not know she was to complete the Wound Care Summary or weekly Skin Report for residents with wounds when she did the weekly Skin Assessments. Further interview with LPN #10, revealed she should have included all the resident's wounds on the weekly Skin Assessment she completed on 05/26/15; however, did not receive any in-service when hired related to how to do the skin assessments. Review of the next weekly Skin Assessment completed by LPN #13, dated 05/28/15, revealed Resident #1 had a Stage II pressure ulcer to the sacrum which measured 2 cm by 3 cm by 1 cm depth with eschar (dead tissue) noted in the wound and a fluid filled blister on the right side of the wound; a SDTI to the right heel measuring 2 cm by 2 cm and was dark purple. However, review of the weekly Skin Report completed by LPN #13, dated 05/28/15 revealed the resident had an open area to the left buttock measuring 3 cm by 1 cm and there was no documented evidence the stage of the wound noted. Interview with LPN #13 on 08/11/15 at 6:15 PM and 08/12/15 at 7:00 PM revealed when she completed the Skin Assessment on 05/28/15, Resident #1 was noted to have a Stage II to the left buttock and she failed to document the stage of the ulcer on the weekly Skin Report and failed to document this ulcer on the weekly Skin Assessment. Further review revealed there was no documented evidence of further weekly Skin Assessments completed for Resident #1 after 05/28/15. However, review of the weekly Skin Report dated 06/04/15, revealed the resident had a sacral/left buttock wound which measured 9.5 cm by 6 cm by 0.5 cm with 75% eschar and 25% red/purple wound bed with purulent drainage and the Report indicated this wound had worsened. Interview with LPN #7 on 08/10/15 at 7:00 PM, revealed she had documented the weekly Skin Report dated 06/04/15 and the measurement performed was for the sacral area only. She revealed she had measured the right heel and had documented the right heel wound on 06/04/15 as SDTI 2 cm by 2.8 cm purple on the weekly Skin Report; however had failed to date the entry. She further acknowledged she had failed to document the area to the left buttock. Further interview with LPN #11 revealed she had not followed through with documenting the wounds on the Wound Care Summary as per protocol or on the weekly Skin Assessments. Review of the Nurse's Notes dated 06/06/15 at 2410 (12:10 AM), completed by LPN #11, revealed Resident #1 was very hot to touch and her/his face was flushed and the resident's temperature was checked which was 102.4 degrees, Tylenol 500 milligrams (mg's) (medication for pain relief and fever reducer) was administered and the nurse would continue to monitor. Review of the Medication Administration Record (MAR) dated June 2015, revealed Tylenol 500 mg was administered on 06/06/15 at 2410; however, there was no documentation on the MAR or further documentation in the Nurse's Notes to indicate if the medication was effective. Interview with LPN #11 on 08/20/15 at 9:30 AM, revealed at the time she wrote the Note on 06/06/15 she obtained a full set of vital signs; however failed to document them. She stated she always followed up with taking another temperature after she had given Tylenol for a fever, and failed to document the effectiveness of the medication. There was no Nurse's Note on the subsequent shift (day shift for 06/06/15) and no documented evidence the nurse on the day shift 06/06/15 assessed Resident #1 except for obtaining a temperature which was recorded on the MAR. Review of the June 2015 MAR revealed on 06/06/15 at 1430 (2:30 PM) Tylenol 500 mg was administered for a temperature of 101.6 and Resident #1's temperature decreased to 97.0 at 1730 (5:30 PM). Interview with LPN #9 on 08/21/15 at 2:10 PM, revealed she would normally assess the resident if the resident had a temperature from the shift before and in Resident #1's case it would include assessing the resident's wound and obtaining vital signs. Per interview revealed she failed to write a note related to her assessment of the resident. Continued review of the June 2015 MAR revealed LPN #8 had documented on 06/07/15 at 1045 (10:45 AM) Tylenol (no dosage noted) was administered for a temperature of 101.6; however, the nurse failed to indicate the dosage administered. Per the MAR, the resident's temperature came down to 99.2 at (1200) 12:00 PM. Review of the physician's orders [REDACTED].#8 revealed orders for a culture of the sacral wound with the next dressing change due to odor, temperature, and drainage. After culture obtained start [MEDICATION NAME] (antibiotic medication) 750 milligrams every day for seven (7) days until the wound culture was received. Although the physician was notified of a change in the sacral wound and the resident having a temperature on 06/07/15 at 1550 (3:50 PM), there was no documentation in the Nurse's Notes of an assessment of Resident #1 related to the wound and the temperature on that shift by LPN #8. Interview with LPN #8 on 08/11/15 at 7:00 PM revealed she had looked at the wound on 06/07/15 and it looked bad so she notified the Physician for orders. Further interview revealed she forgot to chart on the resident and talked to LPN #7 later that evening and asked LPN #7 to chart for her related to notification to the Physician and the orders which were received. Further review of the June 2015 MAR revealed Resident #1 again received Tylenol on 06/07/15 at 1650 (4:50 PM), for a temperature of 102 degrees, and there was no documentation on the MAR to indicate if the medication was effective for the temperature. Interview on 08/12/15 at 12:40 PM with the DON, revealed the dosage of medication administered should be documented on the MAR and when a prn (as needed) medication such as Tylenol was administered for fever, the effectiveness of the medication should be documented on the MAR. There was no subsequent Nurse's Note related to an assessment of the resident after the 06/06/15 at 2410 (12:10 AM) notation until 06/07/15 at 2200 (10:00 PM), over forty-six (46) hours, even though the resident sustained [REDACTED]. Interview with the DON on 08/21/15 at 2:10 PM revealed the nurses assigned to the resident's were ultimately responsible for assessing and documenting the assessment in the residents medical record. She revealed her expectation was for the nurses to assess and document the assessment for a resident who was running a temperature on the prior shift. 2. Review of Resident #10's medical record revealed the facility admitted the resident on 02/02/15 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 02/16/15 on re-admission to the facility after hospitalization , revealed Resident #10 had a 1.3 by 1.0 cm open area to the left sacrum, a 1.7 by 0.8 cm open area to the right sacrum, and a 4.4 cm by 3.8 cm fluid filled purple area to the right heel. Further review revealed Wound Care Summaries (WCSs) continued weekly related to the left and right sacrum areas and the left sacrum healed on 03/02/15 and the right sacrum healed on 03/12/15. Record review revealed on 02/23/15, the resident's right heel was 5.0 cm by 4.0 cm red purple blister, and on 03/02/15 the resident's right heel ulcer was 5.0 cm by 4.0 cm purple blister. On 03/12/15 the right heel wound was unstageable measuring 6.0 cm by 5.0 cm with eschar and brown drainage indicating the wound was deteriorating. On 03/16/15 the right heel unstageable ulcer measured 5.5 cm by 4.5 cm and had greater than 25% eschar. On 03/22/15 the right heel ulcer measured 5.0 cm by 4.0 cm and was described as having eschar, slough and serosanguinous drainage. On 03/30/15 the right heel pressure ulcer was 4.0 cm by 4.0 cm with 75% red wound bed and with 25% deep purple red wound bed, and serosanguinous drainage. Further review of the clinical record revealed on 04/09/15 the right heel pressure ulcer was 75% eschar, 6.5 cm by 7.5 cm wound bed with serosanguinous drainage and Resident #10 also had a SDTI measuring 1.0 cm by 1.0 cm purple area to the left coccyx. On 04/14/15 the SDTI wound to the left coccyx measured 3.0 cm by 3.0 cm's and was purple maroon in color, and the right heel wound measured 5.0 cm by 6.5 cm with 75% eschar and 25% red wound bed, brown drainage with odor. On 04/21/15 the left coccyx SDTI was unstageable and measured 2.0 cm by 3.5 cm with 100% slough, and serosanguinous drainage with non-blanchable skin surrounding the ulcer; the right heel ulcer measured 5.0 cm by 6.5 cm and was described as greater than 75% eschar and brown drainage; and, the resident had a new SDTI measuring 1.0 cm by 1.0 cm non blanching purple maroon in color to the right coccyx. There was no documented evidence of further WCSs related to the left coccyx pressure ulcer, the right coccyx pressure ulcer, or the right heel ulcer from 04/21/15, until 08/14/15 (over three (3) months). Additionally, these areas were not documented on the weekly Skin Report from 04/29/15 until 06/09/15 (over five (5) weeks) and there was no weekly Skin Assessments noted from 04/14/15 until 06/02/15 (seven (7) weeks). In addition, on the 06/02/15 weekly Skin Assessment completed by LPN #13, it was noted the resident had a SDTI to the left inner buttock which was red and non-blanchable measuring 6.0 cm by 5.0 cm. However, on the same date, 06/02/15, physician's orders [REDACTED]. There was no documented evidence the description of the area was transcribed to a Wound Care Summary or to the weekly Skin Report on 06/02/15 and there was no indication the Physician was notified again of the area on the left inner buttock in order to obtain a treatment. Review of the Skin Assessment, dated 06/09/15, revealed the resident's left coccyx wound was described as 7.0 cm by 5.0 cm by 1.0 cm. However, the nurse failed to mention the resident's right coccyx wound. The resident's right heel unstageable ulcer was measured as 6.0 by 7.5 cm with eschar. Also, the weekly Skin Assessment as well as the weekly Skin Report described the resident as having fluid filled blisters to the bilateral upper thighs and a left buttock SDTI measuring 3.0 cm by 1.0 cm. However, there was no indication the Physician was notified of the blisters to the bilateral upper thighs and the left buttock SDTI, although there was no treatment ordered for these areas. Post survey phone interview on 08/25/15 at 7:21 PM with LPN #13, who completed the skin assessment on 06/09/15, revealed if a new area of skin breakdown was found the Physician was to be notified for a treatment order but she could not remember the circumstances related to the SDTI to the resident's left buttock and the blisters to the resident's upper thighs in June. The weekly Skin assessment dated [DATE] completed by LPN #7, failed to mention the resident's right coccyx wound. The resident's unstageable right heel ulcer was measured at 6.0 cm by 8.0 cm with eschar. The resident's left coccyx ulcer was described as Stage II measuring 4 cm x 2.2 cm x 1.5 cm with a 2 cm tunnel to 12 o'clock and the wound bed had 25% eschar. The resident's left lower coccyx was mentioned separately as 1.2 cm x 1 cm stage II. The resident's left inner buttock area was not mentioned in this assessment. Additionally, the posterior left thigh area was described as 6.0 cm by 2.5 cm stage II and there was dried blood blisters to the right thigh. Review of the Wound Care Clinic Note dated 06/22/15, described the resident's coccyx decubitus as measuring 4.0 by 2.0 by 2.0 with pink granulation tissue and loose gray slough in the wound bed. Per the Note, the ulcer was debrided and re-measured at 4.0 by 2.0 by 2.2 cm. The right heel ulcer was debrided and re-measured at 5.5 by 9.5 by 0.5. In addition, the Note stated the resident had a decubitus ulcer to the left ischium with thin eschar which measured 4.0 by 2.5 by unknown depth. However, due to the facility interchanging anatomy sites for the coccyx, buttock, and posterior thigh, and due to the inconsistency in tracking the wounds, it could not be determined if the ischium ulcer had already been identified or was receiving treatment. Interview on 08/21/15 at 2:30 PM with the Nurse Consultant, who was the former Interim Administrator until 07/24/15, revealed after reviewing the record, the nurses were interchanging areas between sacrum, buttocks, coccyx, and thigh and she felt the Wound Clinic Physician changed the terminology of the coccyx wound to the ischium. She stated Our documentation needs work and is not easy to track. Post survey phone interview with the DON on 08/28/15 at 4:00 PM, revealed after reviewing the chart she could not determine for sure which area the Wound Clinic Physician was calling the Ischium; however, she thought it must be the left coccyx. She further stated the nurses completing the skin assessments needed to ensure the terminology was accurate and consistent in order to follow the progress of the wounds. 3. Review of Resident #5's medical record revealed the resident was admitted by the facility on 02/14/13 with [DIAGNOSES REDACTED]. Record review revealed Resident #5 had multiple hospital stays. The resident was hospitalized from [DATE] through 04/18/15 with [MEDICAL CONDITION]/suspected Aspiration Pneumonia/UTI. Review of Nurse's Notes for Resident #5 dated 04/18/15 at 1600 (4:00 PM), on re-admission from the hospital, revealed the resident had a sacral wound which measured 9.7 cm x 7.2 cm and 75% of the wound was covered with hard yellowish slough. Continued review revealed there was two (2) small areas in the center of the wound which were black eschar and the remainder of the wound had a red wound base; the wound extended toward the rectal area and the left heel had a fluid filled blister. Review of the April 2015 Wound Care Summaries (WCSs) for Resident #5, revealed the first WCS for April was dated 04/21/15 which revealed the resident had a 9.7 cm x 8 cm ulcer with 75% slough and 25% eschar in the wound bed surrounded by non-blanchable deep purple skin, and the Summary further revealed the wound was identified on 03/08/15. Although the WCSs were to be completed weekly as per protocol, there was no documented evidence this wound was tracked on the WCS for April until 04/21/15. Further review of the WCS dated 04/21/15 revealed the resident also had a left heel 3 cm x 4 cm blister. Review of the Weekly Skin Report, revealed a Sacral/Coccyx Wound assessment dated [DATE] described the sacral/coccyx wound as unstageable measuring 9.7 cm x 8 cm with 75% slough and 25% eschar, purulent drainage and no odor and the left heel ulcer as 3 cm x 4 cm blister. The next weekly Skin Report dated 04/29/15 described and measured the sacral coccyx wound; however, did not describe/measure the left heel wound. Further review of Resident #5's record revealed he/she was hospitalized from [DATE] through 05/06/15 and was re-admitted on [DATE]. Review of the Nurse's Notes dated 05/23/15 at 1:00 AM, revealed the resident had a Stage II Pressure Ulcer to the Right Lower Buttock; however there was no measurements or description. Review of the subsequent May 2015 Nurse's Notes revealed no further documentation related to the right lower buttocks pressure ulcer. Review of Resident #5's Wound Care Summaries revealed there was no documented evidence a Summary was completed related to the left lower buttock Stage II pressure ulcer wound identified on 05/23/15. Review of May 2015's weekly Skin Report revealed no documented evidence Resident #5 was listed related to any wounds. Also, there was no documented evidence of weekly Skin Assessments completed in May 2015. The resident was transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. Review of the 06/04/15 Re-Admission Note Nurse's Note revealed Resident #5 had a Stage II pressure ulcer to the left lower leg/buttock area, an unstageable pressure ulcer to the coccyx and a fluid filled blister to the right metatarsal; however, there were no documented evidence of measurements of the pressure ulcers. The Resident Data Collection (RDC) form dated 06/04/15 revealed Resident #5 had a stage II pressure ulcer to the lower left buttock and a fluid filled blister to the right metatarsal; however, there was no mention of the coccyx ulcer and there was no measurement of the lower buttock Stage II pressure ulcer. Additionally, the RDC only stated the resident had [MEDICATION NAME] foam to the left heel with no description, measurement or staging of the heel wound. Also, there was no documented evidence of a Wound Care Summary related to the sacral/coccyx wound from 04/21/15 until 06/08/15, which was over six (6) weeks later. On 06/08/15 the WCS described the resident's sacral /coccyx wound as an unstageable ulcer measuring 7.3 cm x 8 cm with green slough throughout the wound bed with copious purulent drainage and odor and surrounding skin had blanchable discoloration. The lower buttock Stage II pressure ulcer, identified on 05/23/15, had no Wound Care Summary completed until 06/08/15, over two (2) weeks later. The WCS dated 06/08/15 revealed Resident #5 had a stage II pressure ulcer to the posterior left thigh/buttock measuring 1 cm x 1 cm with 100% granulation and the surrounding skin had blanchable redness. The WCS dated 06/17/15 revealed this pressure ulcer had healed. Review of the June 2015 weekly Skin Report documentation revealed Resident #5 was reported on 06/08/15 to have a unstageable sacral coccyx wound measuring 7.3 cm length by 8 cm width, with green slough, copious purulent drainage, positive odor and the Report indicated the wound was improved; however, this documentation was incorrect and the wound had worsened per record review. The weekly Skin Report dated 06/08/15 also described Resident #5 as having a stage II posterior left thigh buttock wound measuring 1 cm x 1 cm with a pink red wound bed, a blister to the right metatarsal and blister to the left heel. Record review revealed an SDTI to Resident #5's left great toe knuckle area identified on the 06/16/15 per the Re-admission Nurse's Note and the Admission Resident-Data Collection (RDC) document; however there was no documented evidence of a measurement or site description. Review of the resident's Admission Physician orders [REDACTED]. However, there was no documented evidence of further mention of the area to the left great toe until 07/03/15 when the Re-admission Note described the area as a dark purple blister around/under the resident's nail bed, with no measurement (over two (2) weeks later). The RDC dated 06/16/15 also revealed Resident #5 had a decubitus ulcer to the coccyx which was unstageable measuring 9 cm x 9 cm, and bilateral boggy heels. Review of the next weekly Skin Report dated 06/18/15 revealed this Report only described and measured the coccyx ulcer; however, failed to mention the new SDTI to the left great toe, or the bilateral boggy heels. There was no documented evidence of weekly Skin Reports for Resident #5 in June 2015 after the 06/18/15 Report, although the protocol stated the Reports should be completed weekly. On 06/18/15 the WCS described the resident's coccyx ulcer as 8 cm x 8.5 cm x 0.5 cm with 0.5 cm undermining to 3 o'clock with slough; however, there was no documented evidence of a WCS dated 06/18/15 to describe the SDTI to the left great toe. The WCS dated 06/26/15 described the resident as having a coccyx wound; however the ulcer was not staged. The ulcer was described as measuring 9 cm x 9 cm with slough throughout. The WCS dated 06/26/15 also revealed the resident had a SDTI to the right metatarsal wound; however there was no documented evidence of a measurement of this wound. In addition, the WCS dated 06/26/15 failed to mention of the SDTI to the left great toe. Review of the 07/03/15 Re-admission Note documented the resident had a right lower buttock SDTI which was partially opened with an [MEDICATION NAME] foam treatment applied and was to be changed every three (3) days. Review of the WCS dated 07/03/15 revealed the resident had an area to the coccyx; however there was no staging of the ulcer. The ulcer was described as measuring 8.5 x 9.5 cm with 0.5 cm with undermining to the right of the wound and the periwound was described as dark in color. The WCS dated 07/03/15 also stated the resident had an area to the right buttock which measured 4.1 cm x 1.8 cm and was a SDTI partially opened. Interview, on 08/28/15 at 4:00 PM, with the DON revealed Resident #5's Wound Care Summary related to the SDTI to the right lower buttock, identified 07/03/15, was not accurately assessed by the nurse because it was described as being partially open and an SDTI was not an open wound. Review of the weekly Skin Assessments revealed no documented evidence of Assessments prior to July. The weekly Skin assessment dated [DATE] described the coccyx wound as measuring 6 cm x 6 cm with 0.3 cm undermining and slough throughout; however, no staging was noted of the wound. The Assessment stated the heel was boggy; however, did not specify which heel. Further review revealed there was a blood filled blister on the left inner thigh and the left great toe had a dark purple blood filled blister. Review of the 07/17/15 weekly Skin Assessment revealed the Resident #5 had a unstageable 6 cm x 6 cm pressure ulcer to the coccyx with slough throughout; however, there was no documented evidence the other wounds were mentioned including the boggy heels, the wound to the left inner thigh, or the wound to the left great toe. There was no documented evidence Resident #5 was listed weekly on the QA July weekly Skin Report, the resident was only listed on 07/03/15 and 07/27/15 and was supposed to have been monitored/discussed on the report weekly. The Nurse's Note dated 07/28/15 at 12:30 AM revealed the resident was readmitted to the facility. The left great toe was described as having a 3.0 length x 3.0 width open area; however, there was no wound description, the sacral decubitus was described as 10 cm x 6 cm with tunneling noted at 3 o'clock and 9 o'clock. The RDC on re-admission revealed the resident had a left great toe black raised toenail, bilateral boggy heels and a 3 cm x 3 cm area to the right upper thigh. However the area to the right upper thigh was not described. The resident also had a sacral decubitus measuring 10 cm x 6 cm with tunneling at 3 o'clock and 9 o'clock. Record review revealed there was no Wound Care Summary documentation of tracking and trending the resident's left great toe SDTI site which was identified on 06/16/15. Review of the July 2015 weekly Skin Report revealed the left great toe site was not mentioned until 07/27/15 when the left great toe site was described as a black raised toe nail area, with no measurement noted. There was no documented evidence of a WCS initiated for the right upper thigh wound which was identified on re-admit to the facility on [DATE]. The weekly Skin assessment dated [DATE] revealed there was a Stage II to the left upper thigh; however, there was no documented evidence of measurements of the wound in order to track the wound for healing or deterioration. In July, Resident #5 was only on the weekly Skin Report on dates including 07/03/15 and 07/27/15. However, per protocol the wounds were to be documented on the weekly Skin Report weekly. Review of the August weekly Skin assessment dated [DATE] revealed Resident #5 had a decubitus ulcer on the sacral area measuring 10 cm x 7 cm x 2 cm with yellow slough with no stage specified, a Stage II to the left upper thigh measured as 2.0 cm only (no length/width measurement) with yellow slough and the left great toe nail was missing. Review of Resident #5's August 2015 monthly Physician order [REDACTED]. Post survey phone interview, on 08/28/15 at 4:00 PM, with the DON revealed the August Monthly Physician order [REDACTED]. She reported Pharmacy had already generated the August Monthly Orders when Resident #5 was re-admitted on [DATE], and the order was to be handwritten onto the August orders because the treatment continued; however, this was not done. 4. Review of Resident #7's medical record revealed the resident was admitted by the facility on 07/13/15 with [DIAGNOSES REDACTED]. Review of the admitting Nurse's Notes, dated 07/13/15 at 1910 revealed Resident #7 had [MEDICAL CONDITION] Resistant Staphylococcus (MRSA- a multi-drug resistant organism) cultured from the Cecostomy surgical wound. Review of weekly skin assessments completed on 07/18/15, 07/25/15, 08/01/15 revealed no pressure ulcers. Review of Resident #7's WCS documentation revealed the resident developed facility acquired pressure ulcers: two (2) Stage II to the left buttock and one (1) Stage II to the right buttocks which were identified on 08/04/15. However, there was no documented evidence of measurements, descriptions or assessments of the wound bed/peri-wound per the facility's Wound Protocol. Review of the 08/04/15 Nurse's Note revealed no documentation related to the newly identified pressure wounds. Further review of Physician orders [REDACTED]. 5. Review of Resident #6's medical record revealed the resident was admitted by the facility on 07/09/15 with [DIAGNOSES REDACTED]. Review of the facility's Admission Nurse Note, dated 07/09/15 at 1545 (3:45 PM) revealed Resident #6 was admitted with a Stage II Press

br> Based on interview, record review, review of Quality Assurance (QA) Audits and review of the facility's policy, it was determined the facility failed to develop and implement an effective plan of action when Quality Assurance identified a problem, in May 2015, with skin assessments not being completed weekly, and wound assessment documentation and wound monitoring forms not being completed weekly. Interview and record review revealed the QA action plan failed to implement a skin sweep of all residents to ensure all wounds were identified and documented, failed to ensure skin assessments were completed weekly and were accurate, failed to ensure appropriate descriptions/documentation of wound assessments were completed, failed to ensure wounds were tracked on the facility's Wound Care Summary form and failed to ensure all residents with wounds were listed on the Quality of Care (QOC) monitor- the Weekly Skin Report. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. This failure affected eleven (11) of fourteen (14) sampled residents (Resident #1, #2, #4, #5, #6, #7, #8, #9, #10, #11, and #12). (Refer to F314 and F490) The findings include: Review of the facility's policy: Quality Assurance, dated 08/01/13 revealed the purpose of the program was to ensure a standard of excellence was maintained. Policy review revealed the quality assurance program measured the level of quality services, identified specific deficiencies, and aided in the facility taking corrective action. Interview, on 0810/15 at 3:50 PM and 08/12/15 at 3:00 PM, with the Nurse Consultant and Former Interim Administrator, who was in charge of the facility until 07/24/15, revealed in April 2015, the designated skin nurse was re-assigned to the floor and the facility made a procedural change and assigned floor nursing staff the responsibility to perform weekly skin assessments, and complete the Wound Care Summaries and the weekly QA's Weekly Skin Report form. The Weekly Skin Report was used to monitor resident wounds week to week, and the report was reviewed at the weekly Quality of Care (QOC) meeting. Interview, on 08/12/15 at 11:30 AM, with Quality Assurance Nurses: Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Nurse #2, and MDS Nurse #4 revealed they were aware of the re-assignment of resident skin/wound assessments to floor nurses, but the change had not been discussed at the weekly QOC or monthly QA committee and they were unaware of any related action plan to ensure floor nurses were aware of what was required. Continued interview, on 08/10/15 at 3:50 PM and 08/12/15 at 11:15 AM, and 3:00 PM, with the Nurse Consultant revealed she was unable to attend the QOC meeting at the end of April, but at the next QOC weekly meeting, on 05/07/15, she became aware of a problem with the lack of documentation related to the wound monitoring when she noticed the Weekly Skin Report was not submitted to the QOC meeting. She revealed they identified the problem, and put an action plan in place which included a QA audit performed by herself, the current Administrator, and the Assistant Director of Nursing (ADON), from 05/08/15 through 05/17/15, and every chart in the building was audited for current weekly wound documentation. She stated it was a paper audit and they did not perform a skin sweep and look at residents' skin with this audit. She further revealed they looked at Nurse's Notes, completeness of documentation of skin assessments, analyzed the information, and felt it was a documentation problem. She reported an in-service with nursing staff was conducted on 05/22/15 to discuss skin/wound assessments and which forms were to be used. The Nurse Consultant revealed after the in-service was completed they became aware not all residents with wounds were being included on the QA weekly skin reports. Continued interview, on 08/12/15 at 11:30 AM, with the ADON revealed they identified an issue of skin assessments not being documented on the QA Weekly Skin Report for all residents and she was involved in an audit of all charts. The ADON revealed she audited charts and found skin assessments were not being done or charted appropriately. Per interview, the nurse completed the Wound Care Summary but had not put the wound on the QA Weekly Skin Report or vice versa and not all wounds were measured, staged or described such as including the color or drainage. Interview, on 08/12/15 at 6:20 PM, with the leaders of the QA committee: the Nurse Consultant, the current Administrator, and the Director of Nursing (DON) revealed they performed the audit and reviewed documentation of skin assessments, Wound Summaries, and the Weekly Skin Reports. Continued interview revealed they had the 05/22/15 in-service and talked about wound assessments, what was expected, and the three (3) forms to complete, as well as how to describe, measure, and stage wounds. Further interview revealed after the 05/22/15 in-service, all residents who had wounds were supposed to have been on the Weekly Skin Report and the QOC committee looked at this Report to ensure all residents with wounds were on the report. Record review of a QA document, undated, revealed documentation showing a QA audit was completed and all charts reviewed for current weekly wound documentation. Review of the attached audit information revealed the audit period was from 05/08/15 thru 05/17/15 and included wound documentation concerns identified, but no actual skin assessments performed. The document also included a plan which had the DON audit 5% (five percent) of wounds monthly and review the QOC Weekly Skin Reports. Continued interview, on 08/10/15 at 3:50 PM and 08/12/15 at 11:15 AM, and 3:00 PM, with the Nurse Consultant revealed through further analysis of the audit data she determined the skin/wound documentation problems occurred more on the 7:00 PM to 7:00 AM shifts on Wednesday, Thursday, and Friday. She reported a memo was sent out, to the nurses who worked 7:00 PM-7:00 AM, regarding the audit findings and skin assessments not being completed consistently. In addition, she reported nurses on that shift were individually contacted regarding the documentation concern. Also, she revealed the skin/wound assessment documentation concerns and plan of action were discussed at the 05/28/15 QA meeting. Continued interview on 08/12/15 at 6:20 PM, with the leaders of the QA committee: the Nurse Consultant, the current Administrator, and the DON revealed they had not done a skin sweep when the skin/wound assessment issues were identified to see if all wounds were identified or perform any skin assessments to compare with previous assessments to ensure wound assessments were accurate. In addition, the QA leaders reported they had not performed a 100% audit of the wound residents after the in-service and follow-up memo were completed to determine the effectiveness of the action plan. An audit consisting of 5% of the residents, who had a current wound or a resolved wound, was conducted and the weekly Skin Report was reviewed. The audit did not include just residents with current wounds (the action plan noted the DON was to audit 5% of wounds monthly). They also reported no concerns were identified on the June 2015 audit and the results were discussed at the July QA meeting and no additional actions were put in place. Review of the follow-up audit form, used to perform the June 2015 audit, the Quality Indicator: Pressure Ulcer Review, revealed five (5) residents were reviewed and no concerns identified. Closer review of the form revealed the audit criteria included contributing factors, severity of pressure sore, assessment and plan of care, treatments in place, and treatment outcome. However, the form had no section which addressed the identified QA concerns related to skin assessments completed and wound monitoring. Further interview with the QA leaders, on 08/12/15 at 6:20 PM, revealed the audit form was a standard quality indicator pressure review and looked at multiple areas, but acknowledged the form had no monitors to address the identified QA concerns related to skin assessment documentation and wound assessments and form completion. The leaders reported the staff member who completed the June 2015 Audits was not licensed/trained to perform skin/wound assessments, but was educated to ensure weekly Skin Assessments, Wound Care Summaries and the weekly Skin Report were completed when performing the audit. Continued interview with the QA leaders on 08/12/15 at 6:20 PM, revealed after becoming aware of State Survey Agency's identified issues, they realized the QA program in place was not effective and there was more follow-up needed. Per interview, starting last week the DON performed a head to toe skin sweep of all residents and was now looking at the weekly Skin Reports each morning.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the Physician when there was a significant change in the residents' physical status and a need to alter treatment significantly for two (2) of fourteen (14) sampled residents (Resident #1 and #10). Resident #1 Resident #1 had a sacral wound which was deteriorating, had a foul odor, and showed signs and symptoms of infection. The resident experienced a fever starting on 06/06/15 at 00:10 (12:10) AM which continued; however, there was no documented evidence the Physician was notified of the fevers until 06/07/15 at 3:50 PM, over thirty-nine (39) hours later. Resident #10 was assessed with [REDACTED]. The findings include: Review of the facility Change in a Resident's Condition, dated 08/01/13, revealed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the residents' medical/mental condition. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On Call Physician when there has been a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's physical/emotional/, mental condition. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 03/11/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) of a three (3) indicating cognitive impairment. Further review revealed the facility assessed Resident #1 as requiring extensive assist of two (2) for bed mobility, transfers and toileting, as always incontinent of urine, frequently incontinent of bowel, and as having no pressure ulcers. Review of the Significant Change MDS dated [DATE] revealed the facility assessed Resident #1 as having both short and long term memory loss, as requiring extensive assist of two (2) for bed mobility, transfers, and toileting and as always incontinent of bowel and bladder. Further review revealed the facility assessed Resident #1 as having one (1) Stage II pressure ulcer and having one (1) unstageable pressure ulcer. Review of the Wound Care Clinic Note dated 06/04/15, revealed the resident had an enlarging decubitus ulcer of the left medial buttocks which was described as eighty percent (80%), red granulation to twenty (20%), and measured 10 cm by 6 cm by unknown depth. Review of the Nurse's Notes, dated 06/06/15 at 2410 (12:10 AM), completed by Licensed Practical Nurse (LPN) #11, revealed Resident #1 was very hot to touch, her/his face was flushed and the resident's temperature was up to 102.4 degrees; Tylenol 500 milligrams (mg's) (medication for pain relief and fever reducer) was administered and would continue to monitor. Interview with LPN #11 on 08/20/15 at 9:30 AM, revealed she did not notify the Physician of the temperature because the resident had a standing order for Tylenol for temperature. Review of the June 2015 MAR indicated [REDACTED]. Interview on 08/21/15 at 2:10 PM, with LPN #9 who cared for the resident on 06/06/15, revealed a temperature was a change in condition for the resident; however, she did not notify the Physician because the resident's temperature came down with Tylenol. Further review of the June 2015 MAR indicated [REDACTED]. Review of the physician's orders [REDACTED].#8, revealed orders for a culture of the sacral wound with the next dressing change due to odor, temperature and drainage. After culture obtained start [MEDICATION NAME] (antibiotic medication) 750 milligrams every day for seven (7) days until the wound culture was received. Continued review of the June 2015 MAR indicated [REDACTED]. Review of the Nurse's Notes dated 06/07/15 at 10:00 PM, LPN #7 documented the Physician was notified by LPN #8 about the increased temperature and increased redness around the sacral wound and a new order was received to culture the wound and then start the [MEDICATION NAME] 750 Mg every day for seven (7) days until the culture report returned. Interview with LPN #7 on 08/07/15 at 10:00 AM, revealed on 06/07/15 it was reported to her by LPN #8 that she had called the physician related to the wound change and temperature. LPN #7 stated on her shift on 06/07/15 the resident was having a copious amount of drainage which was serosanguinous, and possibly some brown drainage but she could not remember if there was odor. She further stated there was no redness, open areas or drainage from the vagina. However, she stated there was redness surrounding the sacral wound bed. Continued interview revealed she did not call the Physician related to the wound having a lot of drainage because the Physician had been informed on the previous shift of the wound change and had ordered a culture and antibiotics. The subsequent Nurse's Notes dated 06/08/15 at 10:50 AM completed by LPN #9, revealed the physician was notified of the resident's sacral wound having redness and induration surrounding the wound spreading down the left buttock and up the left labia and there was a 1 cm open area on the left buttock producing a copious amount of gray/red purulent drainage, which was malodorous. According to the Note, new orders were received to send the resident to the hospital emergency room . Interview on 08/12/15 at 12:40 PM, 08/20/15 at 10:00 AM and 08/21/15 at 2:15 PM, with the Director of Nursing (DON), revealed she would not expect the Physician to be notified of a temperature if there was a standing order for Tylenol, unless the temperature did not come down after three (3) attempts of administering Tylenol. Further interview revealed a temperature could imply infection first and foremost and residents with invasive devices or wounds were more at risk for infections. Continued interview revealed the Physician was to be notified if there was a change in condition and if the Tylenol did not work to bring down the temperature the Physician would need to be notified. Interview with the Attending Physician/Medical Director on 08/11/15 at 9:30 AM, revealed sometime between the wound clinic appointment on 06/04/15 and 06/08/15 the wound became infected because there was no mention in the wound clinic note on 06/04/15 of the need for the resident to be hospitalization related to the wounds. Continued interview revealed he should have been notified when Resident #1 ran a temperature of 102.4 degrees on 06/06/15 because the resident had wounds and he would have ordered a culture of the wounds and antibiotics at that time. 2. Review of Resident #10's medical record revealed the facility admitted the resident on 02/02/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a six (6) out of fifteen (15). Continued review of the MDS, revealed the facility assessed the resident as requiring extensive assistance of two (2) for bed mobility, transfers, toilet use, as not rated for urinary incontinence, as always incontinent of bowel and as having one (1) unstageable pressure ulcer. On 05/14/15 a Wound Care Summary was initiated related to a SDTI on the resident's left lower inner buttocks measuring 1.0 centimeter (cm) x 0.5 cm. New physician's orders [REDACTED]. On 06/02/15 a weekly Skin Assessment described the resident's left coccyx wound in which the resident was already being treated, as unstageable measuring 6.0 cm by 3.0 cm by 0.5 cm. Further review revealed the weekly Skin assessment dated [DATE] completed by LPN #13, revealed the resident had a SDTI to the left inner buttock which was red and non blanchable measuring 6.0 cm by 5.0 cm. However, on the same date, 06/02/15, physician's orders [REDACTED]. However, there was no documented evidence the Physician was notified of the new area on the left inner buttock identified on the 06/02/15 assessment in order to obtain a treatment. Review of the weekly Skin Assessment and the weekly Skin Report, dated 06/09/15 and completed by LPN #13, described the resident as having fluid filled blisters to the bilateral upper thighs and a left buttock SDTI measuring 3.0 cm by 1.0 cm. However, there was no indication the Physician was notified of the blisters to the resident's bilateral upper thighs and the left buttock SDTI, even though there was no treatment ordered for these areas. A post survey phone interview was conducted on 08/25/15 at 7:21 PM with LPN #13, who completed the skin assessment on 06/09/15. LPN #13 revealed if a new area of skin breakdown was found the Physician was to be notified for a treatment order but she could not remember the circumstances related to the SDTI to the resident's left buttock and the blisters to the resident's upper thighs in June 2015. Review of the weekly Skin assessment dated [DATE] completed by LPN #7, revealed the resident had a left coccyx ulcer which was described as Stage II measuring 4 cm x 2.2 cm x 1.5 cm with a 2 cm tunnel to 12 o'clock and the wound bed had 25% eschar in which the resident was already receiving treatment. However, the left lower coccyx wound was mentioned separately as a new area measuring 1.2 cm x 1 cm and described as a stage II. The left inner buttock area was not mentioned in this assessment. Additionally, the posterior left thigh area was described as having a stage II pressure ulcer measuring 6.0 cm by 2.5 cm, and there was dried blood blisters to the right thigh. However, there was no documented evidence of Physician's notification for treatment orders to the areas to the thighs or the left lower coccyx. A post survey interview was conducted on 08/26/15 at 7:00 PM with LPN #7, who revealed if new areas of skin breakdown such as new pressure ulcers or blisters were identified, the Physician would need to be notified for a treatment order. However, LPN #7 could not remember about the blisters to the thighs or the area to the left lower coccyx in June 2015. A post survey phone interview with the Director of Nursing (DON), on 08/28/15 at 4:00 PM, revealed any time a new area of skin breakdown was found the Physician would need to be notified for a treatment order.

Based on observation, interview and record review it was determined the facility failed to identify changes in risk factors related to restraint use (side rails) for one (1) of twenty (20) sampled residents (Resident #13). The facility failed to attempt to eliminate or reduce physical restraints for Resident #13. On 06/17/10, Resident #13 fell from the bed with the side rails raised. The facility failed to identify that Resident #13 was at risk for climbing over the side rails per the "Side Rail Assessment". Resident #13 sustained a second fall from the bed with side rails raised on 08/08/10. Resident #13 was hospitalized for [REDACTED]. The findings include: Review of the "Side Rail Assessment" policy revealed side rail assessments should be completed upon admission, quarterly with the Minimum Data Set (MDS) assessment, and with any significant change. Additionally, full side rails could be considered a restraint, and if they were assessed as a restraint, the side rails should be treated accordingly. The side rail assessments were completed with quarterly MDS assessments. Review of the clinical record revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS revealed the facility assessed the resident to have both short and long-term memory deficits, and as being severely impaired in skills for daily decision making. Review of the "Restraint-Physical" policy, dated 01/09/02, revealed no information related to reassessing the use of a restraint after a resident had an incident (fall) which may be related to the use of restraints. Per the facility's policy, restraints were to be re-evaluated at least quarterly to determine their continued need. Additionally, the policy stated the facility should make every effort to eliminate the use of the restraint. Review of the clinical record revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessments dated 05/06/10 revealed the facility assessed Resident #13's side rails to be restraints. Review of the "Side Rail Assessment", dated 04/30/10, revealed the facility assessed that there was no possibility the resident would climb over the side rails. Interview with RN #3/MDS Coordinator revealed when conducting a review of the side rails she would interview staff, review clinical records, and look at any incident reports that may have been completed. Review of Physician's Orders and the "Treatment Record" revealed Resident #13's side rails were initially ordered on [DATE]. Further review revealed the Physician's order did not have a medical condition for the use of the side rails, nor did the Physician's orders identify which type of side rails were to be used. In interview, on 01/21/11 at 6:45 PM, RN #3/MDS nurse stated the Physician's order for side rails times two (2) meant the four side rails would be up. She explained this was due to the facility's beds usually had two (2) full side rails. Review of the "Comprehensive Care Plan" dated 05/12/10, revealed Resident #13's side rails were identified as a restraint. The facility's goal for the side rails was for the resident to be free from injury. Review of the care plan revealed it did not detail the type and/or the number of side rails that were to be used. Review of the "Nurse's Notes" and a "Resident Accident/Incident Report" dated 06/17/10, revealed Resident #13 was found sitting on the floor beside the bed. The facility assessed the resident and found no injuries. Per the incident report, the resident was getting in, or out of bed, and the two (2) long side rails were up. The incident report indicated the facility's recommendation/action taken included continuation of frequent visual checks, encourage resident not to stand/transfer without assistance, and the addition of a pressure pad alarm to the bed. Review of the "Comprehensive Care Plan" revised on 06/17/10, revealed the care plan included the interventions from the "Resident Accident/Incident Report". Interview, on 01/24/11 at 7:19 PM, with Registered Nurse (RN) #2 revealed she was on duty 06/17/10 when Resident #13 was found on the floor. The RN stated the resident had to have "squirmed" through the side rails in order to get out of bed. Interview, on 01/24/11 at 4:51 PM, with State Registered Nurse Aide (SRNA) #13 revealed he was on duty 06/17/10 when Resident #13 was found on the floor. Per the SRNA the side rails were up. The SRNA stated Resident #13 would slide to the foot of the bed and try to get out. He stated the nurses were aware of the resident's habit of sliding to the foot of the bed. In interview, on 01/24/11 at 5:49 PM, SRNA #7 was on duty when Resident #13 fell on [DATE]. SRNA #7 stated the side rails were up when she entered the room to assist with the resident. The SRNA verified the resident would slide to the foot of the bed and attempt to get up. She stated the nurses were aware the residents attempts to get out of bed. Interview, on 01/24/11 at 5:28 PM, with SRNA #5 revealed Resident #13 tried to climb out of the bed prior to the fall on 06/17/10 and "still tries to climb out of the bed". Interview, on 01/25/11 at 3:50 PM, with RN #3/MDS Coordinator revealed after review of the incident report and the Nurse's Note, she did not see anything about the side rails; therefore she did not complete a "Side Rail Assessment" for the 06/17/10 fall. RN #3 stated she had completed the 06/12/10 fall follow-up assessment on Resident #13 after the fall on 06/12/10 and could see no reason to add any other interventions than those she had suggested; even though the documentation on the incident report detailed the resident was getting in and out of bed with side rails up. Interview, on 01/25/11 at 2:53 PM, with Licensed Practical Nurse (LPN) #1, who also completed "Side Rail Assessments", revealed based on her review of the incident report, dated 06/17/10, and the Nurse's Notes for the 06/17/10 fall, she would need to complete a more comprehensive review of the side rails to determine the need for their continued use. Further record review revealed no documented evidence that the facility re-assessed to determine whether Resident #13's continued use of the side rails was safe. Interview, on 01/25/11 at 3:55 PM, with the Vice President of Clinical Operations revealed based on the incident report and the Nurse's Note for the 06/17/10 fall, she would assume the resident had climbed out of the bed but would need additional information. Review of the Minimum Data Set assessments dated 07/30/10 revealed the facility assessed Resident #13's side rails as restraints. Review of the "Side Rail Assessment" dated 07/30/10 revealed the facility continued to assess that there was no possibility that Resident #13 would climb over the side rails. Record review revealed these assessments were completed by RN #3/MDS Coordinator. Interview with RN #3/MDS Coordinator revealed when conducting a review of side rails she would interview staff , review clinical records and look at incident reports that may have been completed. However, further review of these assessments revealed no evidence RN #3/MDS Coordinator considered the 06/17/10 fall involving the side rails when completing the side rail assessment to determine the safety of this resident's continued use of side rails. Review of the "Nurse's Notes", dated 08/08/10 at 9:30 AM, revealed Resident #13 had been found lying on the floor and was assessed to have no injuries. Per the Note, the resident was found on the floor and the side rails were still up. At 9:30 AM, an assessment of Resident #13 revealed no apparent injury. Additional Notes timed at 12:00 PM and 12:30 PM revealed no discomfort was noted. Per the 1:30 PM entry Resident #13 was noted to have pain in the right lower extremity upon transfer to bed and was sent to the hospital for further evaluation. Review of the "Progress Note", dated 08/11/10, revealed the resident had undergone a Total Hip Arthroplasty (hip replacement) after a fracture to the right hip. Additionally, the Nurse's Notes detailed the incident report was faxed to the Physician. However, the facility was unable to provide documented evidence of the incident report, for this fall. Interview, on 01/24/11 at 4:41 PM, with RN #1 revealed she was on duty on 08/08/10, when the resident sustained [REDACTED]. The RN stated the resident would have had to have climbed over the side rails or out the foot of the bed. The RN stated the 08/08/10 fall was the first time she was aware that Resident #13 had fallen getting out of bed. Interview, on 01/25/11 at 10:43 AM, with State Registered Nurse Aide (SRNA) #6 revealed Resident #13 was sitting on the floor when she entered the room on 08/08/10. The aide stated the side rails were up. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed the facility assessed Resident #13's side rails as restraints. Review of the "Resident Assessment Protocol Summary" (RAPS) dated 08/26/10, revealed the facility assessed Resident #13 to have a physical restraint and the use of an alarming seatbelt related to a history of falls from the wheelchair. The RAPS did not identify the resident's side rail usage as a restraint and did not detail any risk factors associated with the use of the side rails. Additionally, the RAPS detailed the resident had experienced a recent fall with [MEDICAL CONDITION]. However, the facility did not identify/address the risk factors related to the use of side rails regarding the resident's falls on 06/17/10 and 08/08/10. Review of the "Side Rail Assessment" for Resident #13 with an assessment date of 08/20/10 revealed the facility continued to assess the resident to have no possibility to climb over the side rails. There was no documented evidence the facility attempted to reduce or eliminate the use of the side rails from 03/15/10 through 01/24/11. Interviews, on 01/24/11 at 4:51 PM, 5:28 PM, and 5:49 PM, with SRNAs #5, #6, #7 and #13 revealed they were aware that Resident #13 would scoot to the foot of the bed and attempt to get up. They stated the nurses were aware Resident #13 would attempt to get out of bed. In interviews, on 01/24/11 at 4:41 PM and 7:18 PM and on 01/25/11 at 2:45 PM RN #1, RN #2, RN #3 and LPN #1 denied knowledge of Resident #13's attempt to get out of bed unassisted. Observation of Resident #13, on 01/21/11 at 11:00 AM, revealed the resident was lying on the bed with side rails in place. Observation, on 01/21/11 at 12:40 PM, revealed the resident was lying on the bed with three (3) half side rails in place. Two (2) side rails on the right and one (1) side rail on the left side. Observations, on 01/24/11 at 3:42 PM, revealed the resident was lying on the bed with three (3) half side rails in place. Two (2) side rails on the left and one (1) side rail on the right side. Observation, on 01/24/11 at 5:15 PM, revealed the resident lying on the bed with four (4) half side rails in place. Random observations, on 01/25/11 from 11:50 AM until 3:20 PM, revealed the resident was lying on the bed with four (4) half side rails in place.

Based on observation, interview and record review it was determined the facility failed to identify environment risk and causal factors for falls related to side rails for one (1) of nineteen (19) sampled residents (Resident #13). On 06/17/10, Resident #13 fell from the bed with the side rails raised. The facility's fall investigation failed to identify side rails as a causal factor to the resident's fall, despite staff knowledge of this resident's attempts to get out of bed with the side rails raised. This failure prevented the facility from re-assessing the resident for continued safe use of side rails. Resident #13 had a second fall from the bed with side rails raised on 08/08/10, and was hospitalized for [REDACTED]. The facility failed to identify causal factors of the two falls and failed to re-evaluate risk factors associated with climbing over side rails on 06/17/10 and on 08/08/10 when Resident #13 sustained a fractured right hip requiring Total Hip Arthroplasty (hip replacement). The findings include: Review of the "Falls Program" revealed incident reports would be reviewed by the Director of Nursing and a fall's assessment would be completed. Review of the "Side Rail Assessment" policy revealed side rail assessments should be completed upon admission, quarterly with the Minimum Data Set (MDS) assessment, and with any significant change. Additionally, full side rails could be considered a restraint and if assessed as a restraint should be treated accordingly. The side rail assessments were completed with the quarterly MDS assessments. Review of the "Restraint-Physical" policy, dated 01/09/02, revealed no information related to reassessing the use of a restraint after a resident had an incident (fall) which may be related to the use of restraints. Per the facility's policy, restraints were to be re-evaluated at least quarterly to determine their continued need. Additionally, the policy stated the facility should make every effort to eliminate the use of the restraint. Review of the clinical record revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Side Rail Assessment, dated 03/15/10, revealed the facility assessed Resident #13 as incapable of climbing over the side rails. Review of the 03/16/10 "physician's orders [REDACTED].#13's positioning and mobility. In interview, on 01/21/11 at 6:45 PM, RN #3/MDS nurse stated the physician's orders [REDACTED]. She explained this was due to the facility beds usually had two (2) full side rails. Review of the 04/30/10 Side Rail Assessment revealed the facility continued to assess Resident #13 to have no possibility to climb over the side rails. Per the quarterly Minimum Data Set (MDS) assessments dated 05/06/10 the facility assessed Resident #13's side rails as restraints. Review of the "Comprehensive Care Plan" dated 05/12/10 revealed Resident #13's side rails were identified as a restraint. The facility's goal related to use of the side rails was for the resident to be free from injury. Additional review of the care plan for the problem "Routine Care Needs" revealed the side rails were to be up times two (2) with interventions which included: dated 05/14/08, the right side rail to be up, dated 05/12/10 seatbelt alarm. Review of the "Nurse's Notes" and a "Resident Accident/Incident Report" dated 06/17/10 revealed Resident #13 was found sitting on the floor beside the bed with two (2) long side rails in use. The facility assessed resident #13 as having no injuries. Per the incident report, the resident was getting in or out of bed. However, review of the incident report revealed no documented evidence that the facility identified the side rails as a casual factor in the resident's fall. Interview, on 01/24/11 at 7:19 PM, with Registered Nurse (RN) #2 revealed she was on duty 06/17/10 when Resident #13 was found on the floor. The RN stated the resident had to have "squirmed" through the side rails in order to get out of bed. Interview, on 01/24/11 at 4:51 PM, with State Registered Nurse Aide (SRNA) #13 revealed he was on duty 06/17/10 when Resident #13 was found on the floor. Per the SRNA the side rails were up. The SRNA stated Resident #13 would slide to the foot of the bed and try to get out. He stated the nurses were aware of the resident's habit of sliding to the foot of the bed. In interview, on 01/24/11 at 5:49 PM, SRNA #7 was on duty when Resident #13 fell on [DATE]. SRNA #7 stated the side rails were up when she entered the room to assist with the resident. The SRNA verified the resident would slide to the foot of the bed and attempt to get up. She stated the nurses were aware the of the resident's attempts to get out of bed. Interview, on 01/24/11 at 5:28 PM, with SRNA #5 revealed Resident #13 tried to climb out of the bed prior to the fall on 06/17/10 and "still tries to climb out of the bed". Interview, on 01/25/11 at 3:50 PM, with RN#3/MDS nurse revealed, after reviewing the incident report and the Nurse's Note, she did not see anything about the side rails; therefore, she did not complete a "Side Rail Assessment" for the 06/17/10 fall. RN #3 stated she had completed the 06/17/10 fall follow-up assessment on Resident #13 and could see no reason to add any other interventions than those she had suggested which included continue visual checks of resident frequently, remind resident not to stand or transfer without assistance, and add a pressure pad alarm to the bed. RN #3/MDS nurse confirmed that she had not identified the side rails as a causal factor to the falls and therefore did not complete a reassessment of Resident#13 to determine if continued use of side rails was safe for this resident. Review of the "Comprehensive Care Plan" revealed the facility identified problems related to trauma, potential for injury related to falls, Psychotropic drug use, bowel and bladder incontinence, and falls on 06/17/10 which included the following interventions: dated 05/14/08 included the right side rail to be up; dated 05/12/10 seatbelt alarm; dated 06/17/10 continue visual checks of resident frequently and remind resident not to stand or transfer without assistance, and, a pressure pad alarm to the bed. Interview, on 01/25/11 at 2:53 PM, with Licensed Practical Nurse (LPN) #1, who also completed "Side Rail Assessments", revealed based on her review of the incident report, dated 06/17/10, and the Nurse's Notes for the 06/17/10 fall, she would need to complete a more comprehensive review of the side rails to determine the need for their continued use. Interview, on 01/25/11 at 3:55 PM, with the Vice President of Clinical Operations revealed based on the incident report and the Nurse's Note for the 06/17/10 fall, she would assume the resident had climbed out of the bed but would need additional information. Review of the "Nurse's Notes", date 08/08/10 at 9:30 AM, revealed the facility staff found Resident #13 lying on the floor and assessed the resident as having no injuries. Interview, on 01/24/11 at 4:41 PM, with RN #1 revealed she was on duty on 08/08/10. The RN stated when she entered the resident's room the resident was lying on the floor. The RN stated the resident would have had to have climbed over the side rails or out the foot of the bed. The RN stated the 08/08/10 fall was the first time she was aware that Resident #13 had fallen getting out of bed. Interview, on 01/25/11 at 10:43 AM, with State Registered Nurse Aide (SRNA) #6 revealed Resident #13 was sitting on the floor when she entered the room on 08/08/10. The SRNA stated the side rails were up, as they always were when the resident was in bed. The facility was unable to provide documented evidence of the incident report or investigation related to this fall. Further review of the Nurse's Note", dated 08/08/10 at 1:30 PM, revealed Resident #13 had pain in the right lower extremity upon transfer to bed and was sent to the hospital for further evaluation. Review of the hospital "Progress Note", dated 08/11/10, revealed Resident #13 had undergone a Total Hip Arthroplasty (hip replacement) after a fracture to the right hip. Review of the "Side Rail Assessment" form revealed the facility continued to assess Resident #13 as having no possibility that he/she climbed over the side rails on 08/20/10. Interview, on 01/25/11 at 3:50 PM, with RN#3/MDS nurse revealed when conducting a review of the side rails she would interview staff, review clinical records, and look at any incident reports that may have been completed. Interviews, on 01/24/11 at 4:51 PM, 5:28 PM, and 5:49 PM, with SRNAs #5, #9, and #7 revealed they were aware that Resident #13 would scoot to the foot of the bed and attempt to get out of bed, by sliding down to the foot of the bed. They stated the Nurses were aware Resident #13 would attempt to get out of bed. While interviews with facility staff identified they were aware of the resident's tendency to attempt to get out of bed while the side rails were raised, additional review of the "Side Rail Assessment" form revealed no evidence the facility re-evaluated Resident #13's side rails as a causal factor for the falls on 06/17/10 or on 08/08/10. Observation of Resident #13, on 01/21/11 at 11:00 AM, revealed the resident was lying on the bed with side rails in place. Observation, on 01/21/11 at 12:40 PM, revealed the resident was lying on the bed with three (3) half side rails in place. Two (2) side rails on the right and one (1) side rail on the left side. Observations, on 01/24/11 at 3:42 PM, revealed the resident was lying on the bed with three (3) half side rails in place. Two (2) side rails on the left and one (1) side rail on the right side. Observation, on 01/24/11 at 5:15 PM, revealed the resident lying on the bed with four (4) half side rails in place. Random observations, on 01/25/11 from 11:50 AM until 3:20 PM, revealed the resident was lying on the bed with four (4) half side rails in place.