Every finding on record at River Haven Nursing And Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for one out of five sampled residents (Resident (R)2). Review of the Diabetes Mellitus Care Plan for R2, revealed the care plan included interventions to provide regular podiatry care as ordered by the medical doctor (MD), which was not implemented.The findings include:Review of the facility's policy titled Comprehensive Care Plans Standard of Practice, reviewed 04/2025, revealed the facility's care planning / Interdisciplinary Team, in coordination with the resident, family, and/or representative were to develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain.Review of the Facesheet revealed the facility admitted R2 on 12/16/2025. Resident 2's diagnoses included diabetes mellitus, acquired absence of right leg above knee, and end stage renal disease (ESRD). Further review revealed R2 was discharged home from the facility on 04/02/2026 and was readmitted on [DATE].Review of the admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/20/2026 revealed the facility assessed R2 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R2 was cognitively intact.Review of the Diabetes Mellitus Care Plan for R2 revealed the care plan was established on 12/22/2025 and included the intervention to provide regular podiatry care as ordered by the medical doctor (MD). Further review of the care plan revealed it was reviewed by the MDS Coordinator on 03/20/2026 and 04/20/2026.Review of the Physician Orders dated 12/16/2025, revealed a general order for R2 to have consults with dental, vision, podiatry, psychiatric, pulmonology, audiology, and tele-medicine MD PRN of resident's choice.Review of the Physician Orders dated 12/16/2025, revealed a treatment order for R2's finger and toenails to be assessed once weekly by a nurse. Review of the Treatment Administration Record (TAR) dated December of 2025 through April of 2026, revealed documentation that an assessment was completed on R2's finger and toenails every seven days within the specified timeframe.Review of a Progress Note, dated 03/26/2026, revealed R2 was complaining that her great toenail had been rubbing against her second toe after sustaining a fall the day before. Further review of the progress note revealed the resident was quoted saying she missed the last time to see the foot doctor because she was at dialysis. Continued review of the progress note revealed the nurse practitioner was made aware and requested a podiatrist for R2.Review of a Progress Note, dated 04/24/2026, revealed Social Worker 1 documented that the dialysis center contacted the facility and asked the facility to make R2 an appointment with podiatry and it is noted that the nurse was made aware and replied she would make the appointment next week.Review of a Progress Note, dated 05/04/2026, revealed the facility sent a referral and request for an appointment with a podiatrist and the podiatry office was to contact the facility to schedule an appointment once approved. Observations in room [ROOM NUMBER] on 05/11/2026 at 4:08 PM, revealed R2 sitting up in her wheelchair. Further observation revealed the resident's right leg had been amputated above the knee and the incision appeared healed. Continued observation revealed the resident removing her sock on her left foot to reveal extremely dry, flaky skin, her big toenail was thick and brown, growing sideways, and touching her second toe.During an interview with R2 on 05/11/2026 at 4:05 PM, she stated that no one at the facility tried to cut her toenail. She stated that the podiatrist had come here, but she was at dialysis when they came. She stated that the staff at the facility knew her toenail was long and touched her second toe. She stated the nurse practitioner did not look at her toes recently.During an interview with Licensed Practical Nurse (LPN)1 on 05/11/2026 at 11:40 AM, she stated that the resident wanted to do 360-care for podiatry and ophthalmology and they figured out that podiatry was coming on the resident's dialysis days and the resident was not able to see them. She stated that the resident wanted to go to Illinois to see a provider that she was already established with, but could not, due to her having insurance with Kentucky Medicaid. She stated that the resident had an ophthalmology appointment this month and the podiatrist's office was supposed to call with an appointment.During an interview with the podiatry company's MD on 05/11/2026 at 12:45 PM, he stated that the company sent consultants to the facility to see the residents for their podiatry needs. He stated that they were usually there monthly and saw patients on a rotating basis between every two to three months. He stated that they would come sooner if there was an urgent issue or medical necessity, upon request. He stated that it was 100% possible to rearrange or schedule to come on a different date than what was scheduled to accommodate the needs of the residents. He stated that they just received an email on 04/29/2026 from the facility's social services staff about coming on a different day for R2. He stated that they were scheduled to be at the facility on Tuesday, 05/26/2026. He stated that R2 was on their list to see on January 13th, and she refused to be seen. He stated that the next time they came was on 02/23/2026 and she was at dialysis and she was put back on the list to be seen on 04/10/2026, but she was discharged . He stated that after that they got the email on 04/29/2026 to tell them to come on a Tuesday or a Thursday. He stated that when they were there, they did a foot exam, checked for skin issues, looked for areas that may be breaking down, cut toenails, checked for interdigital infections, and would let the attending know if something needed to be looked at or followed.During an interview with R2's nurse at the dialysis center on 05/11/2026 at 4:49 PM, she stated that every time a foot check had been completed on R2, from initial admission at the clinic (December 2025) to date, she called the facility to ask about a podiatry referral. She stated on the initial foot check of 12/17/2025 and definitively on 02/11/2026, 03/13/2026, and 04/22/2026, she called to ask about the status of obtaining podiatry services for R2.During an interview with RN1 on 05/12/2026 at 9:00 AM, she stated that they had a treatment for R2's toe where we had to put iodine on her feet/nails. She stated that she missed her podiatry appointment, after that she discharged home and when she came back, she stated that she did not want to use the podiatrist that comes to the facility. She stated that she had not seen her toes recently and last time she saw it, it was curved over. She stated that she was not comfortable with cutting the resident's toenails herself. She stated that the resident had a podiatrist appointment that she missed. She stated that she was never notified by the dialysis center about their concerns. She stated that her DON handles rescheduling the providers that come to the facility. She stated that to her knowledge, she would be seen by an outside podiatrist.During an interview with LPN2 on 05/12/2026 at 11:00 AM, she stated that she normally worked on the 100-hall. She stated that social services was responsible for making sure the residents were seen by specialists in-house. She stated that they could give the podiatrists a call back to come see the residents if there was a need. She stated that foot wounds would not heal and it was imperative that someone looked at it because it could cause all kinds of complications like infections and amputations. She stated that the nurse should notify social services to call podiatry back to let them know the resident needed to be seen. She stated that she would follow up with them to make sure the resident was on the schedule to be seen. She stated that the nurses could cut toenails if they were not too thick and if they did not need a specialized tool to cut them. She stated that she was aware that a call could be made for urgency or a missed appointment. She stated that she would let them know this resident needed to be seen as soon as possible.During an interview with the MDS Nurse on 05/12/2026 at 2:52 PM, she stated that a care plan was what they set up at the beginning of the residents' stay and it is updated throughout their stay. She stated that when residents come in, they start discharge planning and tailoring their care plans to the individual, so they are able to meet their highest functional ability. She stated that they have an interdisciplinary team and as of right now but, overall, it would be the MDS nurse to ensure the residents' care plans were updated properly. She stated that as of right now, the MDS nurse was implementing the care plans. She stated that the admitting nurse would initiate the care plan if the MDS nurse or interdisciplinary team was not available. She stated that she expected the care plans to be followed. She stated that she would see it as a concern if interventions were not followed on the care plan and she would investigate further if that occurred. She stated that R2 not being seen by podiatry thus far, is a problem because she had a care plan intervention for regular podiatry care. She stated that R2 came to this facility very sick and did not need to be discharged from the hospital based on her condition. She stated that the standard of practice for foot care in a long-term care facility is to assess the foot as part of their skin assessments. She stated that she did her own assessments rather than rely on the information that is charted in the system. During an interview with the Director of Nursing (DON) on 05/12/2026 at 4:07 PM, she stated that on admission, they did a baseline care plan and from the baseline, the MDS nurse came in and did a comprehensive care plan, and she and the IDT team would personalize it as needed. She stated that she expected the care plans to be followed and implemented. She stated that not following the care plan was a concern due to the negative outcomes of the resident not receiving the care they needed that was tailored to them individually. During an interview with the Administrator on 05/12/2026 at 4:42 PM, he stated that he expected his staff to reach out to the podiatrist to schedule the evaluation and treatment and for any reason if it needed to be rescheduled. He stated that he expected staff to follow the resident's care plan. Negative outcomes of the residents not following the care plans, in the situation of R2, she could cut her foot and have complications from that.

Based on observation, interview, and record review the facility failed to ensure that residents received proper treatment and care to maintain good foot health. Additionally, the facility failed to provide foot care and treatment for Resident (R) R2 in accordance with professional standards of practice that included preventing complications from the resident's medical condition(s), assisting the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments, if needed for one of five sampled Residents (R2). An observation on 05/11/2026 at 4:08 PM revealed R2's left great toenail was thick, long, and curved to the left halfway over and was touching the 2nd digit.The findings include:During an interview with the Director of Nursing (DON) on 05/12/2026 at 2:02 PM, she stated the facility did not have a policy related to foot or nail care.Review of the Facesheet revealed the facility admitted R2 on 12/16/2025. Resident 2's diagnoses included diabetes mellitus, acquired absence of right leg above knee, and end stage renal disease (ESRD). Further review revealed R2 was discharged home from the facility on 04/02/2026 and was readmitted on [DATE].Review of the admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/20/2026 revealed the facility assessed R2 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R2 was cognitively intact.Review of the Diabetes Mellitus Care Plan for R2 revealed the care plan was established on 12/22/2025 and included the intervention to provide regular podiatry care as ordered by the medical doctor (MD). Further review of the care plan revealed it was reviewed by the MDS Coordinator on 03/20/2026 and 04/20/2026.Review of the Physician Orders dated 12/16/2025, revealed a general order for R2 to have consults with dental, vision, podiatry, psychiatry, pulmonology, audiology, and tele-medicine MD PRN of resident's choice.Review of the Physician Orders dated 12/16/2025, revealed a treatment order for R2's finger and toenails to be assessed once weekly by a nurse. Review of the Treatment Administration Record (TAR) dated December of 2025 through April of 2026, revealed documentation that an assessment was completed on R2's finger and toenails every seven days within the specified timeframe.Review of a Progress Note, dated 03/26/2026, revealed R2 was complaining that her great toenail had been rubbing against her second toe after sustaining a fall the day before. Further review of the progress note revealed the resident was quoted saying she missed the last time to see the foot doctor because she was at dialysis. Continued review of the progress note revealed the nurse practitioner was made aware and requested a podiatrist for R2.Review of a Progress Note, dated 04/24/2026, revealed Social Worker 1 documented that the dialysis center contacted the facility and asked the facility to make R2 an appointment with podiatry and it was noted that the nurse was made aware and replied she would make the appointment next week.Review of a Progress Note, dated 05/04/2026, revealed the facility sent a referral and request for an appointment with a podiatrist and the podiatry office was to contact the facility to schedule an appointment once approved. Observations in room [ROOM NUMBER] on 05/11/2026 at 4:08 PM, revealed R2 sitting up in her wheelchair. Further observation revealed the resident's right leg had been amputated above the knee and the incision appeared healed. Continued observation revealed the resident removing her sock on her left foot to reveal extremely dry, flaky skin, her big toenail was thick and brown, growing sideways, and touching her second toe.During an interview with R2 on 05/11/2026 at 4:05 PM, she stated that no one at the facility tried to cut her toenail. She stated that the podiatrist came, but she was at dialysis when they came. She stated that the staff at the facility knew her toenail was long and touched her second toe. She stated the nurse practitioner did not look at her toes recently.During an interview with Licensed Practical Nurse (LPN)1 on 05/11/2026 at 11:40 AM, she stated that the resident wanted to do 360-care for podiatry and ophthalmology and they figured out that podiatry was coming on the resident's dialysis days and the resident was not able to see them. She stated that the resident wanted to go to Illinois to see a provider that she was already established with, but could not, because she had insurance with Kentucky Medicaid. She stated that the resident had an ophthalmology appointment this month and the podiatrist's office is supposed to call with an appointment.During an interview with the podiatry company's MD on 05/11/2026 at 12:45 PM, he stated that the company sent consultants to the facility to see the residents for their podiatry needs. He stated that they were usually there monthly and saw patients on a rotating basis between every two to three months. He stated that they could come sooner if there was an urgent issue or medical necessity, upon request. He stated that it was 100% possible to rearrange or schedule to come on a different date than what was scheduled to accommodate the needs of the residents. He stated that they just received an email on 04/29/2026 from the facility's social services staff about coming on a different day for R2. He stated that they were scheduled to be at the facility on Tuesday, 05/26/2026. He stated that R2 had been on their list to see on January 13th, and she refused to be seen. He stated that the next time they came was on 02/23/2026 and she was at dialysis and she was put back on the list to be seen on 04/10/2026, but she had been discharged . He stated that after that they got the email on 04/29/2026 to tell them to come on a Tuesday or a Thursday. He stated that when they were there, they did a foot exam, checked for skin issues, and looked for areas that may be breaking down, cut toenails, and checked for interdigital infections and would let the attending know if something needed to be looked at or followed.During an interview with R2's nurse at the dialysis center on 05/11/2026 at 4:49 PM, she stated that every time a foot check had been completed on R2, from initial admission at the clinic (December 2025) to date, she called the facility to ask about a podiatry referral. She stated on the initial foot check of 12/17/2025 and definitively on 02/11/2026, 03/13/2026, and 04/22/2026, she called to ask about the status of obtaining podiatry services for R2.During an interview with RN1 on 05/12/2026 at 9:00 AM, she stated that they had a treatment for R2's toe where we had to put iodine on her feet/nails. She stated that she missed her podiatry appointment, after that she discharged home and when she came back, she stated that she did not want to use the podiatrist that came to the facility. She stated that she had not seen her toes recently and last time she saw it, it was curved over. She stated that she was not comfortable with cutting the resident's toenails herself. She stated that the resident had a podiatrist appointment that she missed. She stated that she was never notified by the dialysis center about their concerns. She stated that her DON handled rescheduling the providers that come to the facility. She stated that to her knowledge, she would be seen by an outside podiatrist.During an interview with the Social Services Director on 05/12/2026 at 10:05 AM, she stated that the nurse was responsible for making appointments and making sure residents were seen by an outside provider. She stated that she was responsible for making sure the resident was on the list to be seen by an in-house provider. She stated they had R2 on the list to be seen by their in-house podiatry and she refused to be seen. She stated that the resident was non-compliant and if the resident continued to refuse, they would not see her. She stated that she treated everything with urgency and she sent emails to the Podiatry Company to see if they could see her sooner because the resident asked her. She stated that when the resident told her at first that she wanted to see an outside provider, they worked on a referral for an outside provider. She stated that when there was a referral for an outside provider, the in-house providers did not see them. She stated that nursing sent a referral out for R2 for podiatry and ophthalmology. She stated that she had never spoken with anyone from dialysis about R2.During an interview with LPN2 on 05/12/2026 at 11:00 AM, she stated that she normally worked on the 100-hall. She stated that social services was responsible for making sure the residents were seen by specialists in-house. She stated that they gave the podiatrists a call back to come see the resident if there was a need. She stated that foot wounds would not heal and it was imperative that someone looked at it because it could cause all kinds of complications like infections and amputations. She stated that the nurse should notify social services to call podiatry back to let them know the resident needed to be seen. She stated that she would follow up with them to make sure the resident was on the schedule to be seen. She stated that the nurses could cut toenails if they were not too thick and if they did not need a specialized tool to cut them. She stated that she was aware that a call could be made for urgency or a missed appointment. She stated that she would let them know this resident needed to be seen as soon as possible.During an interview with the Nurse Practitioner for the facility on 05/12/2026 at 12:10 PM, she stated that she was familiar with R2. She stated that she remembered putting in a note on her chart requesting podiatry services for the resident. She stated that she did not remember when she last looked at the resident's foot, but she stated that she did not have any open areas and she had elongated toenails. She stated that the resident told her that she was not able to see podiatry when they were at the facility because they came on her dialysis days. She stated that she spoke to the ADON about it. She stated that it was important that she got her toenails cut because she lost her other foot to diabetic ulcers. She stated that R2 was a difficult resident and non-compliant. She stated that she often left dialysis early due to various excuses. She stated that when she was discharged from the facility last time, she did not follow through with her orders, her diet, her medicine, and continued to smoke and complain of shortness of breath. She stated that now she was making all kinds of complaints because the doctor would not restart her pain medicines because she did not need narcotic pain medicine for the kind of pain she was complaining of, like glaucoma pain. During an interview with the Director of Nursing (DON) on 05/12/2026 at 4:07 PM, she stated that R2 was admitted in December and they put her on the list for podiatry to see her and when they came, she refused. She stated that her feet were being assessed frequently. She stated that they reached out to in-house podiatry in April to ask them to come see her when she was not at dialysis. She stated that they also tried to send a referral to an outside provider, and the provider did not receive the fax they sent for the referral. She stated that if they could not get her a referral for an outside podiatry, in-house podiatry would see her. She stated that she expected the nurses to assess open areas, thick, long toenails, and report it to her and the doctor to get further orders. She stated that the patient was a diabetic and if she was to get an open area to the foot, they were harder to heal and the resident had a history of amputation of her other leg.During an interview with the Administrator on 05/12/2026 at 4:42 PM, he stated that he expected his staff to reach out to the podiatrist to schedule the evaluation and treatment and for any reason if it needed to be rescheduled. He stated that he expected staff to follow the resident's care plan. Negative outcomes of the residents not following the care plans, in the situation of R2, she could cut her foot and have complications from that.

Based on observation and interview, it was determined that the facility failed to ensure the mechanical lift slings were retired in accordance with the manufacturer's recommendations. Per the sewn-on manufacturer's label, the working life is six months. One sling out of six slings inspected in the 100 Hall had a legible date handwritten in black, which had expired, and there were no legible handwritten dates on all seven slings located in the 200 Hall.The findings include: Inspection of the sling wash and inspection log on [DATE] at 10:15 AM revealed that the last time it had been signed was on [DATE]. Laundry #13 could not reveal why the log had not been completed since that date and could not identify the purpose of the log. An interview with Maintenance #9 on [DATE] at 3:42 PM revealed that he maintained the hoist but does not do anything related to the slings and is not aware of sling recommendations. An interview with Central Supply #12 on [DATE] at 3:46 PM, revealed she did not track sling age, cleaning, and inspection, and was unsure of who was responsible for inspections. She was unable to answer how long the service life was for slings used to lift residents. Upon opening a new sling from Emerald Supply and reading the sewn-on manufacturer's label, she reported that the lifespan of the new sling is 6 months. An inspection of the 200 Hall with Central Supply #12 on [DATE] at 3:54 PM revealed the slings with legible labels were from Medline with a recommended service life of six months per the sewn-on manufacturer's label. Three slings out of seven had manufacturer tags where the print was not legible. One sling had 1/22 written on it, and Central Supply #12 could not identify a date related to the numbers handwritten on the label. An inspection of six slings in the 100 Hall on [DATE] at 4:03 PM, one sling with what appeared to be cigarette holes in the fabric, and another sling that was dated with a black marker [DATE], and two slings with a safety label that is not legible. An interview with the Administrator on [DATE] at 10:00 AM revealed they did not have a policy and or facility written guidance related to sling use, maintenance, or cleaning, and were unaware of the service life of the slings used in lifting residents.

Based on interview, record review, and facility policy review, the facility failed to report an alleged violation of abuse related to an allegation that occurred on or around 03/10/2025 for 1 of 5 residents sampled for abuse out of the total 26 sampled residents, (Resident (R)8). The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice reviewed 04/2025, revealed sexual abuse was defined as nonconsensual sexual contact of any type with a resident/patient. Continued review revealed it was the policy of the facility to report allegations of sexual abuse to the State Survey Agency (SSA), Adult Protective Services (APS), and all other required agencies within the specified time frames. Further policy review revealed the results of all investigations were to be reported to the appropriate state agency within 5 working days of the alleged violation's initial report. Review of the admission Facesheet for R8 revealed the facility admitted the resident on 01/17/2025, with diagnoses that included acute upper respiratory infection, alcohol abuse, bipolar disorder, and cellulitis of unspecified part of limb. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/22/2025, revealed the facility assessed R8 as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident had intact cognitive function. Review of a facility document titled, Assessment, dated 04/22/2025, provided by APS, revealed R8 called APS on 04/22/2025 to report on an unspecified date in March of 2025, he woke up to Certified Nurse Aide (CNA) 6 touching him inappropriately in a sexual nature, in his private region. Continued review of the document revealed R8 told APS he reported that information to the facility and was told not to go around CNA 6 anymore. Further review revealed in was noted the facility told CNA 6 he could not work with R8 anymore and to not go into the area where R8's room was. Review of Rehab (self care) care plans, dated 01/17/2025 through 04/16/2025, for R8 revealed a care plan started on 03/10/2025, with a description/intervention of Resident prefers no male caregivers. During interview with Department for Community Based Services (DCBS) 2 on 08/19/2025 at 2:49 PM, he stated he could not figure out why R8 had been in the nursing home to begin with because he was so independent. He stated R8 told him that he overheard a staff member talking to his boyfriend on the phone which triggered a discussion about homosexuality. DCBS 2 reported R8 told him he did not have anything against gay people, but he did not swing that way. He said R8 reported he had been lying on his stomach in his bed and felt the staff member touch the back of his right leg and thigh. DCBS 2 explained R8 told him the staff member also knelt down beside him like he was going to give him oral sex. He stated R8 told him that had made him really uncomfortable, and he talked about it all the time like he was going to pursue legal action. DCBS 2 reported he had spoken to the Administrator about the incident involving R8, and the Administrator was very dismissive of the allegation and at first denied knowing about the incident. He said he (DCBS 2) had to drag it out of him (the Administrator). DCBS 2 stated R8 told him he told the Social Worker (SW) about what happened, and SW denied being told about the incident by R8. He further stated he unsubstantiated his investigation against CNA 6 because it had basically been one person's word against the other. During interview with the facility's Administrator on 08/20/2025 at 11:00 AM, she stated the facility had no investigation file related to the alleged sexual abuse incident that occurred on or around 03/10/2025, involving R8 and CNA 6. During interview with CNA 5 on 08/20/2025 at 4:00 PM, she stated she remembered R8 used to talk her head off about somebody trying to hit on him. She said R8 had already told everyone, including the Administrator about the incident. CNA 5 explained she told the nurse about what R8 was saying, but did not remember who the nurse was. She further stated R8 told her that it was a male staff member that was gay, but they had like four gay male staff members, so she never knew who it was. During interview with the facility's former Administrator on 08/20/2025 at 4:46 PM, he stated he remembered R8, and said the incident in question had been reported to APS by the resident. He reported he had been aware R8 made allegations of a staff member touching him inappropriately, but come to find out he just was not used to people waking him up in the middle of the night because he had been in prison. The Administrator explained he did not report the allegations/incident to OIG (Office of Inspector General) or perform an investigation, because nothing happened. He further stated the facility had a soft file on the incident, and he did not know where the file was located as he was not the Administrator anymore. Review of a soft file (requested after the interview with the former Administrator) provided by the facility's current Administrator, for the incident involving R8, revealed it contained no documentation related to the incident involving R8 and CNA 6. Continued review of the soft file revealed it contained only a grievance form dated 01/29/2025, and abuse questionnaires with interviewable residents dated 04/29/2025, which were conducted 13 days after the facility discharged R8 on 04/16/2025. During interview with CNA 6 on 08/21/2025 at 8:19 AM, he stated he remembered the incident with R8, and had already gotten cleared by APS. He said the night of the incident he had been doing his rounds, and went to check on R8, who was independent. The CNA explained he knocked on R8's door, and told the resident he was coming into his room to clean up and take the trash out. CNA 6 said he noticed R8 had a suitcase on his bed, and all of his clothes were pulled out of the suitcase. He reported he grabbed the suitcase to make room on R8's bed and got the resident some ice water. The CNA stated he leaned down and asked if R8 if he needed anything else and then helped the resident's girlfriend, who was another resident, into his room. He reported R8 had not said anything to him at that time about any allegations, and he only heard about it from his coworkers about five days after the incident. CNA 6 said none of his superiors talked to him about anything, but R8 had been talking badly about him to everyone the whole time. He stated the solution the DON and Administrator came up with was not to allow any male caregivers in R8's room; however, at times, he was still assigned to the resident's hall just not allowed to go into his room. The CNA explained he never had a conversation with or had been questioned by anyone that worked at the facility, including the Administrator. He further stated he had only been questioned/interviewed by APS. During interview with the Social Services Director (SSD) on 08/21/2025 at 8:55 AM, she stated she did not recall R8 reporting a male staff member touching him inappropriately. She said the only incident she could remember concerning R8, was when he reported a male staff member touching him on his shoulder. The SSD stated R8 told them he did not want fags in his room. She explained she had not reported it (the incident she was aware of) to anyone because the Administrator knew about it and had told her about it. She reported she was not sure why the incident would not have been reported or investigated. The SSD stated when a resident made an allegation of sexual abuse, staff should tell the Administrator about it so they could take it from there. She further stated she did not know of a negative outcome that could happen if suspected abuse was not reported, as she reported everything as required. During interview with R17 on 08/21/2025 at 4:00 PM, she stated that she remembered R8, as she had been his girlfriend at one point in time when he resided at the facility. She stated she remembered the incident when R8 accused a male staff member of touching him inappropriately and making gestures towards him. She explained R8 had also accused another male staff member of touching him inappropriately, but that staff member did not work at the facility anymore, and she could not remember his name. R17 further stated R8 told the ombudsman, the Administrator, and everyone who would listen to him. She additionally stated she did not know if anything had been done about the incident except for the facility barring male staff members from going in his (R8's) room. Telephonic (Phone) attempts were made from 08/19/2025 through 08/26/2025, to interview R8; however, were unsuccessful as the phone calls went straight to voicemail and no return calls were received. During interview with the DON on 08/26/2025 at 11:30 AM, she stated that she expected all staff to report abuse allegations to her or the abuse coordinator. She said if an abuse allegation was brought to her, she would investigate and report it to OIG (Office of Inspector General) within 2 hours and continue the investigation. The DON explained physical abuse, mental abuse, psychosocial, misappropriation of property, and sexual abuse all fell under the category of abuse. She reported even if the resident who made the allegation had a history of making false accusations, the allegation still needed to be investigated as abuse and needed to be reported within 2 hours with a 5-day follow up performed. During additional interview with the facility's Administrator on 08/26/2025 at 11:45 AM, she stated she expected staff to follow the facility's policy, and state and federal guidelines regarding reporting abuse.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents had a right to a safe, clean, comfortable, and homelike environment which had the potential to affect all of the facility's 81 residents.The findings include: Review of the facility policy titled, Homelike Environment Standard of Practice, reviewed 04/2025, revealed the facility was to provide residents with a safe, clean, comfortable, and homelike environment. In addition, policy review revealed the facility was to encourage residents to use their personal belongings to the extent possible. Further review revealed the facility's protocol included cleanliness and order. Review of the facility policy titled, Resident Rights Standard of Practice, reviewed 04/2025, revealed the facility was to ensure each resident was treated with respect and dignity, and cared for in a manner that promoted maintenance or enhancement of his/her quality of life. Further review revealed the facility's residents had the right to a safe, clean, comfortable, and homelike environment. Observation on 08/19/2025 at 9:30 AM, of the 100 Hall shower room, revealed a dirty adult brief lying in a shower chair and a pile of dirty linens lying on the floor. Continued observation of the shower room revealed the toilet was full of feces, and a mold-like substance on the ceiling and wall tiles in the shower. During interview with Housekeeper (HK) 1 on 08/19/2025 at 9:55 AM, she stated she had worked at the facility for three months, and mold was all over the facility. She said the mold was there when she started working at the facility; however, she had not reported it to anyone. HK 1 said the residents deserved a clean and safe place to live. She further stated she was responsible for cleaning the shower rooms daily, but they were short staffed and only had six hours a day to get their jobs done. During interview with the HK Supervisor on 08/19/2025 at 3:10 PM, she stated the facility was aware of the mold issue, but had failed to do anything about it. She said she and her staff worked for a contract company. The HK Supervisor reported she expected the showers to be cleaned daily and deep cleaned once a week. She further stated they were short staffed and were only allotted six hours to clean the whole facility. During interview with Resident (R)2 on 08/20/2025 at 1:15 PM, she stated she had seen mold in the shower room. She reported the mold was all over. R2 further stated she had not said anything to anyone about it because she thought they already knew. During interview with R26 on 08/20/2025 at 2:20 PM, he stated mold was all over the showers, including the walls, ceiling and floors. He further stated he did not said anything about it though because the facility would not have done anything about it. During interview with the Maintenance Director on 08/20/2025 at 4:00 PM, he stated the black substance on the shower floors was most likely the grout he just replaced. He reported however, the ceiling and wall tiles were probably molded. The Maintenance Director said he had noticed the mold on 08/18/2025, and had one of the assistants put some sealer on the ceiling earlier today. He stated nobody had reported the mold to him though. The Maintenance Director further explained the facility did have a system in place to report things that needed to be repaired or replaced and he was trying to educate staff to use it. He said there had been a lot of staff turnover in the last few months since he started working at the facility. The Maintenance Director further stated he was unsure of the cause of the mold because he had not had time to crawl into the attic to investigate it. During interview with the Director of Nursing (DON) on 08/26/2025 at 11:30 AM, she stated she was unaware of mold being in the shower rooms. She further stated mold could cause respiratory problems and skin rashes for residents or staff. During interview with the Administrator on 08/26/2025 at 11:45 AM, she stated maintenance was responsible for checking for (water) leaks. She stated she expected mold issues in shower rooms to be identified and treated. The Administrator reported she expected staff to follow facility policy as well as state and federal guidelines. She further stated going forward, shower rooms would be inspected periodically to identify issues before they became problems.

Based on interview, record review, and facility policy review, the facility failed to thoroughly investigate an alleged abuse violation related to an allegation that occurred on or around 03/10/2025 for 1 of 5 residents sampled for abuse out of the total sample of 26, (Resident (R)8). The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice reviewed 04/2025, revealed sexual abuse was defined as nonconsensual sexual contact of any type with a resident/patient. Per review, the facility's Administrator or designee was to oversee the center in conducting an internal investigation of any violation/alleged violation of abuse. Continued review revealed a report of the results of the investigation to the enforcement agency was to occur in accordance with state law, including the State Survey Agency (SSA) within five working days of the incident. Policy review revealed the (facility's) investigations were to be prompt, comprehensive, and responsive to the situation. Review of the policy revealed the facility's investigation was to include: notification of physician and resident/resident representative; identification and removal of the alleged person or persons; type of alleged abuse and where and when the incident occurred. Further review revealed the investigation was to also include: interviews of all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations to obtain factual information; and follow-up resolution and measures to prevent repeat incidents. In addition, review revealed all material and documentation of the pertinent data to the investigation was to be collected, maintained, and safeguarded by the center (facility). Review of R8's Facesheet revealed the facility admitted him on 01/17/2025, with diagnoses that included bipolar disorder, cellulitis of unspecified part of limb, acute upper respiratory infection, and alcohol abuse. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/22/2025, revealed the facility assessed R8 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating he was cognitively intact. Review of a document, provided by the State Adult Protective Services (APS) agency, titled, Assessment, dated 04/22/2025, revealed R8 called APS on 04/22/2025, to report on an unspecified date in March of 2025, he woke up to Certified Nurse Aide (CNA) 6 touching him inappropriately in a sexual nature, in his private area. Per review, R8 reported that information to the facility and he was told not to go around CNA 6 anymore. Review further revealed R8 also reported the facility told CNA 6 he could not work with the resident anymore and was not to go into the area where R8's room was located. Review of the facility's Rehab (self care) care plans, dated 01/17/2025 through 04/16/2025, revealed a care plan for R8 initiated on 03/10/2025, with an intervention noting, Resident prefers no male caregivers. In interview on 08/19/2025 at 2:49 PM, Department for Community Based Services (DCBS) 2 (an APS worker) stated R8 was independent and he could not figure out why the resident was in the nursing home. DCBS 2 said R8 told him he (R8) overheard a male staff member talking to his boyfriend on the phone that triggered a discussion with the resident about homosexuality. He explained R8 said he did not have anything against gay people; however, he did not swing that way. DCBS 2 informed him he (R8) had been lying on his stomach on his bed when he felt the (male) staff member touch the back of his right leg and thigh. He reported R8 told him the staff member also had knelt down beside him like he was going to give him oral sex, which made him really uncomfortable. DCBS 2 said he spoke to the Administrator about it and the Administrator had been very dismissive of the allegation and at first denied knowing about the incident involving R8. He stated he had to drag it out of him (the Administrator). DCBS 2 said R8 told him he told the Social Worker (SW) about it and the SW had denied being told about the incident by the resident. DCBS 2 further stated that he unsubstantiated his investigation against CNA 6 because it had basically been one person's word against the other. In interview on 08/20/2025 at 11:00 AM, the (current) Administrator stated there was no investigation file regarding the alleged sexual abuse incident that occurred on or around 03/10/2025 involving R8 and CNA 6. In interview on 08/20/2025 at 4:00 PM, CNA 5 stated she recalled R8 used to talk her (the aide's) head off about somebody trying to hit on him. She said R8 had already told everyone including the Administrator about the incident. The CNA further stated R8 told her it was a male staff member that was gay, but they had like 4 gay male staff members, so she never knew who it was. In interview on 08/20/2025 at 4:46 PM, the facility's former Administrator stated he was familiar with R8, and said the incident in question had been reported to APS by the resident. He reported he had been aware R8 made allegations about a staff member touching him inappropriately; however, had not performed an investigation. The former Administrator said the facility had a soft file (unofficial file) on the incident, but he did not know where the soft file was because he was no longer the Administrator. Review of soft file documentation (requested after the interview with the former Administrator), provided by the facility's current Administrator, revealed it contained no documented evidence of information related to the alleged incident that happened around 03/10/2025, involving R8. In interview on 08/21/2025 at 8:19 AM, CNA 6 stated that he remembered the incident with R8, and had gone into the resident's room on the incident to check on him. He said R8 had a suitcase on his bed and all of the resident's clothes were pulled out of the suitcase leaving no room on the bed. CNA 6 explained he moved the suitcase to make room on R8's bed and got the resident some ice water. He reported after doing that, he leaned down and asked R8 if he needed anything else and then assisted the resident's girlfriend, who was another resident, into his room. The CNA stated R8 had said anything to him at that time about any allegations, and had only heard about it from his coworkers about five days after the incident. He said the Director of Nursing (DON) and Administrator came up with a solution of not allowing any male caregivers in R8's room. CNA 6 further stated the Administrator never questioned him about the incident, and the only person who had questioned or interviewed him was an APS worker. In interview on 08/21/2025 at 8:55 AM, the Social Services Director (SSD) stated the only incident she recalled was concerning R8 was when the resident reported a male staff member touching him on his shoulder. The SSD said R8 told them he did not want fags in his room. She stated she did not report that incident to anyone because the Administrator knew about it and had told her about it. The SSD reported when a resident made an allegation of sexual abuse, staff should tell the Administrator about it so they could take it from there. In interview on 08/26/2025 at 11:30 AM, the DON stated if an abuse allegation was brought to her, she would begin to investigate it and report it to OIG (Office of Inspector General) within two hours and then continue her investigation. She further stated even if a resident, with a history of making false accusations, was the person making an allegation, the allegation still needed to be investigated as abuse; reported; and have a 5-day follow up performed. In interview on 08/26/2025 at 11:45 AM, the facility's current Administrator stated she was the person responsible for investigating abuse allegations now; however, had not been Administrator at the time of the incident involving R8. She further stated investigations should be conducted as per facility policy.

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures had the potential to affect eighty-two (82) of eighty-eight (88) residents in the facility who consumed food from the kitchen. The findings include: Review of the facility's policy titled, Food Storage: Cold Foods, dated 04/2018, revealed All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation during the initial kitchen tour on 10/22/2024 at 9:10 AM, with the Certified Dietary Manager (CDM), revealed the walk in cooler contained a larger plastic container half full of cut up raw potatoes in water that were not labeled or dated; a larger plastic container half full of prepared apple crisp that was dated 10/17/2024 - 10/23/2024; and a small container of red peppers that were not labeled or dated. Observation revealed the CDM removed the items from the cooler. In an interview with the CDM on 10/25/2024 at 2:19 PM, she stated she expected staff to follow the guidelines as stated and to use items that were opened first. She stated day one starts the day that you open a container and depending on what the food item was, items could be stored up to seven days. The CDM stated leftovers (such as the apple crisp) could only be stored for three to four days. She further stated everything stored was to be dated and labeled properly and if items were found stored past the dates they should be discarded immediately. In an interview with the Administrator on 10/25/2024 at 5:03 PM, he stated the kitchen staff were contracted and he expected them to label and date items prior to storing them.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 2 of 21 sampled residents (Resident (R)39 and R42). 1. R39 developed a facility acquired stage 4 pressure ulcer in 05/2024. However, there was no documented evidence the facility reviewed and further developed R39's care plan with additional interventions. Further, R39's comprehensive care plan (CCP) did not include measurable data elements to monitor progress towards the expected outcomes and goals. 2. R42 received tube feeding and was care planned to have the head of bed (HOB) elevated. However, observations on 10/21/2024 at 1:15 PM and 3:18 PM, revealed R42's HOB was flat. The findings include: Review of the facility policy, Comprehensive Care Plans Standard of Practice, dated 10/2020, revealed an individualized comprehensive care plan (CCP) that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs was to be developed for each resident. Continued review revealed each residents' CCP was to be designed to identify problem areas and incorporate risk factors associated with the identified problems. Per review, the CCP was to reflect treatment goals, timetables, and objectives in measurable outcomes to aid in preventing or reducing declines in a resident's functional status and or functional levels. Further review revealed areas of concerns that were triggered during the resident assessment were to be evaluated using specific assessment tools before interventions were added to the care plan. Additionally, review revealed assessments of residents was ongoing and care plans were revised as information about the resident and condition changes. 1. Review of the facility's, Admission Record for R39 revealed the facility admitted the resident on 01/10/2024, with diagnoses including paraplegia, unspecified; chronic pain syndrome; and multiple (6) pressure ulcers. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/13/2024, revealed the facility assessed R39 to have a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated moderate cognitive impairment. Review of the Wound Care Provider's initial, Wound Evaluation and Management Summary, for R39's left heel wound dated 05/02/2024, revealed the Physician had made recommendations that included: offloading the wound; turning the resident side to side and front to back in bed every one to two hours if able. Review of the Wound Evaluation and Management Summary dated 10/17/2024, revealed the Wound Physician's recommendations included: turning the resident side to side in bed every one to two hours, if able, and offload the wound. Review of the facility's CCP for R39 revealed a focus problem for impaired skin integrity, dated 01/04/2424, that noted the resident had pressure sores with presence of skin breakdown or was at high risk for skin breakdown. Continued review revealed interventions dated 01/11/2024, that included: cushion pressure reduction; mattress pressure reduction; providing gentle support when turning, positioning, or transferring; and providing wound care as ordered by the Physician. In addition, review revealed the goal for R42 stated, improve nutritional status and avoid prolonged pressure to skin. However, review of the CCP further revealed no documented evidence the facility developed and implemented additional interventions for R39's actual pressure ulcer, such as use of the wedge cushion or heel boots. Additionally, there was no documented evidence the facility developed R39's CCP to include the Wound Physician's recommendations to turn the resident side to side in the bed every one to two hours if able and offload the wound. Additional review of the CCP for R39 revealed a focus problem for pressure ulcer, actual, dated 01/11/2024, which noted pressure ulcers. Continued review revealed on 05/02/2024, documentation noting R39 developed a new stage 4 pressure wound of the left heel. Per review, the interventions were dated 01/19/2024, and included: pressure relieving device chair cushion; pressure relieving device mattress; applying skin treatments as ordered; and weekly skin rounds to monitor progress of pressure ulcers. Further review revealed the goal dated 01/19/2024, noted R39 would have a decrease in stage of pressure ulcer through the next review date of 01/06/2025. Additionally, review of the CCP documentation revealed R39's care plan was reviewed on: 04/10/2024, 04/29/2024, 07/08/2024, 07/11/2024, 07/29/2024, 08/20/2024, and 10/16/2024. Review revealed however, the care plan was not reviewed or updated with R39's new pressure ulcer noted on 05/02/2024. Review of the CCP further revealed no documented evidence the facility developed and implemented care plan interventions on 5/02/2024 when R39 developed the new pressure ulcer, such as use of a wedge cushion or heel boots. In addition CCP revealed there was no documented evidence the facility developed R39's CCP to include the Wound Physician's recommendations to turn the resident side to side in the bed every one to two hours if able and offload the wound. Further review of the CCP for R39 revealed a focus problem for pain dated 01/11/2024, related to wounds and malnutrition. Per review, the interventions included adjusting daily routine as necessary to aid in pain relief; identifying location and rating pain prior to and after any interventions; medications as ordered; pain assessment as ordered and as needed; and reporting unrelieved or unacceptable levels of pain to the Physician as needed. In interview with Certified Nursing Assistant (CNA) 3 on 10/25/2024 at 9:13 AM, she stated the CNA's received a report from other CNA's at the beginning of their shift. She stated the CNA's also reviewed the facility's resident care guide (RCG) for residents which let them know what care to provide. CNA 3 stated she was not aware of any interventions that were in place for R39. In interview with CNA 8 on 10/25/2024 at 9:22 AM, she stated she was aware that R39 had wounds. CNA 8 stated that R39 had a pillow they placed between her knees, but she was not aware of any wedge cushions or heel boots that were to be used. She further stated she reviewed the RCG on the computer and could not recall seeing any heel boots or wedge cushions to be used for R39. In interview on 10/25/2024 at 2:42 PM, UM 1 on the 100 unit, stated staff positioned R39 as the resident would allow. She stated she had not looked at R39's care plan and was not aware of interventions for the resident. The UM stated if pain medication was needed or was ineffective the NP or Physician was to be made aware. She stated she was unaware of recommendations from the Wound Physician for R39 to be turned side to side and stated recommendations were given to the NP. UM 1 further stated she did not know if a resident requiring side to side positioning, would have that information on their care plan. In a post exit interview with the Wound Physician on 10/29/2024 at 3:18 PM, she stated she saw R39 weekly at the facility. She stated if she had given recommendations for R39 to be turned side to side, she would expect the facility to follow that recommendation, as the resident would allow. 2. Review of the facility's Admission Record for R42 revealed the facility admitted the resident on 01/29/2021, with diagnoses to include gastrostomy status, cerebral palsy, and epilepsy unspecified. Review of the Quarterly MDS Assessment with an ARD of 09/05/2024, revealed the facility assessed R42 as rarely or never understood. Further MDS review revealed R42 received total nutrition by artificial means. Review of the Physician's order undated for R42, revealed an order for Jevity (tube feeding formula) 1.5 to infuse at 65 milliliters (ml) an hour for protein-calorie malnutrition. Review of another undated Physician's order revealed the head of R42's bed was to be elevated 30 to 45 at all times except during care. Review of the CCP for R42 revealed a nutritional services care plan dated 01/29/2021, related to the resident having a feeding tube due to diagnoses of cerebral palsy and dysphagia. Continued review revealed interventions that included tube feeding as ordered to meet nutritional needs; and head of bed elevated at least 30 degrees while delivering the tube feeds. In additional interview with CNA 3 on 10/25/2024 at 9:13 AM, she stated she was aware that R42's HOB was to be elevated because of tube feeding and that information was on the resident's RCG. In interview with the Minimum Data Set (MDS) Nurse on 10/25/2024 at 10:24 AM, she stated she was responsible for residents' care plans. She stated the baseline care plan was initiated on admission and completed within 48 hours. The MDS Nurse said the comprehensive admission MDS assessment built the comprehensive care plan. She stated the purpose of the care plan was to guide residents' care, so that staff would know what kind of care to provide. The MDS Nurse stated all nurses could and knew how to update and revise residents' care plans. She stated if residents needed to be turned and repositioned that information should be on their care plan and on the RCG. Per the MDS Nurse in interview, the Unit Managers (UM) were responsible for updating the RCG for the floor staff (CNA's). She further stated if the care plan was not updated to reflect the resident's current condition, then staff, the CNA's specifically, might not get the information they needed to provide the correct care for residents. During an interview with the DON on 10/25/2024 at 3:11 PM, she stated care plans were updated with new orders during the facility's clinical meetings. She stated the MDS Nurse was responsible for updating resident's care plans and that floor nurses did not update residents' care plans. The DON further stated she would expect specific interventions to be on residents' care plans so staff were aware of those interventions. In interview with the Administrator on 10/25/2024 at 5:03 PM, he stated he expected staff to follow residents' care plan. He further stated care plans were to be reviewed and updated if needed when a resident had a change in condition.

Based on observation, interview and review of the facility policy, it was determined the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 21 sampled residents (Resident (R)39). Observation on 10/24/2024 at 11:20 AM, during the left heel dressing change for R39 revealed the resident had a grimace on her face prior to being turned by staff. R39 was observed placing the neckline of her gown in her mouth and biting down to keep from yelling out. R39 had tense facial expressions, facial grimacing and verbalizations of oh, oh, oh me during the dressing change. The State Survey Agency (SSA) Surveyor requested the wound care halted and R39 be assessed for pain. The Unit Manager (UM) stated R39 had received pain medication prior to the dressing change. However, review of R39's narcotic sign out sheet with the Regional Nurse revealed R39 had not received the pain medication since 10/22/2024. The findings include: Review of the facility policy titled, Pain Management Standard of Practice, dated 07/2020 revealed, the facility worked to ensure compliance with the regulatory intent of F697. Per policy review, the facility worked to ensure compliance by ensuring pain management was provided to residents consistent with professional standards of practice, the comprehensive care plan, and the resident goals and preferences. Continued review revealed in conjunction with the resident's physician, the facility was to work to prevent or manage pain, consistent with the care plan and the resident's goals and preferences, and to address/treat the underlying cause(s) of pain to the extent possible. Further review revealed the facility was to consider both non-pharmacological and pharmacological interventions/approaches, modify approaches to pain management as necessary and recognize expressions of pain might be verbal or nonverbal and were subjective. Review of the facility's, Admission Record revealed the facility admitted R39 on 01/10/2024 with diagnoses including chronic pain syndrome, paraplegia, unspecified, and reduced mobility. Review of the Quarterly Minimum Data Set (MDS), Assessment with an Assessment Reference Date (ARD) of 09/13/2024, revealed the facility assessed R39 as having a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated the resident was moderately cognitively impaired. Review of the Comprehensive Care Plan (CCP) for R39 revealed a focus problem for pain, risk for alteration on comfort related to wounds and malnutrition, dated 01/11/2024. Continued review revealed the interventions included adjusting daily routine as necessary to aid in pain relief; identify location and rate pain prior to and after any interventions, and medications as ordered. Per review, additional interventions included: notifying family/responsible party of any changes; pain assessment as ordered and as needed; reporting unrelieved or unacceptable levels of pain to the Physician as needed. Further review revealed R39 s goal noted to maintain tolerable level of pain through the next review, and for the resident to be free from constipation related to narcotic analgesic for 90 days. Review of the Physician's orders dated 10/12/2024, revealed an order for R39 to receive Oxycodone/Acetaminophen (Percocet) oral tablet 5/325 milligrams (mg) one tablet every six hours as needed for chronic pain syndrome. Observation on 10/24/2024 at 11:20 AM, of the pressure ulcer dressing change for R39, revealed the resident was observed with non-verbal signs of pain that included, tense facial expressions with facial grimacing, placing her gown in her mouth and biting down on it. Per observation, R39's verbalizations of pain included, oh, oh, oh me. The Unit Manager (UM)stated R39 received pain medication prior to dressing changes. The SSA Surveyor left R39's room to inquire when R39 had received the pain medication. Review of R39's narcotic sign out sheet with the Regional Nurse, revealed no documented evidence the resident had received pain medication since 10/22/2024. The SSA Surveyor requested R39's wound care be stopped and the resident assessed for pain and for the wound care to be completed after lunch. The SSA Surveyor reviewed R39's Medication Administration Record (MAR) on 10/24/2024 at 2:20 PM, to ensure the resident had been administered pain medication; however, there was no documented evidence R39 had received pain medication. In interview with R39 at 2:25 PM, she stated she had not received any pain medication. In interview on 10/24/2024 at 2:28 PM, the Staff Development Coordinator (SDC), who was working as a floor nurse, stated she could not recall UM 1 telling her to administer pain medication to R39. The SDC then administered Oxycodone/Acetaminophen oral tablet 5/325 milligrams to R39 at 2:38 PM. UM 1 informed the SSA Surveyor on 10/24/2024 at 4:00 PM, she was ready to continue with R39's dressing change. In interview at that time, R39 stated she was okay to proceed with the dressing change. Per observation, R39 continued to have facial grimacing during the dressing change; however, stated she was okay. During an interview with Certified Nursing Assistant (CNA) 3 on 10/25/2024 at 9:13 AM, she stated she provided care for R39 and said the resident always had pain with any movement. She stated R39's pain was better now than it was when the resident was first admitted . CNA 3 further stated R39 seldom voiced pain, but would bite her gown and have a pained expression on her face when being moved. During an interview with CNA 8 on 10/25/2024 at 9:22 AM, she stated she was aware that R39 had wounds. She stated R39 often had facial grimacing and chewed on her gown to keep from crying out. The CNA stated R39 had facial grimacing with movement to her legs due to contractures, but never verbally complained of pain. In interview with Registered Nurse (RN) 8 on 10/25/2024 at 9:38 AM, she stated a resident's pain was assessed and documented on their MAR. She started R39 was able to voice pain but seldom did that. The RN stated she had observed nonverbal signs of pain in R39, such as facial grimacing and biting down on her gown. She stated she had administered pain medication to R39 before, but was unable to recall if it was before wound care was provided. She stated R39 had an air mattress for wound prevention and a pillow placed between her knees. RN 8 stated she was not aware of any non-pharmacological interventions to use for pain relief. She stated all residents were turned and repositioned and that should be on the residents' care plan. RN 8 stated the CNAs usually reported when residents had pain and they (CNAs) were made aware of new interventions for residents by open communication to the staff. In interview on 10/25/2024 at 2:42 PM, UM 1, on the 100 unit, stated she had asked the nurse on the hall to administer pain medication to R39 at 8:30 AM, after the resident complained of pain with the dressing change to the G-tube site. She stated she found out it had not been administered after she completed the dressing change to the left heel. UM 1 stated we stopped the wound care at approximately 11:30 AM; however, said R39 did not receive pain medication until 2:30 PM. She further stated she did not know why it took so long for the pain medication to be administered to R39. During an interview with the DON on 10/25/2024 at 3:11 PM, she stated residents' pain was assessed and documented on their MAR each shift. She stated she expected nurses to assess residents' pain and administer pain medication if the residents had pressure ulcers, before completing wound care so it lessened the residents' pain. In interview with the Administrator on 10/25/2024 at 5:03 PM, he stated pain management was different with each resident. He stated if pain was identified he would expect the nurse to administer any ordered pain medication. The Administrator further stated a resident's pain should be reassessed as needed and staff should consult with the NP on how to treat pain if current regimen was not working.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident fed by enteral means (feeding tube) received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia for 2 of 7 residents receiving enteral feeding (Resident (R)39, R42). In interview the Director of Nursing (DON) stated it was a standard of practice for a resident's head of bed (HOB) to be elevated during (tube) feedings and for the tube feeding to be changed every 24 hours. 1. However, observation on 10/21/2024 at 1:15 PM, revealed R42's HOB was flat when the resident was receiving enteral feeding. Additionally, the enteral feeding R42 was receiving was dated 10/20/2024 at 10:08 AM (over 24 hours). Observation revealed R42 continued lying flat two hours later at 3:18 PM. Observation on 10/22/2024 at 9:58 AM, revealed R42's feeding pump was turned off and was not attached to the resident. In addition, R42's feeding bottle remained unchanged (as it was still dated 10/20/2024 at 10:08 AM). Observation at 10:08 AM, revealed Licensed Practical Nurse (LPN) 7 entered R42's room with new feeding to hang. 2. Observation of R39's room on 10/21/2024 at 1:35 PM, 4:37 PM, and on 10/22/2024 at 9:46 AM, revealed a feeding pump with a dried wash cloth over it and a piston syringe present dated 10/15/2024. The findings include: In interview with the DON on 10/22/2024 at 1:30 PM, she stated the facility did not have a policy on gastrostomy tubes or enteral feeds. She stated it was a standard of practice for (tube) feedings to be changed every 24 hours and for the HOB to be elevated. When asked by the State Survey Agency (SSA) Survey what told her that, she stated she just knew it. 1. Review of the facility's, Admission Record for R42 revealed the facility admitted the resident on 01/29/2021, with diagnoses to include gastrostomy status, cerebral palsy, gastrostomy status, and epilepsy unspecified. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/05/2024, revealed the facility assessed R42 as rarely or never understood. Further MDS review revealed R42 received total nutrition by artificial means. Review of the physician's order, undated for R42, revealed an order for Jevity (tube feeding formula) 1.5 to infuse at 65 milliliters (ml) an hour for protein-calorie malnutrition. Review of another undated physician's order, revealed the head of bed was to be elevated 30 to 45 at all times except during care. Review of R42's Comprehensive Care Plan (CCP) revealed a Nutritional Services care plan dated 01/29/2021, related to R42 having a feeding tube due to diagnoses of cerebral palsy and dysphagia. Continued review revealed interventions that included tube feeding as ordered to meet nutritional needs; and head of bed elevated at least 30 degrees while delivering the tube feeds. Review of the facility's Resident Care Profile (RCP), the care guide for Certified Nursing Assistants, dated 03/19/2024, revealed under special instructions, (R42's) HOB was to be elevated at 45 degrees. However, observation on 10/21/2024 at 1:15 PM, revealed R42 receiving enteral feeding with the head of bed (HOB) flat. Continued observation revealed a piston syringe and feeding bottle dated 10/20/2024 at 5:00 AM, which indicated the tube feeding had been hanging for 32 hours. Observation at 3:18 PM, revealed R42's HOB remained flat. Observation on 10/22/2024 at 9:58 AM, revealed the (tube) feeding pump was turned off and was not attached to R42. Per observation, the tube feeding bottle remained unchanged, as it was still dated 10/20/2024 at 5:00 AM. Additional observation at 10:08 AM, revealed LPN 7 entered R42's room with new tube feeding and piston syringe. In interview with LPN 7 on 10/22/2024 at 11:33 PM, she stated she provided care for R42 and worked one day a week. She stated R42 received medication and the resident's tube feedings were to be held (stopped) one hour before and one hour after administration. The LPN stated she had elevated R42 s bed that morning when she went in and saw that it was not elevated. 2. Review of the facility's Admission Record for R39 revealed the facility admitted the resident on 01/10/2024, with diagnoses including paraplegia; chronic pain syndrome; and reduced mobility. Review of R39's Quarterly MDS, with an ARD of 09/13/2024, revealed the facility assessed the resident to have a BIMS score of 12 of 15, indicating moderate cognitive impairment. Review of the physicians' order for R39, undated, revealed an order for Glucerna 1.2 to infuse at 60 milliliters (ml) per hour from 6:00 PM to 6:00 AM. Additionally, review revealed an undated order to flush R39's gastrostomy tube (G-tube) with 30 ml water before and after medication pass at 6:00 AM, 11:00 AM and 3:00 PM. Observation of R39's room on 10/21/2024 at 1:35 PM, and at 4:37 PM; and on 10/22/2024 at 9:46 AM, revealed a tube feeding pump present with a dried wash cloth over it and a piston syringe that was dated 10/15/2024. In interview with CNA 5 on 10/22/2024 at 8:42 PM, she stated R42 and R39 had feeding tubes and the heads of their beds were to be elevated. She stated that information was on the residents' RCP. In interview with CNA 9 on 10/23/2024 at 8:54 AM, she stated R42 had a feeding tube and when the tube feeding was turned on the HOB was to be elevated. She stated if R42 was having a seizure the HOB might not be elevated. CNA 9 stated R39 received tube feeding at night; however, the HOB was usually elevated during the day. She further stated she never paid attention to the syringes present with the tube feedings, as the nurses took care of those. In continued interview with LPN 7 on 10/22/2024 at 11:33 PM, she stated she also provided care for R39. She stated R39 did not receive tube feeding on day shift and she had not noticed the syringe dated 10/15/2024 present in the resident's room. The LPN further stated she would change the syringe immediately. In interview with LPN 3 on 10/22/2024 at 8:15 PM, she stated she worked the 100 hall three nights a week and provided care for both, R39 and R42. She stated she was sure there was a policy on feeding tubes but she was not certain. LPN 3 stated it was standard procedure to change feedings and syringes every 24 hours. She said she learned that a long time ago. The LPN further stated the heads of R39's and R42's beds should have been elevated when their tube feeds were infusing. She additionally stated that information was on the residents' treatment administration records (TARs). In interview with Unit Manager (UM) 1 on 10/22/2022 AT 8:30 PM, she stated the syringe for enteral feeds was to be changed daily. The UM said tube feeding could hang for 48 hours; however, she would have to look at the manufacturers' recommendations. She stated she did not know if the facility had a policy on enteral feeds or G-tubes, but she would ask the Staff Development Coordinator (SDC) or the Assistant Director of Nursing (ADON) and would follow what they told her. She further stated she did not know what reference the facility used for standards of practice. In additional interview with UM 1 on 10/25/2024 at 2:00 PM, she stated new hires were trained by the facility nurses. She stated she had not been aware the facility did not have a policy regarding tube feedings. UM 1 stated tube feeding included the tubing and piston syringes which were to be changed daily. In interview with the SDC on 10/23/2024 at 10:01 AM, she stated the facility did not have a policy on enteral feedings or G-tubes. The SDC stated the facility followed the physician's orders. She stated the orders should include changing of the tube feeding bottles and syringes every 24 hours. The SDC stated for residents receiving tube feeding, their HOB was to be elevated. Per the SDC in interview, there was to be an order for their tube feedings and that information was to be reflected on the residents' care plan. She further stated the nurses did competency checks on hire and all facility nurses had been checked off on tube feedings. During the interview the SSA Surveyor requested to review the facility's competency checks for nurses. The SSA Surveyor received the competency checks from the SDC, on 10/23/2024 at 2:15 PM. The SDC stated at that time that feeding tubes and enteral feeds were not part of the facility's competency check list. In interview with the facility's Nurse Practitioner (NP) on 10/24/2024 at 9:07 AM, she stated she had been the facility's NP since August 2024. She stated she did not have long-term care experience and was learning. The NP stated she had no expectations of staff at the facility, as that was not part of her job. She stated the DON and ADON handled the staff at the facility. The NP further stated for residents receiving enteral feedings, their HOB was to be elevated; however, she was unaware of how often the piston syringes or feeding formulas should be hung. In interview with the DON on 10/25/2024 at 3:11 PM, she stated she had been the DON for a year. She stated she expected the nurses to follow what they learned in nursing school when caring for residents' G-tubes. The DON said the facility used an online training portal for staff education. She stated she expected staff to ensure the HOB of residents receiving tube feeding was elevated during the tube feeding. The DON further stated a potential (negative) outcome if the HOB of a resident receiving tube feeding was not elevated was aspiration of the feeding. In interview with the Administrator on 10/25/2024 at 5:03 PM, he stated he expected staff to follow the physician's orders and to contact the physician if clarification was needed. He stated he expected the HOB of residents receiving tube feeding to be elevated. The Administrator further stated possible (negative) outcomes for a resident whose HOB was not elevated, was potential aspiration.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 21 sampled residents (Resident (R)43, and R54). 1. R43 was tested for symptoms of a urinary tract infection (UTI) on 10/13/2024 and the laboratory (lab) results were finalized on 10/16/2024. However, the facility failed to ensure the lab results were received resulting in R43 not receiving the necessary treatment for a UTI until 10/23/2024, seven days later. 2. R54 received a recommendation for a gradual dose reduction on 09/15/2024. The recommendation was approved and signed by the facility Nurse Practitioner on 09/17/2024. However, the facility failed to initiate the recommendation until 10/18/2024, 33 days after the recommendation was made. The findings include: Review of the facility policy titled, Lab and Diagnostics Standard of Practice, reviewed 05/2021, revealed the facility was to provide or obtain laboratory services when ordered by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). Continued review revealed the facility was to promptly notify the ordering physician, PA, NP, or CNS of results that were outside the clinical reference ranges or in accordance with the notification parameters per the ordering physician's orders. Review of the Admission Face Sheet for R43 revealed the facility admitted the resident on 07/02/2020, with diagnoses to include: hemiplegia and hemiparesis following cerebral infarction, neurologic neglect syndrome, and generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/04/2024, revealed the facility assessed R43 to have a Brief Interview for Mental Status (BIMS) score of a 13 out of 15, indicating the resident was cognitively intact. Review of the progress note dated 10/13/2024 at 5:54 PM, revealed the facility sent R43 to the emergency room (ER) after sustaining a fall while working with physical therapy (PT). Per review, R43 bent over too far while pulling up her pants and PT reported she fell on to her left side onto the wheelchair foot rest. Continued review revealed R43 complained of left sided rib pain, shortness of air, and left arm and hand pain. Further review revealed R43 also had three skin tears that were bandaged prior to EMS arrival. Review of the Emergency Department (ED) Encounter for R43, dated 10/13/2024, revealed the resident reported concerns of having a UTI. Continued review revealed a urinalysis (U/A) was completed with abnormal findings of dark yellow urine, small blood, small leukocyte esterase (white blood cells). Per review, microscopic urinalysis showed the following abnormal findings: white blood cells of 15 and red blood cells of 12. Further review revealed the ER Physician documented a urine culture was sent to the lab. In addition, the ER Physician noted no antibiotics were started at that time for the UTI due to R43 reporting a history of Clostridium difficile (c-diff) on two (2) occasions. Review of the progress note dated 10/13/2024 at 5:54 PM for R43, documented by Unit Manager (UM) 1, revealed the resident returned to the facility and had a UTI. Continued review revealed however, the ER doctor was waiting for the preliminary culture to decide if an antibiotic was needed. Review of the urine culture lab results dated 10/16/2024, revealed a heavy growth of Escherichia coli (e-coli). Review of the Result Care Coordination note, dated 10/16/2024 at 3:08 PM, completed by the Physician Assistant (PA), revealed the PA documented he attempted to call the results to the telephone (phone) number on file; however, that phone number was not a working number. Continued review of the electronic medical record (EMR) for R43 revealed no documented evidence the urine culture results were obtained until 10/23/2024. Review of the progress note dated 10/23/2024 at 6:59 PM for R43 revealed a new Physician's order for Macrobid (an antibiotic) 100 milligram (mg) twice a day for seven days to treat a UTI. Review of the facility's Medication Administration Record (MAR) dated October 2024 for R43, on 10/23/2024, revealed an order for Nitrofurantoin (generic for Macrobid) 100 mg one capsule by mouth twice a day for 14 doses. During interview with R43 on 10/22/2024 at 2:19 PM, she stated she had lower back pain and an odor to her urine for months, which she had reported to the floor nurses. R43 stated she was told to drink more water. The resident stated she sustained a fall on 10/13/2024, and was sent to the hospital. She further stated she had been she had blood and white blood cells in her urine and had a UTI, but she had not received any medication for it. During interview with UM 1 on 10/24/2024 at 9:15 AM, she stated the UM or floor nurse was responsible to follow up on all lab results. UM 1 stated pending results were discussed during morning clinical meetings and added to the tracking board to ensure the results did not get overlooked. She stated R43's pending lab results were not added to the tracking board; however, should have been followed up on. UM 1 said the facility did not receive R43's urine culture results until 10/23/2024, which showed the resident had a UTI. She further stated she then notified the on call NP and was given an order for R43 to begin an antibiotic. The UM additionally stated R43 received the first dose of the antibiotic on 10/23/2024 on night shift. During interview with the Assistant Director of Nursing (ADON) on 10/25/2024 at 9:12 AM, she stated typically the facility would have to call the hospital for lab results done in the ER, and the UM's were responsible for that task. The ADON stated the UM had called the hospital on 10/23/2024, (after the State Survey Agency [SSA] Surveyor had questioned staff about R43's complaints on that date) and the results were then faxed to the facility. She stated she expected the UM's to follow up on any pending lab results within three (3) days. The ADON further stated she also expected the UM's to reach out to the Physician or NP for orders to treat the resident if it was necessary. During interview with the DON on 10/24/2024 at 10:15 AM, she stated the UM's were responsible for tracking pending results on their assigned hall. She stated UM 1 failed to follow up on R43's pending urine culture. She stated the facility realized they had not received R43's results on 10/23/2024 and called last night to obtain them. The DON stated the NP on call was notified once the results were obtained and she gave an order for R43 to begin an antibiotic to treat the UTI. She stated she expected results to be followed up on as they should to ensure residents received the proper treatment in a timely manner. During an interview with the Administrator on 10/25/2024 at 4:15 PM, he stated pending results should be taken to clinical meetings every morning and placed on the white board in the DON's office. He stated he expected any orders to be on the resident's medication administration record and administered as prescribed and all pending results should be followed up on by the Unit Managers. The Administrator further stated the Unit Managers should continue to follow up on the results until they had been received to prevent the resident from going untreated. 44370 2. Review of the facility's Pharmacy Policy titled, Consultant Pharmacist Provider Requirements, undated revealed, the consultant pharmacist would establish a system whereby the consultant pharmacist's observations and recommendations regarding customers' drug therapy are communicated to those with authority and or responsibility to implement and or respond to the recommendation in an appropriate and timely fashion. Review of R54's Admission Record revealed the facility admitted the resident on 05/05/2022, with diagnoses of major depressive disorder, type 2 diabetes mellitus without complication, excoriation, and skin picking disorder. Review of the Physician's orders dated 09/2024 for R54, revealed an order for Alprazolam (Xanax, an antianxiety medication) 0.25 milligrams (mg) 1 tablet two times a day. Review of the Pharmacist Recommendation to Prescriber documentation dated 09/15/2024, revealed a Pharmacist's recommendation to decrease R54's Alprazolam to 0.125 mg two times a day. Further review revealed the recommendation was agreed to and signed by the Nurse Practitioner (NP) on 09/17/2024. However, further review of R54's electronic medical record (EMR) revealed no documented evidence of an order to decrease R54's Alprazolam, until an order was transcribed on 10/18/2024, 33 days after the recommendation was made. Review of the progress note dated 09/16/2024 for R54, documented by the consulting Pharmacist revealed the medication regimen review had been completed and recommendations made. Review of the Physician's order dated 10/18/2024 for R54, revealed an order for Xanax oral tablet 0.25 milligrams give 1/2 tab by mouth twice daily, which had been entered by the UM. In an interview with the facility's NP on 10/24/2024 at 9:07 AM, she stated she had been the NP for the facility since August 2024. She stated she received the pharmacy's recommendations from the DON; reviewed and agreed with them or not; and then returned them to the DON. She stated she expected any recommendations or orders to be entered into a resident's EMR within 24 hours. The NP further stated she was unaware that R54's Alprazolam order had not been entered until the SSA Surveyor made her aware of that issue. In interview with the Consultant Pharmacist on 10/24/2024 at 8:55 AM, she stated she performed monthly reviews of medications on all residents. She stated she emailed her recommendations to the DON and ADON. The Consultant Pharmacist stated she noticed R54's recommended Alprazolam reduction had been signed and returned to her; however, the order had not been entered and she made the DON aware of that issue. During interview with UM 1 on 10/25/2024 at 2:00 PM, she stated she thought the facility's NP received the pharmacy recommendations from the DON and returned them to the DON after reviewing them. She stated she had not received R54's recommendation from the DON until 10/18/2024 when she entered the order. During interview with the DON on 10/25/2024 at 8:23 AM, she stated she received pharmacy recommendations via email. She stated she printed those recommendations and gave them to the NP for review. The DON said the NP returned the recommendations back to her after review and she emailed them back to the Pharmacist and gave them to the UM. The DON further stated she had given R54's signed recommendation to UM 1 and did not know why the order had not been entered as required. In interview with the Administrator on 10/25/2024 at 5:03 PM, he stated he expected the DON to follow up timely when the Consultant Pharmacist completed the monthly Medication Regimen Reviews and made any recommendations. He stated the DON was to give the recommendations to the UM's when she received them so they could be addressed timely.

Based on observation, interview, and review of facility policy, the facility failed to ensure drugs and biologicals used in the facility were safely stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on [DATE] of the 300 hall medication storage room revealed multiple expired medical supplies. Observation further revealed a small refrigerator utilized for storage of milk and beer with the temperature reading out of the acceptable range according to the internal thermometer of the device. The findings include: Review of the facility's policy entitled, Medication administration standard of practice, dated ,d+[DATE], revealed medications were to be administered in a safe and timely manner, and as prescribed. Observation of the 300 hall medication room on [DATE] at 2:30 PM, with the Unit Manager (UM), revealed the following expired medical supplies: three individual boxes of glucose test strips with an expiration date of ,d+[DATE]; four individual bottles of wound cleanser with an expiration date of ,d+[DATE]; suction tubing product DYND50216 with an expiration date of ,d+[DATE]; and two individual boxes of tracheostomy (trach) tubes with an expiration date of ,d+[DATE]. Continued observation of the 300 hall medication room on [DATE] at 2:30 PM, revealed a small refrigerator utilized for storing milk and beer had a temperature reading of 50 degrees Fahrenheit (F), which the UM indicated during that observation, the temperature was out of the acceptable temperature parameters. Observation also revealed upon entering the medication room the State Survey Agency (SSA) Surveyor observed water on the floor which was leaking from the refrigerator. The UM stated, at the time of observation, the problem with the refrigerator temperature was because a staff member told her that day a resident complained of the milk being too cold, so the staff member turned up the temperature. She stated she would discard the observed supplies from the refrigerator which included milk and beer. During an interview with the Director of Nursing (DON) on [DATE] at 10:00 AM, she stated, If the care plan had a diabetes care plan for sugar checks and the supplies were expired, they could get a false blood sugar reading. The DON stated it was part of the UM's monthly routine to check for expired supplies, and Pharmacy staff came in as well to look through things for us. She stated the expectation was for management to look through medication rooms and medication carts as well, looking for expired items, throw the expired items away, and if supplies were missing, they needed to restock them. The DON said if any packaging had damage we get rid of it. She stated night shift nurses were in charge of checking (refrigerator) temperatures. The DON stated They fill out a paper log for the temperature and leave it in the room. She further stated nursing staff should report an unacceptable refrigerator temperature reading to leadership and management.

Based on observation, interview, and review of the facility's policy, it was determined 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. Observations of Certified Nursing Assistant (CNA) 10 on 10/22/2024 at 11:40 AM, revealed she pulled gloves from a box sitting on top of a medication cart and placed them in her pants pocket prior to entering Resident 7 ' s room to provide care. The findings include: Review of the facility policy titled, Infection Control revised 10/01/2018, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage the transmission of diseases. Review of facility policy titled, Infection Control Program Standard of Practice, revised 11/01/2016, revealed the facility's standard of practice was for all isolation precautions and hand washing techniques to be followed per the www.cdc.gov/longtermcare/guidelines. Observation on 10/22/2024 at 11:40 AM, this State Surveyor Agency (SSA) revealed Personal Protective Equipment (PPE) Bin 1 did not contain disposable gloves or gowns for staff's use, and only contained face masks. Per observation, Bin 1 was located in front of two (2) residents' rooms which were noted to be on Enhanced Barrier Precautions (EBP). Continued observation revealed staff were pulling gloves from a box stored on top of a medication cart and stuffing the gloves in their pants pockets before going into residents' rooms to provide care. In interview with Certified Nursing Assistant (CNA) 10 on 10/22/2024 at 11:49 AM, she stated PPE was kept in a cabinet outside of the residents' rooms in the hall. She stated before staff went into a resident's room to provide care they put gloves in their pockets; performed hand hygiene; donned a gown if needed; and then went into a resident's room to perform care. CNA 10 stated she thought it would be more convenient if the supplies were left in the resident's room and readily available for staff. She further stated there could be a possible infection control issue by for residents with staff carrying gloves around in their pockets. In interview with Unit Manager (UM) 1 on 10/25/24 at 1:31 PM, she stated before 10/01/2024 the facility had two (2) central supply employees who had been responsible for making sure the PPE bins were stocked. UM 1 stated however, one of the central supply employees got promoted to another position after that date and she was unsure who was responsible now. She stated she tried her best to make sure the PPE bins on her hall stayed stocked and if she was made aware she would go track down the necessary supplies. The UM stated it was okay not having the bins stocked in the rooms it just made the day a little bit longer. She stated she just started in her position eight months ago and at that time the facility was not keeping gloves stored in the residents' rooms. UM 1 stated she was always used to grabbing gloves before she went in a room and that did not bother her. She further stated she had not seen any CNAs grab gloves and put them in their pockets. In interview with the Infection Preventionist/Assistant Director of Nursing (IP/ADON) on 10/25/24 at 9:30 AM, she stated staff putting gloves in their pockets was an infection control issue. She stated staff had been educated on not doing that and gloves had been placed back in residents' rooms for accessibility. The IP/ADON further stated the nursing staff had pocket sized hand sanitizer containers they kept on their person to help with hand hygiene. In interview with the Director of Nursing (DON) on 10/25/24 at 3:11 PM, she stated staff placing gloves in their pockets was a cause for concern regarding infection control, as she did not know what they kept in their pockets. She stated the facility in general was responsible for making sure nursing staff had the necessary PPE supplies they needed to perform their job duties. The DON said this responsibility mainly fell on the Staff Development Coordinator (SDC) and Central Supply Department. She stated as far as she knew there was always someone in the Central Supply Department ordering supplies and putting the supplies away. Per the DON in interview, if staff just let her know they did not have what they needed she would get it for them. She further stated it was her expectation of staff to inform her if they were needing supplies to perform their job duties, in order for her to obtain the necessary items. In interview with the Administrator on 10/24/2024 at 4:52 PM, he stated he had not been made aware of the facility being out of some of their supplies. He stated he usually went out and purchased what was needed if staff happened to run out before the next shipment arrived. The Administrator said sometimes things like that just happened, but his expectation was for staff to let him know what was needed. He said if they were out supplies and having trouble obtaining them from the vendors staff needed to let him know. The Administrator stated he was opposed to not having gloves stored in residents' rooms and had expressed his concerns to his superiors. He further stated however, he was not given instructions on returning the gloves to residents' rooms until that week. In addition, the Administrator stated it was an infection control issue with staff placing gloves in their pockets.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents received care consistent with professional standards for 1 of 3 residents sampled as at risk for developing pressure ulcers out of the total sample of 21 (Resident (R)39). In interview on 10/22/2024 at 9:48 AM, R39 stated she had been at the facility since January and had a wound on her foot. Observation, at the time of interview, revealed R39 lying on her back on an alternating pressure mattress (APM), with two wedge cushions and a heel boot stored on a shelf in the corner of the room. R39 stated she received the heel boot for her left heel at the hospital; however, staff removed it when she returned to the facility. She stated the left heel boot had not been placed back on her since. R39 stated staff did not utilize wedge cushions or pillows for positioning her. Additional observations on that date at 11:08 AM, 1:50 PM, 4:18 PM, and 8:15 PM, revealed R39 remained lying on her back on the pressure reducing mattress. In addition, review of R39's EMR revealed R39 documentation noting the resident had developed a new stage 4 pressure ulcer. The findings include: Review of the facility policy titled, Skin Care Standard of Practice dated 07/2020, revealed, the facility would ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers. Per review, the facility was also to ensure residents did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable. Continued review revealed a resident with pressure ulcers was to receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. In interview with the Director of Nursing (DON) on 10/22/024 at 1:30 PM, she stated the facility did not have a policy on Pressure Ulcer Prevention. Review of the facility's, Admission Record for R39 revealed the facility admitted the resident on 01/10/2024, with diagnoses including multiple (6) pressure ulcers; paraplegia, unspecified; and chronic pain syndrome. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/13/2024, revealed the facility assessed R39 to have a Brief Interview for Mental Status (BIMS) score of 12 of 15, indicating moderate cognitive impairment. Continued review revealed the facility assessed the resident as dependent on staff to roll from side to side and to a supine (laying on the back) position while in bed. Additionally, the facility assessed the resident as having pressure ulcers and as at risk for the development of pressure ulcers. Review of the facility's, Comprehensive Care Plan (CCP) for R39 revealed a focus problem for impaired skin integrity, dated 01/04/2424, related to pressure sores with presence of skin breakdown or as at high risk for skin breakdown. Per review, the interventions dated 01/11/2024 included: pressure reduction cushion; mattress pressure reduction; and providing gentle support when turning, positioning, or transferring. Continued review revealed the interventions also included: providing protein supplements; providing wound care as ordered by the Physician; and providing skin care regularly. Review revealed the goals read: improve nutritional status and avoid prolonged pressure to skin. Further review revealed however, no documented evidence the facility developed and implemented additional interventions for R39's risk for pressure sores or skin breakdown, such as use of the wedge cushion or heel boots. Continued review of the CCP for R39 revealed a focus problem for pressure ulcer, actual, dated 01/11/2024, noting the resident had pressure ulcers. Per review, on 05/02/2024, R39 developed a new stage 4 pressure wound of the left heel. CCP review revealed the interventions dated 01/19/2024, included pressure relieving device chair cushion; pressure relieving device mattress; and weekly skin rounds to monitor progress of pressure ulcers. Further review of the CCP revealed however, no documented evidence the facility developed and implemented additional interventions for R39's actual pressure ulcer, such as use of the wedge cushion or heel boots. Review of the Wound Evaluation and Management Summary, for R39 dated 05/02/2024, revealed the resident had developed a non-pressure wound to the left heel documented as moisture associated skin damage (MASD). Further review revealed the wound measured 2 centimeters (cm) x 3 cm x 0.1 cm. Review of the Wound Evaluation and Management Summary, for R39 dated 10/17/2024, revealed the area to the left heel was documented as a stage 4 pressure wound which measured 6.5 cm by 4.0 cm by 0.3 cm. Observation on 10/22/2024 at 9:48 AM, revealed R39 lying on an alternating pressure mattress on the bed. In interview, at the time of observation, R39 stated she had a wound on her foot. Continued observation revealed R39 was lying supine (on her back) on the bed with no devices (such as heel boots or wedge cushions) in use. Observation revealed however, two wedge cushions and a heel boot stored on a shelf in the corner of the resident's room. Additional observations on 10/22/2024 at 11:08 AM, 1:50 PM, 4:18 PM, and 8:15 PM, revealed R39 remained lying supine on the bed with no devices in use. Observation on 10/24/2024 at 11:20 AM, revealed Unit Manager (UM) 1 completed a dressing change for R39's pressure wound. Observation revealed the wound had tissue loss, and the appearance of a stage 4 pressure ulcer to the left heel. Continued observation revealed the UM measured the wound as 6 cm by 4.5 cm; however, the UM failed to measure the depth of the wound. In interview, at the time of observation, the UM stated she thought R39's heel wound was a stage 3 pressure ulcer. During an interview with Certified Nursing Assistant (CNA) 3 on 10/25/2024 at 9:13 AM, she stated she was aware R39 had wounds and used to have boots on her feet when she was in bed. CNA 3 stated she could not recall any other devices for R39 (to assist with pressure relief). She stated R39 did not like to turn as it caused her pain. The CNA further stated CNA's had the resident care profiles (RCP) to look at for residents' care needs. She additionally stated however, she was not aware of what interventions were on the RCP for R39. During an interview with CNA 8 on 10/25/2024 at 9:22 AM, she stated she was aware R39 had wounds, as she had assisted the nurses with dressing changes. CNA 8 stated R39 had a pillow placed between her knees, but she was not aware of any wedge cushions or heel boots that should be used for the resident. In interview with UM 1 on 10/25/2024 at 2:00 PM, she stated R39 had an air mattress in place for pressure prevention. She stated she did not know if the facility had a policy on prevention of pressure ulcers. The UM stated she had not looked at R39's care plan to see what interventions were in place for the resident. She stated staff repositioned R39 as she would allow; however, the resident preferred to lie on her back. UM 1 further stated she was unaware of any wound physician's recommendations for R39 to be turned side to side. During an interview with the Director of Nursing (DON) on 10/25/2024 at 3:11 PM, she stated all residents had a pressure-reducing mattress on their beds and R39 had an air mattress for pressure relief on her bed. She stated R39 had been admitted with multiple wounds and was followed by the wound care physician weekly. The DON stated R39 often refused care; however, she was unsure if the refusals were care planned. She further stated wedge cushions or pillows, as well as turning and repositioning were interventions and should be on the resident's care plan and the RCP. The DON additionally stated wounds had the potential to not heal if interventions were not in place. In interview with the Medical Director on 10/25/2024 at 4:39 PM, he stated R39 had wounds, but she was in much better shape than when she was first admitted to the facility. He further stated the facility should have policies in place for pressure ulcer prevention. In interview with the Administrator on 10/25/2024 at 5:03 PM, he stated he expected staff to follow the Physician's orders and to contact the Physician if clarification of orders were needed. He stated he expected residents to have interventions for pressure ulcers in place. The Administrator further stated possible (negative) outcomes for residents with pressure ulcers would be worsening of the wound and/or development of new wounds.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure the person centered comprehensive care plan was implemented for one (1) of four (4) sampled residents (Resident #1). The facility care planned Resident #1 as a choking risk due to behaviors of reaching and grabbing food not on his/her diet, The resident required a pureed diet. In addition, one to one (1:1) supervision, when out of bed. The facility failed to implement the nursing care plan interventions to prevent Resident #1 from getting food not on his/her diet, nor the 1:1 supervision when out of bed. On [DATE], Resident #1 obtained a peanut butter sandwich from the snack tray on the medication cart. Resident #1 grabbed and consumed half of the half of peanut butter sandwich before staff intervention and choked. Staff performed the [MEDICATION NAME] maneuver (abdominal thrusts to remove object causing to choke) and Resident #1 coded with staff initiating Cardiopulmonary Resuscitation (CPR) (chest compressions often with artificial ventilation). Resident #1 was transferred to an acute care facility where he/she was intubated, placed on a ventilator (machine that provides mechanical ventilation {air/breaths}), and a (Nasogastric tube) feeding tube was placed. The facility's failure to implement the care plan has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility policy titled, Comprehensive Care Plan, revealed the Comprehensive Care Plan was developed to promote communication of the resident's needs, goal, and interventions to promote successful goal attainment. Each residents care plan was designed to incorporate identified problem areas, and identify the professional services that were responsible for each element of care. Record review revealed the facility readmitted Resident #1, on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Further review revealed the resident required supervision with meal setup. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for Nutritional Decline. The Care Plan stated the resident exhibited alterations in mood/behavior of attempting to bite, grab, and scratch staff and other residents. The interventions directed staff to provide 1:1 supervision until further notice, when out of bed (dated [DATE]), and to supervise meals as indicated for reaching in and getting food not on his/her diet. However, interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:46 AM and 11:45 AM; and on [DATE] at 2:25 PM, revealed Resident #1 was supposed to be on 1:1 supervision and she tried to call a Certified Nurse Aide (CNA) into work to provide the 1:1 supervision, but was unsuccessful. LPN #1 stated she did not have enough staff to assign a 1:1, so she tried to keep the resident by the medication cart while she administered medications and handed out snacks. She stated she had the tray of snacks on top of the medication cart. She revealed while she was pouring water to administer a resident's medications, Resident #1 grabbed a half peanut butter sandwich off the snack tray and ate half of it before she could get it away from the resident. She stated the resident choked and she provided the [MEDICATION NAME] maneuver unsuccessfully and Resident #1 coded requiring CPR. She stated Emergency Medical System was called and Resident #1 was transferred to hospital. Further interview with LPN #1 revealed she was aware Resident #1 was care planned for 1:1 supervision and was on the list of residents who grab food in the nurses book at the nursing station. LPN #1 stated it was the nurse who determined staff assignment of the 1:1, but when doing 1:1 staff still had other duties. She stated she did not think the resident could reach the top of the med cart to grab the sandwich off the snack tray. Review of hospital records dated [DATE], revealed Resident #1 was admitted to hospital via the emergency room (ER) after choking on a peanut butter sandwich. Resident #1 was intubated at 10:07 PM on [DATE]. Interview with Administrator, on [DATE] at 3:45 PM revealed the resident was still in the hospital and remained intubated with a tracheotomy, on a ventilator, and a nasogastric tube for feeding. Interviews with CNA #1, on [DATE] at 7:41 AM; and, CNA #2 on [DATE] at 9:27 AM, and [DATE] at 3:31 PM, revealed they were attending to other duties and not really paying any attention to Resident #1 sitting on the hallway. The CNA's stated they were aware that Resident #1 was care planned to be on 1:1 when out of bed and someone was to be with him/her at all times and within touching distance, but there was not enough staff to provide the required 1:1 supervision. The CNA's revealed there was not enough staff to sit with the resident 1:1, so no one does 1:1, we just watch resident while doing care on the hall and sometimes the nurse watched the resident. The CNA's stated Resident #1 would grab anything in reach. Interview with Director of Nursing (DON), on [DATE] at 12:00 PM, revealed care plans were to be followed related to dietary needs and supervision. Interview with Administrator, on [DATE] at 4:12 PM, and [DATE] at 4:42 PM, revealed 1:1 supervision was provided depending on why the resident was placed on 1:1. She stated Resident #1 was care planned for 1:1 supervision due to grabbing and scratching other residents; so the staff only had to keep the resident in line of sight to ensure the resident was not within reaching distance of another resident. She further revealed she was not aware Resident #1 would grab at everything and was care planned for reaching in and getting food not on his/her diet. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred from the facility on [DATE] and has not returned to the facility. 2. The Dietary Manager provided a list of all current residents on mechanical altered diets (17 residents) on [DATE]. The Administrator completed a review of the care plans of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. The Administrator, Social Service Director, and/or licensed nurse completed a review of psychosocial/behavior care plans for any resident currently identified as requiring 1:1 supervision, on [DATE]. There were no additional residents at this time requiring 1:1 supervision. This was completed on [DATE]. 4. The Regional Director of Operations provided education to the Administrator on [DATE] regarding: One-to-one supervision regarding one staff member dedicated to the supervision of one resident with no other assigned duties during the time. 5. The Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 6. The DON provided education to assigned licensed nurses (4) and director of medical records/medication technician (a train the trainer education) on [DATE] through [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the Director of Nursing when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 7. Education was provided to the facility nursing staff, (licensed nurses and nursing assistants), and facility dietary staff by the DON, Administrator, and Regional Quality Manager beginning [DATE] through [DATE], regarding: Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 8. Verbal acknowledgement of understanding along with signed education was obtained after the inservice. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 9. The Regional Quality Manager provided education to the DON on [DATE] regarding: To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 10. The DON provided education (train the trainer) to the staff development Coordinator on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 11. The Regional Quality Manager, the DON and or Staff Development Coordinator (SDC) provided education to the licensed nursing staff on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 12. Verbal acknowledgement of understanding along with signed education was obtained after the inservices. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 13. An ad-hoc meeting was held on [DATE] to review the summary of Immediate Jeopardy findings and discuss the development of the action items to be completed. This meeting included the Administrator, DON, Social Services, Activities, Dietary, Therapy, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone on [DATE]. 14. The Administrator, Assistant Administrator, DON, and/or Weekend Department Manager Supervisor would observe five (5) times (X) a week on various shifts to include weekends for two (2) weeks, then three (3) X week for two (2) weeks, then two (2) X week for four (4) weeks for the following: All snacks would be placed in a covered container by dietary staff. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. The nursing staff member would place the container on the ice chest cart and begin snack pass to the residents. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. Any identified concern will be addressed at the time of discovery by the monitor. The audit began on [DATE]. 15. In the morning clinical meeting beginning [DATE], the Administrator, the DON, and/or assigned licensed nursing staff would review the plan of care for all residents requiring 1:1 supervision. 16. The Administrator or the DON would review and sign off on the staffing assignments sheets daily in regards to potential need for any 1:1 supervision. A review of the weekend staffing sheet would be completed on Fridays. The Administrator, the DON was to be notified at any time a resident required a 1:1 supervision. 17. Beginning [DATE], the DON and/or assigned licensed staff would audit five (5) residents requiring 1:1 supervision, risk for diet non-compliance, and/or (if no 1:1 supervision) with mechanically altered diets weekly times four (4) weeks for: Care plans interventions in place and observe the resident for care plan implementation as written in the plan of care 18. The results of the monitoring would be reviewed at a minimum of weekly in the QAPI meetings being held to track the facility's progress toward regulatory compliance. 19. A second ad hoc QAPI meeting was held on [DATE], to review the initial audit findings of the list of residents with mechanically altered diets and subsequent care plan review. This meeting included the Administrator, DON, Social Services, Dietary, Activities, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone, on [DATE]. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Notice of Emergency Transfer and Nurses Progress, dated [DATE] at 8:20 PM, revealed Resident #1 was sent to hospital via EMS (emergency management services) related to choking incident. Interview with Administrator, on [DATE] at 3:45 PM, revealed Resident #1 had not returned from the hospital. 2. Interview with Dietary Manager on [DATE] at 11:40 AM revealed she provided a list of residents who were on a mechanically altered diet to the Administrator. Review of care plans of residents that were identified as on mechanically altered diets revealed the Administrator reviewed the care plans, on [DATE] to ensure if resident was known to grab food; it was addressed on the resident's care plan. Interview on [DATE] at 3:45 PM, with Administrator revealed she had reviewed dietary needs of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. Interviews on [DATE] with Administrator at 3:45 PM, Social Service Director at 10:15 AM, and Director of Nursing (DON) at 12:00 PM revealed there were no additional residents at this time requiring 1:1 supervision. 4. Interview on [DATE] at 3:05 PM, with Regional Quality Manager, revealed the Regional Director of Operations provided education to the Administrator, on [DATE]. Interview with Administrator, on [DATE] at 3:45 PM, revealed she was educated by the Regional Director of Operations to ensure staffing would be provided for 1:1 supervised residents with no other duties assigned to that staff member. Review of education documentation revealed the Administrator signed the form indicating she had received education related to one staff member dedicated to the supervision of one resident with no other assigned duties during the time provided on [DATE] 5. Interview with the Regional Quality Manager (RQM) revealed she provided education to the Director of Nursing (DON), on [DATE]. Interview with DON, on [DATE] at 12:00 PM, revealed she was educated by RQM to ensure if there was 1:1 supervision of a resident, then a staff member would be assigned and have no other duties. She stated in addition she was educated on the new process of dietary delivering, and nursing storing and delivering dietary snacks. 6. Interview with DON, on [DATE] at 12:00 PM, revealed she provided education to SDC, LPN #4 and weekend staff, on [DATE] through [DATE], to ensure they knew the requirements for the 1:1 supervision and snack pass process. Interviews on [DATE] with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed they were educated on 1:1 supervision, the new snack pass process and snack requirement, and care plan implementation. They also stated they were educated to call DON and/or Administrator when a resident was placed on 1:1. 7. Interviews on [DATE] with LPN #5 at 4:20 PM, LPN #7 at 4:27 PM, and LPN #3 at 4:30 PM; on [DATE] with Dietary Manager at 11:40 AM, Dietary Aide #1 at 2:30 PM, Dietary Aide #2 at 2:50 PM, SDC at 10:15 AM, SSD at 10:15 AM, KMA#1/Director of Medical Records/Central Supply at 11:00 AM, LPN #1 at 11:20 AM, DON at 12:00 PM, UM #2 at 2:50 PM, RQM at 3:05 PM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, CNA #2 at 3:28 PM, and CNA #4 at 1:58 PM revealed they were educated on the new process for resident snack delivery and storage. Observation on [DATE] at 2:10 PM, revealed staff followed the new snack pass guidelines. 8. Review of education documentation revealed all nursing staff and dietary staff signed the education to acknowledge understanding of education. Additionally, interview with LPN #7 (new hire), on [DATE] at 4:27 PM, revealed she was educated on the new process for snacks, 1:1 resident supervision and care plan implementation. 9. Interview on [DATE] at 3:05 PM, with Regional Quality Manager, revealed she provided education to the DON, on [DATE], to ensure she was aware she and/or the Administrator should be notified when a resident was placed on 1:1, and the care plan was to be implemented, as indicated for 1:1 supervision. Interview with DON, on [DATE] at 12:00 PM, revealed she was educated on being notified if a resident was placed on 1:1, and care plan implementation of 1:1 by RQM. Review of education documentation dated [DATE], revealed the DON signed the form indicating she understood the education provided by the RQM. 10. Review of education documentation (train the trainer) provided by DON to the Staff Development Coordinator (SDC), on [DATE], revealed the DON educated the SDC and the SDC signed the form indicating she understood the education. Interview with SDC, on [DATE] at 10:00 AM and 4:00 PM, revealed she was educated by the DON on the new snack process, that the DON and the Administrator must be notified if a resident was placed on 1:1 supervision, and that staff assigned to that resident would have no other duties but the 1:1. 11. Interviews on [DATE] with LPN #7 at 4:27 PM; on [DATE] with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, LPN #3 at 4:30 PM, and LPN #5 at 4:20 PM, revealed they were educated that staff assigned 1:1 supervision of a resident would not be assigned any other duties, nursing staff were to notify DON and/or the Administrator if a resident was placed on 1:1, and care plan implementation of the 1:1 supervision. Review of education documentation revealed all licensed nursing staff signed they understood the education provided on [DATE] 12. Interviews on [DATE] LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed verbal acknowledgement of provision of education and signing of signature page for verification of education. 13. Interviews on [DATE] with Administrator at 3:45 PM, DON at 12:00 PM, SSD at 10:15 AM, Dietary at 11:40 PM; and Therapy at 2:15 PM revealed an ad-hoc meeting was held on [DATE] to review the summary of Immediate Jeopardy findings with discussion of action plan to address findings of Immediate Jeopardy. Interview with Administrator on [DATE] at 3:45 PM, and with Medical Director on [DATE] at 4:14 PM, revealed the Administrator made the Medical Director aware of the action plan and obtained his input. 14. Review of the Monitoring Tools for Snack Pass, revealed monitoring was conducted five times during the week of ,[DATE]-[DATE] and continued to be completed with no concerns identified. The monitors were signed by the DON/or weekend supervisor. 15. Interviews on [DATE] with Administrator at 3:45 PM, Administrator in Training (AIT) at 9:37 AM and at 3:45 PM, the DON at 12:00 PM, UM #2 at 2:50 PM, and MDS #1 at 4:06 PM revealed there were no residents on 1:1 at this time but were aware they would review care plans for all residents requiring 1:1 supervision. Review of a facility form that was developed to use to review the plans of care revealed a place to document Resident Name, Follow-up needed, Initials, Assigned to, and date. 16. Interview on [DATE] with the DON at 3:45 PM, the AIT at 9:37 AM and 3:45 PM, and the Administrator at 3:45 PM, revealed they were to be notified at any time a resident required a 1:1 supervision, and that the staffing sheets were being reviewed daily and weekend staffing sheets reviewed on Friday, but at this time there were no residents on 1:1 supervision. A list of reviewed staffing sheets was present in the AOC binder for review 17. Interview on [DATE] at 12:00 PM, with DON, revealed she was auditing accuracy of care plans related to supervision of 1:1, dietary needs, and watched a meal of audited resident that day. 18. Review of documented QAPI meetings revealed a review of facility progress with discussion of any issues dealt with immediately upon point of discovery. Interview on [DATE] with DON at 12:00 PM, Administrator at 3:45 PM, AIT at approximately 9:37 AM and 3:45 PM, revealed they were meeting weekly to discuss any issues identified with during monitoring. 19. Interviews on [DATE] with SSD at 10:15 AM, Dietary Manager at 11:40 AM, DON at 12:00 PM, Administrator at 3:45 PM, AIT at 9:37 AM and 3:45 PM, MDS at 4:06 PM and Medical Director at 4:14 PM revealed there were ongoing reviews of facility's progress toward compliance.

Based on interview, record review, review of the Staff Assignment Sheet, facility education documentation, hospital records, and facility policy review, it was determined the facility failed to ensure sufficient staff had the appropriate competencies and skill sets to provide nursing and related services to ensure one (1) of four (4) sampled residents (Resident#1) safety as determined by resident assessments and care plans. The facility assessed and care planned Resident #1 with a history of grabbing food off trays, was at risk for choking, and required 1:1 supervision when out of bed. However, on [DATE], the facility did not assign staff to provide 1:1 supervision, due to insufficient staffing. Interview with Licensed Practical Nurse (LPN) #1 revealed Resident #1 was kept within line of sight during medication pass due to not having enough staff to implement the required 1:1 supervision. In addition, LPN #1 stated she placed a tray of snacks on top of the medication cart with Resident #1 near the cart. Resident #1 grabbed a half of a peanut butter sandwich off the tray and consumed half the sandwich before staff intervention. Resident #1 became choked with staff providing [MEDICATION NAME] (abdominal thrusts to remove object causing to choke) and Cardiopulmonary Resuscitation (CPR) (chest compressions with artificial respirations). Resident #1 was transferred to an acute care facility where he/she was intubated, placed on a ventilator and a (Nasogastric tube) feeding tube was placed. The facility's failure to provide sufficient staff to provide nursing and related services has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator, on [DATE] at 3:45 PM, revealed the facility did not have a staffing policy. Review of facility policy titled, Facility Assessment Tool Record dated [DATE], revealed care provision was monitored on a daily basis to ensure that each resident received the care and services that were dictated by the plan of care. Staffing patterns were reviewed on a daily basis. The facility worked to cover the needs of residents on a daily basis, including accounting for call-ins, etc. This was an approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time based on resident population and their needs for care and support. Review of facility education documentation provided to staff, on [DATE], [DATE], and [DATE], titled, Following Care Plans and Resident to Resident Procedure, revealed when a resident was on 1:1 staffing it was because they have been evaluated as needing continuous supervision. This meant that these residents must always be in the line of sight of the staff member assigned to them. Staff cannot leave the resident sitting unattended while attending to another resident or any other task unless someone else was watching them. Record review revealed the facility admitted Resident #1 on [DATE] and readmitted on [DATE] with diagnoses, which included Dementia, [MEDICAL CONDITION], Unspecified [MEDICAL CONDITIONS], Altered Mental Status (AMS), [MEDICAL CONDITION], and Dysphagia. Review of a Speech Therapy Evaluation dated [DATE]; a Comprehensive Care Plan for at risk for nutritional decline, dated [DATE]; and a Comprehensive Care Plan for alterations in mood/behavior revealed, Resident #1 was was assessed and care planned to require 1:1 Supervision due to grabbing food not on his/her diet, and having behaviors of scratching, hitting, and grabbing others. Review of Daily Staffing Sheet, dated [DATE], revealed there was one nurse and two Certified Nurse Aides (CNA's) assigned to Resident #1's unit on the 2:30 PM-10:30 PM shift. Further review revealed there was no one assigned for 1:1 supervision of Resident #1. Review of Nurses Note, dated [DATE] at 8:02 PM by LPN #1, revealed LPN #1 witnessed Resident #1 take a peanut butter sandwich from snack tray on medication cart in hallway and take a large bite of sandwich before LPN #1 could get sandwich from resident. The Resident choked and licensed staff performed the [MEDICATION NAME] maneuver multiple times, and the resident coded with staff providing CPR with success. EMS arrived and took over care of Resident #1 and transported resident to hospital. Review of Emergency Department to Hospital Admission Records dated [DATE] at 8:30 PM and interview with hospital Advanced Registered Nurse Practitioner (ARNP), on [DATE] at 10:05 AM, revealed Resident #1 had to be intubated and placed on respirator and admitted to hospital with acute hypoxic [MEDICAL CONDITION] and aspiration. An ear/nose/throat (ENT) specialist was consulted for a tracheotomy and it was planned for [DATE]. Resident may have to be discharged to go to long-term acute care at the hospital to get off the vent. Interview with Administrator, on [DATE] at 3:45 PM, revealed the resident was still in the hospital and remained intubated with a tracheotomy, on a ventilator, and a nasogastric tube for feeding. Interview with LPN #1, on [DATE] at 9:46 AM, 11:45 AM and on [DATE] at 2:25 PM, revealed, Resident #1 required 1:1 supervision and she did not have enough staff to provide 1:1. She stated she tried to call another CNA into work to provide the 1:1, with no success. She stated one CNA was supervising resident smoke break outside, one CNA was providing resident care in room, and she was administering medications and had placed the snack tray on the medication cart, so she could administer snacks at the same time. She revealed Resident #1 smoked but was out of cigarettes so she had no choice but to try to keep Resident #1 by the medication cart while she administered the medications and passed snacks. She stated as she was pouring a cup of water to administer another resident's medications, Resident #1 grabbed a half of a peanut butter sandwich off of med cart and had eaten half of it before she could stop the resident. LPN #1 stated the facility had sitters for Resident #1, but the sitters were done away with, and the routine scheduled staff had to provide 1:1 supervision along with the duties they already had. Interview with CNA #1, on [DATE] at 7:41 AM, and CNA #2 on [DATE] at 9:27 AM and [DATE] at 3:31 PM, revealed CNA #1 was outside providing supervision for residents' smoke break and CNA #2 was in a resident's room providing resident care. The CNA's stated Resident #1 was sitting in the hallway but they were not paying attention to Resident #1. The CNA's revealed Resident #1 was supposed to be on 1:1 when out of bed and someone was to be with him/her at all times and within touching distance. The CNA's stated they did not have enough staff to provide 1:1 to the resident so the resident wandered up and down the hall and the staff on the hall tried to keep an eye on the resident. CNA #2 revealed the facility used to have a sitter for Resident #1, but now staff have to watch the resident but there was no one to assign to watch the resident on their shift. Interview with Registered Nurse (RN) #2, on [DATE] at 12:40 AM, revealed she did not think there was enough staff to do 1:1 with Resident #1. RN #2 stated the few times that she provided care for Resident #1 it was a struggle. She revealed the resident's behavior was to grab anything off the desk or a cart. She stated the resident would pull things out of staff pockets, and would pull lanyard off staff's neck. She stated the resident would even reach from the bedside to grab the television and try to pull it off the table in his/her room. Interview with Unit Manager (UM) #1, on [DATE] at 2:10 PM, revealed the staff for each hall stayed the same on the Day Shift (6AM-6:00 PM), with one nurse and three aides for halls 100 and 200; and one nurse and two aides on 300 hall. She stated when there was a resident that required 1:1 supervision they were able to pull the Hospitality Aide, Restorative Aide or transportation aide when needed. She stated on Night Shift (6:00 PM-6:00 PM) there were five (5) CNA's and three nurses in building and a Kentucky Medication Assistant, four nights a week. She stated the hospitality aide, restorative aide, and transportation aide would not be available on night shift. She further revealed if there is not enough staff to provide 1:1, the nurse could call a CNA into work. She stated staff were not necessarily assigned to do 1:1 with other duties, but if able to watch the resident and keep in view, it would be okay. She stated Resident #1 was mobile in his/her broda chair and would grab staff, residents and other items when saw them. She was not aware the resident would grab food. Interview with the Director of Nursing (DON) (hired [DATE]) and Administrator, on [DATE] at 11:20 AM, revealed the Unit Managers and Staff Development Coordinator do the daily staffing sheets. The DON stated staffing was determined by the amount of activity going on. The DON revealed staff had been moved around since COVID, as all three (3) halls used to have the same amount of staff. She stated since the 300 hall was now used mainly for new admits and possible COVID residents, there were less residents on the hall and the 300 hall had less staff. She stated when there was a resident on 1:1, it was handled with staff throughout the building not just that unit. The Administrator and DON both were not able to describe exactly how they determined the number of staff that were required on each unit. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred from the facility on [DATE] and has not returned to the facility. 2. The Dietary Manager provided a list of all current residents on mechanical altered diets (17 residents) on [DATE]. The Administrator completed a review of the care plans of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. The Administrator, Social Service Director, and/or licensed nurse completed a review of psychosocial/behavior care plans for any resident currently identified as requiring 1:1 supervision, on [DATE]. There were no additional residents at this time requiring 1:1 supervision. This was completed on [DATE]. 4. The Regional Director of Operations provided education to the Administrator on [DATE] regarding: One-to-one supervision regarding one staff member dedicated to the supervision of one resident with no other assigned duties during the time. 5. The Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 6. The DON provided education to assigned licensed nurses (4) and director of medical records/medication technician (a train the trainer education) on [DATE] through [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the Director of Nursing when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 7. Education was provided to the facility nursing staff, (licensed nurses and nursing assistants), and facility dietary staff by the DON, Administrator, and Regional Quality Manager beginning [DATE] through [DATE], regarding: Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 8. Verbal acknowledgement of understanding along with signed education was obtained after the inservice. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 9. The Regional Quality Manager provided education to the DON on [DATE] regarding: To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 10. The DON provided education (train the trainer) to the staff development Coordinator on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 11. The Regional Quality Manager, the DON and or Staff Development Coordinator (SDC) provided education to the licensed nursing staff on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 12. Verbal acknowledgement of understanding along with signed education was obtained after the inservices. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 13. An ad-hoc meeting was held on [DATE] to review the summary of Immediate Jeopardy findings and discuss the development of the action items to be completed. This meeting included the Administrator, DON, Social Services, Activities, Dietary, Therapy, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone on [DATE]. 14. The Administrator, Assistant Administrator, DON, and/or Weekend Department Manager Supervisor would observe five (5) times (X) a week on various shifts to include weekends for two (2) weeks, then three (3) X week for two (2) weeks, then two (2) X week for four (4) weeks for the following: All snacks would be placed in a covered container by dietary staff. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. The nursing staff member would place the container on the ice chest cart and begin snack pass to the residents. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. Any identified concern will be addressed at the time of discovery by the monitor. The audit began on [DATE]. 15. In the morning clinical meeting beginning [DATE], the Administrator, the DON, and/or assigned licensed nursing staff would review the plan of care for all residents requiring 1:1 supervision. 16. The Administrator or the DON would review and sign off on the staffing assignments sheets daily in regards to potential need for any 1:1 supervision. A review of the weekend staffing sheet would be completed on Fridays. The Administrator, the DON was to be notified at any time a resident required a 1:1 supervision. 17. Beginning [DATE], the DON and/or assigned licensed staff would audit five (5) residents requiring 1:1 supervision, risk for diet non-compliance, and/or (if no 1:1 supervision) with mechanically altered diets weekly times four (4) weeks for: Care plans interventions in place and observe the resident for care plan implementation as written in the plan of care 18. The results of the monitoring would be reviewed at a minimum of weekly in the QAPI meetings being held to track the facility's progress toward regulatory compliance. 19. A second ad hoc QAPI meeting was held on [DATE], to review the initial audit findings of the list of residents with mechanically altered diets and subsequent care plan review. This meeting included the Administrator, DON, Social Services, Dietary, Activities, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone, on [DATE]. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Notice of Emergency Transfer and Nurses Progress, dated [DATE] at 8:20 PM, revealed Resident #1 was sent to hospital via EMS (emergency management services) related to choking incident. Interview with Administrator, on [DATE] at 3:45 PM, revealed Resident #1 had not returned from the hospital. 2. Interview with Dietary Manager on [DATE] at 11:40 AM revealed she provided a list of residents who were on a mechanically altered diet to the Administrator. Review of care plans of residents that were identified as on mechanically altered diets revealed the Administrator reviewed the care plans, on [DATE] to ensure if resident was known to grab food; it was addressed on the resident's care plan. Interview on [DATE] at 3:45 PM, with Administrator revealed she had reviewed dietary needs of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. Interviews on [DATE] with Administrator at 3:45 PM, Social Service Director at 10:15 AM, and Director of Nursing (DON) at 12:00 PM revealed there were no additional residents at this time requiring 1:1 supervision. 4. Interview on [DATE] at 3:05 PM, with Regional Quality Manager, revealed the Regional Director of Operations provided education to the Administrator, on [DATE]. Interview with Administrator, on [DATE] at 3:45 PM, revealed she was educated by the Regional Director of Operations to ensure staffing would be provided for 1:1 supervised residents with no other duties assigned to that staff member. Review of education documentation revealed the Administrator signed the form indicating she had received education related to one staff member dedicated to the supervision of one resident with no other assigned duties during the time provided on [DATE] 5. Interview with the Regional Quality Manager (RQM) revealed she provided education to the Director of Nursing (DON), on [DATE]. Interview with DON, on [DATE] at 12:00 PM, revealed she was educated by RQM to ensure if there was 1:1 supervision of a resident, then a staff member would be assigned and have no other duties. She stated in addition she was educated on the new process of dietary delivering, and nursing storing and delivering dietary snacks. 6. Interview with DON, on [DATE] at 12:00 PM, revealed she provided education to SDC, LPN #4 and weekend staff, on [DATE] through [DATE], to ensure they knew the requirements for the 1:1 supervision and snack pass process. Interviews on [DATE] with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed they were educated on 1:1 supervision, the new snack pass process and snack requirement, and care plan implementation. They also stated they were educated to call DON and/or Administrator when a resident was placed on 1:1. 7. Interviews on [DATE] with LPN #5 at 4:20 PM, LPN #7 at 4:27 PM, and LPN #3 at 4:30 PM; on [DATE] with Dietary Manager at 11:40 AM, Dietary Aide #1 at 2:30 PM, Dietary Aide #2 at 2:50 PM, SDC at 10:15 AM, SSD at 10:15 AM, KMA#1/Director of Medical Records/Central Supply at 11:00 AM, LPN #1 at 11:20 AM, DON at 12:00 PM, UM #2 at 2:50 PM, RQM at 3:05 PM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, CNA #2 at 3:28 PM, and CNA #4 at 1:58 PM revealed they were educated on the new process for resident snack delivery and storage. Observation on [DATE] at 2:10 PM, revealed staff followed the new snack pass guidelines. 8. Review of education documentation revealed all nursing staff and dietary staff signed the education to acknowledge understanding of education. Additionally, interview with LPN #7 (new hire), on [DATE] at 4:27 PM, revealed she was educated on the new process for snacks, 1:1 resident supervision and care plan implementation. 9. Interview on [DATE] at 3:05 PM, with Regional Quality Manager, revealed she provided education to the DON, on [DATE], to ensure she was aware she and/or the Administrator should be notified when a resident was placed on 1:1, and the care plan was to be implemented, as indicated for 1:1 supervision. Interview with DON, on [DATE] at 12:00 PM, revealed she was educated on being notified if a resident was placed on 1:1, and care plan implementation of 1:1 by RQM. Review of education documentation dated [DATE], revealed the DON signed the form indicating she understood the education provided by the RQM. 10. Review of education documentation (train the trainer) provided by DON to the Staff Development Coordinator (SDC), on [DATE], revealed the DON educated the SDC and the SDC signed the form indicating she understood the education. Interview with SDC, on [DATE] at 10:00 AM and 4:00 PM, revealed she was educated by the DON on the new snack process, that the DON and the Administrator must be notified if a resident was placed on 1:1 supervision, and that staff assigned to that resident would have no other duties but the 1:1. 11. Interviews on [DATE] with LPN #7 at 4:27 PM; on [DATE] with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, LPN #3 at 4:30 PM, and LPN #5 at 4:20 PM, revealed they were educated that staff assigned 1:1 supervision of a resident would not be assigned any other duties, nursing staff were to notify DON and/or the Administrator if a resident was placed on 1:1, and care plan implementation of the 1:1 supervision. Review of education documentation revealed all licensed nursing staff signed they understood the education provided on [DATE] 12. Interviews on [DATE] LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed verbal acknowledgement of provision of education and signing of signature page for verification of education. 13. Interviews on [DATE] with Administrator at 3:45 PM, DON at 12:00 PM, SSD at 10:15 AM, Dietary at 11:40 PM; and Therapy at 2:15 PM revealed an ad-hoc meeting was held on [DATE] to review the summary of Immediate Jeopardy findings with discussion of action plan to address findings of Immediate Jeopardy. Interview with Administrator on [DATE] at 3:45 PM, and with Medical Director on [DATE] at 4:14 PM, revealed the Administrator made the Medical Director aware of the action plan and obtained his input. 14. Review of the Monitoring Tools for Snack Pass, revealed monitoring was conducted five times during the week of ,[DATE]-[DATE] and continued to be completed with no concerns identified. The monitors were signed by the DON/or weekend supervisor. 15. Interviews on [DATE] with Administrator at 3:45 PM, Administrator in Training (AIT) at 9:37 AM and at 3:45 PM, the DON at 12:00 PM, UM #2 at 2:50 PM, and MDS #1 at 4:06 PM revealed there were no residents on 1:1 at this time but were aware they would review care plans for all residents requiring 1:1 supervision. Review of a facility form that was developed to use to review the plans of care revealed a place to document Resident Name, Follow-up needed, Initials, Assigned to, and date. 16. Interview on [DATE] with the DON at 3:45 PM, the AIT at 9:37 AM and 3:45 PM, and the Administrator at 3:45 PM, revealed they were to be notified at any time a resident required a 1:1 supervision, and that the staffing sheets were being reviewed daily and weekend staffing sheets reviewed on Friday, but at this time there were no residents on 1:1 supervision. A list of reviewed staffing sheets was present in the AOC binder for review 17. Interview on [DATE] at 12:00 PM, with DON, revealed she was auditing accuracy of care plans related to supervision of 1:1, dietary needs, and watched a meal of audited resident that day. 18. Review of documented QAPI meetings revealed a review of facility progress with discussion of any issues dealt with immediately upon point of discovery. Interview on [DATE] with DON at 12:00 PM, Administrator at 3:45 PM, AIT at approximately 9:37 AM and 3:45 PM, revealed they were meeting weekly to discuss any issues identified with during monitoring. 19. Interviews on [DATE] with SSD at 10:15 AM, Dietary Manager at 11:40 AM, DON at 12:00 PM, Administrator at 3:45 PM, AIT at 9:37 AM and 3:45 PM, MDS at 4:06 PM and Medical Director at 4:14 PM revealed there were ongoing reviews of facility's progress toward compliance.

Based on observation, interview, record review, hospital record review, review of Nurse's book, Staff Assignment Sheet, and facility education review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision to prevent accidents. The facility assessed Resident #1 required one to one (1:1) supervision when out of bed; however, the facility did not ensure this assessed need was met. Interviews and record review revealed, on [DATE], there was no staff to provide 1:1 supervision. One Certified Nurse Aide (CNA) was outside providing supervision during the residents' smoke break, one CNA was providing resident care in a resident room, and the nurse was administering medication. Resident #1 was sitting beside the medication cart while the nurse prepared medication to administer to a resident. There was a snack tray on the medication cart. Resident #1 grabbed a half of a peanut butter sandwich off the tray and ate half of the sandwich before the nurse could stop him/her. Resident #1 choked and staff provided [MEDICATION NAME] maneuver (abdominal thrusts to remove object causing to choke). Resident #1 coded and staff initiated Cardiopulmonary Resuscitation (CPR) (chest compressions often with artificial ventilation). Resident #1 was transferred to an acute care facility where he/she was intubated (insertion of a tube into the patient's body) and placed on a ventilator (machine that provides mechanical ventilation (air/breaths) and a feeding tube was placed. The facility's failure to provide adequate supervision to prevent accidents has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with Regional Quality Manager #2 (RQM), Administrator, Administrator in Training (AIT), and Director of Nursing (DON), on [DATE] at approximately 4:25 PM, revealed there was no facility policy that addressed 1:1 supervision. However, review of facility education documentation provided to staff on [DATE], [DATE], and [DATE] titled, Following Care Plans and Resident to Resident Procedure revealed when a resident was on 1:1 staffing, it was because the resident was evaluated as needing continuous supervision. This meant that the resident must always be in the line of sight of the staff member assigned to them and was a care-planned intervention. Further review of the education revealed not to leave the resident sitting, to attend to another resident or any other task unless someone else was watching them. Record review revealed the facility readmitted Resident #1 on [DATE] with diagnoses, which included Dementia, [MEDICAL CONDITION], Unspecified [MEDICAL CONDITIONS], Altered Mental Status (AMS), [MEDICAL CONDITION], and Dysphagia. Review of Resident #1's Comprehensive Care Plan for at risk for nutritional decline dated [DATE], revealed the resident was at risk due to Dementia, Behavior Disturbances, [MEDICAL CONDITION], Depression, Anxiety, Pseudobulbar Affect, [MEDICAL CONDITIONS] Disease, Muscle Weakness, Lack of Coordination, Altered Mental Status (AMS), [MEDICAL CONDITION], Pain, Convulsions, Adult Failure to Thrive (AFTT), [MEDICAL CONDITION], Risk for Malnutrition, Difficulty Chewing/Swallowing, and Edentulous. Further review of the care plan revealed a goal to tolerate diet without chewing or swallowing problems thru next review and an interventions for continual feeding assist at mealtimes, diet as ordered, and supervised meals as indicated for reaching in and getting food not on his/her diet. Review of Resident #1's Comprehensive Care Plan for alterations in mood/behavior and known for attempting to bite, grab, and scratch staff and other residents revealed an intervention dated [DATE] to provide 1:1 until further notice when out of bed. Review of 100 Hall Nurses Book revealed a list of residents that were identified as at risk of taking food. Resident #1 was on this list. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS assessment, revealed the resident required supervision and meal setup, and had behaviors of scratching, hitting, screaming, and disruptive sounds toward others. Review of Speech Therapy Evaluation and Plan of Treatment, dated [DATE], revealed Resident #1 was downgraded to a puree diet in [DATE], secondary to decreased toleration of mechanical soft diet. The evaluation revealed the resident's history included effects of anoxia with [MEDICAL CONDITION], mental impairments and decreased safety awareness; with background medical assessment to include combative and impulsive behaviors and resident has a habit of reaching out, and grabbing. Further review of the assessment revealed Resident #1 was at risk for aspiration, with recommendations of intake, puree consistencies; and close supervision. Review of [DATE] Physician Orders, revealed Resident #1 was to receive a Dysphagia Pureed Consistency diet, and to provide 1:1 supervision when out of bed. Review of the Staff Assignment Sheet, for [DATE] for 2:30 PM - 10:30 PM shift, revealed there was one nurse and two CNA's assigned to Resident #1's Unit. Review of a 1:1 documentation form, dated [DATE], revealed LPN #1 had initialed she provided 1:1 supervision to Resident #1 from 6:00 PM-8:00 PM. Review of Nursing Progress Note, dated [DATE] at 8:02 PM written by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was in broda chair and was 1:1 with LPN #1, when LPN #1 witnessed resident taking a peanut butter sandwich from snack tray on cart in hallway. Resident #1 would not release sandwich and took a bite before LPN was able to remove from resident. Further review of the note revealed when LPN #1 attempted to redirect the resident, she saw the resident was showing signs of choking. LPN #1 encouraged resident to cough and resident unable to, so LPN attempted sweeping of mouth digitally, and then performed [MEDICATION NAME] maneuver multiple times and called for help. Resident produced small bolus of food from mouth but still showed signs of aspiration. Continued review of the note revealed LPN #2 (from another unit) came to assist LPN #1 with [MEDICATION NAME]; and an Automated External Defibrillator (AED) and Crash Cart were brought with O2 via nasal cannula applied and suction hooked up and provided. The physician was notified with orders received to send to emergency room (ER) and Emergency Medical System (EMS) called. The Nursing Note further revealed Resident became unconscious and cyanotic (bluish discoloration of skin related to an inadequate supply of oxygen being provided to the blood), pulse was not palpable, respirations ceased, and Resident's fingers and face began turning blue. Resident was full code so the LPN's initiated CPR. Resident gasped for air and began vomiting, was rolled to side, and resident color returned. Resident began using accessory muscles to breathe, pulse bounding, resident then began resisting care, kicking at staff while vomitus continued from mouth. Further review revealed at 8:18 PM, EMS was on site and took over care. Resident was kicking, coughing, and yelling while on stretcher and EMS left facility with emergency lights activated. Review of Emergency Department to Hospital Admission records, dated [DATE] at 8:30 PM, revealed Resident #1 from LTC (long term facility) apparently ate a peanut butter sandwich and became acutely choked and EMS was called, EMS retrieved a fair amount of peanut butter material out of oropharynx. However, resumption of normal oxygenation could not be accomplished and because of this Resident #1 was transported to hospital for further care. Resident was quite restless, and pulling at all equipment and fighting EMS and their ability to oxygenate resident. The last oxygen saturation EMS able to obtain was 71% and resident had blue lips upon arrival. Resident was intubated at 10:07 PM on [DATE], and placed on a respirator with resident admitted . Interview with LPN #1, on [DATE] at 9:46 AM and 11:45 AM, revealed there were two (2) CNA's and herself assigned to the unit. She stated she was administering medications, and one CNA was outside supervising resident smoke break and one CNA was providing care in a resident's room. She stated Resident #1 smokes but he/she was out of cigarettes so she was sitting to the left of the medication cart while she was administering medications and passing snacks since the two CNA's were busy. She stated while she was pouring a glass of water for another resident to take his/her medications, Resident #1 grabbed a half of a peanut butter sandwich off the snack tray on the med cart and took a bite (half of half of sandwich) before she was able to get the sandwich from him/her. LPN #1 revealed she saw Resident #1 was choking on the sandwich and saw CNA #1 coming up the hall and told her to get LPN #2 from the other hall. She stated they performed the [MEDICATION NAME] maneuver, and initiated CPR and tried to suction the resident because the resident had no pulse. She stated EMS arrived and took over care of the resident. LPN #1 stated Resident #1 was on 1:1 for a prior incident as he/she had grabbed another resident and given them a skin tear. She further revealed Resident #1 does get manic, upset, grabs at everything, and was an elopement risk as the resident tried to go to the door anytime he/she was up. Further interview with LPN #1, on [DATE] at 2:25 PM, revealed she had received training in [DATE] or [DATE], related to Resident #1's being on 1:1 anytime out of bed. She stated a staff member (nurse or aide) had to be present and ensure the resident was out of reach or grabbing distance of other residents. LPN #1 revealed when giving medications and watching the resident on 1:1 that she pulled the resident along in his/her wheelchair (w/c), keeping the resident beside the med cart. She stated most of the time residents would be in their w/c and she gave their meds at their room door but if she had to go into a room it was only for a minute. She stated the nurse determines who does the 1:1, and when staff were doing 1:1, they still have other duties. LPN #1 stated that she was aware Resident #1's care plan stated that resident would grab food from other residents, and the resident's name was in the nurse book at the desk indicating would grab food. She stated she had also seen Resident #1 grab food out of another residents lap. She further stated she did not think the resident could reach the top of the med cart to grab the sandwich off the snack tray. Interview with LPN #2, on [DATE] at 7:43 AM, and on [DATE] at 12:30 AM, revealed he was on another hall and LPN #1 was the nurse on Resident #1's hall. LPN #2 stated CNA #1 screamed to him that Resident #1 was choking and he responded. He stated he saw Resident #1 about midway down the hall, on the floor, on his/her bottom, but slouched over with head falling down. He stated the resident's eyes were shut, lips were pale, and was not breathing, LPN #2 stated they performed the [MEDICATION NAME] maneuver on the resident three (3) times with nothing coming up, so they initiated CPR because the resident did not have a pulse. He revealed when they started compressions the resident tried to cough the food up and they turned him/her to side and got some to come out. He stated he opened the resident's mouth to see if could swipe anything out and could not so he suctioned the resident. He revealed an ambulance was called and the resident was transferred to the hospital. He revealed he thought the incident happened about 8:00 PM, because he was passing meds when called. LPN #2 revealed Resident #1 was on 1:1 and had been for a while. He stated the aides watched him/her or if the aides were busy, the nurse watched the resident. LPN #2 further revealed Resident #1 was on 1:1, because he/she grabbed things, was real mobile and strong. The resident could grab on to things, people and all kinds of things like that. He stated the resident was on a pureed diet. Interview with CNA #1, on [DATE] at 12:17 PM, revealed she brought residents who smoke in from smoke break and was starting to get residents ready for the night when she came out of a resident's room and saw Resident #1 moving around on the hallway close to the medication cart. She stated she did not notice if Resident #1 had anything in his/her hand She revealed she thought LPN #1 was passing medications because the medication cart was at the back of the hallway. CNA #1 stated a little while after that she and CNA #2 were in hall talking about who we had left to take care of and which one would be taking break; when she observed LPN #1 and then heard her say Resident #1 was choking. She revealed she saw LPN #1 grab Resident #1 and do the [MEDICATION NAME]. She stated LPN #1 told her to get LPN #2 and she obtained crash cart and called 911. She stated the licensed staff had to perform CPR. She revealed Resident #1 was supposed to be on 1:1 when out of bed and someone was to be with him/her at all times and within touching distance. CNA #1 stated they do not have enough staff to provide 1:1. Interview with CNA #2, on [DATE] at 9:27 AM and [DATE] at 3:31 PM, revealed Resident #1 was on 1:1 supervision when out of bed but there was not enough staff to provide 1:1 care. CNA #2 stated the last time she saw Resident #1, he/she was roaming hallway. She revealed staff were not allowed to put the brakes on the resident's chair because it was considered a restraint. CNA #2 stated the nurse was in a room administering medication at the back of the hall, Resident #1 was roaming the hall, and she was in the shower room disposing of dirty laundry. CNA #2 stated when she came out of shower room, she saw the nurse place something on the medication cart, push the cart away, grab Resident #1, and perform the [MEDICATION NAME] maneuver on the resident. She stated she did not see the resident grab the sandwich and did not see any remains of peanut butter sandwich or the plastic bag it came in. She revealed LPN #1 told her that Resident #1 had grabbed a peanut butter sandwich. CNA #2 stated the snack tray was on the end of the med cart, because the nurse served the nighttime snacks as she passed meds. CNA #2 stated Resident #1 was acting like he/she was choking and his/her color went from pink to blue. She revealed LPN #2 and LPN #1 provided CPR when Resident #1 coded. She stated EMS was called and arrived to transport Resident #1 to the hospital. CNA #2 stated we do not have the staff to sit with the resident 1:1, so no one does 1:1, we just watch resident while doing care on the hall and sometimes the nurse watched the resident. CNA #2 further stated Resident #1 grabbed staff and residents, and anything else in reach. Interview with hospital Advanced Registered Nurse Practitioner (ARNP), on [DATE] at 10:05 AM, revealed Resident #1 was brought into ER with blue lips, O2 in 70's and restless but alert and altered level of consciousness (ALOC). She stated a video assisted intubation was provided, and the resident was admitted to hospital with acute hypoxic [MEDICAL CONDITION], aspiration, and was put on ventilator for hypoxic [MEDICAL CONDITION] at time of intubation. She stated she consulted an ear/nose/throat (ENT) specialist [MEDICAL CONDITION] it has not been done yet, the plan was for [DATE]. She revealed she did not know when the resident would be discharged as he/she may have to go to long term acute care at the hospital to get off the ventilator Interview with Registered Nurse (RN) #2, on [DATE] at 12:40 AM, revealed 1:1 meats the resident was at least in eyesight; if not right beside staff. She stated she did not think there was enough staff to provide 1:1 supervision for Resident #1. RN #2 revealed the few times that she provided care for Resident #1 it was a struggle. She stated the resident's behavior was to grab anything off the desk or carts. In addition, the resident would pull things out of staff pockets, and would pull lanyard off of staff's neck. She further revealed the resident would grab anything within reach, even in his/her room, the resident would reach and try to pull his/her TV off the table. Interview on [DATE] at 5:51 PM, with CNA #16, revealed when Resident #1 was out of bed the resident was supposed to be 1:1, because the resident was feisty and would grab people and stuff. Interview with Social Services Director (SSD) #2, on [DATE] at approximately 3:35 PM, revealed Resident #1 had been on 1:1 for quite some time, and was constantly reaching out grabbing residents. She stated the resident had scratched them, was a constant wanderer, and would try to get out the doors. She stated the resident needed staff within arms length of him/her at all times while out of bed (OOB). She stated she was sure Resident #1 grabbed food, as he/she liked to grab just about anything, and she believed Resident #1 was on a mechanical soft or pureed diet. Interview with Staff Development Coordinator (SDC), on [DATE] at 3:36 PM, revealed Resident #1 must be constantly observed when up. She stated the resident was care planned for 1:1 supervision and needed to be constantly observed. She stated staff needed to be pretty close as that was the reason for 1:1 supervision. Interview with Administrator, on [DATE] at 3:20 PM, [DATE] at 9:45 AM and [DATE] at 4:42 PM, revealed when asked what 1:1 entailed for a resident she stated it depended on the reason the resident was on 1:1. She stated Resident #1 was care planned for 1:1 supervision when out of bed due to grabbing and scratching other residents, so the staff only had to keep the resident in line of sight to ensure the resident was not within reaching distance of another resident. She stated she was not aware the resident would constantly grab items and people and was care planned for grabbing food not on his/her diet. Further interview with Administrator, on [DATE] at 3:45 PM, revealed Resident #1 was still in the hospital and remained intubated with a tracheotomy, on a ventilator, and a nasogastric tube for feeding. The Administrator further revealed the facility had identified the snacks were being left on the medication cart while the nurse was passing medications which enabled residents to have access to food that was not on their prescribed diets. She stated staff had been educated to ensure snacks were kept at nursing station and each snack passed out from there by a staff member so snacks were not left unsupervised with residents having access to them. However, observation on [DATE] at 10:02 AM, revealed a dietary staff delivered the snacks to the nurse on the 200 hall. The nurse went down the hall and placed the snack tray on the med cart. Further observation revealed the nurse obtained a snack from the tray then delivered the snack to resident in their room, leaving snack tray on the cart unsupervised. There was a half peanut butter sandwich and peanut butter crackers still on the snack tray. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred from the facility on [DATE] and has not returned to the facility. 2. The Dietary Manager provided a list of all current residents on mechanical altered diets (17 residents) on [DATE]. The Administrator completed a review of the care plans of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. The Administrator, Social Service Director, and/or licensed nurse completed a review of psychosocial/behavior care plans for any resident currently identified as requiring 1:1 supervision, on [DATE]. There were no additional residents at this time requiring 1:1 supervision. This was completed on [DATE]. 4. The Regional Director of Operations provided education to the Administrator on [DATE] regarding: One-to-one supervision regarding one staff member dedicated to the supervision of one resident with no other assigned duties during the time. 5. The Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 6. The DON provided education to assigned licensed nurses (4) and director of medical records/medication technician (a train the trainer education) on [DATE] through [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the Director of Nursing when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 7. Education was provided to the facility nursing staff, (licensed nurses and nursing assistants), and facility dietary staff by the DON, Administrator, and Regional Quality Manager beginning [DATE] through [DATE], regarding: Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 8. Verbal acknowledgement of understanding along with signed education was obtained after the inservice. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 9. The Regional Quality Manager provided education to the DON on [DATE] regarding: To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 10. The DON provided education (train the trainer) to the staff development Coordinator on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. Dietary would provide a list of mechanically altered diets and thickened liquids with each snack pass delivery. All snacks would be placed in a covered container by the dietary staff prior to handling off to nursing staff. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. 11. The Regional Quality Manager, the DON and or Staff Development Coordinator (SDC) provided education to the licensed nursing staff on [DATE] regarding: One to one supervision requires one staff member dedicated to the supervision of one resident with no other assigned duties during this time. To notify the Administrator and/or the DON when there was a need to add a care plan intervention for 1:1 supervision of a resident. The care plan was to be implemented as indicated for 1:1 supervision. 12. Verbal acknowledgement of understanding along with signed education was obtained after the inservices. The facility employs no agency staff. Employed nursing or contracted dietary staff currently on leave or newly hired to the facility will receive this education from the DON or assigned facility manager before assuming duties. 13. An ad-hoc meeting was held on [DATE] to review the summary of Immediate Jeopardy findings and discuss the development of the action items to be completed. This meeting included the Administrator, DON, Social Services, Activities, Dietary, Therapy, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone on [DATE]. 14. The Administrator, Assistant Administrator, DON, and/or Weekend Department Manager Supervisor would observe five (5) times (X) a week on various shifts to include weekends for two (2) weeks, then three (3) X week for two (2) weeks, then two (2) X week for four (4) weeks for the following: All snacks would be placed in a covered container by dietary staff. Dietary staff would hand off snacks to the nursing staff. If for any reason the nursing staff was unavailable, the snack pass was to be placed in the secured nourishment station. The nursing staff member would place the container on the ice chest cart and begin snack pass to the residents. A closed container system would now be used for snack pass versus an open tray. Following snack pass, the closed container of snacks should be returned to dietary. Any identified concern will be addressed at the time of discovery by the monitor. The audit began on [DATE]. 15. In the morning clinical meeting beginning [DATE], the Administrator, the DON, and/or assigned licensed nursing staff would review the plan of care for all residents requiring 1:1 supervision. 16. The Administrator or the DON would review and sign off on the staffing assignments sheets daily in regards to potential need for any 1:1 supervision. A review of the weekend staffing sheet would be completed on Fridays. The Administrator, the DON was to be notified at any time a resident required a 1:1 supervision. 17. Beginning [DATE], the DON and/or assigned licensed staff would audit five (5) residents requiring 1:1 supervision, risk for diet non-compliance, and/or (if no 1:1 supervision) with mechanically altered diets weekly times four (4) weeks for: Care plans interventions in place and observe the resident for care plan implementation as written in the plan of care 18. The results of the monitoring would be reviewed at a minimum of weekly in the QAPI meetings being held to track the facility's progress toward regulatory compliance. 19. A second ad hoc QAPI meeting was held on [DATE], to review the initial audit findings of the list of residents with mechanically altered diets and subsequent care plan review. This meeting included the Administrator, DON, Social Services, Dietary, Activities, and MDS. This information was reviewed with the facility Medical Director by the Administrator via the phone, on [DATE]. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Notice of Emergency Transfer and Nurses Progress, dated [DATE] at 8:20 PM, revealed Resident #1 was sent to hospital via EMS (emergency management services) related to choking incident. Interview with Administrator, on [DATE] at 3:45 PM, revealed Resident #1 had not returned from the hospital. 2. Interview with Dietary Manager on [DATE] at 11:40 AM revealed she provided a list of residents who were on a mechanically altered diet to the Administrator. Review of care plans of residents that were identified as on mechanically altered diets revealed the Administrator reviewed the care plans, on [DATE] to ensure if resident was known to grab food; it was addressed on the resident's care plan. Interview on [DATE] at 3:45 PM, with Administrator revealed she had reviewed dietary needs of residents with mechanical soft and pureed diets in regard for the potential for reaching for food not on their meal tray. 3. Interviews on [DATE] with Administrator at 3:45 PM, Social Service Director at 10:15 AM, and Director of Nursing (DON) at 12:00 PM revealed there were no additional residents at this time requiring 1:1 supervision. 4. Interview on [DATE] at 3:05 PM, with Regional Quality Manager, revealed the Regional Director of Operations provided education to the Administrator, on [DATE]. Interview with Administrator, on [DATE] at 3:45 PM, revealed she was educated by the Regional Director of Operations to ensure staffing would be provided for 1:1 supervised residents with no other duties assigned to that staff member. Review of education documentation revealed the Administrator signed the form indicating she had received education related to one staff member dedicated to the supervision of one resident with no other assigned duties during the time provided on [DATE] 5. Interview with the Regional Quality Manager (RQM) revealed she provided education to the Director of Nursing (DON), on [DATE]. Interview with DON, on [DATE] at 12:00 PM, revealed she was educated by RQM to ensure if there was 1:1 supervision of a resident, then a staff member would be assigned and have no other duties. She stated in addition she was educated on the new process of dietary delivering, and nursing storing and delivering dietary snacks. 6. Interview with DON, on [DATE] at 12:00 PM, revealed she provided education to SDC, LPN #4 and weekend staff, on [DATE] through [DATE], to ensure they knew the requirements for the 1:1 supervision and snack pass process. Interviews on [DATE] with LPN #1 at 11:20 AM, LPN #2 at 3:11 PM, CNA #1 at 2:25 PM, and CNA #2 at 3:28 PM, revealed they were educated on 1:1 supervision, the new snack pass process and snack requirement, and care plan implementation. They also stated they were educated to call DON and/or Administrator when a resident was placed on 1:1. 7. Interviews on [DATE] with LPN #5 at 4:20 PM, LPN #7 at 4:27 PM, and LPN #3 at 4:30 PM; on [DATE] with Dietary Manager at 11:40 AM, Dietary Aide #1 at 2:30 PM, Dietary Aide #2 at 2:50 PM,

Based on observation, interview, record review, review of the facility's policies/procedures, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to prevent the possible spread of COVID-19. Observations revealed personal protective equipment (PPE) was not available on hall, and multiple staff failed to don PPE prior to entering residents' rooms who were on isolation precautions (due to being newly admitted and/or possibly exposed to COVID-19). In addition, one staff failed to remove PPE prior to exiting resident room. The findings include: Review of facility policy titled, Infection Prevention and Control Policy and Procedure: Subject: Novel Coronavirus (2020-nCoV), last revised 03/25/2020, revealed Coronavirus were a large family of viruses that were common in people. The incubation time was 2-14 days and [MEDICAL CONDITION] could be transmitted from asymptomatic patients. The length of time [MEDICAL CONDITION] could live on surfaces was not clear at present. The facility would conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of [MEDICAL CONDITION]. The facility would implement actions according to CDC, DOH, and the World Health Organization Review of facility policy titled, Isolation- Categories of Transmission-Based Precautions, not dated, revealed Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (generated by cough/sneeze/talking). Masks would be worn when entering the room and gloves, gown, and goggles should be worn if there was a risk of spraying respiratory secretions. Review of facility inservice records dated 03/16/2020, provided by Staff Development Coordinator SDC/Infection Control Nurse (IFC) revealed staff were educated per CDC guidelines of removal of PPE (including gown) before exiting resident rooms. Further review revealed they were educated the type of PPE would vary based on level of precautions required, with instruction for donning of gown, gloves, mask, goggles, respirator or shield provided. Review of the CDC Preparing for COVID-19 in Nursing Homes, guidance, updated 06/25/2020, revealed HCP (Health Care Professional) should wear N95 or higher level respirator, eye protection (goggles or a face shield that covered the front and sides of the face), gloves, and gown when caring for these residents. 1. Tour with SDC/Infection Control Nurse on 08/17/2020 at approximately 4:00 PM, revealed bins on hall 300 with no PPE supplies for isolation rooms. Observation of isolation room [ROOM NUMBER] on 200 hall, revealed there was no PPE available for staff to provide care to residents in room. Interview on 08/17/2020 at 4:00 PM with Licensed Practical Nurse (LPN) #3, revealed the bins on the hall did not have needed PPE in them for staff to provide care to the residents on isolation. Interview on 08/17/2020 at 3:58 PM, with Certified Nursing Assistant (CNA) #7, revealed there were no gowns on the hall available for use. Interview on 08/18/2020 at 4:08 PM, with LPN #3, revealed the IFC/SDC was responsible to put the gowns in the bins. LPN #3 stated there were no gowns in bin at Isolation room [ROOM NUMBER], and she had to go all the way up to room [ROOM NUMBER] to obtain the gowns. Interview on 08/17/2020 with Staff Development Coordinator/Infection Control Nurse (ICN) at 4:13 PM, 4:25 PM at 5:15 PM, revealed the isolation rooms were supposed to have the required PPE (gown/gloves/masks) in the bins at each room. She stated she needed to educate the staff that when they run out they need to get some from the nurses. She stated Central Supply (CS) was responsible for ensuring PPE was available in the bins. Interview on 08/18/2020 at 3:45 PM with CS revealed she had not been told and did not know she was responsible to put PPE (gowns/goggles/mask) in the supply bins at the isolation rooms. 2. Observation of signs posted at isolation rooms on 300 hall, on 08/17/2020 at 3:45 PM revealed gown, gloves and mask required related to droplet precautions. Observation on 08/17/2020 at 5:30 PM, revealed CNA #5 exited room [ROOM NUMBER] (Resident #41{[MEDICAL TREATMENT] Resident on isolation}) with gown on and untied and carrying supper tray. CNA #5 then went to meal cart and placed meal tray on cart. Interview on 08/17/2020 at 5:30 PM with CNA #5, revealed she should have taken gown off in room before coming into the hallway. 3. Observation on 08/24/2020 at 11:40 AM, revealed Maintenance Director in room [ROOM NUMBER] not wearing any PPE and resident in room. The Maintenance Director was observed leaning over and touching bed while addressing plug in and attempting to plug in a cord to the socket and touching the A/C Unit in room. Interview on 08/24/2020 at 3:10 PM, with Maintenance Director revealed he had not thought about wearing PPE when coming into contact with the bed of resident, while checking his/her air conditioner and plug ins. 4. Observation on 08/17/2020 at approximately 5:50 PM, revealed CNA #5 sitting in a resident room with (2) new Residents (Resident #370 and #372) who were new admits and persons under investigation (PUI) for exposure to COVID-19) with no gown on feeding Resident #370. In addition, there was no sign on the door to indicate the residents were on isolation or gloves, gown, and masks were required. Interview with CNA #5, on 08/17/2020 at 5:15 PM and on 09/01/2020 at 5:15 PM, revealed there was no PPE available and that the residents were admitted over the weekend. In addition, there was not a sign on the door, but they were on isolation because they were new admits. Observation on 08/24/2020 at 5:17 PM, revealed CNA #4 and CNA #6 exited Resident #370's and #372's room carrying a meal tray with no gloves or gown on while in room. Interviews with CNA #4, on 08/24/2020 at approximately 5:20 PM, revealed they had fed Resident #370, and did not wear gloves or gown while in room. Interview with CNA #6, on 08/27/2020 at 10:08 AM, revealed she did not realize she needed to wear gloves and gown while in the room providing direct care. She stated the facility did not communicate needed information, and the sign was not there and no one had told her to wear PPE in that room. Observation on 08/24/2020 at approximately 11:40 AM, revealed Physical Therapist (PT) #1 was helping Resident #370 in bathroom for continent care and was not wearing the appropriate PPE. Interview on 09/24/2020, at approximately 11:45 AM with Physical Therapist #1, revealed that he had been in the room helping Resident #370 with bathroom care and was not wearing any PPE at the time. Observation on 08/18/2020 at approximately 4:29 PM, revealed CNA #7 in Resident #370's and #372's room without gown on while in room. Interview on 08/18/2020 at approximately 4:20 PM, with CNA #7, revealed that she should have put a gown on prior to going into a resident's room due to the resident being on isolation precautions. Interview on 08/18/2020 at approximately 4:29 PM with LPN # 3, revealed staff should put a gown on prior to entering Resident #370's and #372's room. Interview on 09/01/2020 at approximately 4:05 PM, with LPN #4, revealed staff was to wear gown, gloves, and mask when going into a room, and the PPE should be taken prior to exiting room. In addition, supplies should be available in the bins for staff to wear in rooms. Interview on 08/24/2020 at 11:55 AM with DON revealed if staff was providing direct patient care staff needed to wear PPE. Interview on 08/18/2020 at 5:15 PM, with Administrator revealed there was no need for staff to wear gowns unless there was potential for staff to come in contact with body fluids, such as doing incontinent care, or come into contact with residents. 5. Observations on 09/02/2020 at 8:13 AM, revealed signage on Resident #21's room indicating isolation and PPE outside the resident's doorway. LPN #7 entered Resident #21's isolation room without donning the appropriate personal protective equipment (PPE) to provide care to the resident. Further observation revealed LPN #7 standing over Resident #21 and administering medications. Interview with Licensed Practical Nurse (LPN) #7, on 09/02/2020 at 8:15 AM, revealed she should have taken appropriate precautions to include the use of goggles and gloves when administering medications to residents on the isolation unit. LPN #7 further stated the resident was on droplet precautions and wearing the PPE keeps staff and residents safe. Interview with the Director of Nursing (DON), on 09/04/2020 at 11:23 AM, revealed she expected staff to follow the CDC guidelines and facility policy when providing care to residents on the isolation unit. The DON further stated signs are posted outside the door and PPE is available for staff.

Based on observation and interview, it was determined the facility failed to prepare food under sanitary conditions. Observation during initial kitchen tour revealed dusty ceiling vents over the production area. The findings include: Observation on 09/01/2020 at 9:59 AM, during the initial kitchen tour revealed a build up of dust on the air vents over the production area. Interview on 09/04/2020 at 9:15 AM, with Certified Dietary Manager, revealed the maintenance department was responsible for cleaning the kitchen ceiling air vents. Interview on 09/03/2020 at 4:50 PM, with Maintenance, revealed maintenance was not responsible for cleaning the kitchen ceiling air vents. Interview on 09/04/2020 at 10:55 AM, with Administration, revealed maintenance dusted the high ceiling areas and dietary dusted the lower areas of the ceiling that were in reach.

Based on observation, interview, facility menu review, and review of facility policy, it was determined the facility failed to follow the standardized four (4) week cycle menus as determined by menu changes not assessed by the Dietitian for prior approval. The findings include: Review of the facility policy titled Menus, not dated, revealed facility menus were planned in advance to meet the nutritional need of Residents in accordance with established national guidelines. Menus would be developed to meet the criteria through the use of an approved menu planning guide. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutritional professional reviews and approved the menus. The RDN or other clinically qualified nutrition professional would adjust the individual meal plan to meet the individual requests including cultural, religious, or ethnic preferences, as appropriate. Review of the facility menus titled, Week-AT-A-Glance Southern 2020, week 1 through week 4, not dated, revealed the menus were not followed. The posted weekly menu for the last weekend of August 2020 and the first week of September 2020 did not correspond to any of the standardized four (4) cycle menus. Further review and comparison of the weekly-posted menu with the standardized four (4) week cycle menus revealed the individual menu's food items changed or were removed from the original standardized menu. Observation on 09/01/2020 at 4:00 PM, of the posted weekly menu, revealed the menu did not appear within the current set of four (4) week cycle menus. Interview on 09/02/2020 at 3:50 PM, with Account Manager, revealed she followed the menus, however, she wrote out the menu for the week. She stated she discussed substitutions with the dietitian and she selected, each meal from the four (4) week cycle menus, to create her own weekly menu. She continued to reveal she selected some menus from week four (4) and some menus from the other weeks to create the current weekly posted menu. Interview on 09/02/2020 at 2:30 PM, with the Registered Dietitian, Licensed Dietitian (RD) (LD) revealed she had instructed the account manager concerning substitutions. She stated she was not aware the Account Manager was creating her own menu from the four (4) week cycle menus. She further revealed the Account manager needed RD approval for any changes to the menu prior to posting the menu for the week. She stated she expected the cycle menus to be followed and there to be prior approval by the RD for any changes. Interview on 09/04/2020 at 10:55 AM,with Administration, revealed she expected the menus to be followed and any changes pre-approved by the dietitian.

Based on interview, record review, and review of facility policy, it was determined the facility failed to provide treatment and care in accordance with professional standards of practice, for one (1) of three (3) sampled residents (Resident #1). Licensed staff failed to monitor Resident #1 after they identified Resident #1 was sweaty, had a heart rate (pulse) of 135 (normal ,[DATE]); blood pressure (B/P) of ,[DATE] (normal:104-,[DATE]-86); oxygen saturation of 79% on room air (normal: 95%); respiratory rate of 26 (normal:,[DATE]); and, blood sugar was 301 on [DATE] at 5:50 AM. The facility notified the Emergency Medical Services (EMS): however, the facility's licensed staff failed to stay with Resident #1 until the Emergency Medical Services (EMS) arrived. The licensed staff left the resident delegating the task of staying with the resident to a Certified Nursing Assistant (CNA); and the CNA also left the resident alone. EMS arrived and when they entered the resident's room, the resident was alone, was not breathing, had no pulse, and his/her eyes were fixed and dilated. Cardiopulmonary Resuscitation (CPR) was initiated without success. The facility's failure to provide appropriate care, treatment, and monitoring has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Change in Status, last revised (MONTH) 2011, revealed the charge nurse will notify the resident's Attending Physician or On-call physician when there had been a significant change in condition, and need to transfer the resident to a hospital/treatment center. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Kentucky Board of Nursing Advisory Opinion Statement #15, dated (MONTH) (YEAR), revealed in accordance with Kentucky Revised Statue (KRS) 314.021(2), nurses are held responsible and accountable for their decisions regarding the supervision and delegation of nursing acts to unlicensed personnel who provide nursing assistance, based upon the nurses' educational preparation and current clinical competence in nursing. In a supervising capacity, the licensed practical nurse (LPN) should provide direction and assistance to those unlicensed individuals supervised, observe and monitor the activities of those supervised, and evaluate the effectiveness of tasks performed under supervision. In this opinion statement, an example of a task that could be delegated to an unlicensed person would be performing task of a routine nature that do not require ongoing nursing assessment and nursing judgement. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS assessment revealed the facility assessed that the resident required extensive assist of two (2) persons for bed mobility, ambulation in room and hall; was continent of bowel and occasionally incontinent of urine; no limitation in range of motion and was receiving physical therapy, speech therapy and occupational therapy. This MDS further revealed the discharge plan was to return home. Review of Resident #1's Admission physician's orders [REDACTED]. Review of a Comprehensive Care Plan for Resident #1 initiated on [DATE], revealed the facility care planned the resident for Alteration of circulation/oxygenation related to Hypertension, [MEDICAL CONDITIONS] of the Left Lung with interventions which included: medications/treatments as ordered, lung sounds per protocol, report any abnormal lung sounds, monitor for signs/symptoms of [MEDICAL CONDITION], monitor for increased shortness of breath (SOB), dyspnea (difficulty breathing), chest pain or other signs/symptoms (s/s) of cardiac distress and notify MD as needed, monitor for increased SOB, Dyspnea, cyanosis or other S/S of respiratory distress and notify MD as needed. Further review of the Comprehensive Care Plan, initiated [DATE], revealed Resident #1 was care planned for status as a Full Code/CPR with interventions to place Code Status on chart. Review of physician's orders [REDACTED]. Review of a computerized Nursing Progress Note, dated [DATE] at 6:55 AM (late entry for 5:50 AM) by Licensed Practical Nurse (LPN) #3 revealed Certified Nurse Aide (CNA) #2 notified him Resident #1 was not acting normal. LPN #3 went into the resident's room, asked the resident how he/she was feeling and the resident responded okay. LPN #3 documented the resident did not appear to be his/her normal self, and appeared zoned out. Further review revealed LPN #3 checked the resident's blood sugar (BS) which was two-hundred eighty-two (282), and rechecked it and it was three-hundred eleven (311). However, no time was documented for the recheck. LPN #3 charted the resident's vital signs were: Blood pressure (B/P): ,[DATE] (normal: 104-,[DATE]-86), respirations (R): ,[DATE] (normal: ,[DATE]), oxygen saturation (O2 sat): eighty percent (80%) on room air (normal: 95%), Pulse: 135 (normal ,[DATE]). Oxygen was applied at three (3) liters per minute nasal cannula. Further review revealed there was no documented evidence either nurse listened to the resident' lung sounds or offered a breathing treatment due to the resident's SOA per the resident's care plan. Review of a Nursing Note dated [DATE] at 5:50 AM by LPN #4 revealed LPN #3 called the resident's physician and Baptist emergency room (ER), and LPN #4 called Emergency Medical Services (EMS) around 5:55 AM. Review of a Nursing Note by LPN #4 dated [DATE], at 5:55 AM revealed CNA #2 was to remain with the resident. LPN #4 charted at 6:05 AM that she let EMS into the facility, and EMS went to the Hall 200. Further review revealed LPN #4 documented she was helping another resident at the dining room door and was called by CNA #2 to come to Resident #1's room. She stated upon entering the resident's room, EMS stated the resident did not look like (he/she) was breathing. Further review of the Progress Note revealed LPN#4 told EMS that the resident was a full code, then checked the resident's pulse, and called for the crash cart. LPN #2 from the 100 Hall retrieved the crash cart. LPNs #2 and #4 stated after EMS hooked up the heart monitor they got a faint heart beat and transferred the resident to the ambulance. However, interview with both EMT #1 on [DATE] at 8:35 AM and Paramedic #1 on [DATE] at 9:50 AM revealed Resident #1 never had a pulse or any organized heart rhythm on the monitor and they continued CPR as they went to the ambulance. LPN #4 charted she notified the Director of Nursing (DON) at 6:36 AM. Further review of the Nursing Notes, revealed there was no documented evidence any further assessments or monitoring of the resident to include vital signs were completed from 5:50 AM until 6:20 AM when Emergency Medical Service (EMS) arrived. Review of the Emergency Medical Services (EMS) ambulance run report dated [DATE], revealed EMS received the dispatch call from the facility at 6:11 AM not 5:50 AM per the Nurses' Note. EMS arrived at the facility at 6:18 AM, and was at Resident #1's bedside at 6:20 AM, not 6:05 AM, per Nurse's Note Interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 2:44 PM and on [DATE] at 1:30 PM, revealed when making regular rounds on [DATE] at 5:30 AM, she noticed Resident #1 did not seem like himself/herself, had a blank stare, was short of air (SOA), sweaty, and when asked if the resident wanted air turned on the resident stated Yes. CNA #2 stated she knew it was 5:30 AM, as she had just checked the clock in another resident's room close to Resident #1's room and this was her regular rounding schedule. CNA #2 revealed she notified LPN #3, who was in charge of that hall (Hall 200) of this change in the resident. She stated LPN #4, who had come over from Hall 300, came in the room with LPN #3 to check the resident. CNA #2 stated LPN #3 placed oxygen on the resident and instructed her to stay with the resident while the nurses went to make calls and do paperwork. She further revealed LPN #3 and the day shift nurse (LPN #1) went by the resident's door and said they were going to count narcotics and LPN #3 asked her one time how things were going, but she did not remember what time that was. She revealed she was right outside the resident's door the whole time because the nurses asked her to stay with the resident, but she did leave the room to go answer a call light as she was the only CNA on the hall. CNA #2 stated the other CNA that was working was sick and left at 3:00 AM and the resident who pressed the call light was prone to falls. She stated she left the room around the time EMS arrived. The CNA stated when EMS arrived, one of the EMS personnel (EMT #1) said to her that Resident #1 was not breathing and she went to get LPN #4, and told LPN #4, I need you now. CNA #2 stated when she went in room this time, the resident was unresponsive and pupils fixed and dilated and she knew the resident was gone. Interview with LPN #4 on [DATE] at 1:29 PM and LPN #3 on [DATE] at 1:55 PM, revealed upon assessing Resident #1, the resident was found to have SOA, was sweaty, with a heart rate (pulse) of 135, B/P of ,[DATE], O2 sat of 79% on room air, respiratory rate of 26, and blood sugar was 301. LPN #4 stated LPN #3 placed oxygen on the resident at three (3) liters per minute. LPN # 4 further revealed she was not aware the resident had breathing treatments ordered as she was not the resident's nurse. Interview with LPN #3 on [DATE] at 1:55 PM revealed he and LPN #1 went to the medication room at 6:10 AM to get report and count narcotics and came out of the room at 6:15 AM. Interview with LPN #3 on [DATE] at 11:03 AM, revealed it was 6:10 AM or 6:15 AM when he and LPN #1 went to the medication room. He stated when they came out it was 6:20 AM or 6:25 AM and EMS was in Resident #1's room and LPN #4 was doing CPR. LPN #3 revealed he could not remember if he or LPN #4 placed the O2 on the resident after assessing Resident #1 at 5:50 AM. He stated the resident's O2 sat increased to 83% after the O2 was applied. He revealed he and LPN #4 did provide any further care for Resident #1 related to the resident's low O2 sat level or provide the resident's physician ordered breathing treatment for [REDACTED]. Interview with both EMT #1 on [DATE] at 8:35 AM, and Paramedic #1 on [DATE] at 9:50 AM revealed when they entered the room Resident #1 was alone, was not responsive, not breathing, still warm to touch, and there was no oxygen. EMT #1 stated when he assessed the resident there was no pulse, and the resident's eyes were fixed and dilated. EMT #1 and Paramedic #1 further stated the time run report was correct, that they report to dispatch as soon as they leave the station with their mileage and, as soon as they arrive at the facility; and, the hospital and dispatch record the mileage and time. Interview with the Director of Nursing (DON) on [DATE] at 5:30 PM, revealed the nurses left CNA #2 with Resident #1 as they felt the resident was stable as he/she was talking to them. She stated monitoring was not a good word as staff cannot monitor residents ,[DATE]. The DON stated the nurses assessed the resident, and called the Physician, EMS, the hospital and family. She stated in regards to her expectations, she was not there that morning so could not really say. Further interview revealed Resident #1 had a history of [REDACTED]. She stated, No, a CNA cannot be responsible for 'monitoring' a resident but, can watch them. The DON stated she expected staff to follow the care plan. Continued interview with the DON revealed there was no documentation of any nurse physically checking on the resident or assessing the resident's V/S, or oxygen saturation, for thirty minutes after initially assessing the resident at 5:50 AM (per Nursing Notes) and finding the resident with abnormal V/S (low B/P, low O2 Sat., rapid HR), sweaty, shaky, and SOA. She stated she did not believe the times on the EMS run report and believed the times were incorrect. She stated she thought the EMS girls messed up and were trying to cover up. Further interview revealed when asked what she meant by that statement (above statement) she replied, Well I do not believe either of them were ACLS (Advanced Cardiac Life Support) trained and not even Paramedics. Interview with the Administrator on [DATE] at 5:45 PM, revealed the nurses did monitor the resident, called the ER, Physician, hospital and took the resident's V/S. She stated the nurses left CNA #2 with the resident as the resident was stable and had a history of [REDACTED]. She asked, How often you want them to check a resident? The Administartor stated, The resident was assessed at 5:50 AM and per Nurses' Notes was coded at 6:05 AM, that's just fifteen minutes. When the SSA (State Survey Agency) Surveyor brought to the Administrator's attention, that according to the EMS run report, the resident was coded after EMS arrived at 6:20 AM; and, per interview with staff and documentation, no further v/s, or assessment were done prior to the time of the code, the Administrator stated he did not believe the EMS run report was correct. He stated, We hire nurses and they are educated, we expect them to use their nursing judgement to best of their ability. He stated in regards to following/implementing the care plan, he expected staff to follow the care plan. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Licensed nurses, Social Services, and the Activities Director completed an audit on [DATE] of the care plans for all current residents to confirm that care plan interventions were in place as per the plan of care. Any concerns identified were corrected immediately. Licensed nurses completed an assessment of current residents and compared the assessment to the residents' care plans on [DATE] to identify a change in the resident's condition. The assessment included but, was not limited to vital signs, lungs sounds and oxygen saturation. 2. The Director of Nursing (DON) and Staff Development Coordinator (SDC) were re-educated on [DATE] by the Regional Quality Manager on Quality of Care as it related to following the resident's plan of care. Education included but, was not limited to monitoring residents during an acute change in condition, and the expectation that a nurse would stay at the resident's bedside and provide an ongoing assessment. A post-test was successfully completed to validate understanding of the education material provided. 3. The licensed nurses present during Resident #1's change in condition were re-educated by the DON and SDC on [DATE] on Quality of Care as it related to following the resident's plan of care. Education included but, was not limited to monitoring residents during an acute change of condition, implementing care plan interventions, and the expectation that a nurse stay at the resident's bedside and provide an ongoing assessment. A posttest was successfully completed to validate understanding of the education material provided. 4. Licensed nurses on duty on [DATE] and approximately 50% of all nurses were re-educated by the DON and SDC on [DATE] on following the resident's care plan. Educating included but, was not limited to, monitoring residents during an acute change in condition, implementing care plan interventions, and expectation that a nurse stay at the resident's bedside providing an ongoing assessment. A posttest was successfully completed to validate understanding of the education material provided. Licensed nurses working on [DATE] were re-educated on [DATE] by the DON and SDC on completing an assessment for a change in condition that would include but was not limited to; taking vital signs, lungs sounds, and oxygen saturations. A posttest was successfully completed. 5. The DON and SDC were educated on [DATE] by the Regional Quality Manager on completing an assessment for a change in condition that would include but was not limited to; taking vital signs, lungs sounds and oxygen saturations. A posttest was successfully completed. 6. Licensed nurses will not work at the facility until education and a successful posttest had been completed. Licensed nurses have been notified via phone of the citations and need for education and posttest completion prior to working again at the facility. A list of nurses educated is maintained by the SDC and DON. The education was for all licensed nurses on Quality of Care as it related to following the resident's plan of care. Education included but was not limited to, monitoring residents during an acute change of condition, completing an assessment for a change in condition that will include but not limited to; taking vital signs, lung sounds, and oxygen saturations; implementing care plan interventions, and the expectation that a nurse will remain at the resident's bedside and provide an ongoing assessment. A posttest was successfully completed 7. New hire licensed nurses will be educated during orientation to the requirements set forth in F659 Comprehensive Care Plan and implementing the interventions and F684 Quality of Care as it related to following the resident's plan of care. Education included but was not limited to monitoring a resident during an acute change of condition, implementing care plan interventions, the expectation that a nurse stay at the resident's bedside and providing ongoing assessment that will include but not be limited to vital signs, lung sounds, and oxygen saturation. A posttest will be successfully completed to validate understanding of the education material provided prior to working. The facility does not use agency staffing. 8. The DON, Unit Manager (UM) or designated licensed nurse, will complete an audit of ten (10) resident care plans weekly times four (4) weeks, monthly times two (2) months, and then quarterly to determine that interventions are implemented according to the plan of care by comparing the resident's care plan and observing the resident; and, comparing the resident's assessment to the care plan. Any concerns or change in condition identified will be corrected immediately and the physician notified. The results of the audit will be submitted to the Administrator when completed for review and submitted to the Quality Assurance Committee for further review and recommendations. 9. An Ad Hoc Quality Assurance meeting was held on [DATE] with the Administrator, DON, Regional Quality Manger, Unit Manager, Minimum Data Set (MDS) Director, Medical Records and Medical Director via phone to review the Office of Inspector General's IJ Notification and A[NAME]. A second Quality Assurance meeting was held on [DATE] with the Administrator, DON, Regional Quality Manager (RQM), Unit Manager, MDS Director, Social Services Director, Activity Director, Medical Records, and Medical Director to review results of the audits completed on [DATE] of care plans for current residents to determine that care plan interventions were in place, as per the plan of care. A third Quality Assurance (QA) meeting was held on [DATE] with the Administrator, DON, and Medical Director to review updates to the Allegation of Compliance (A[NAME]) that included an audit of resident assessment for change in condition and comparison of the resident's plan of care and licensed nurse education of completing an assessment that included but was not limited to taking vital signs, lung sounds, and oxygen saturations. A fourth QA meeting was held on [DATE] with the Administrator, DON, RQM, UM, MDS Director, Social Services Director, Activity Director, Medical Records, and Medical Director to review results of the assessment of current residents and compared the assessment to the resident's care plan completed by licensed nurses on [DATE]. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's audit of care plans for all current residents and review of assessments of current residents revealed a flow sheet was used with the resident's name, resident assessment compared to the plan of care, any change in condition identified, MD notified of any change in status, signature and title of person completing the Resident Care Plan. Observations were made for all residents on [DATE] by the DON. Interview with the Social Services Director (SSD) on [DATE] at 3:16 PM, revealed she helped with the audits of the Care Plans to ensure all were correct with appropriate interventions and that the care plans matched the resident. The SSD stated nursing staff compared residents with the nursing care plan and the CNA care plan to make sure everything on the care plans correlated with the resident and was in place. Interview with the Activity Director on [DATE] at 3:00 PM, revealed staff teamed up with the nurses to do audits on care plans and she had Hall 300. She stated she went over the residents' care plans and compared them with each resident, compared the nursing care plan to the care guide for CNA's to make sure they were accurate. She revealed she also went in rooms to physically see how the resident looked and to ensure all interventions on the care plan were in place. Interview with Unit Manager for day shift (8AM-4:30 PM) on [DATE] at 2:24 PM revealed she helped with audits of care plans to make sure that interventions were in place and followed. 2. Interview with the Staff Development Coordinator (SDC) on [DATE] at 3:11 PM and with the Director of Nursing (DON) on [DATE] at 3:20 PM revealed they were re-educated by the Regional Quality Manager (RQM) on [DATE] about care plan updating, and following the care plan. Both the DON and SDC stated the education included monitoring of residents during an acute change, and a nurse should stay at the resident's bedside and do an ongoing assessment including v/s, listening to lung sounds and checking oxygen saturation levels. They revealed they took a posttest to validate understanding. 3. Interviews on [DATE] with LPN #4 at 3:49 PM, LPN #2 at 4:04 PM, and LPN #3 at 4:15 PM revealed the DON and SDC educated them on following the care plan, and that if there was any change in the resident's condition, a nurse was to stay with the resident, not the CNA. They stated nurses were to assess residents more closely if there was a change in condition, to include monitoring of the resident's O2 sat, V/S, lung sounds, until the resident was transferred to hospital. They revealed they were educated if nebulizer treatments were ordered to administer them if the resident was SOA or their oxygen level was not coming up. In addition, they stated they should get an order to increase the oxygen or put a mask on if the resident was still SOA and/or his/her saturation was not coming up. The LPN's stated they could not work until they received the education and completed the posttest. 4. Review of inservice sheets revealed signatures of all staff attending education on care plan implementation and monitoring of residents for changes in condition, expectation that a nurse stay at the bedside for a resident with a change in condition. Review of the POS [REDACTED]. Review of in-service sheets revealed signatures of nurses completing education and posttest on [DATE]. Interviews on [DATE] with the Social Services Director (SSD) at 3:16 PM, Activity Director at 3:00 PM, Unit Manager at 2:24 PM, and LPN #6 at 2:14 PM, revealed they were educated on following the care plan, and that if there was any change in the resident's condition, a nurse was to stay with the resident, not the CNA. They stated nurses were to assess residents more closely for change in condition, to include monitoring of the resident's O2 sat, V/S, lung sounds, until the resident goes to hospital. Further interview revealed they were educated that if nebulizer treatments were ordered to administer them if the resident was SOA or his/her oxygen level was not coming up. In addition, they stated they should get an order to increase the oxygen or put a mask on if the resident was still SOA and/or their saturation was not coming up. Interview with CNA #5 on [DATE] at 2:37 PM revealed she was educated to tell the nurse of any change in condition of a resident. CNA #5 stated that the nurse should stay with an unstable resident. 5. Review of inservice sheets revealed signatures of the DON and SDC for completion of education with posttest on assessment for a change in condition including taking vital signs, listening to lung sounds, and checking oxygen saturations levels. Interviews on [DATE] with the SDC at 3:11 PM and DON at 3:20 PM revealed they received the education. 6. Review of signatures for nurses attending in-service and completing posttest revealed all staff had completed education and posttest except one (1) PRN staff member. 7. No new nurses have been hired. Documentation provided included of a list of all current employees. 8. Interview with the DON on [DATE] at 3:20 PM revealed she has been doing the audits and as of [DATE], all were completed for all residents and will continue to do the audit for ten (10) residents weekly for four (4) weeks, monthly times two (2) months, and then quarterly to ensure the care plans were being implemented correctly for each resident according to the resident's needs, observing and assessing residents to ensure the care plan correlates with the resident. Review of four (4) records revealed care plans had been updated with appropriate interventions. Assessments completed included v/s, lung sounds, oxygen saturation, and neurological status. Observations of these residents on [DATE] revealed the care plan correlated with the resident. Nursing Notes included documentation of v/s, lung sounds, and oxygen levels and if the resident was wearing oxygen or not. 9. Review of documentation of Quality Assurance meetings revealed they were held on [DATE] at 1:45 PM and 6:00 PM, on [DATE] and on [DATE] with those in attendance listed. Review of the [DATE] at 1:45 PM Ad Hoc meeting minutes revealed the facility reviewed the IJ notification and A[NAME]; and, at 6:00 PM, they reviewed the results of the audits of care plans for all current residents, completed on [DATE] to determine that the care plan interventions were in place. On [DATE], they reviewed an audit of resident assessment for change in condition and compared it to the resident's plan of care. Also reviewed licensed nurses' education of completing an assessment that includes but was not limited to taking vital signs, listening to lung sounds, and checking oxygen saturation. Interview with MDS Coordinator on [DATE] at 3:07 PM, revealed they had several Quality Assurance meetings in regards to care plans and monitoring residents for change in condition. Interview with Administrator on [DATE] at 4:45 PM revealed several Quality Assurance meetings were held to ensure measures put in place were ongoing and being monitored.

Based on interview, record review, and review of facility policy it was determined the facility failed to implement the care plan for one of three (3) sampled residents (Resident #1). The facility care planned to monitor Resident #1 for increased shortness of breath (SOB), dyspnea (difficulty in breathing), cyanosis or other signs/symptoms (s/s) of respiratory distress or cardiac distress. On [DATE] at 5:50 AM, the resident was found to be sweaty, had shortness of air (SOA) and the resident's vital signs were abnormal; however, the licensed staff failed to monitor the resident according to the resident's care plan. At 6:20 AM, Emergency Medical Services (EMS) arrived, and Resident #1 was found to be unresponsive, not breathing, with no pulse, and pupils fixed and dilated. CPR (Cardiopulmonary resuscitation) was initiated, the resident was transferred to the hospital with CPR in progress, and the code was called (ceased) at 7:14 AM by the emergency room Physician as the resident never responded nor regained a heartbeat. The facility's failure to ensure resident's received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Director of Nursing (DON) on [DATE] at 3:58 PM, revealed the facility id not have a policy on Care Plans. She stated they go by the Resident Assessment Instrument (RAI). Review of the Resident Assessment Instrument (RAI), Version 3.0, revealed the following related to the overall care plan orientation recommended by the Centers for Medicare and Medicaid (CMS): Managing risk factors to the extent possible, addressing ways to preserve and build upon resident strengths, prevent avoidable declines in functioning or functional level, evaluate care with measurable objectives, timetables, and care outcomes for the resident, assessing and planning care for the resident's medical, nursing, mental, and psychosocial needs, involve direct care staff with care planning process, address additional issues relevant to meeting the resident's needs. Furthermore, the Comprehensive Care Plan must describe the means by which a resident may attain or maintain his highest practicable physical, mental, and psychological wellbeing while receiving nursing home services. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review of the record revealed Resident #1 was a Full Code (wanted to receive Cardiopulmanary Resuscitation if found with no breath sounds or heartbeat). Review of a Comprehensive Care Plan for Resident #1 initiated on [DATE] revealed the facility care planned the resident for Potential for Alteration of circulation/oxygenation related to Hypertension, [MEDICAL CONDITIONS] of the Left Lung with interventions which included: medications/treatments as ordered, lung sounds per protocol, report any abnormal lung sounds, monitor for signs/symptoms of [MEDICAL CONDITION], monitor for increased shortness of breath (SOB), dyspnea (difficulty breathing), chest pain or other signs/symptoms (s/s) of cardiac distress and notify MD as needed, monitor for increased SOB, Dyspnea, cyanosis or other s/s respiratory distress and notify MD as needed. Review of physician's orders [REDACTED]. Review of a computerized Nursing Progress Note, dated [DATE] at 6:55 AM (late entry for 5:50 AM), and Nursing Notes dated [DATE] at 5:50 AM, and [DATE] at 5:55 AM, and interviews with Certified Nurse Aide (CNA) #2 on [DATE] at 2:44 PM and on [DATE] at 1:30 PM; LPN #4 on [DATE] at 1:29 PM and LPN #3 on [DATE] at 1:55 PM, revealed Certified Nurse Aide (CNA) #2 notified Licensed Practical Nurse (LPN) #3, revealed Resident #1 was acting abnormal. LPN #3 and LPN #4 assessed Resident #1 and identified the resident was sweaty, had shortness of air (SOA) and the resident's vital signs were: Blood pressure (B/P): ,[DATE] (normal: 104-,[DATE]-86), respirations (R): ,[DATE] (normal: ,[DATE]), oxygen saturation (O2 sat): eighty percent (80%) on room air (normal: 95%), Pulse: 135 (normal ,[DATE]). LPN #3 applied oxygen at three (3) liters per minute per nasal cannula. The LPN's asked CNA #2 to stay with the resident and the nurses called Emergency Medical Services. EMS arrived and when they entered Resident #1's room the resident was not breathing. Further review revealed LPN #3 was called to the room and she made EMS aware the resident was a full Code. CPR was initiated and continued as EMS left the facility. However, further review of these Nursing Notes and interviews with LPNs #3 and #4 revealed the licensed staff failed to listen to the resident's lung sounds, offer a breathing treatment due to the resident's SOB, and failed to provide ongoing monitoring of the resident related to the increased SOB, dyspnea, and abnormal vital signs, per the resident's care plan from 5:50 AM until 6:20 AM when EMS arrived (according to the EMS run report). Review of the Emergency Medical Services (EMS) ambulance run report dated [DATE] revealed EMS received the dispatch call from the facility at 6:11 AM, arrived at the facility at 6:18 AM, and was at Resident #1's bedside at 6:20 AM. Interview with Emergency Medical Technician #1 on [DATE] at 8:35 AM and Paramedic #1 on [DATE] at 9:50 AM revealed when they entered the room there was no staff in the room. Resident #1 was not responsive, not breathing, was still warm to touch, and there was no oxygen on the resident. They stated when they assessed the resident, the resident had no pulse and his/her eyes were fixed and dilated. Further interview revealed Resident #1 never had a pulse or any organized heart rhythm on the monitor, but they (EMS) continued CPR as they went to the ambulance. Interview with Director of Nursing on [DATE] at 5:30 PM revealed monitoring was not a good word as staff cannot monitor residents ,[DATE]. She stated she expected staff to follow the resident's care plan. Interview with the Administrator on [DATE] at 5:45 PM revealed he expected staff to follow the care plan. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Licensed nurses, Social Services, and the Activities Director completed an audit on [DATE] of the care plans for all current residents to confirm that care plan interventions were in place as per the plan of care. Any concerns identified were corrected immediately. Licensed nurses completed an assessment of current residents and compared the assessment to the residents' care plans on [DATE] to identify a change in the resident's condition. The assessment included but, was not limited to vital signs, lungs sounds and oxygen saturation. 2. The Director of Nursing (DON) and Staff Development Coordinator (SDC) were re-educated on [DATE] by the Regional Quality Manager on Quality of Care as it related to following the resident's plan of care. Education included but, was not limited to monitoring residents during an acute change in condition, and the expectation that a nurse would stay at the resident's bedside and provide an ongoing assessment. A post-test was successfully completed to validate understanding of the education material provided. 3. The licensed nurses present during Resident #1's change in condition were re-educated by the DON and SDC on [DATE] on Quality of Care as it related to following the resident's plan of care. Education included but, was not limited to monitoring residents during an acute change of condition, implementing care plan interventions, and the expectation that a nurse stay at the resident's bedside and provide an ongoing assessment. A posttest was successfully completed to validate understanding of the education material provided. 4. Licensed nurses on duty on [DATE] and approximately 50% of all nurses were re-educated by the DON and SDC on [DATE] on following the resident's care plan. Educating included but, was not limited to, monitoring residents during an acute change in condition, implementing care plan interventions, and expectation that a nurse stay at the resident's bedside providing an ongoing assessment. A posttest was successfully completed to validate understanding of the education material provided. Licensed nurses working on [DATE] were re-educated on [DATE] by the DON and SDC on completing an assessment for a change in condition that would include but was not limited to; taking vital signs, lungs sounds, and oxygen saturations. A posttest was successfully completed. 5. The DON and SDC were educated on [DATE] by the Regional Quality Manager on completing an assessment for a change in condition that would include but was not limited to; taking vital signs, lungs sounds and oxygen saturations. A posttest was successfully completed. 6. Licensed nurses will not work at the facility until education and a successful posttest had been completed. Licensed nurses have been notified via phone of the citations and need for education and posttest completion prior to working again at the facility. A list of nurses educated is maintained by the SDC and DON. The education was for all licensed nurses on Quality of Care as it related to following the resident's plan of care. Education included but was not limited to, monitoring residents during an acute change of condition, completing an assessment for a change in condition that will include but not limited to; taking vital signs, lung sounds, and oxygen saturations; implementing care plan interventions, and the expectation that a nurse will remain at the resident's bedside and provide an ongoing assessment. A posttest was successfully completed 7. New hire licensed nurses will be educated during orientation to the requirements set forth in F659 Comprehensive Care Plan and implementing the interventions and F684 Quality of Care as it related to following the resident's plan of care. Education included but was not limited to monitoring a resident during an acute change of condition, implementing care plan interventions, the expectation that a nurse stay at the resident's bedside and providing ongoing assessment that will include but not be limited to vital signs, lung sounds, and oxygen saturation. A posttest will be successfully completed to validate understanding of the education material provided prior to working. The facility does not use agency staffing. 8. The DON, Unit Manager (UM) or designated licensed nurse, will complete an audit of ten (10) resident care plans weekly times four (4) weeks, monthly times two (2) months, and then quarterly to determine that interventions are implemented according to the plan of care by comparing the resident's care plan and observing the resident; and, comparing the resident's assessment to the care plan. Any concerns or change in condition identified will be corrected immediately and the physician notified. The results of the audit will be submitted to the Administrator when completed for review and submitted to the Quality Assurance Committee for further review and recommendations. 9. An Ad Hoc Quality Assurance meeting was held on [DATE] with the Administrator, DON, Regional Quality Manger, Unit Manager, Minimum Data Set (MDS) Director, Medical Records and Medical Director via phone to review the Office of Inspector General's IJ Notification and A[NAME]. A second Quality Assurance meeting was held on [DATE] with the Administrator, DON, Regional Quality Manager (RQM), Unit Manager, MDS Director, Social Services Director, Activity Director, Medical Records, and Medical Director to review results of the audits completed on [DATE] of care plans for current residents to determine that care plan interventions were in place, as per the plan of care. A third Quality Assurance (QA) meeting was held on [DATE] with the Administrator, DON, and Medical Director to review updates to the Allegation of Compliance (A[NAME]) that included an audit of resident assessment for change in condition and comparison of the resident's plan of care and licensed nurse education of completing an assessment that included but was not limited to taking vital signs, lung sounds, and oxygen saturations. A fourth QA meeting was held on [DATE] with the Administrator, DON, RQM, UM, MDS Director, Social Services Director, Activity Director, Medical Records, and Medical Director to review results of the assessment of current residents and compared the assessment to the resident's care plan completed by licensed nurses on [DATE]. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's audit of care plans for all current residents and review of assessments of current residents revealed a flow sheet was used with the resident's name, resident assessment compared to the plan of care, any change in condition identified, MD notified of any change in status, signature and title of person completing the Resident Care Plan. Observations were made for all residents on [DATE] by the DON. Interview with the Social Services Director (SSD) on [DATE] at 3:16 PM, revealed she helped with the audits of the Care Plans to ensure all were correct with appropriate interventions and that the care plans matched the resident. The SSD stated nursing staff compared residents with the nursing care plan and the CNA care plan to make sure everything on the care plans correlated with the resident and was in place. Interview with the Activity Director on [DATE] at 3:00 PM, revealed staff teamed up with the nurses to do audits on care plans and she had Hall 300. She stated she went over the residents' care plans and compared them with each resident, compared the nursing care plan to the care guide for CNA's to make sure they were accurate. She revealed she also went in rooms to physically see how the resident looked and to ensure all interventions on the care plan were in place. Interview with Unit Manager for day shift (8AM-4:30 PM) on [DATE] at 2:24 PM revealed she helped with audits of care plans to make sure that interventions were in place and followed. 2. Interview with the Staff Development Coordinator (SDC) on [DATE] at 3:11 PM and with the Director of Nursing (DON) on [DATE] at 3:20 PM revealed they were re-educated by the Regional Quality Manager (RQM) on [DATE] about care plan updating, and following the care plan. Both the DON and SDC stated the education included monitoring of residents during an acute change, and a nurse should stay at the resident's bedside and do an ongoing assessment including v/s, listening to lung sounds and checking oxygen saturation levels. They revealed they took a posttest to validate understanding. 3. Interviews on [DATE] with LPN #4 at 3:49 PM, LPN #2 at 4:04 PM, and LPN #3 at 4:15 PM revealed the DON and SDC educated them on following the care plan, and that if there was any change in the resident's condition, a nurse was to stay with the resident, not the CNA. They stated nurses were to assess residents more closely if there was a change in condition, to include monitoring of the resident's O2 sat, V/S, lung sounds, until the resident was transferred to hospital. They revealed they were educated if nebulizer treatments were ordered to administer them if the resident was SOA or their oxygen level was not coming up. In addition, they stated they should get an order to increase the oxygen or put a mask on if the resident was still SOA and/or his/her saturation was not coming up. The LPN's stated they could not work until they received the education and completed the posttest. 4. Review of inservice sheets revealed signatures of all staff attending education on care plan implementation and monitoring of residents for changes in condition, expectation that a nurse stay at the bedside for a resident with a change in condition. Review of the POS [REDACTED]. Review of in-service sheets revealed signatures of nurses completing education and posttest on [DATE]. Interviews on [DATE] with the Social Services Director (SSD) at 3:16 PM, Activity Director at 3:00 PM, Unit Manager at 2:24 PM, and LPN #6 at 2:14 PM, revealed they were educated on following the care plan, and that if there was any change in the resident's condition, a nurse was to stay with the resident, not the CNA. They stated nurses were to assess residents more closely for change in condition, to include monitoring of the resident's O2 sat, V/S, lung sounds, until the resident goes to hospital. Further interview revealed they were educated that if nebulizer treatments were ordered to administer them if the resident was SOA or his/her oxygen level was not coming up. In addition, they stated they should get an order to increase the oxygen or put a mask on if the resident was still SOA and/or their saturation was not coming up. Interview with CNA #5 on [DATE] at 2:37 PM revealed she was educated to tell the nurse of any change in condition of a resident. CNA #5 stated that the nurse should stay with an unstable resident. 5. Review of inservice sheets revealed signatures of the DON and SDC for completion of education with posttest on assessment for a change in condition including taking vital signs, listening to lung sounds, and checking oxygen saturations levels. Interviews on [DATE] with the SDC at 3:11 PM and DON at 3:20 PM revealed they received the education. 6. Review of signatures for nurses attending in-service and completing posttest revealed all staff had completed education and posttest except one (1) PRN staff member. 7. No new nurses have been hired. Documentation provided included of a list of all current employees. 8. Interview with the DON on [DATE] at 3:20 PM revealed she has been doing the audits and as of [DATE], all were completed for all residents and will continue to do the audit for ten (10) residents weekly for four (4) weeks, monthly times two (2) months, and then quarterly to ensure the care plans were being implemented correctly for each resident according to the resident's needs, observing and assessing residents to ensure the care plan correlates with the resident. Review of four (4) records revealed care plans had been updated with appropriate interventions. Assessments completed included v/s, lung sounds, oxygen saturation, and neurological status. Observations of these residents on [DATE] revealed the care plan correlated with the resident. Nursing Notes included documentation of v/s, lung sounds, and oxygen levels and if the resident was wearing oxygen or not. 9. Review of documentation of Quality Assurance meetings revealed they were held on [DATE] at 1:45 PM and 6:00 PM, on [DATE] and on [DATE] with those in attendance listed. Review of the [DATE] at 1:45 PM Ad Hoc meeting minutes revealed the facility reviewed the IJ notification and A[NAME]; and, at 6:00 PM, they reviewed the results of the audits of care plans for all current residents, completed on [DATE] to determine that the care plan interventions were in place. On [DATE], they reviewed an audit of resident assessment for change in condition and compared it to the resident's plan of care. Also reviewed licensed nurses' education of completing an assessment that includes but was not limited to taking vital signs, listening to lung sounds, and checking oxygen saturation. Interview with MDS Coordinator on [DATE] at 3:07 PM, revealed they had several Quality Assurance meetings in regards to care plans and monitoring residents for change in condition. Interview with Administrator on [DATE] at 4:45 PM revealed several Quality Assurance meetings were held to ensure measures put in place were ongoing and being monitored.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure staff were knowledgeable related to the facility's policies and procedures and equipment protocol for the wanderguards/transmitters (a band worn around the resident's ankle to alert staff if a resident was trying to exit an exterior door). The facility's failure to ensure staff were educated on the facility's policies and procedures related to performing an elopement assessment to determine the root cause of the exit seeking behavior and/or elopement, put interventions in place, and then updating the care plan with the new interventions and communicated to staff to reduce the risk of elopements for residents exit seeking or who have eloped has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/29/18 and determined to exist on 04/19/18. The facility was notified of the Immediate Jeopardy on 05/29/18. An acceptable Allegation of Compliance (AoC) was received on 06/04/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 05/30/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Elopement Protocol, dated 08/15, revealed in the event of elopement or onset of exit seeking behaviors the nurse will complete the Elopement/Wandering Risk Data Set, put interventions in place to reduce the risk of elopement, update the resident's Care Plan and communicate to staff. The Elopement book, which contains residents who are identified at risk for elopement and wandering, is available twenty-four (24) hours a day at a designated place as determined by the facility. Review of the Alarm System Manufacturer's Guidelines, dated 12/11/17, revealed each transmitter should be tested daily to ensure the transmitter was working properly, and during this time the expiration date should be checked as well. A post survey interview with the Administrator, on 06/28/18 at 5:00 PM, revealed there were eight (8) residents at risk for wandering. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED].(YEAR) physician's orders [REDACTED]. Further review revealed Resident #1 exited the building on 05/05/18; however, an Elopement Assessment was not completed until two (2) days later and the care plan was not updated. Resident #1 exited the building again on 05/09/18 and went into the road without staff's knowledge. Furthermore, the care plan was not updated with new interventions to reduce the risk of elopement. Review of Resident #2's record revealed the resident exited the building on 04/19/18 without staff knowledge and an Elopement Assessment nor the care plan was updated with new interventions to reduce the risk of elopement. Interview with Licensed Practical Nurse (LPN) #7, a new nurse graduate, on 05/24/18 at 10:16 AM, revealed she received no training on elopement or what to do if a resident was trying to elope when she started, about a month ago. She stated she was told by the Staff Development Coordinator (SDC) to read a paper, but she could not find the paper to read over elopement. LPN #7 stated she was not aware she should complete an Elopement/Wandering Risk Data Set and she did not know what that assessment was or what an elopement meant. She stated she had not received any education on the care plan,or who was responsible for updating them. Interview, at 1:05 PM, revealed she was not aware of any residents that were at risk for elopement when she started work at the facility. She stated she was not aware there was a book at the desk which listed the residents at risk for eloping. LPN #7 further stated since she was told in report of Resident #1's behaviors of wandering and that he/she had gotten out of the building a couple of days before and to keep a close eye on the resident. She stated she made a nursing judgement and put him/her on every twenty (20) minutes, but no later then thirty (30) minutes. She stated she was just doing the checks herself and had not communicated that information to her staff on the floor. Interview with LPN #1, an agency nurse, on 05/24/18 at 1:13 PM, revealed when he was hired he did not know the residents who were at risk for elopement and received no training on elopement. He stated the nurses do not take care of updating the care plan. LPN #1 stated he had not received training on the care plan. He stated there was not much training for agency nurses. Interview with LPN #8, who is an agency nurse, on 05/26/18 at 9:50 PM, revealed when she started working at the facility on 04/20/18, she was not trained much on anything and was not trained on elopement on hire. She stated she was placed to work the floor the same day she was hired. She further stated she went to the office over the lack of education. The LPN stated she . did not like being turned over to the wolves. LPN #8 stated the Director of Nursing (DON) informed her that the recruiter stated, You (LPN #8) would be ready to hit the floor when you arrived to work. She stated she was not aware of which residents were at risk for elopement when she started working and she was not aware of a book at the desk with residents' names and picture, who were at risk for elopement. LPN #8 stated she had not received any kind of education on updating the care plan or the Elopement/Wandering Risk Data Sets and she was not aware, (as of this date) what that assessment was. Interview, on 05/26/18 at 10:21 PM, revealed she did not know much about care plans as she seemed to mostly pass pills. She further stated her main job as a nurse was to get medications passed. Interview with LPN #9, on 05/28/18 at 9:56 PM, who is also an agency nurse, revealed when she started work on 05/01/18, she was never oriented by anyone on the floor. She stated she was told there was a book at the desk of residents at risk for elopement. She further stated the MDS Nurses updated the care plans, as she was not told anything about updating the care plan when she started working. She stated she was not aware of what an Elopement/Wander Risk Data Set was used for or when to complete it. Interview with the Minimum Data Set (MDS) Coordinator, on 05/24/18 at 3:30 PM, revealed the nurses should update the care plan when residents exhibited exit seeking behaviors. They should communicate new interventions to the floor staff and oncoming shift. She stated the Director of Nursing, (DON) was responsible to ensure that was done. She stated the care plan should not wait to be updated until the MDS Coordinator came in to work. However, she stated she was the primary person who updated the care plan. Interview, on 05/29/18 at 10:53 AM, revealed the nurses on the floor should have updated the care plan on 04/19/18 when Resident #2 eloped. However, the elopement assessment updating the care plan was not covered in orientation. She stated the nurse should have performed an Elopement/Wandering Risk Data Set and applied new interventions as indicated and updated the care plan. She stated if a resident eloped, there should be a new intervention put into place. Interview, on 05/31/18 at 3:57 PM, revealed she was not aware of what interventions were put into place after Resident #2 eloped on 04/19/18 if not placed on the care plan. Interview with Regional Reimbursement Nurse, on 05/23/18 at 4:03 PM, revealed wanderguards/transmitters were checked for functioning every week but were changing the orders today to reflect to check every day. Interview, on 05/24/18 at 5:45 PM, revealed the Interim DON was responsible to ensure communication to her staff and follow the policy. She stated the facility provided an inservice on the elopement policy after the incident on 04/19/18, but it did not include the Wandering/Elopement Risk Data Sets or care planning. Interview with the Staff Development Coordinator (SDC), on 05/24/18 at 4:05 PM, revealed the DON was responsible to communicate to staff if the resident was on one (1) to one (1) or on any checks. She stated the DON never came to her requesting she educate staff of any new interventions. She further stated the nurses were responsible to update the care plan for new interventions. The SDC stated the care plans were reviewed in morning meeting; therefore, unless MDS Coordinator came in on the weekend, the care plan was not reviewed until Monday. She stated LPN #7 was responsible to update Resident #1's and #2's care plan. She stated staff were inserviced on the Elopement policy after the 05/09/18 elopement; however, updating the care plan and performing an Elopement/Wandering Risk Data Set for residents that were exit seeking or have eloped was not discussed, although that was part of the policy. She stated she would start inservicing nursing staff of the Elopement/Wandering Risk Data Sets and updating the care plan per the policy. Interview with the Interim DON, on 05/24/18 at 1:40 PM, revealed she expected, according to the facility's Elopement Policy, for the care plan to be updated with new interventions with a resident who is exit seeking, or have eloped. She further stated there were a lot of agency staff in the building now and they had not received much training before starting work, just paperwork and a tour of the facility. She stated MDS updated the care plan Monday thru Friday, but over the weekend the care plan should be updated when an event occurred, not wait until MDS Coordinator updated it on Monday. She stated she expected an Elopement/Wandering Risk Data Set to be completed when a resident had exit seeking behaviors or eloped, as she expected one completed on 04/19/18 on Resident #2. Interview, at 3:33 PM, revealed she gave the SDC instructions to put out a communication to the staff for new interventions for Resident #1. She stated the care plan should have had the interventions put in place for both residents. Interview, on 05/25/18 at 12:18 PM, revealed the nurse should have completed an Elopement/Wandering Risk Data Set on Resident #2 when he/she eloped to assist with new interventions. Interview with the Administrator, on 05/24/18 at 1:45 PM, revealed if the policy stated to perform an Elopement/Wandering Risk Data Set, then he expected one to be completed when a resident was exit seeking. He stated the Elopement book had always been at the desk. The Administrator stated the nurses should have communicated that information to the staff. He stated the MDS staff were responsible to update the care plan, but any nurse could update the care plan. He further stated he remembered in morning meeting the care plan needed to be updated. A post survey interview with the Administrator, on 06/28/18 at 5:00 PM, revealed every agency staff was pre-screened and goes through orientation and a tour of the facility. He stated the SDC goes over everything with the new employees, to include the agency staff. He revealed, that on 04/19/18, there was one (1) agency CNA and the remainder was their own facility staff, which was sixteen (16) percent agency staff. Additionally, he stated, that on 05/05/18, starting at 6:00 AM through 6:00 AM the next morning, there were four (4) agency CNA's and one (1) agency Nurse, which was thirty-five (35) percent agency staff; and on 05/09/18, starting at 6:00 AM through 6:00 AM the next morning, there was one (1) agency CNA and three (3) agency Nurses, which was eleven (11) percent agency staff. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 05/22/18, Resident #1 was discharged from the facility. Resident #2 remains at the facility with no further incidents of elopements. Supervision of residents identified at risk for elopement starts with completion of the elopement assessments to indicate risk, identify the need for transmitter/wanderguard placement which would allow for alarming if the resident was to attempt to exit the facility exterior access door, and assist in defining appropriate care plan interventions. Daily interaction and visual observation determines if the elopement plan of care interventions are appropriate or if there would be a need for plan modifications. 2. On 05/29/18, an Ad Hoc Quality Assurance (QA) meeting was held to discuss the Immediate Jeopardy (IJ) allegation and develop an action plan. Attendees included the Administrator, DON, MDS Coordinator, Activity Director, Medical Records, and Dietary Manager. The Administrator corresponded with the Medical Director via phone on this date to review the IJ cited and, plan for the development of the immediate action items to be initiated. 3. On 05/22/18, the Door Alarm Service provider was on-site to evaluate a potential issue with front entrance door not functioning/signaling properly with the wanderguard bracelet. The key pad to the front entrance was replaced and the signal strength was increased to four (4) to five (5) feet. The antenna strength was also adjusted for the side door entrance. All doors were tested by the vendor with the Maintenance Supervisor. The vendor reported that all doors were in proper working order at time of his departure. 4. All resident transmitters/wanderguards were checked for placement and function on 05/10/18, 05/24/18, and 05/25/18 by Unit Managers and or Charge Nurses. No issues were identified. 5. Elopement Assessments for all residents identified as being at risk for elopement were audited for accuracy. Care plans were reviewed by the Unit Managers and/or Charge Nurse on 05/10/18, 05/11/18, 05/15/18, and 05/25/18. No issues were noted. 6. The MAR indicated [REDACTED]. 7. On 05/10/18, the SDC and Business Office Manager (BOM) were educated by the Regional Reimbursement Nurse on the facility's elopement protocols to include reporting exit seeking behavior to the Administrator/DON immediately, even if the resident has a transmitter/wanderguard to determine immediate interventions; elopement attempts and exit seeking behaviors; and, documenting exit seeking behavior on the 24 Hour Nursing Report. This education was then provided to all facility staff by the SDC and BOM and completed by 05/15/18. 8. On 05/29/18, licensed nurses, including agency nurses, were educated by the DON and SDC in regards to updating the care plan related to elopement/exit seeking behavior, updating risk assessments with any new event, and review residents at-risk for wandering/exit seeking behaviors as identified in the Elopement Book located at each nurses' station. After 05/29/18, any licensed nurse, including agency, that did not receive the education will not be permitted to assume duties until first receiving the education. Understanding of the education was validated through post education instructor led discussion regarding education provided. 9. On 05//10/18, the Administrator provided education to the Maintenance Director on how to best test for alarm sensitivity during the internal weekly audits. This included placement of a transmitter/wanderguard unit in a shoe and closely follow someone out the door. 10. On 05/24/18, the education was provided to the Maintenance Director by the Administrator in regard to expected door functioning, wanderguard/alarm system functioning, appropriate testing procedures for system/locks, as well as timely notification to the Administrator of any identified concerns. 11. On 05/24/18, the DON was in-serviced by the Regional Reimbursement Nurse in regard to following policies and communicating updated care plan interventions to staff; including behaviors, incidents, and wandering/exit seeking/elopement. 12. On 05/10/18, initial elopement drills were completed on all three (3) shifts. Timed Door Alarm Response Drills were completed by the Regional Director of Operations and/or Regional Reimbursement Nurse on 05/15/18, 05/17/18, 05/22/18, and 05/24/18. Elopement drills will continue a minimum of once weekly for three (3) months, in addition to Timed Door Alarm Response Drills a minimum of once weekly for three (3) months. If no issues, the facility will then resume a minimum of once monthly/rotating shift on an on-going basis. 13. Beginning 05/10/18, the DON and/or Unit Managers will audit the 24 Hour Reports and Nurses' Notes in the morning clinical meetings Monday through Friday for documentation of exit seeking behaviors to ensure that all follow-up actions were implemented such as elopement assessment, wander guard placement, documentation, and care planning. A Manager on-Duty is on-site on weekends and available to review documentation of exit seeking behavior. In addition the 24 Hour Reports, Friday through Sunday are reviewed during the Monday clinical meetings. 14. Effective 05/29/18, any residents exhibiting exit seeking behavior will have an updated elopement assessment completed by licensed nurse to assist in identifying root cause and determine interventions that may need to be included in the plan of care. 15. A QA meeting will be held a minimum of weekly until substantial compliance is achieved and monthly thereafter. In addition, to the facility QA team, a member of the Regional Team (Regional Director of Operations, Regional Reimbursement Nurse, and/or Regulatory Liaison) will be in attendance for the weekly QA Meeting. This team includes at a minimum the Administrator, DON, SDC, MDS Coordinator, Unit Managers, BOM, with Medical Director at least quarterly. 16. Beginning 05/29/18, all exterior doors (7) will be assessed by the Administrator, Maintenance Director and/or assigned department manager to ensure proper functioning and alarming in conjunction with the wanderguard bracelet/system. This audit will be completed daily for two (2) weeks, then a minimum of three (3) times per week for four (4) weeks. If no concerns are identified, then the facility will resume with the regularly scheduled weekly schedule. 17. Beginning 05/29/18, the DON and/or Unit Manager will review all elopement assessments and corresponding care plans for identified at-risk residents, a minimum of three (3) times per week for two (2) weeks, then weekly for two (2) weeks. 18. Audits will be reviewed at a minimum of weekly at the weekly QA meeting with a member of the Regional team in attendance for review and any needed recommendation, until compliance is achieved. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's chart revealed the resident was discharged to another facility on 05/22/18. Observation on 06/11/18 revealed Resident #2 was on one to one (1:1) observation. Review of Resident #2's care plan revealed Resident #2 had been on one to one (1:1) supervision since 05/24/18. Interview with the Administrator, on 06/11/18 at 10:30 AM, revealed Resident #1 was discharged to a secure unit on 05/22/18. Resident #2 was making comments of wanting to go home on 05/24/18 and he decided to put Resident #2 on one (1:1) supervision while the facility looked into alternate placement of a secured unit. He stated the staff follow the Elopement Policy for the supervision of residents identified at risk for elopement which includes an elopement assessment to indicate risk. Staff would assist in defining appropriate care plan interventions and identify the need for a transmitter/wanderguard which would alarm if the resident attempted to exit the facility exterior access door. He stated the daily interaction and observation of residents would also determine if the elopement plan of care interventions were appropriate or if there was a need for modifications. 2. Review of the AdHoc QA meeting held on 05/29/18, revealed the members, which included the Administrator, DON, Unit Managers, Director of Rehabilitation, Admissions Director, BOM, Activity Director, Medical Records, and Dietary Manager discussed the IJ allegations, elopement policy, and developed an action plan. The Medical Director was in attendance via phone. Interviews with the SDC (interim DON) on 06/11/18 at 5:15 PM, the BOM on 06/12/18 at 9:49 AM, Unit Manager of 200 Hall at 10:00 AM, prior Unit Manager of 100 Hall at 10:19 AM, and Director of Rehabilitation at 11:20 AM, revealed they were present for the 05/29/18 meeting and discussed the IJ's. Further interview revealed they developed a plan of action which included education, elopement assessments, orders to meet manufacture's guidelines, and updating care plans. 3. Review of the Door Alarm Service provider Field Work Order, dated 05/22/18 with departure time of 11:00 PM revealed the front door signal was minimal and the keypad was replaced. The signal strength was increased to four (4) to five (5) feet. In addition, the provider adjusted the side door antenna strength and tested all doors with maintenance. Doors were in proper working order at the time of departure. Interview with the Maintenance Director, on 06/12/18 at 12:03 PM, revealed, on 05/22/18, all doors were checked by the Door Alarm Service provider and they all alarmed as they should before the technician left the building. 4. Review of list of residents with transmitters/wanderguards, dated 05/10/18, 05/24/18, and 05/25/18, revealed the DON and Unit Manager of the 100 Hall checked all wanderguards for placement and function. Interview with the prior 100 Hall Unit Manager, on 06/12/18 at 10:19 AM, revealed she checked all the transmitters/wanderguards in the building on 05/10/18, 05/24/18, and 05/25/18 to ensure they were all working and functioning properly. 5. Review of Action Plan completed by the Regional Reimbursement Nurse revealed, on 05/10-11/18 and 05/15/18, they validated each identified resident had a current elopement assessment; their care plan had been updated to reflect their elopement risk status; and, each resident identified had a current photo and face sheet in the elopement book. Review of the facility's Allegation of Compliance (AoC) binder revealed all residents identified at risk for elopement had their care plans and Elopement Assessments audited and updated on 05/25/18. Interview, on 06/12/18 at 10:00 AM, with the Unit Manager of the 200 Hall and interview with the prior Unit Manager of the 100 Hall, at 10:19 AM, revealed they reviewed and updated the care plans, if needed for residents at risk for elopement and performed Elopement Assessments on all at risk residents on 05/25/18. 6. Review of the facility AoC binder revealed all residents with wanderguards that were at risk for elopement had their MAR's/orders updated on 05/24/18 to reflect the Manufacture's Guidelines to Check the wanderguard function and expiration daily by the Unit Managers. Interview, on 06/12/18 at 10:00 AM, with the Unit Manager of 200 Hall and interview with prior Unit Manager of 100 Hall, at 10:19 AM, revealed they changed all the orders for the residents with transmitters/wanderguards to reflect the Manufacture Guidelines to check the transmitter/wanderguard function and expiration daily on 05/24/18. 7. Review of education on elopement protocol on 05/10/18 revealed the BOM, Assistant BOM, and SDC was educated by the Regional Reimbursement Nurse. Interview with the SDC (interim DON), on 06/11/18 at 5:15 PM, and the BOM on 06/12/18 at 9:49 AM, revealed they received education from the Regional Reimbursement Nurse, on 05/10/18, prior to educating staff on the Elopement Protocol which included updating the care plan if exit seeking, communicating interventions to staff, elopement assessment completed after exit seeking attempts, and staff checking doors and looking both ways when the door is alarming before shutting off alarm. Review of In-Service Record, dated 05/10/18, 05/14/18 and 05/15/18, provided by the BOM, Assistant BOM, Administrator, and SDC revealed all but three (3) staff were inserviced by 05/15/18 on the Elopement Protocol. Interview with LPN #6, on 06/11/18 at 11:20 AM, revealed she was inserviced by the SDC earlier in (MONTH) about updating the care plan for residents wandering and updating the elopement assessment when a resident exhibited exit seeking behaviors. Interview with Cook #1, on 06/12/18 at 11:04 AM, revealed she was inserviced about elopement several weeks ago. The inservice was provided by the BOM. It included information related to if a door alarm goes off to look both ways and if a resident is seen going outside bring the resident in and report to the charge nurse. Interview with Housekeeper #1, at 11:11 AM, revealed he was inserviced by the Administrator in (MONTH) about the code for a resident elopement and if door alarm was sounding go out the door and look both ways before turning off the alarm. Interview with CNA #8, on 06/11/18 at 10:47 AM, revealed she received an inservice a couple weeks ago on elopement, presented by the SDC, on how to respond to a door alarm by looking both ways before shutting off alarm. 8. Review of In-Service Record, dated 05/29/18, revealed all nurses were educated by the SDC in regard to updating the Elopement Assessment per policy for exit seeking and elopement behaviors, updating the care plan with interventions, providing adequate supervision which can include fifteen (15) minute checks or one to one (1:1), and the manufacture guideline for checking the function of the transmitter/wanderguard bracelet. Interview with LPN #5, on 06/11/18 at 11:10 AM, revealed she received an inservice about two (2) weeks ago on elopement which included the elopement assessment, the nurses responsible to update the care plan if an event of wandering or elopement occurs, and providing supervision. Interview with LPN #6, on 06/11/18 at 11:20 AM, revealed she had received inservices on elopement for the past month, but there was a special inservice for nurses related to nurses updating the care plan for elopements, updating the elopement assessment, notifying the DON, Administrator, Physician, and Responsible Party if an elopement or a resident was exit seeking. She further stated in the Elopement Book at the desk there was now a list of how to write the order for the wanderguard with the function check every day, as well as how to do an Elopement Assessment. She stated the Department Heads go around asking questions about elopement to see if they recalled. Interview with LPN #2 and the Unit Manager of the 200 Hall, on 06/12/18 at 10:00 AM, revealed she was inserviced by the SDC on the Elopement Policy. Interview with LPN #10, on 06/11/18 at 10:48 AM, revealed she had started two (2) days ago and had orientation before working the floor. Information covered included explaining the elopement policy, resident's at risk in a book at the desk, explanation on how to do an elopement assessment for someone wandering or eloped, and how to write the wanderguard order. Furthermore, she stated the transmitters/wanderguards were checked daily. She stated the nurses were responsible to update the care plan with interventions on the paper copy and the MDS Coordinator would update the information in the computer. 9. Review of the facility provided inservice, dated 05/10/18, revealed the Maintenance Director was inserviced by the Administrator on placing the wanderguard in his shoe to simulate a resident during weekly door checks. Interview with the Maintenance Director, on 06/12/18 at 12:03 PM, revealed, on 05/10/18, the Administrator educated him on placing the transmitter/wanderguard in his shoe for alarm sensitivity for the weekly door testing. 10. Review of 05/24/18 inservice, dated 05/24/18, revealed the Maintenance Director was inserviced by the Administrator for testing the exterior doors according to the company policy including the testing procedure for locks and testing operations, informing the Administrator with any issues of the doors, expected door functioning, and transmitter/wanderguard functioning. Interview with the Maintenance Director, on 06/12/18 at 12:03 PM, revealed he received education on 05/24/18 from the Administrator on the Elopement Policy, door checks and how the door was to alarm with the wanderguard, simulating a resident with a wanderguard by continuing to place in his shoe, and notification to the Administrator immediately if there was an issue with the door. He further stated if a door was not functioning properly someone would guard the door until it was repaired. 11. Review of 05/24/18 inservice revealed the DON was inserviced by the Regional Reimbursement Nurse on following policies, communicating changes to staff, updating the care plan with new interventions in regards to residents' behaviors, wandering, and elopement. Interview with the SDC (interim DON), on 06/11/18 at 5:15 PM, revealed she was trained by the Regional Reimbursement Nurse on the elopement policy, updating the care plan for new interventions related to resident behaviors, incidents, wandering/exit seeking/elopement and communicating the information to the staff. 12. Review of elopement drills, dated 05/10/18, with staff signatures revealed drills were completed on all three (3) shifts. Review of the Timed Door Alarm Response Drills were conducted by a Regional Team member on 05/15/18, 05/17/18, 05/22/18, and 05/24/18. Interview with CNA #8, on 06/11/18 at 10:47 AM, LPN #2 and the Unit Manager of the 200 Hall on 06/12/18 at 10:00 AM, Unit Manager for 100 hall at 10:19 AM, Cook #1 at 11:04 AM, Housekeeper #1 at 11:11 AM, LPN #5 at 11:10 AM, revealed they were receiving elopement drills at least weekly. They also stated they checked the alarms by pushing on a door causing it to alarm and see how long it would take for staff to respond at least weekly. 13. Review of the facility AoC binder revealed daily audits of the 24 Hour Report book and Nurse's Notes performed by the DON and/or Unit Managers for documentation of exit seeking behaviors Monday through Friday. A facility provided list revealed a Manager on Duty would be available for weekend reviews for any exit seeking behaviors. Interview with the Administrator, on 06/11/18 at 3:00 PM, revealed all Department Heads alternated weekends. Their duty during that time included checking the doors, questioning staff regarding any issues, and notifying the Administrator with concerns. Interview on 06/11/18 at 5:15 PM, with the SDC (interim DON) and interview on 06/12/18 with Unit Manager of 100 Hall at 10:19 AM, Unit Manager of 200 Hall at 10:00 AM, revealed prior to the clinical morning meeting the Unit Managers and the DON reviewed the Nurse's Notes and the 24 Hour Report book for any changes such as wandering/exit seeking. If any behaviors/changes were found then they would proceed to review the assessments and care plans to ensure a process was in place. They stated on the weekend the Department Manager, would check the doors to ensure they were alarming, as well as talk with staff to ensure no resident was exhibiting exit seeking or wandering behaviors. Furthermore, they would review the 24 Hour Report book for any changes noted. In addition, a phone call would be made to the Administrator. 14. Review of Unsampled A, who was exhibiting exit seeking behaviors on 06/08/18, revealed an elopement assessment was updated and interventions included on the care plan. Interview with the SDC (interim DON), on 06/11/18 at 5:00 PM, revealed a resident was exhibiting exit seeking behaviors on 06/08/18 and the elopement assessment was updated, as well as interventions included on the care plan on 06/08/18. She stated no other resident had exhibited exit seeking behaviors since 05/25/18. 15. Review of the QA meetings revealed the facility has met weekly on 05/29/18, 05/31/18, and 06/07/18 with a Regional Team member present at each meeting. In addition, the team included the Administrator, DON, SDC (in (TRUNCATED)

Based on observation, interview, record review, review of the facility's investigation, facility policy review, and review of the alarm manufacturer's guidelines, it was determined the facility failed to provide adequate supervision to prevent accidents for two (2) of three (3) sampled residents (Residents #1 and #2). On 04/19/18, Resident #2 exited the building without staff's knowledge. The facility failed to identify staff did not hear the alarm and failed to reassess Resident #2 for elopement risk. On 05/05/18, Resident #1 exited the building behind staff. Staff shut the exterior door and the resident continued to press on the exterior door and the door opened without staff knowledge. The facility failed to reassess the resident's risk for elopement at that time. The assessment was not completed until two (2) days later on 05/07/18. On 05/09/18, Resident #1 exited the building without staff's knowledge or staff hearing the alarm. The resident was found in the road approximately 200 feet from the facility on a two lane busy street. However, the facility failed to identify staff were unable to hear the alarm when they were not on the hall, and when they were in residents' rooms providing care. In addition, the facility failed to follow the manufacturer's guidelines related to testing the transmitter (wanderguard) for proper operation on a daily basis to ensure the transmitter/wanderguard was working properly. They also failed to check for the expiration date of the alarm at that time. While testing the doors with the Maintenance Director, on 05/22/18 at 4:15 PM, the front door did not alarm or lock down when the door code was pressed and a transmitter/wanderguard was within two (2) to three (3) feet away. The wanderguard device was able to continue to go out the door without any type of alarming. However, the exterior doors should alarm and lock down if a transmitter/wanderguard was within two (2) to three (3) feet of the door. The facility's failure to ensure adequate supervision was provided to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/29/18 and determined to exist on 04/19/18. The facility was notified of the Immediate Jeopardy on 05/29/18. An acceptable Allegation of Compliance (AoC) was received on 06/04/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 05/30/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Elopement Protocol, dated (MONTH) (YEAR), revealed elopement is the ability of a resident who is not capable of protecting himself/herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. Any residents with a change in condition including elopement attempts or exit seeking behavior will be reassessed for the need of further intervention to reduce the risk of elopement. The nurse or social worker/designee will complete the Elopement/Wandering Risk Data Set. If a problem is noted with the door alarm, the facility will post a staff member at the exit until the door alarm is functional. In the event of an elopement or onset of exit seeking behavior, where immediate interventions are needed to keep the resident safe, the resident will be put on Behavior Monitoring for elopement/exit seeking behavior until the behavior subsides. The nurse will complete the Elopement/Wandering Risk Data Set, and interventions to reduce the risk of elopement will be updated to the resident's Care Plan and communicated with staff. Review of the alarm system's Manufacture Guidelines, dated 12/11/17, revealed the alarm system company required facilities to test the transmitter/wanderguard for proper operation on a daily basis to ensure the transmitter/wanderguard worked properly; and to check for the expiration date of the transmitter/wanderguard at this time. Further review of the Guidelines revealed the system was not intended as a substitute for the careful identification and monitoring of the residents by the facility's professional staff. 1. Record review revealed the facility admitted Resident #1 on 01/17/17 with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/28/18, revealed the facility assessed Resident #1 as unable to complete the cognition interview with a Brief Interview for Mental Status (BIMS) score, which was coded as 99. Further review of the MDS revealed the facility assessed Resident #1 as usually understood and sometimes understands; required supervision of one (1) assist with locomotion, and had no behaviors, mood, or wandering. Review of Resident #1's Wandering Care Plan, dated 02/13/17, revealed interventions for a wanderguard (a band on a resident's ankle to alert staff with an alarm if the resident was near a door trying to exit seek), as appropriate; verify placement and function, per protocol. Continued review revealed interventions included monitor whereabouts when wandering, redirect as needed, check Code Alert bracelet (wanderguard device) placement and function every shift, and reassess risk for elopement quarterly and, as needed. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. However, review of the manufacturer's guidelines revealed to test the transmitter/wanderguard for proper operation on a daily basis to ensure the transmitter/wanderguard worked properly. Review of the Elopement/Wandering Risk Data Set, dated 04/05/18, revealed Resident #1 was at risk for elopement due to his/her ability to transport self independently in a wheelchair, aimless locomotion, night locomotion, purposeful exit seeking, total disorientation; and, [DIAGNOSES REDACTED]. Review of a facility investigation, not dated, revealed Resident #1 exited the building on 05/05/18, following staff out the 300 Hall exterior door wanting to smoke. Staff brought the resident back in the facility and the resident was placed on one to one (1:1) supervision. Interview with Licensed Practical Nurse (LPN) #3, on 05/23/18 at 3:08 PM, revealed when Resident #1 got out on 05/05/18, there were corporate staff in the conference room with the door closed reviewing charts. They did not hear the alarm go off. She stated the resident went out the 300 Hall exterior door. Interview (Post Survey) with a sister facility's Director of Nursing (DON), on 06/21/18 at 9:30 AM, revealed she was outside the 300 Hall exterior doors on 05/05/18 when Resident #1 came to the door and pushed on it to go outside. She stated the resident was unable to open the door as the door was locked because of the transmitter/wanderguard. The DON stated once the resident held on the door, the door opened and the resident came out on the sidewalk. She took the resident back inside to the nurse's station. Review of Nurse's Notes, dated 05/05/18, revealed no documentation related to Resident #1 going out the 300 Hall door. Further review of Resident #1's record revealed there was no Elopement/Wandering Risk Data Set completed after staff identified Resident #1 was exit seeking, per facility policy, until 05/07/18, two (2) days after the resident exited the building on 05/05/18. Review of the assessment revealed the resident was at risk for elopement due to history of one (1) to two (2) elopement episodes in the past six (6) months, able to transport self independently by a wheelchair, increased confusion at night, purposeful exit seeking, total disorientation; and, [DIAGNOSES REDACTED]. Review of the Nurse's Notes and care plan revealed no documented evidence an intervention was put into place. Review of the Nurse's Note, dated 05/09/18 at 8:18 PM, revealed the resident was being checked every twenty (20) minutes related to exit seeking behavior identified after given [MEDICATION NAME] (a synthetic [MEDICATION NAME] which could cause confusion, anxiety, coordination disturbance, visual disturbances and other reactions) at 6:46 PM. However, while the nurse provided care in another resident's room, Resident #1 wandered out the front door and into the road. The resident was returned by LPN #2 at 7:45 PM. LPN #2 stated the resident was down the road when she found him/her. Further review of the Nurse's Note revealed the Certified Nurse Aides (CNAs) and the nurse did not hear the ankle monitor (wanderguard) go off when the resident exited the facility, out the door. The LPN checked for functioning of the ankle monitor (wanderguard) and it was working. There were no signs of injury. The resident had a CNA with him/her at all times after the resident was brought back into the facility. Review of the National Weather Service from the Barkley Regional Airport site revealed the temperature on 05/09/18 was 88 degrees Fahrenheit (F). Interview with LPN #7, on 05/24/18 at 10:16 AM, revealed she could not remember what the resident was wearing that day. Observation, on 05/24/18 at 8:56 AM, revealed the speed limit was 25 mile per hour (mph). Further observation, at this time, revealed numerous semi-trucks going down the road. Interview with LPN #2, on 05/23/18 at 2:48 PM, revealed she found Resident #1 on the road and he/she was approximately 200 feet from the facility. Review of the facility's investigation by LPN #7, dated 05/09/18, who was responsible for the initial investigation, revealed Resident #1 exited the building on 05/09/18 and was found by LPN #2 down the road. The resident was brought back into the facility at 7:45 PM. It was noted that the door alarm did not sound. The transmitter/wanderguard on the resident's ankle was checked and was functioning. Further review revealed the resident was placed on 1:1 and was noted to have confusion/disorientation. Prior to the incident the resident was on twenty (20) minute checks. However, there was no documented evidence of any checks prior to the resident's second elopement. Interviews with CNAs, who worked with the resident at the time of the elopement, were not aware of any checks for the resident. LPN #7 stated, on 05/24/18 at 10:16 AM, she decided to place the resident on 20 minute checks after she administered the 6:46 PM dose of [MEDICATION NAME] to the resident. Further review of the investigation revealed, the front door was identified to have a low sensitivity alarm setting. All transmitters/wanderguards were checked and were functioning properly. All staff were re-educated on the elopement process. Review of the facility's root cause analysis revealed the door did not alarm allowing the resident to go outside and nursing staff did not reassess the resident when he/she exhibited exit seeking behaviors. According to the facility's investigation and staff interview, the door did not alarm. Interview with LPN #2, on 05/23/18 at 2:48 PM, revealed when she left the faciity on [DATE], she looked back at the facility as she turned down an adjacent street across from the facility and saw Resident #1 rolling down the side parking lot. She stated she had to wait for a car to pass and by the time she reached the resident he/she was in the road. LPN #2 stated she was able to get to the resident and brought him/her in the building to LPN #7. She further stated LPN #7 stated no one heard an alarm go off. She stated before this incident, families would get the code and the Maintenance Director would have to change the code. Further interview revealed the doors should alarm if a resident with a transmitter/wanderguard tried to go out the door. She stated the nurses checked the functioning of the transmitter/wanderguard weekly. Further interview revealed when a resident was exit seeking, an Elopement/Wandering Risk Data Sets should be completed in the computer by the nurse in charge. However, Resident #2 did not have an Elopement Assessment and Resident #1 did not have an Elopement Assessment completed until two (2) days after the first elopement. Interview with Certified Nurse Aide (CNA) #3, on 05/23/18 at 5:25 PM, revealed he had not worked a couple days prior to 05/09/18 and was not aware Resident #1 had been exit seeking or having behaviors. CNA #3 stated he was not aware of any special checks or close supervision for Resident #1. He stated at approximately 7:00 PM, the resident went out to smoke and came back in with staff around 7:30-7:40 PM. The CNA stated he saw Resident #1 sitting at the nurse's desk. He stated that he and the other CNA on the hall were in a resident's room and the nurse was passing medications around 7:45-7:50 PM when LPN #2 brought Resident #1 to the desk and stated the resident had been outside. CNA #3 stated no door alarm had sounded; the nurse checked the transmitter/wanderguard to ensure it would sound. He stated the nurse placed the resident on 1:1 care and the resident was agitated and cursing. He further stated if he would have known the resident was exit seeking he could have initiated more precautionary measures and kept a better eye on the resident. Interview with CNA #4, on 05/23/18 at 5:55 PM, revealed he was on a different hall a couple of days before 05/09/18 and he was not aware Resident #1 was exit seeking. He stated the resident was not on any special checks that he was aware of on 05/09/18. He stated if he would have known that the resident had been exit seeking and got out of the building prior to 05/09/18, he would have put the resident on increased checks. CNA #4 stated around 7:45 PM-7:50 PM, he took Resident #1 out to smoke and brought him/her back to the nurse's desk around 8:15 PM and started his bed checks. He stated about ten (10) minutes later, CNA #3 came to him and stated Resident #1 was placed on one (1) to one (1) as he/she just got out of the building. CNA #4 stated he never heard a door alarm. He stated he thought maybe Resident #1 followed a visitor out the front door and the door did not close. Interview with CNA #2, on 05/23/18 at 5:15 PM, revealed Resident #1 exit seeks at times and would open the fire doors on the 300 Hall. She stated the Regional Reimbursement Nurse told her to do twenty (20) minute checks on Resident #1 before he/she eloped again on 05/09/18 (after the second time). Interview with LPN #7, a new LPN graduate, was the nurse responsible for Residents #1 and #2. Interview with LPN #7, on 05/24/18 at 10:16 AM, revealed Resident #1 had exit seeking behaviors on 05/09/18, prior to her coming on the shift. She stated that she thinks she was told in report to keep an eye on the resident. LPN #7 stated she put the resident on twenty (20) to thirty (30) minute checks just as a precaution around 7:00 PM, but she did not communicate this to staff as she was just going to check on the resident periodically while passing medications. She stated she was just doing the checks herself and did not communicate that information to her staff on the floor. She further stated she was not aware of an elopement policy as that was never discussed with her when she was hired at the facility. The LPN stated no one had told her to put the resident on twenty (20) minute checks. She stated she did not document the checks anywhere until after the resident got out of the building, then she documented on the incident report. Further interview revealed she and her staff did not know the resident went outside as no door alarm went off; she stated she believed the resident followed someone out the door. She stated when the resident got out of the building all staff were in residents' rooms providing care. LPN #7 stated when the resident was brought back in, he/she was placed on 1:1 supervision. She stated she was not aware she should complete an Elopement/Wandering Risk Data Set. Further interview revealed LPN #7 was not aware of the Elopement/Wandering Risk Data Set assessment. Interview, on 05/24/18 at 1:05 PM, revealed she was not aware of which residents were at risk for elopement when she started work at the facility. She stated she did not even know what an elopement was. LPN #7 stated she was not aware there was a book at the desk which listed the residents at risk for elopement and she had received no training on elopement or what to do if a resident was trying to elope when she started a month ago. The LPN stated she was told by the Staff Development Coordinator (SDC) to read a paper, but she could not find the paper to read over elopement. She stated when she was hired, she did not receive any education on the care plans or who was responsible for updating the care plans. Interview with LPN #9 (an agency nurse), on 05/28/18 at 9:56 PM, revealed she worked the night of 05/09/18 and did not hear the door alarm when Resident #1 got out of the building. She stated she was not aware of any twenty (20) minute checks on Resident #1 prior to the second elopement. LPN #9, stated she started work on 05/01/18 and she was never orientated by anyone on the floor. She stated she was told there was a book at the desk of residents at risk for elopement. The LPN stated the transmitters/wanderguards were checked weekly. She further stated the MDS Nurses updated the care plans as she was not told anything about updating care plans when she started working. LPN #9 stated she was not aware of what an Elopement/Wander Risk Data Set was used for or when it should be completed. She further stated when she was on the back of the hall working, it was hard to hear the door alarm. Interview with Certified Medication Aide (CMA) #1, on 05/24/18 at 10:40 AM, revealed Resident #1 followed staff out the 300 Hall door on 05/05/18 and was brought back into the facility. She stated the resident had been exit seeking and was placed on 1:1 for a few days after the 05/05/18 incident, then somehow got out again on 05/09/18. CMA #1 further stated the resident was taken off of 1:1 prior to him/her exiting the facility on 05/09/18. She stated there was no paper at the desk to document the resident was on any kind of checks after the 1:1 ended. The CMA stated if someone was on checks, there would be a paper at the desk for staff to sign on the assigned increment on time. Interview with LPN #8 (agency staff), on 05/26/18 at 9:50 PM, revealed when she started working at the facility on 04/20/18, she was not trained much on anything and was not trained on elopement. She stated she was placed to work the floor the same day she was hired. LPN #8 further stated she went to the office because she did not feel comfortable working without the proper education and stated she did not like being turned over to the wolves. She stated that according to the Director of Nursing (DON), the recruiter stated, You (LPN #8) would be ready to hit the floor when you arrived to work. LPN #8 stated she was not aware of the residents at risk for elopement when she started working and she was not aware of a book at the desk with residents' names and pictures that were at risk for elopement. She further stated she was not aware Resident #1 was on any kind of twenty (20) minute checks. Furthermore, she stated the MDS Coordinator was responsible to update the care plans as needed. She stated she did not receive any kind of education on updating the care plan or the Elopement/Wandering Risk Data Sets. LPN #8 stated she was not aware, as of this date, what the assessment was. She stated the wanderguard/transmitters on the residents were checked for functioning every week. Interview, on 05/26/18 at 10:21 PM, revealed she did not know much about care plans as she seemed to mostly pass pills. She stated she hoped the CNAs were following the care plan, but she could not be for certain they were. LPN #8 stated, I probably should look at the care plan to ensure they are She further stated her main job as a nurse was to get medications passed. Interviews with LPN #3, on 05/23/18 at 3:08 PM, and LPN #6 on 05/24/18 at 9:16 AM, revealed the functioning of the transmitter/wanderguard was checked weekly and placement checked every shift. She stated this was documented on the MAR. LPN #3 stated if a resident eloped or attempted to elope, an Elopement/Wandering Risk Data Set should be completed. Interview with the MDS Coordinator, on 05/24/18 at 3:30 PM, revealed the nurse at the time should have performed an Elopement/Wandering Risk Data Set after the elopements and applied new interventions as indicated and updated the care plan. She stated if a resident eloped, there should be a new intervention put into place. 2. Record review revealed the facility admitted Resident #2 on 02/15/17, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/11/18 revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Further review of the MDS Assessment, revealed staff assessed Resident #2 to have no behaviors, no wandering or mood issues, and required limited assist with one (1) person for locomotion. Review of the Wandering Care Plan, dated 02/23/17, revealed interventions that included transmitter/wanderguard as ordered, verify placement and function per protocol, monitor whereabouts when wandering and redirect as needed, check Wanderguard bracelet placement and function every shift and expiration date per protocol, reassess risk for elopement quarterly and, as needed. If the resident voiced a plan or was actively attempting to elope, redirect the resident and proceed with the facility's policy and, notify the Director of Nursing (DON) and Administrator. Review of the Elopement/Wandering Risk Data Sets, dated 04/05/18, revealed the resident was at risk for elopement due to his/her ability to transport self independent by a wheelchair, [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 04/20/18 at 3:36 PM, revealed, Staff was alerted to the front door opening at approximately 8:00 PM last evening. (Resident #2) was in (his/her) wheelchair and had left the building, but was in the fenced area. No injury noted, (resident) returned easily. (Resident) being observed for exit seeking behaviors. No further exit seeking noted. Review of the facility's investigation, dated 04/20/18, revealed Resident #2 went out the front door and the door alarmed when the resident went out the door. However, interviews with staff revealed they did not hear an alarm. Further review revealed the resident was seen at the dining room door in the courtyard by a staff member trying to get back in the facility. Further review of the investigation revealed no documentation of any immediate actions taken or what was determined to be the root cause. Post survey interview with the Administrator, on 06/21/18 at 9:25 AM, revealed the Director of Sales and Marketing came out of the conference room and up 300 Hall and heard the door alarm and responded to the dining room door where he saw Resident #2 outside. He then went and found CMA #1 and she retrieved the resident. Interview with Certified Medication Aide (CMA) #1, on 05/24/18 at 10:40 AM, revealed Resident #2 got out of the building through the front door and went around to the dining room door trying to get back in the building. She stated she heard no door alarm go off while she was passing medications on the hall. She further stated the resident had been saying he/she wanted to leave and go home. CMA #1 stated staff try to keep the resident at the desk when he/she says that, but the staff were busy providing care. She further stated the resident could have followed someone out the door, but she did not know. Further interview, on 05/28/18 at 9:50 PM, revealed it was hard to hear the door alarm go off. She stated as she got closer to the door she could hear the alarm go off from the resident trying to get back in the dining room door. Interview with LPN #7, on 05/24/18 at 10:16 AM, revealed on the evening Resident #2 got out of the building CMA #1 brought the resident to her and stated the resident was outside in the smoking area trying to get back in through the dining room door. She stated when staff were in a resident's room providing care, they could not hear the door alarms. Interview with CNA #6, on 05/27/18 at 9:55 PM, (telephone interview) revealed the door alarms could not be heard when staff were in residents' rooms providing care at the back of the hall. She stated on the evening of 04/19/18, she did not hear the door alarm go off when Resident #2 got out of the building. Interview with CNA #5 (agency staff), on 05/26/18 at 10:00 PM, revealed when she started working at the facility around 04/21/18, she was not aware of the residents at risk for elopement, unless she saw the transmitter/wanderguard on the residents' ankles when she provided care. Interview with CNA #7 (agency staff), on 05/27/18 at 10:10 PM, revealed she was just put on the floor when she started working at the facility around 04/26/18. She stated she was not aware of which residents were at risk of elopement or wandering when she started working. CNA #7 further stated there was no orientation about elopements or the policy until about a week and a half ago. She stated there was only one (1) resident at risk for elopement and that was Resident #2. However, review of a facility list at the desk, dated 05/15/18, revealed there were eight (8) residents at risk for elopement/wandering. Interview with LPN #1 (agency staff), on 05/24/18 at 1:13 PM, revealed when he was hired he did not know the residents that were at risk for elopement and received no training on elopement. He stated now he knew there was a book at the desk with residents that were high risk for elopement. LPN #1 stated the nurses do not take care of updating the care plans. He further stated he did not receive training on the care plan and there was not much training for agency nurses. Interview with the Regional Reimbursement Nurse, on 05/23/18 at 4:03 PM, revealed the transmitters/wanderguards were checked for functioning every week but they were changing the orders today to reflect to check every day. She stated after Resident #1 had a Gradual Dose Reduction and his/her as needed [MEDICATION NAME] (anti-anxiety medication) was discontinued, the resident had increased behaviors. She stated the resident required redirection before the elopement and had just started on twenty (20) minute checks with one completed before the resident eloped on 05/09/18. Interview, on 05/24/18 at 5:45 PM, revealed the Interim DON was responsible to ensure communication to staff and follow the policy. Interview, on 05/29/18 at 2:25 PM, revealed the facility did not have a policy on increased supervision or 1:1 as it was nursing judgement. She stated the facility provided an inservice on the elopement policy after the incident on 04/19/18, but did not include the Wandering/Elopement Risk Data Set or care planning. Three (3) staff members were not educated on the policy. Interview, on 06/01/18 at 12:08 PM, revealed Resident #2 was placed on (1:1) for twenty-four (24) hours after the 04/19/18 elopement. Interview with the Staff Development Coordinator (SDC), on 05/24/18 at 4:05 PM, revealed the DON was responsible for communicating to staff if the resident was on 1:1 or on any checks. She stated the DON never came to her requesting she educate staff on twenty (20) minute checks for Resident #1. The SDC stated the nurses were responsible for updating the care plan for new interventions. She stated the care plans were reviewed in morning meeting therefore, unless the MDS Coordinator came in on the weekend the care plan was not reviewed until Monday. She stated LPN #7 was responsible for updating Resident #1's and #2's care plans and she would inservice nurses on this. She stated staff was inserviced on the Elopement policy after the 05/09/18 elopement. However, care planning and performing an Elopement/Wandering Risk Data Set were not discussed, even though it was part of the policy. Review of Resident #1's and Resident #2's (MONTH) (YEAR) physician's orders [REDACTED]. However, the manufacturer's guidelines revealed the transmitter/wanderguard should be checked for proper operation on a daily basis to ensure the transmitter was working properly; and, to check for the expiration date at this time. Observation, on 05/29/18 at 10:38 AM, revealed the front door alarm was activated by the Business Office Manager while the Administrator and State Surveyor were at the end of the 300 Hall to check the sound of the alarms. Observation was in a vacant room without a television; the door alarm was noted to be very faint. Further observation, on 05/29/18 at 10:41 AM, revealed the front door alarm was activated while the Administrator and State Surveyor were at the end of the 100 Hall, in a room, with a television on, and the door open; the door alarm was not able to be heard. Review of the facility's weekly door inspection form revealed to check patient transmitter/wanderguard to make sure the door stayed locked and the alarm sounds. Further review revealed to confirm the security panels at the Nurse's Station activated when the door was opened and that it properly indicated the location of the door released. However, observation on 05/22/18 at 4:15 PM, revealed the wanderguard/transmitter was allowed to exit the front door without the door alarming when the door code was entered. Interview with the Maintenance Director, on 05/22/18 at 4:15 PM, revealed the alarm service company came to the facility on [DATE], and replaced the antennas to the front door so the distance to pick up a transmitter/wanderguard was increased from two (2) feet to three (3) feet. While testing the doors with the Maintenance Director, on 05/22/18 at 4:15 PM, the front door did not alarm or lock down when the door code was pressed and a transmitter/wanderguard was within two (2) to three (3) feet away. The transmitter/wanderguard was able to continue to go out the door without any type of alarming. The Maintenance Director stated the front door was to perform that way as to allow residents with a transmitter/wanderguard to go to doctor's appointments. Other doors were tested and those doors locked down and alarmed when the transmitter/wanderguard was near, the Maintenance Director stated he may need to call the alarm service company to service the front door again. The front door was tested again at 4:55 PM and the alarm did not sound, nor did the door lock down when the door code was pressed with a transmitter/wanderguard present. However, the door should have alarmed. Further interview, on 05/23/18 at 9:10 AM, revealed he noticed the front door not alarming and not locking down since his last door check, which was 05/18/18. He stated he did not report this to anyone. Interview, on 05/24/18 at 9:45 AM, revealed he would take care of the issue with the doors before addressing it to the Administrator. Interview with the interim DON, on 05/24/18 at 1:40 PM, revealed she expected the care plan to be updated with new interventions when a resident was exit seeking. She stated the IDT also updated the care plan with interventions. Interview at 2:30 PM revealed the staff should have been inserviced when Resident #1 was placed on fifteen (15) to twenty (20) minute checks. She further stated there was a lot of agency staff in the building now and they do not receive much training before starting work. The DON stated the MDS Coordinator updated the care pl (TRUNCATED)

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plans according to the residents' needs for two (2) of three (3) sampled residents (Residents #1 and #2). Resident #1 exited the building on 05/05/18. After this incident, the resident was placed on one to one (1:1) for forty-eight (48) hours. However, the facility failed to update Resident #1's care plan related to the 1:1 supervision; and, failed to put an intervention in place to reduce the risk of elopement once the 1:1 was discontinued. On 05/09/18, Resident #1 exited the building again without staff knowledge and was found in the road. In addition, Resident #2 exited the building on 04/19/18 and the care plan was not updated to reflect the 1:1 supervision to reduce the risk of elopement. Furthermore, the facility failed to put an intervention in place to reduce the risk for elopement and for increase exit seeking behaviors once the 1:1 intervention was discontinued. The facility's failure to communicate to staff interventions put into place and update the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/29/18 and determined to exist on 04/19/18. The facility was notified of the Immediate Jeopardy on 05/29/18. An acceptable Allegation of Compliance (AoC) was received on 06/04/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 05/30/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, CMS RAI (Centers for Medicare and Medicaid Resident Assessment Instrument) Version 3.0 Manual, dated (MONTH) (YEAR), revealed the care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Key staff or the Interdisciplinary Team (IDT) should review and revise the current care plan as needed and communicate the plan. Review of the facility's policy titled, Elopement Protocol, dated (MONTH) (YEAR), revealed any resident with a change in condition including elopement attempts or exit seeking behavior will be reassessed for the need of further intervention to reduce the risk of elopement. The nurse will complete the Elopement/Wandering Risk Data Set and, interventions to reduce the risk of elopement will be updated to the resident's Care Plan and communicated with staff. 1. Record review revealed the facility admitted Resident #1 on 01/17/17 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/28/18, revealed the facility assessed that Resident #1 was unable to complete the cognition interview with a Brief Interview for Mental Status (BIMS) score code of 99. The facility assessed the resident to usually be understood and sometimes understands. Resident #1 was discharged on [DATE]. Review of Resident #1's Care Plan for Wandering, dated 02/13/17, revealed interventions included a code alert bracelet (wanderguard), which the resident wore on his/her ankle to alert staff when the resident attempted to exit the exterior door, as appropriate. Other interventions included to verify placement and function per protocol of the code alert bracelet (wanderguard); monitor whereabouts when wandering; redirect as needed; check the code alert bracelet (wanderguard) placement and function every shift; and, reassess the risk for elopement quarterly and, as needed. Review of a facility investigation, not dated, revealed Resident #1 exited the building on 05/05/18 (Saturday), following staff out the 300 Hall door wanting to smoke. The 300 Hall doors were kept closed to detour traffic. Staff brought the resident back in the facility and the resident was placed on 1:1 supervision for forty-eight (48) hours. Further review of Resident #1's Care Plan for Wandering, dated 02/13/17, revealed the care plan was revised to state exit seeking, but the care plan was not updated to include the 1:1 care and there was no intervention added to the care plan to reduce the risk of elopement after the 1:1 supervision was discontinued. Interview with the Administrator, on 05/24/18 at 1:45 PM, revealed the resident was placed on 1:1 on 05/05/18 for forty-eight (48) hours, then discontinued. Review of Nurse's Notes, dated 05/09/18 at 8:18 PM; the facility's investigation dated 05/09/18; interviews with Licensed Practical Nurse (LPN) #7, on 05/24/18 at 10:16 AM; and, LPN #2, on 05/23/18 at 2:48 PM, revealed Resident #1 was checked every twenty (20) minutes related to exit seeking behavior starting around 7:00 PM on 05/09/18 (Friday). LPN #7 stated she placed the resident on twenty (20) minute checks at 7:00 PM, but she did not make the staff aware of the twenty (20) minute checks, as she was just doing them herself. However, Resident #1 wandered out the front door and into the road, without staff knowledge. Interview with LPN #7, on 05/24/18 at 10:16 AM, revealed she put the resident on twenty (20) to thirty (30) minute checks just as a precaution around 7:00 PM, as the last time she observed the resident was while she was passing medications. LPN #7 stated she did not communicate this information to the staff. She further stated she and her staff did not know the resident went outside as no door alarm went off. LPN #2 found Resident #1 on a busy two (2) lane road approximately 200 feet from the facility at approximately 7:45 PM. The resident had no signs of injury and a Certified Nurse Aide (CNA) was placed with him/her at all times. The nurse checked for functioning of the code alert bracelet (wanderguard), as the CNAs and the nurse did not hear the resident's code alert bracelet (wanderguard) go off when the resident went out the door. Interview with CNA #3, on 05/23/18 at 5:25 PM, and CNA #4 at 5:55 PM, revealed they had not worked with Resident #1 a couple days prior to 05/09/18 and they were not aware Resident #1 had been exit seeking or was having behaviors. The CNA's further stated they were not aware of any special checks or close supervision required for Resident #1 on the day he/she eloped (05/09/18). The CNA's stated if they would have known Resident #1 was exit seeking they could have initiated more precautionary measures. 2. Record review revealed the facility admitted Resident #2 on 02/15/17 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 02/11/18, revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of Resident #2's Wandering Care Plan, dated 02/23/17, revealed interventions for a code alert bracelet (wanderguard) as ordered; verify placement and function per protocol; monitor whereabouts when wandering; redirect as needed; check the code alert bracelet (wanderguard) placement and function every shift; expiration date per protocol; and, reassess risk for elopement quarterly and as needed. Further review revealed an intervention which stated if the resident voiced a plan or was actively attempting to elope, then redirect the resident, proceed with the facility's policy, and notify the Director of Nursing (DON) and Administrator. Review of Resident #2's Nurse's Note, dated 04/20/18 (Friday) at 3:36 PM, the facility's investigation dated 04/19/18, and interviews on 05/24/18 with Certified Medication Aide (CMA) #1 at 10:40 AM and LPN #7 at 10:16 AM, revealed the resident exited the building through the front door at approximately 8:00 PM without staff's knowledge. The resident was outside trying to get back in the building through the dining room door. However, further review of Resident #2's Wandering Care Plan, dated 02/23/17, revealed the care plan was not updated to reflect the 1:1 supervision to reduce the risk of elopement or exit seeking behaviors after the elopement occurred. Furthermore, the facility failed to put an intervention in place to reduce the risk for elopement and for increase exit seeking behaviors once the 1:1 intervention was discontinued. Further interview with LPN #7, on 05/24/18 at 10:16 AM, revealed she did not receive any education on the care plan, or on who was responsible for updating the care plan when she was hired. She stated when the resident was brought back in, he/she was placed on 1:1 care, but she did not update the care plan. Interview with LPN #2, on 05/23/18 at 2:48 PM, revealed she was not aware Resident #2 had eloped or what interventions were put into place, as none were placed on the care plan. Interview with LPN #3, on 05/23/18 at 3:08 PM, revealed she thought Resident #2 was placed on fifteen (15) minute checks after he/she eloped on 04/19/18, but she was not sure, as it was not documented on the care plan. She stated Resident #1 was placed on twenty (20) minute checks; however, there was no documentation of checks for the resident. Interview with LPN #5, on 05/24/18 at 9:11 AM, revealed when she began work this month, nothing was discussed about the care plan or updating the care plan. Interview with LPN #1 (an agency nurse), on 05/24/18 at 1:13 PM, revealed the nurses do not take care of updating the care plan. He stated he did not receive training on the care plan or the policy and there was not much training for agency nurses. However, review of the Elopement Policy revealed any residents with changes of condition including elopement, elopement attempts or exit seeking behaviors will be assessed for need of further intervention to reduce the risk of elopement. Furthermore, the care plan was to be updated with resident specific information to promote resident's safety. Interview with LPN #8, on 05/26/18 at 9:50 PM, revealed she was not aware of Resident #1 being on any kind of twenty (20) minute checks. She stated the MDS Coordinator was responsible to update the care plan, as needed. LPN #8 stated she did not receive any kind of education on updating the care plan. Interview with LPN #6, on 05/24/18 at 9:16 AM, revealed the DON updated the care plans, if needed related to exit seeking behaviors. The DON received this information by reviewing the Twenty-four (24) Hour Report book. Interview with LPN #9, on 05/28/18 at 9:56 PM, revealed she started work on 05/01/18. She stated she was never orientated by anyone on the floor. LPN #9 stated the MDS nurses updated the care plan. She stated she was not told anything about updating the care plan when she started working. Interview with the MDS Coordinator, on 05/24/18 at 3:30 PM, revealed the nurses should update the care plan related to exit seeking behaviors and communicate new interventions to the floor staff and oncoming shift. She stated the DON was responsible to ensure this was done. She stated the care plan should not wait to be updated until the MDS Coordinator was available. However, she stated she was the primary person who updated the care plan. Further interview, on 05/29/18 at 10:53 AM, revealed the nurses on the floor should have updated the care plan on 04/19/18 when Resident #2 eloped. She stated if a resident eloped, there should be a new intervention put into place. Interview, on 05/31/18 at 3:57 PM, revealed she was not aware of what intervention was put into place after Resident #2 eloped on 04/19/18, since there was no documentation and the intervention was not placed on the care plan. Interview with the Regional Reimbursement Nurse, on 05/24/18 at 5:45 PM, revealed the Interim DON was responsible to ensure communication to her staff and follow the policy. Further interview, on 05/29/18 at 2:25 PM, revealed the facility provided an inservice on the elopement policy after the incident on 04/19/18; however, this inservice did not include care planning. Interview, on 06/01/18 at 12:08 PM, revealed Resident #2 was placed on 1:1 supervision for twenty-four (24) hours after the 04/19/18 elopement; however, the care plan was not updated. Interview with the Staff Development Coordinator (SDC), on 05/24/18 at 4:05 PM, revealed the DON was responsible to communicate to staff if the resident was on 1:1 or on any checks. She stated the nurses were responsible for updating the care plan for new interventions. The SDC stated the care plans were reviewed in the morning meeting; therefore, unless the MDS Coordinator came in on the weekend, the care plan was not reviewed until Monday. She stated LPN #7 was responsible for updating Resident #1 and #2's care plans. The SDC stated part of the nurses duties was to put interventions in place, communicate to staff and update the care plan. She stated when staff were inserviced on the Elopement policy after the 05/09/18 elopement, updating the care plan was not discussed, although that was part of the policy. Interview with the DON, on 05/24/18 at 1:40 PM, revealed she was the DON when the elopements occurred, but had just started at the facility. She further stated she was only the interim DON. She stated she expected the care plan to be updated with new interventions with a resident exit seeking. The DON stated the Interdisciplinary Team updated the care plan with interventions. Further interview, on 05/24/18 at 2:30 PM, revealed the staff should have been inserviced when Resident #1 was placed on fifteen (15) to twenty (20) minute checks. She stated there was a lot of agency staff in the building now and they had not received much training before starting to work, as they were intended to start work immediately after they completed paperwork with a quick inservice on the lift, and a tour of the facility . She stated the MDS Coordinator updated the care plan, but staff should not wait until Monday, if it was a weekend to update the care plan. The DON stated the resident was placed on 1:1 on 05/05/18, after he/she went out the door, and after forty-eight (48) hours the resident did not exhibit exit seeking behavior. Further interview revealed the resident was on fifteen (15) to twenty (20) minute checks when he/she eloped a second time, on 05/09/18. The DON stated the care plan should have had the interventions put in place for both residents as the staff were not aware of the fifteen (15) to twenty (20) minute checks for Resident #1. She stated the system to update care plans was discussed in the morning meeting Monday through Friday by the MDS staff; however, the care plans did not get updated for these interventions. She further stated it was the responsibility of the DON and Unit Manager to ensure the care plans were updated and to ensure the staff were aware of changes; however, the system failed. Interview with the Administrator, on 05/23/18 at 4:20 PM, revealed the monitoring of both residents should have been put on paper as they had been discussed in morning meeting that the residents needed frequent checks. He stated the DON was responsible to ensure the staff were aware of new interventions and ensure the care plans were updated with any new interventions. He stated Resident #1 was on 1:1 supervision for forty-eight (48) hours after he/she got out of the building on 05/05/18, then he/she was placed on fifteen (15) to twenty (20) checks on 05/07/18 (Resident #1 was placed on twenty (20) minute checks on 05/09/18). He stated the nurses should have communicated that information to the staff and that information should have been updated on the care plan. He stated the MDS staff was responsible for updating the care plan, but any nurse could update the care plan. He further stated he remembered discussing in morning meeting the care plan needed to be updated. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's chart revealed the resident was discharged to another facility on 05/22/18. Observation on 06/11/18 revealed Resident #2 was on one to one (1:1) observation. Review of Resident #2's care plan revealed Resident #2 had been on one to one (1:1) supervision since 05/24/18. Interview with the Administrator, on 06/11/18 at 10:30 AM, revealed Resident #1 was discharged to a secure unit on 05/22/18. Resident #2 was making comments of wanting to go home on 05/24/18 and he decided to put Resident #2 on one (1:1) supervision while the facility looked into alternate placement of a secured unit. He stated the staff follow the Elopement Policy for the supervision of residents identified at risk for elopement which includes an elopement assessment to indicate risk. Staff would assist in defining appropriate care plan interventions and identify the need for a transmitter/wanderguard which would alarm if the resident attempted to exit the facility exterior access door. He stated the daily interaction and observation of residents would also determine if the elopement plan of care interventions were appropriate or if there was a need for modifications. 2. Review of the AdHoc QA meeting held on 05/29/18, revealed the members, which included the Administrator, DON, Unit Managers, Director of Rehabilitation, Admissions Director, BOM, Activity Director, Medical Records, and Dietary Manager discussed the IJ allegations, elopement policy, and developed an action plan. The Medical Director was in attendance via phone. Interviews with the SDC (interim DON) on 06/11/18 at 5:15 PM, the BOM on 06/12/18 at 9:49 AM, Unit Manager of 200 Hall at 10:00 AM, prior Unit Manager of 100 Hall at 10:19 AM, and Director of Rehabilitation at 11:20 AM, revealed they were present for the 05/29/18 meeting and discussed the IJ's. Further interview revealed they developed a plan of action which included education, elopement assessments, orders to meet manufacture's guidelines, and updating care plans. 3. Review of the Door Alarm Service provider Field Work Order, dated 05/22/18 with departure time of 11:00 PM revealed the front door signal was minimal and the keypad was replaced. The signal strength was increased to four (4) to five (5) feet. In addition, the provider adjusted the side door antenna strength and tested all doors with maintenance. Doors were in proper working order at the time of departure. Interview with the Maintenance Director, on 06/12/18 at 12:03 PM, revealed, on 05/22/18, all doors were checked by the Door Alarm Service provider and they all alarmed as they should before the technician left the building. 4. Review of list of residents with transmitters/wanderguards, dated 05/10/18, 05/24/18, and 05/25/18, revealed the DON and Unit Manager of the 100 Hall checked all wanderguards for placement and function. Interview with the prior 100 Hall Unit Manager, on 06/12/18 at 10:19 AM, revealed she checked all the transmitters/wanderguards in the building on 05/10/18, 05/24/18, and 05/25/18 to ensure they were all working and functioning properly. 5. Review of Action Plan completed by the Regional Reimbursement Nurse revealed, on 05/10-11/18 and 05/15/18, they validated each identified resident had a current elopement assessment; their care plan had been updated to reflect their elopement risk status; and, each resident identified had a current photo and face sheet in the elopement book. Review of the facility's Allegation of Compliance (AoC) binder revealed all residents identified at risk for elopement had their care plans and Elopement Assessments audited and updated on 05/25/18. Interview, on 06/12/18 at 10:00 AM, with the Unit Manager of the 200 Hall and interview with the prior Unit Manager of the 100 Hall, at 10:19 AM, revealed they reviewed and updated the care plans, if needed for residents at risk for elopement and performed Elopement Assessments on all at risk residents on 05/25/18. 6. Review of the facility AoC binder revealed all residents with wanderguards that were at risk for elopement had their MAR's/orders updated on 05/24/18 to reflect the Manufacture's Guidelines to Check the wanderguard function and expiration daily by the Unit Managers. Interview, on 06/12/18 at 10:00 AM, with the Unit Manager of 200 Hall and interview with prior Unit Manager of 100 Hall, at 10:19 AM, revealed they changed all the orders for the residents with transmitters/wanderguards to reflect the Manufacture Guidelines to check the transmitter/wanderguard function and expiration daily on 05/24/18. 7. Review of education on elopement protocol on 05/10/18 revealed the BOM, Assistant BOM, and SDC was educated by the Regional Reimbursement Nurse. Interview with the SDC (interim DON), on 06/11/18 at 5:15 PM, and the BOM on 06/12/18 at 9:49 AM, revealed they received education from the Regional Reimbursement Nurse, on 05/10/18, prior to educating staff on the Elopement Protocol which included updating the care plan if exit seeking, communicating interventions to staff, elopement assessment completed after exit seeking attempts, and staff checking doors and looking both ways when the door is alarming before shutting off alarm. Review of In-Service Record, dated 05/10/18, 05/14/18 and 05/15/18, provided by the BOM, Assistant BOM, Administrator, and SDC revealed all but three (3) staff were inserviced by 05/15/18 on the Elopement Protocol. Interview with LPN #6, on 06/11/18 at 11:20 AM, revealed she was inserviced by the SDC earlier in (MONTH) about updating the care plan for residents wandering and updating the elopement assessment when a resident exhibited exit seeking behaviors. Interview with Cook #1, on 06/12/18 at 11:04 AM, revealed she was inserviced about elopement several weeks ago. The inservice was provided by the BOM. It included information related to if a door alarm goes off to look both ways and if a resident is seen going outside bring the resident in and report to the charge nurse. Interview with Housekeeper #1, at 11:11 AM, revealed he was inserviced by the Administrator in (MONTH) about the code for a resident elopement and if door alarm was sounding go out the door and look both ways before turning off the alarm. Interview with CNA #8, on 06/11/18 at 10:47 AM, revealed she received an inservice a couple weeks ago on elopement, presented by the SDC, on how to respond to a door alarm by looking both ways before shutting off alarm. 8. Review of In-Service Record, dated 05/29/18, revealed all nurses were educated by the SDC in regard to updating the Elopement Assessment per policy for exit seeking and elopement behaviors, updating the care plan with interventions, providing adequate supervision which can include fifteen (15) minute checks or one to one (1:1), and the manufacture guideline for checking the function of the transmitter/wanderguard bracelet. Interview with LPN #5, on 06/11/18 at 11:10 AM, revealed she received an inservice about two (2) weeks ago on elopement which included the elopement assessment, the nurses responsible to update the care plan if an event of wandering or elopement occurs, and providing supervision. Interview with LPN #6, on 06/11/18 at 11:20 AM, revealed she had received inservices on elopement for the past month, but there was a special inservice for nurses related to nurses updating the care plan for elopements, updating the elopement assessment, notifying the DON, Administrator, Physician, and Responsible Party if an elopement or a resident was exit seeking. She further stated in the Elopement Book at the desk there was now a list of how to write the order for the wanderguard with the function check every day, as well as how to do an Elopement Assessment. She stated the Department Heads go around asking questions about elopement to see if they recalled. Interview with LPN #2 and the Unit Manager of the 200 Hall, on 06/12/18 at 10:00 AM, revealed she was inserviced by the SDC on the Elopement Policy. Interview with LPN #10, on 06/11/18 at 10:48 AM, revealed she had started two (2) days ago and had orientation before working the floor. Information covered included explaining the elopement policy, resident's at risk in a book at the desk, explanation on how to do an elopement assessment for someone wandering or eloped, and how to write the wanderguard order. Furthermore, she stated the transmitters/wanderguards were checked daily. She stated the nurses were responsible to update the care plan with interventions on the paper copy and the MDS Coordinator would update the information in the computer. 9. Review of the facility provided inservice, dated 05/10/18, revealed the Maintenance Director was inserviced by the Administrator on placing the wanderguard in his shoe to simulate a resident during weekly door checks. Interview with the Maintenance Director, on 06/12/18 at 12:03 PM, revealed, on 05/10/18, the Administrator educated him on placing the transmitter/wanderguard in his shoe for alarm sensitivity for the weekly door testing. 10. Review of 05/24/18 inservice, dated 05/24/18, revealed the Maintenance Director was inserviced by the Administrator for testing the exterior doors according to the company policy including the testing procedure for locks and testing operations, informing the Administrator with any issues of the doors, expected door functioning, and transmitter/wanderguard functioning. Interview with the Maintenance Director, on 06/12/18 at 12:03 PM, revealed he received education on 05/24/18 from the Administrator on the Elopement Policy, door checks and how the door was to alarm with the wanderguard, simulating a resident with a wanderguard by continuing to place in his shoe, and notification to the Administrator immediately if there was an issue with the door. He further stated if a door was not functioning properly someone would guard the door until it was repaired. 11. Review of 05/24/18 inservice revealed the DON was inserviced by the Regional Reimbursement Nurse on following policies, communicating changes to staff, updating the care plan with new interventions in regards to residents' behaviors, wandering, and elopement. Interview with the SDC (interim DON), on 06/11/18 at 5:15 PM, revealed she was trained by the Regional Reimbursement Nurse on the elopement policy, updating the care plan for new interventions related to resident behaviors, incidents, wandering/exit seeking/elopement and communicating the information to the staff. 12. Review of elopement drills, dated 05/10/18, with staff signatures revealed drills were completed on all three (3) shifts. Review of the Timed Door Alarm Response Drills were conducted by a Regional Team member on 05/15/18, 05/17/18, 05/22/18, and 05/24/18. Interview with CNA #8, on 06/11/18 at 10:47 AM, LPN #2 and the Unit Manager of the 200 Hall on 06/12/18 at 10:00 AM, Unit Manager for 100 hall at 10:19 AM, Cook #1 at 11:04 AM, Housekeeper #1 at 11:11 AM, LPN #5 at 11:10 AM, revealed they were receiving elopement drills at least weekly. They also stated they checked the alarms by pushing on a door causing it to alarm and see how long it would take for staff to respond at least weekly. 13. Review of the facility AoC binder revealed daily audits of the 24 Hour Report book and Nurse's Notes performed by the DON and/or Unit Managers for documentation of exit seeking behaviors Monday through Friday. A facility provided list revealed a Manager on Duty would be available for weekend reviews for any exit seeking behaviors. Interview with the Administrator, on 06/11/18 at 3:00 PM, revealed all Department Heads alternated weekends. Their duty during that time included checking the doors, questioning staff regarding any issues, and notifying the Administrator with concerns. Interview on 06/11/18 at 5:15 PM, with the SDC (interim DON) and interview on 06/12/18 with Unit Manager of 100 Hall at 10:19 AM, Unit Manager of 200 Hall at 10:00 AM, revealed prior to the clinical morning meeting the Unit Managers and the DON reviewed the Nurse's Notes and the 24 Hour Report book for any changes such as wandering/exit seeking. If any behaviors/changes were found then they would proceed to review the assessments and care plans to ensure a process was in place. They stated on the weekend the Department Manager, would check the doors to ensure they were alarming, as well as talk with staff to ensure no resident was exhibiting exit seeking or wandering behaviors. Furthermore, they would review the 24 Hour Report book for any changes noted. In addition, a phone call would be made to the Administrator. 14. Review of Unsampled A, who was exhibiting exit seeking behaviors on 06/08/18, revealed an elopement assessment was updated and interventions included on the care plan. Interview with the SDC (interim DON), on 06/11/18 at 5:00 PM, revealed a resident was exhibiting exit seeking behaviors on 06/08/18 and the elopement assessment was updated, as well as interventions included on the care plan on 06/08/18. She stated no other resident had exhibited exit seeking behaviors since 05/25/18. 15. Review of the QA meetings revealed the facility has met weekly on 05/29/18, 05/31/18, and 06/07/18 with a Regional Team member present at each meeting. In addition, the team included the Administrator, DON, SDC (interim DON), MDS, Unit Managers, BOM, and Medical Director. Interview with the SDC on 06/11/18 at 5:15 PM, the BOM on 06/12/18 at 9:49 AM, Unit Manager for 200 Hall at 10:00 AM, Unit Manager for 100 Hall at 10:19 AM, Director of Rehabilitation at 11:20 AM, Regional Team member (Regulatory Liaison) at 11:45 AM, revealed they have met weekly to discuss the open tags and why the IJs were given to the facility, reviewed audits performed for the week as well as track and trend the audits to see if there needed to be any changes to the plan. 16. Review of facility's audit revealed door checks on all exterior doors (7) were completed daily since 05/29/18. Observation, on 06/12/18 at 12:12 PM, revealed all the doors alarmed when a transmitter/wanderguard was present and staff responded to alarm. Interviews, on 06/12/18 with the BOM at 9:49 AM, Unit Manager for 100 Hall at 10:19 AM, and Maintenance Director at 12:03 PM, revealed the Maintenance Director checked the doors Monday-Friday and the Department Manager on duty checked the doors on the weekend. 17. Review of a facility audit, revealed beginning 05/29/18, the DON reviewed all elopement assessments and care plans for identified at-risk residents three (3) times a week. Interview with the SDC (interim DON), on 06/11/18 at 5:15 PM, revealed she reviewed the residents at risk for elopement including their assessments and care plans to ensure no changes were needed. 18. Review of the facility weekly QA revealed the team reviewed the audits for the week with a member of the Regional Team present. Interview with the SDC, on 06/11/18 at 5:15 PM, the BOM on 06/12/18 at 9:49 AM, Unit Manager for 200 Hall at 10:00 AM, Unit Manager for 100 Hall at 10:19 AM, Director of Rehabilitation at 11:20 AM, Regional Team member (Regulatory Liaison) at 11:45 AM, revealed they have met weekly to review audits performed for the week as well as track and trend the audits to see if there needed to be any changes to the plan.

Based on interview and record review, it was determined the Medical Director failed to ensure the coordination of medical care in the facility, failed to ensure implementation of resident care policies and failed to ensure the facility sustained compliance as evidenced by deficient practice in the following areas: (Refer F561, F580, F600, F656, F657, F658, F684, F686, F690, F697, F725, F760, F773, and F842). The facility's failure to ensure the Medical Director coordinated medical care in the facility has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, Residents #20, #33, and #41 were all recently admitted to the facility; however, there was no documented evidence of a history and physical (H&P) in the charts; physician's orders [REDACTED]. The findings include: Review of the Agreement For Medical Director Services, (no date), revealed : 1. Duties and Obligations of the Medical Director: A. Services. The Medical Director agreed to provide administrative and professional services required as needed and requested to assist the Company, to ensure the adequacy and appropriateness of the care rendered to residents of the Facility and to supervise the medical care of the residents at the Facility. In order to fulfill the responsibilities, the Medical Director would provide the following services in accordance with currently accepted professional standards, and applicable federal, state, and local laws and regulations, twenty-four (24) hours per day in the case of an emergency, and otherwise as needed to provide advice, service and consultation in person. by telephone and through written reports and statements. 1. Patient Care Policies. The Medical Director would participate as requested in the ongoing development of the Facility's Patient Care Polices and providing guidance to the Administrator and the Director of Nursing on their implementation and execution of such policies. 2. Physicians Services Polices. The Medical Director would participate as requested in the ongoing development of Physician Service Policies, specifying the duties, responsibilities and rights of each physician attending Residents of the Facility, which included, but was not limited to, the appropriate and timely intervals for physician visits. 3. Ongoing Consultation. The Medical Director would consult with and advise the Administrator and Director of Nursing on the medical related aspects of patient care at the Facility, operations, employee health, community relations and staff education and development. 4. Liaison With Attending Physicians. The Medical Director would act as a liaison with attending physicians as requested to promote their understanding of an compliance with federal and state laws, rules and regulations, and the Facility's polices and procedures, which included, but was not limited to, the appropriate and timely intervals for physician visits and requirements for the use of physician assistants and nurse practitioners. 5. Monitoring Attending Physician Services. The Medical Director would make recommendations as requested regarding attending physician's compliance with federal and state requirements for physician services, which included, but was not limited to, the frequency of physician's visits, delegation of duties to physician assistants and nurse practitioners, and personal approval of an admission recommendation. In the event a resident's attending physician had not performed such physician services, the Medical Director would, upon request of the Administrator, notify said physician of such non-compliance. If the attending physician did not comply, the Medical Director would perform such services. 6. Emergency and Routine Physician Coverage. The Medical Director shall participate as requested in the establishment of policies and procedures to provide for essential and emergency physician coverage and services, to include on call physician coverage. 7. Visits. The Medical Director would visit the Facility as reasonably appropriate to fulfill the Medical Director's responsibilities hereunder. 8. Committee Service. The Medical Director would participate as an active member of the Facility's committees, to include, but not limited to, the Utilization Review Committee, Patient Care Committee, Infections Control Committee, and the Pharmacy Committee, as requested by the Administrator. 9. Coverage. The Medical Director would arrange for a qualified physician, acceptable to Facility, to perform the obligations of this Agreement during any absence, vacation, or other periods when the Medical Director would be unavailable. Review of the Resource Guide, (Physician Services) dated 06/01/12, given to new admissions, revealed the selected physician (or his/her designee) would direct the care of the residents while at the nursing facility. In addition, the Medical Director would coordinate the medical services provided to the residents to include routine and emergency services. 1. On 03/07/18, the facility failed to ensure Resident #3's environment remained as free from accidents and hazards as possible related to he/she was transferred by a new lift, with staff, Certified Nurse Aides (CNA) #9 and #13, using the incorrect sling. This transfer resulted in the resident falling out of the sling onto the floor. The facility failed to revise the resident's care plan to ensure the correct lift and sling were used on Resident #3. 2. On 03/24/18, (CNA's) #1 and #19 used a lift to transfer Resident #15 against his/her will. Resident #15 grabbed the grab bars of the bed to attempt to not be transferred with the lift. The two (2) CNA's pried his/her hands off the grab bar and forced him/her to use the lift. The resident ended up in the lift without a call light and stated he/she panics without a call light. The resident had a sore right hand the next day with bruising noted on the right second and third knuckle. Resident #15 stated it was very demeaning. 2. Resident #64 was assessed to have three (3) Stage IV Pressure Ulcers: the left buttock, the right buttock, and sacrum; and two (2) unstagable pressure ulcers: left and right heels due to necrosis. Review of the Physician order [REDACTED]., (made from diluted bleach,) covered with gauze and secured with tape. Two Stage IV areas to the bilateral heels were to have been treated with Skin-Prep (a liquid, film-forming agent that forms a protective film around intact skin) and left open to air. All dressings were ordered to have been changed twice a day (BID.) A foam dressing was to have been applied to a scar on the resident's right chest and was to have been changed weekly on Fridays.Record review revealed there was no evidence the resident was provided treatments on 04/01/18-04/06/18 at 7:00 AM and 7:00 PM, except for one entry on 04/04/18 at 7:00 AM and no evidence the physician or wound care center was made aware of the treatments not being completed. Resident #64 was also care planned for staff to turn and reposition every two (2) hours; however, observations on 04/04/18 at 10:15 AM, 12:15 PM, 2:20 PM, 4:40 PM and 5:18 PM and throughout the survey, on 04/03-05/18, revealed there were multiple observations of the resident lying supine. In addition, the resident was ordered [MEDICATION NAME] every three (3) hours and [MEDICATION NAME] and Tylenol, as needed (PRN) for pain and care planned to administer pain medications thirty (30) minutes prior to the extensive dressing changes for five (5) Stage IV Pressure Ulcers; or if the resident complained of pain during this treatment, the staff were to have stopped the treatment and after ensuring the resident was safe, sought pain relief and returned when the pain was reported as acceptable; and to report any unrelieved or unacceptable levels of pain to the physician. However, observation of dressing changes on 04/05/18 at 3:35 PM, revealed staff failed to administer pain medication prior to or during the dressing changes and the resident screamed at the staff how bad he/she was hurting, tears were in his/her eyes, and he/she had facial grimacing. Observation of Resident #64's dressings to the sacral area on 04/03/18 at 5:18 PM, revealed the dressing site to sacral area, had visible dampness and was not secured, was dated 04/02/18 even though the resident was supposed to receive dressing changes two (2) times a day, and there was a darkened area noted below the dressing site. Further review of a Physician order [REDACTED]. However, review of the Narcotic Count Sheet and observation of the date of the patch on Resident #64's shoulder revealed the patch was not administered to the resident until 04/07/18 at 11:00 AM. 3. Resident #56 was admitted with a burn to the right lower leg on 02/20/18 and was assessed, care planned and had physician orders [REDACTED]. However, observations, interviews, and review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the resident's treatments were not being completed as care planned and ordered. Resident #56 had orders to apply Santyl (chemical debrider) ointment to the lower right [MEDICAL CONDITION] washing with soap and water and to receive showers every other day to prepare the burn wounds for skin graph. Resident #56 did not receive a shower from 03/29/18 through 04/04/18 and dressing changes on 03/30/18, 03/31/18, 04/01/18 and 04/02/18 on either shift. On 04/03/18, Resident #56 was observed lying in bed with a large amount of green drainage on dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed. 4. On 02/12/18, Resident #51 had orders for a Urinalysis and Culture and Sensitivity (C&S); however, the facility failed to ensure the C&S results were obtained and the Physician was notified of the results. Review of the laboratory documentation, revealed the facility was notified by facsimile (fax) on 02/15/18 of the C&S results but there was no documented evidence of physician notification. On 02/28/18 (approximately two {2} weeks later), review of the nursing notes revealed the resident was noted to not respond verbally, not follow with his/her pupils and his/her eyes were dilated. In addition, the resident had a temperature of 95 degrees Fahrenheit. The resident was hospitalized with [DIAGNOSES REDACTED]. 5. Review of the Medication Administration Records (MARs) revealed the facility failed to ensure residents were free of any significant medication errors for twenty-six (26) of thirty-six (36) sampled residents (Residents #2, #13, #20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, ). Additionally, the licensed staff failed to administer [MEDICATION NAME] and blood thinners, Insulin, blood pressure medication, [MEDICAL CONDITION] medication, and/or Antipsychotics to Residents #2, #13, #20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #57, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, #625. 6. The facility failed to ensure the clinical records were accurate and complete related to documentation on the Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for twenty-five (25) of thirty-six (36) residents (Residents #2, #13, #20, #29, #30, #35, #40 ,#43, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #67. #73, #74, #125, #275, #575 and #625). 7. Staff interviews revealed Certified Medication Aides (CMA's) were being pulled from the medication administration tasks to work on the units as CNA's due to not enough CNA's to provide care which resulted in residents experiencing declines in their overall status related to pain management, wound/pressure sore care, significant medication errors, resident hospitalization s, and lack of documentation in the clinical record to assure provision of necessary care and services to the residents. Resident interviews revealed complaints of not receiving care and services. Interview with the Medical Director, on 04/07/15 at 8:45 PM, revealed there had been no consistency in leadership of the facility and there was not a good flow to the system. He stated he believed the facility having three (3), four (4) or five (5) Director of Nursings in the past year was the biggest problem as there had not been a steady rudder for the ship. 8. Record review revealed the facility admitted Resident #20 on 12/13/17 with [DIAGNOSES REDACTED]. However, review of Resident #20's clinical record revealed there was no documented evidence of a H&P, or that the Physicians' Orders were signed for (MONTH) (YEAR) and January, (YEAR); and, no evidence the Physician saw the resident from (MONTH) (YEAR) through (MONTH) (YEAR). 9. Record review revealed the facility admitted Resident #41 on 08/21/17 with [DIAGNOSES REDACTED]. However, review of Resident #41's clinical record revealed there was no documented evidence of a H&P on the chart and no evidence the Physician saw the resident from (MONTH) (YEAR) through February, (YEAR), 10. Record review revealed the facility admitted Resident #32 on 11/08/17 with [DIAGNOSES REDACTED]. However, further review of Resident #32's clinical record revealed there was no documented evidence of a H&P on the chart, and no evidence the Physician saw the resident from (MONTH) (YEAR) through January, (YEAR). Attempts to contact the residents' primary care physician were unsuccessful. A phone call was made on 04/06/18 at 1:13 PM with no answer; on 04/09/18 at 9:30 AM with a message with call back information left on the answering machine; and, on 04/19/18 at 2:30 PM with no answer. Interview with the Medical Records Coordinator (MRC) on 04/19/18 at 8:58 AM revealed it was her responsibility to make sure all the records were current and up-to-date. She stated, if she did not have the documents, she could not put them on the chart. The MRC further stated it was difficult to get progress notes, signed orders and H&Ps from the primary physician. She stated she had to hand deliver orders for the primary physician's signature, and the primary physician may sign the orders at that time or it may take her two to three (2-3) weeks to sign them. The MRC stated the primary physician visits the residents, when she feels like it, and visits are not on a routine basis. The MRC further stated when the primary physician visits the residents, she did not write a progress note in the facility, she does them at home and they pile up there. The MRC further revealed she made the Medical Director aware of the situation, and the Medical Director informed her he's . not her (primary physician) boss. Interview with the Divisional Director of Operations on 04/20/18 at 5:37 PM revealed the H&P's should have been on the charts, . but we do not have them and we could not get them. Interview with the Medical Director (MD) on 04/19/18 at 10:30 AM revealed he was aware of his responsibility as Medical Director to organize and coordinate medical care and physician services as they relate to resident care in the facility. He stated he was aware of the visits and the progress notes not being done by the Primary Physician. He stated, She (primary physician) has always been that way. The MD further stated if the primary physician did not want to see nursing home residents and do her job, she should not have accepted the responsibilities. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & (TRUNCATED)

Based on interviews it was determined the facility failed to ensure it had a governing body, or designated persons functioning as a governing body, that was legally responsible for establishing and implementing policies regarding the management and operation of the facility; and, failed to ensure the facility sustained compliance as evidenced by deficient practice (Refer F561, F580, F600, F656, F657, F658, F684, F686, F690, F697, F725, F760, F773, and F842). The facility's failure to have a governing body in place to assure the facility was administered in a manner that promoted, protected and enhanced the health and safety of each resident, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator, on 04/07/18 at 4:30 PM, revealed there was no policy related to governing body and the facility followed regulatory guidelines which states the facility will have designated persons functioning as a governing body, that was legally responsible for establishing and implementing policies regarding the management and operation of the facility. The members of the governing body included the Medical Director, Administrator, Director of Nursing and the Regional Director of Operations. Further interview with the Administrator, on 04/07/18 at 8:35 PM, revealed the governing body was aware of the issues with the turnover in the DONs at the facility and was attempting to change that; however, nothing had been changed. She stated they were aware of the concerns related to revision of the comprehensive care plan, abuse, neglect, pressure sore/wound care, resident rights, infection control, pain management, lab monitoring, staffing, medication errors, lack of documentation in the clinical record, pain management and ongoing assessment of clinical change of condition of residents in the facility (F561, 580, F600, F656, F657, F658, F684, F686, F690, F697, F725, F760, F773, F775, and F842). She stated there had been a mock survey conducted in (MONTH) (YEAR) and it was identified that the DON was not engaged in her job duties and there wasn't enough staff in the building to put action plans in place to correct identified deficiencies effectively. She stated she was on a timeline to get plans in place to correct the identified concerns but there was no full leadership team to assist her. She stated she expected staff to perform their duties and to follow the facility's policies and procedures; however, she was unaware of the magnitude of the lack of follow through. Interview with the Medical Director, on 04/07/15 at 8:45 PM, revealed he believed the biggest problem was turnover in staffing related to the Director of Nursing (DON) as the facility had three (3), four (4) or five (5) in the past year and there had not been a steady rudder for the ship. He stated there had been no consistency in leadership of the facility and there was not a good flow to the system. Interview with the Regional Nursing Manager, on 04/07/18 at 8:30 PM, revealed the governing body was aware of the facility's current and ongoing problems and were available when needed. However, after the mock survey was conducted in (MONTH) (YEAR), corrective actions were not put into place to address the identified concerns in the facility such as staffing, lab reporting, medication documentation, wound care, infection control, Resident Rights, care plan review and implementation, pain management, etc. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. Review of medication records to identify and address medication errors for Residents #29, 43, 73, 20, 61, 2, 57, 125, 47, 53, 62, 64, 575, 67, 74, 65, 60, 63, 13, 40, 30, 275 and 16 was performed by 04/18/18. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure sore management; medication administration in regards to documentation and timeliness; HIPPA (privacy); use of lifts/slings; lock out/tag out system for mechanical lifts; implementation and revision of care plans; and the responsibilities and job duties of a licensed nurses. Interview with Certified Medication Tech (CMT) #2 on 04/20/18 at 11:05 AM, revealed she had received education related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination); HIPPA (privacy); and medication administration in regards to documentation and timeliness. 13. Review of the newly adapted ADL competency check list revealed all CNA's were educated by the RN Nurse Consultants on the new check list and ADL competencies were being evaluated and completed by 04/18/18 as alleged. 14. Review of the audit log sheets, dated 04/09/18, revealed MAR and TAR audits initiated on and had been conducted daily from 04/09/18 through 04/17/18. 15. Review of audit documentation revealed lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 16. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 17. Review of the Clinical QAPI process Form revealed it was updated by RN nurse consultant to include monitoring of pain management control. Review of the action plan for pain management (no date) revealed the goal was to reach optimum pain management of identified clients and prevent other clients in the facility from being at risk for the occurrence. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 18. Review of the contract agreements, titled Prime Time Health Care, dated 04/09/18, Healthcare Staffing Agreement, dated 04/09/18, and Tru Staff for travel personal staffing agreement, dated 04/19/18 revealed the facility had obtained contracts with staffing agencies and was utilizing staff from sister facilities for licensed staff to ensure appropriate staffing levels by 04/18/18 as alleged in the AoC. 19. Review of the daily stand up meeting sign in sheets revealed the DON and Administrator attended the daily morning meetings. Interviews with the Administrator and Interim DON, on 04/20/18 at 2:30 PM, revealed they were both attending the daily stand up meetings. 20. Review of QA Committee Privileged, QA meeting on 04/10/18; revealed Agenda discussed; Discuss Survey IJ Outcome, Discuss Plan of correction, Discuss organization and of evaluations, auditing and monitoring, Discussed in-service and training, and competency checks, Discussed daily plan for monitoring, Discussed consult reviews, Obtained feedback from Medical Director, QA Committee will meet again 04/17/18 to review status plan of the current issues at the facility. 21. Review of QA meeting notes dated 04/17/18, revealed the Regional Director of Operations/Interim Administrator; Acting DON, Interim Social Worker; Activities Director; Rehab Manager, MDS Nurse; Business Office Manager; Human Resources Manager; Medical Director; Quality and Compliance Specialist were present. Both the administrator and DON will be participating in daily stand up meetings, weekly QA, and regular reporting to the Governing body regarding achieving an maintaining ongoing substantial compliance.

Based on observation, interview, record review and review of the Administrator's Job Description, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a selected sample of thirty-six (36) residents and nine (9) unsampled residents. Seven (7) tags were cited at a scope/severity of a K and thirteen (13) tags were cited at a scope/severity of a J related to the failure to provide care and services related to abuse, neglect, pressure sore/wound care, resident rights, infection control, pain management, lab monitoring, staffing, medication errors, lack of documentation in the clinical record, pain management and ongoing assessment of clinical change of condition of residents in the facility . The facility's failure to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Administrator's Job Description, (not dated), revealed the Administrator was responsible for planning, organizing, developing and directing the overall operation of the facility in accordance with current applicable Federal, State, local and corporate regulations, standards, guidelines, and policies as may be directed by the State Executive Director to ensure quality services at all times, provide leadership, supervision and direction to all departments to actively monitor effectiveness of services, personnel management and overall facility operations; monitors turnover statistics and employee morale and develops interventions as needed to decrease the turnover; ensures effective, sound health and safety practices are in place to provide for the well-being of residents, staff and visitors to the facility, and that incident/accident reporting are in place and followed, assures internal follow up and audit procedures are in place to measure the accuracy, quality and delivery of services according to the regulatory and corporate requirements. Interview with the Administrator, on 04/07/18 at 8:30 PM, revealed she was aware of the concerns related to revision of the comprehensive care plan, abuse, neglect, pressure sore/wound care, resident rights, infection control, pain management, lab monitoring, staffing, medication errors, lack of documentation in the clinical record, pain management and ongoing assessment of clinical change of condition of residents in the facility (F561, 580, F600, F656, F657, F658, F684, F686, F690, F697, F725, F760, F773, and F842). She stated there had been a mock survey conducted in (MONTH) (YEAR) and it was identified that the DON was not engaged in her job duties and there wasn't enough staff in the building to put action plans in place to correct identified deficiencies effectively. She stated she was on a timeline to get plans in place to correct the identified concerns but there was no full leadership team to assist her. She stated she expected staff to perform their duties and to follow the facility's policies and procedures; however, she was unaware of the magnitude of the lack of follow through. 1. Resident #56 had orders to apply Santyl (chemical debrider) ointment to the lower right [MEDICAL CONDITION] washing with soap and water. However, there was no documented evidence the treatment had been completed or the shower had been given on 03/30/18 and 03/31/18. On 04/03/18, Resident #56 was observed lying in bed with a large amount of green drainage on dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed. In addition, on 04/04/18, an order was received to shower Resident #56 daily with soap and water, pat wound dry then apply treatment. However, there was no documented evidence the new order was documented on the (MONTH) (YEAR) MAR, shower list, or care plan. (Refer to F684, F656, F658 & F657). 2. Resident #64 was assessed to have three (3) Stage IV Pressure Ulcers: the left buttock, the right buttock, and sacrum; and two (2) unstagable pressure ulcers: left and right heels due to necrosis. The resident was ordered [MEDICATION NAME] every three (3) hours and [MEDICATION NAME] and Tylenol, as needed (PRN) for pain. However, licensed staff failed to provide pain medication prior to dressing changes on 04/05/18 at 3:35 PM. The resident called out repeatedly in pain and the licensed staff stated (He/She) always screams like that, as they continued to fill the deep wounds in the resident's back side. In addition, the dressing to the right torso, dated 04/03/18, had a moderate amount of thick green, foul smelling drainage, that covered the nine inch by nine inch dressing and was seeping from under the dressing site and on to the resident's gown. Necrotic areas at both heels were cleaned with a skin prep solution and placed back into blood splattered heel boots, while the resident begged the staff tearfully not to place them back into the boots. (Refer to F686, F656, F697, F658 & F657). 3. Resident #51 received orders to obtain urine for Urinalysis (UA), and Culture and Sensitivity (C&S) on 02/12/18 with UA results received on 02/13/18. The C&S results were reported to the facility via facsimile (fax) on 02/15/18. There was no documented evidence licensed staff monitored the receipt of laboratory results, notified the lab the results were not received within twenty-four (24) hours or as indicated; and notified the supervisor and physician of any delays in receipt of lab results. On 02/28/18 (fifteen {15} days later), the resident had Altered Mental Status, urine with strong odor, and a temperature of 95.7 degrees Fahrenheit and was transferred and admitted to the hospital [DIAGNOSES REDACTED]. 4. Interview and record review revealed Resident #51 was not allowed to exercise his/her rights related to refusing to have a mechanical lift for transfers used and was injured by CNA's who forced him/her to use the lift against his/her will (Refer to F600 & F561). 5. On 03/07/18, two (2) Certified Nurse Aides (CNA's) transferred Resident #3 with a new mechanical lift using the old lift sling; which resulted in the resident falling out of the sling onto the floor. The facility determined staff required reeducation and removed the new lift from the floor. However, the facility failed to educate all staff to not use the new lift, and on the proper use of lifts. 6. Interview and record review revealed Physician notification was not made in regards to significant medication errors for (Residents #2, #5, #13, #15, #16, ,#20, #29, #30, #35, #40, #43, #47, #53, #56, #57, #59, #60, #61, #62, #63, #65, #67, #73, #74, #125, #275, #575, and #625 treatment omission for Residents #56 & 64. (Refer to F760 & F580). 7. Review of Medication Administration Records (MARS) and Treatment Administration Records (TAR's) revealed medical records were not complete for Residents #2, #13, #20, #29, #30, #35, #40 ,#43, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #67, #73, #74, #125, #275, #575 and #625. (Refer to F842). 8. Observations, interviews, record review, and review of staffing sheets revealed there was not adequate staffing to ensure medications to include pain medications were passed or passed timely which resulted in significant medication errors, to ensure treatments were being provided to improve wounds and prevent infection, and that labs were followed up on timely. (Refer to F684, F725, F690, F760, F773). Interview with the Regional Nurse Manager, on 04/07/18 at 8:40 PM, revealed the Chief Nursing Officer was aware of the facility's concerns and there was a lot of dead weight in the building. However, there had not been any significant changes to correct the concerns with the operation of the facility. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. Review of medication records to identify and address medication errors for Residents #29, 43, 73, 20, 61, 2, 57, 125, 47, 53, 62, 64, 575, 67, 74, 65, 60, 63, 13, 40, 30, 275 and 16 was performed by 04/18/18. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure sore management; medication administration in regards to documentation and timeliness; HIPPA (privacy); use of lifts/slings; lock out/tag out system for mechanical lifts; implementation and revision of care plans; and the responsibilities and job duties of a licensed nurses. Interview with Certified Medication Tech (CMT) #2 on 04/20/18 at 11:05 AM, revealed she had received education related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination); HIPPA (privacy); and medication administration in regards to documentation and timeliness. 13. Review of the newly adapted ADL competency check list revealed all CNA's were educated by the RN Nurse Consultants on the new check list and ADL competencies were being evaluated and completed by 04/18/18 as alleged. 14. Review of the audit log sheets, dated 04/09/18, revealed MAR and TAR audits initiated on and had been conducted daily from 04/09/18 through 04/17/18. 15. Review of audit documentation revealed lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 16. Review of a reference tool in use as of 04/10/18, revealed daily mo (TRUNCATED)

Based on observation, interview, record review, review of staffing sheets, and review of staffing procedure guidelines, it was determined the facility failed to assure that care and services were provided to residents related to a failure to provide sufficient licensed personnel for supervision and monitoring; assure that staff assigned to provide care and services to residents were trained, competent, and oriented to the facility's policies and procedures; and failed to assure that the status of each resident's condition was assessed by qualified nursing licensed personnel. Further evidence to support the facility's failure to assure sufficient nursing staff included the facility's failure to develop/implement systems to monitor staffing levels and develop/implement systems to assure that staff providing care and services was trained and competent to deliver the services. The failure to assure that sufficient qualified nursing staff was available on a daily basis to meet the residents' needs for nursing care and services resulted in residents experiencing declines in physical, mental, and/or psychosocial well-being and ongoing immediate and serious threat to the residents of the facility (Census 77). Staff interviews revealed Certified Medication Aides (CMA's) were pulled from the medication administration tasks to work on the units as CNA's due to not enough CNA's to provide care which resulted in residents experiencing declines in their overall status related to pain management, wound/pressure sore care, significant medication errors, resident hospitalization s, and lack of documentation in the clinical record to assure provision of necessary care and services to the residents. Resident interviews revealed complaints of not receiving care and services. The facility's failure to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Staffing Procedure Guidelines, dated 04/07/18, revealed during shift where the facility had deemed additional staffing was optimal as deemed by the Administrator, DON (Director of Nursing) and/or ADON (Assistant Director of Nursing), the facility would enact staffing procedures to ensure coverage was secured. Short notice schedule modifications or changes may be initiated to ensure staffing was maintained. Direct care personnel may be required to arrive early or extend their current shift or shifts during instances where there was a call off that occurred on the off going or oncoming shift. The extension would remain in effect until staffing was secured to fill the shift (s) and management's (DON, ADON or Administrator) approved leave was granted to the impacted employee. Review of the staffing sheets dated 04/03/18 through 04/06/18, revealed a shortage in Certified Nursing Assistants (CNA) coverage as follows: On 04/03/18, the required number of CNA's for day shift (6:30 AM to 2:30 PM) were eight (8) and there were six (6) assigned; for second shift (2:30 PM to 10:30 PM) the required number was seven (7) and there was six (6) assigned; for night shift (10:30 PM to 6:30 AM) the required number was four (4) and two (2) were assigned. Further review revealed there were (3) licensed staff required on day shift (6:00 AM-6:00 PM) and three were assigned; and three licensed nurses were required on the evening/nigh shift (6:00 PM-6:00 AM) with one (1) Registered Nurse (RN), one (1) LPN and one (1) Certified Medication Aide (CMA) assigned for evening/night shift. On 04/04/18, the required number of CNA's for day shift was eight (8) and there were six (6) assigned, on second shift there were seven (CNA) required and there were six (6) assigned; and, on night shift the required number was four (4) and there were three (3) assigned. Further review revealed there were three (3) licensed staff required on day shift and there was one (1) RN and two (2) LPNs assigned; and, there were three licensed staff required on night shift with two (2) LPNs and one (1) CMA assigned. On 04/05/18, the required number of CNA's for day shift was eight (8) and there were six (6) assigned; for second shift the required number was seven (7) and there were six (6) assigned; and on night shift the required number was four (4) with three (3) were assigned. Further review revealed there were three licensed staff required on day shift with two (2) LPNs and one (1) RN assigned; there were three (3) licensed staff required on evening/night shift with one (1) RN and one (1) LPN assigned. On 04/06/18, the required number of CNA's for day shift was eight (8) and there were six (6) assigned, on second shift there were seven (CNA) required and there were five (5) assigned; and, on night shift the required number was four (4) and there were three (3) assigned. Further review revealed there were three (3) licensed staff required on day shift and there were three LPN's assigned, and, there were three licensed staff required on night shift with one (1) RN, one (1) LPN's and one (1) CMA assigned. On 03/07/18, two (2) Certified Nurse Aides (CNA's) transferred Resident #3 with the new mechanical lift using the old lift sling; which resulted in the resident falling out of the sling onto the floor. The facility determined staff required reeducation and removed the new lift from the floor. However, the facility failed to educate all staff to not use the new lift, and on the proper use of lifts. 1. Resident #64 was assessed to have three (3) Stage IV Pressure Ulcers: the left buttock, the right buttock, and sacrum; and two (2) unstagable pressure ulcers: left and right heels due to necrosis. The resident was ordered [MEDICATION NAME] every three (3) hours and [MEDICATION NAME] and Tylenol, as needed (PRN) for pain. However, licensed staff failed to provide pain medication prior to dressing changes on 04/05/18 at 3:35 PM. The resident called out repeatedly in pain and the licensed staff stated (He/She) always screams like that, as they continued to fill the deep wounds in the resident's back side. In addition, the dressing to the right torso, dated 04/03/18, had a moderate amount of thick green, foul smelling drainage, that covered the nine inch by nine inch dressing and was seeping from under the dressing site and on to the resident's gown. Necrotic areas at both heels were cleaned with a skin prep solution and placed back into blood splattered heel boots, while the resident begged the staff tearfully not to place them back into the boots 2. Resident #56 had orders to apply Santyl (chemical debrider) ointment to the lower right [MEDICAL CONDITION] washing with soap and water. However, there was no documented evidence the treatment had been completed or the shower had been given on 03/30/18 and 03/31/18. On 04/03/18, Resident #56 was observed lying in bed with a large amount of green drainage on dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed. In addition, on 04/04/18, an order was received to shower Resident #56 daily with soap and water, pat wound dry then apply treatment. However, there was no documented evidence the new order was documented on the (MONTH) (YEAR) MAR, shower list, or care plan. Interview with the Director of Nursing (DON), on 04/06/18 at 4:20 PM, revealed she had been hired in (MONTH) (YEAR) and due to staff walking out and being terminated, she was having to work the hallways and stated she had to work the evening shift all Easter weekend on the floor, because there was no one to take her place. She stated the treatment nurse was fired on 03/28/18 and the Administrator stated the charge nurses were responsible for the dressing changes after this. She stated she was not aware until recently that they were not being completed. 3. Resident #51 received orders to obtain urine for Urinalysis (UA), and Culture and Sensitivity (C&S) on 02/12/18 with UA results received on 02/13/18. Laboratory (lab) personnel revealed the C&S results were reported to the facility via facsimile (fax) on 02/15/18. However, there was no documented evidence licensed staff monitored for receipt of the laboratory results, notified the lab the results were not received within twenty-four (24) hours or as indicated; and notified the supervisor and physician of any delays in receipt of lab results. On 02/28/18 (fifteen {15} days later), the resident had Altered Mental Status, urine with strong odor, and a temperature of 95.7 degrees Fahrenheit. The resident was transferred to the hospital and admitted with [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #1 on 04/07/18 at 2:48 PM, revealed she had been responsible for tracking and logging labs, however, with her added duties she just didn't have time to take care of three (3) units. 4. On 03/07/18, the facility failed to ensure Resident #3's environment remained as free from accidents and hazards as possible when Certified Nurse Aides (CNA) #9 and CNA #13 transferred Resident #3 with a new lift without any training on the proper use of the lift. The CNA's used the old lift sling which resulted in the resident falling out of the sling onto the floor. The facility failed to have an effective system in place to train staff on new equipment; train on the lock out tag out system; and communicate to staff which lift and sling to be used on each resident to ensure the residents' environment remains as free from accidents and hazards as possible; or to ensure adequate supervision was provided while transferring with a lift for two (2) of thirty-six (36) sampled residents. Interview with the Regional Nurse Consultant on 03/28/18 at 3:12 PM revealed the staff had not received education on the new lift prior to use. She stated the facility did not have slings for the new lift and it should not have been available for staff use. 5. Resident #15 was assessed as an assist of two for transfer without a mechanical lift. However, on 03/24/18, Resident #15 was forced to get up into the wheelchair by the use of a mechanical lift by two (2) Certified Nurse Aides (CNA). Resident #15 stated he/she grabbed the bars of the bed so not to be transferred by the lift but the two (2) CNAs pried his/her hands off the grab bar and forced him/her to use the lift against his/her will. Resident #15 ended up in the lift without a call light, which terrifies him/her to be without his/her call light. He/she also stated it was very demeaning. 6. Licensed staff failed to ensure Resident's #2, #13, #20, #29, #30, #31, #35, #40, #43, #47, #50, #53, #56, #57, #59, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, and #625 received medication and treatments in accordance with professional standards and Residents #23, #35 and #49 were provided ongoing assessments of [MEDICAL TREATMENT] shunts. In addition, the licensed staff failed to notify the physician of the medication omissions and document accurately to show if the resident received his/her medications/treatments or not. 5. Licensed staff failed to ensure Residents #2, #13, #20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #57, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, #625 were free from significant medication/treatment errors. Interview with the Director of Nursing (DON) on 04/04/18 at 6:40 PM, revealed she was not aware there was not a nurse assigned to Hall 200 to administer medication on the morning of 04/04/18. The DON stated the scheduling person was responsible to ensure adequate amount of staff but the scheduling person received a call-in from the nurse scheduled to come in at 6:00 AM on 04/04/18; but did not report the call-in to anyone and left for vacation. Interview with Certified Medication Technician (CMT) #8 on 04/05/18 at 11:30 AM, revealed LPN #7 called her to come in to work on 04/03/18 at about 7:30 PM to help give the 6:00 PM medications and other night time medications on 300 Hall (above residents). She stated by the time she got to the facility, the 8:00 PM medications were late and the residents were begging for their medications so the two (2) of them passed the medications together to get them passed faster. She revealed after the medications were passed, she went back home because LPN #7 stated she would sign out the medications, but she did not. CMT #8 stated she did not sign out any medications, even though she administered medications. She stated about a month ago the CMT's were pulled to work as CNA's and the nurses had to start passing their own medications . Interview with the Director of Nursing on 04/06/18 at 2:00 PM revealed she expected to be notified if medications or treatment were not received or refused. She stated the nurse that had worked the first and second shift on 04/02/18 was escorted out of the facility at 4:00 AM, on the morning of 04/03/18 due to being under the influence of something. The DON stated the nurse was to impaired to do the narcotic count before leaving, so she was unsure if the medications were given or not. She stated this nurse had also worked on 04/01/18. Interview with Certified Nurse Aide (CNA) #16, on 04/04/18 at 8:45 AM, revealed she had left the facility feeling as though she had not been able to provide sufficient care for the residents because there was not enough staff. Interview with CNA #10 on 04/03/18 at 5:08 PM, revealed she had been unable to check on Resident #64 since she started her shift at 2:30 PM and stated she was covered up with work needing to be completed. Interview on 04/05/18 at 4:35 PM, revealed she was unable to turn Resident #64, as she started her shift at 2:30 PM and was the only CNA on 300 Wing. Interview with CNA #4 on 04/04/18 at 3:12 PM, revealed some residents had been sitting up in the wheel chairs all day, because there was not enough staff to put them back to bed after meals. She also stated the CNA's had to start putting the residents back to bed at 4:15 PM, in order to get everyone in bed and most of the time, the resident's had to eat their supper meal in their room, due to a lack of staffing. Interview with CNA #2, on 04/06/18 at 8:20 AM, revealed there were more days of not having enough staff than days with enough staff and she left the facility from 2:30 PM to 10:30 PM shift feeling as though the residents did not receive the care they deserved. Interview with CNA/Certified Medication Aide (CMA) #2 on 04/03/18 at 5:10 PM, revealed she had been unable to assist with medication administration lately due to short staffing and having to work the floor as a CNA, so the licensed staff have been passing medications and completing treatments. Interview with Certified Medication Tech (CMT) #1, on 04/04/18 at 11:25 AM, revealed there was not enough staff in the building and medications were being given late and residents were coming to the medication cart to receive their medication because they were in pain. She revealed there was not enough time to complete the necessary tasks to care for the residents. Interview with Licensed Practical Nurse (LPN) #4, on 04/04/18 at 10:15 AM, revealed there was not enough staff in the building to assure care was provided to the residents and the ones who did show up were not doing their jobs. Additionally, she revealed the CMA's were being taken from their duties of passing medications and assigned to the floor to work as a CNA and there was not enough nurses to get everything done and pass medications as well. Interview with LPN #7 on 04/03/18 at 4:15 PM, revealed due to short staffing, she was just now able to call the physician for an order for [REDACTED]. Interview with Registered Nurse (RN) #3, on 04/06/18 at 8:00 AM, revealed the facility was having a staffing problem related to not having enough CNA's in the building to split between one (1) and two (2) halls. Interview with Registered Nurse (RN) #2 on 04/04/18 at 10:54 AM, revealed she had been the wound care nurse and had been taken off this position for budgeting concerns on 03/28/18 (terminated for suspected drug abuse). She stated there were concerns the pressure sore treatments were not being completed as ordered, due to short staffing and had not been changed for several days and not done at all on the week-ends. She also stated the staff ask the resident if he/she would like the dressings changed, instead of saying we are going to change your dressings now, to which the resident usually complied. Interview with the Staff Development Coordinator (SDC)/RN on 04/04/18 at 6:55 PM, revealed due to short staffing, she and the DON had been working the floor and both worked the Easter Weekend. Interview with the Medical Director, on 04/07/18 at 8:40 PM, revealed he believed the biggest problem with staffing in the building was the turnover rate of the Director of Nursing (DON) position because there had been three (3) or (4) in the past year. He stated there had been no consistency in leadership (no steady rudder for the ship). He revealed there had been a failure in the Quality Assurance (QA) process and the facility had not gotten a good flow to the system. Interview with the Administrator, on 04/07/18 at 8:30 PM, revealed the facility did not have a policy and procedure for staffing and staffing had been reviewed by her and there had been multiple call offs from work from licensed nursing staff. She stated the Staffing Coordinator had not been in the facility for the past two (2) days (04/05/18 and 04/06/18) due to being on vacation. She revealed there had been shifted budget items which had affected staffing and some of the nursing staff had been working overtime and some were on Family Medical Leave Act (FMLA). She stated one (1) Registered Nurse (RN) had to be terminated and others were not happy about having the CMT's pulled from the medication carts to work as CNA's on the floor leaving them to pass the medications. She stated she did not believe there was a nursing shortage in the facility, but the licensed nurses who were working were not performing their job duties. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to

Based on observation, interview and record review, it was determined the facility failed to have an effective system in place to identify quality issues and/or develop and implement an effective plan to correct identified quality deficiencies in a timely manner related to significant medication errors, developing and implementing care plans, reviewing and revising care plans, infections, hospitalization s, quality of care, abuse/neglect, self- determination, physician notification, staffing, accuracy of clinical records, pain management and wound/pressure sore care. On 03/07/18, the facility determined two (2) Certified Nurse Aides (CNA's) transferred Resident #3 with the new mechanical lift using the old lift sling; which resulted in the resident falling out of the sling onto the floor. However, the facility failed to educate all staff to not use the new lift, and on the proper use of lifts. On 02/13/18, Resident #51 received orders for staff to obtain urine for Urinalysis (UA), and Culture and Sensitivity (C&S) on 02/12/18 with UA results received on 02/13/18. There was no documented evidence licensed staff monitored for receipt of the laboratory results, notified the lab the results were not received within twenty-four (24) hours, and notified the supervisor and physician of any delays in receipt of lab results. In addition, laboratory (lab) personnel revealed the C&S results had been reported to the facility via facsimile (fax) on 02/15/18. On 02/28/18 (fifteen {15} days later), the resident was identified by staff to have Altered Mental Status, urine with strong odor, and a temperature of 95.7 degrees Fahrenheit. The resident was admitted with [DIAGNOSES REDACTED]. Resident #64 was assessed, care planned and had physician orders [REDACTED]. However, the resident failed to receive twice a day (BID) dressing changes for five (5) Stage IV Pressure Ulcers, from 04/01-05/18, which promoted increasing and unnecessary pain and a worsening of the resident's pressure areas and condition, causing mental anguish and serious physical harm. Resident #56 was assessed to have a lower right [MEDICAL CONDITION] orders to apply Santyl (chemical debrider) ointment after washing [MEDICAL CONDITION] soap and water and showering every other day to [MEDICAL CONDITION] skin graphs. However, there was no documented evidence the treatment had been completed or the shower had been given on 03/30/18 and 03/31/18. On 04/03/18, Resident #56 was observed lying in bed with a large amount of green drainage on dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed. In addition, on 04/04/18, an order was received to shower Resident #56 daily with soap and water, pat wound dry then apply treatment. However, there was no documented evidence the new order was documented on the (MONTH) (YEAR) MAR, shower list, or care plan. The facility's failure to develop and implement appropriate plans of action to correct identified quality deficiencies has caused or was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator, on 04/07/18 at 8:35 PM, revealed the QA meetings were held monthly and the members included the Director of Nursing (DON), Medical Director, Business Office Manager, Social Service Director, Minimum Data Set (MDS) Nurses, Maintenance Director, Activities, Housekeeping Supervisor and Dietary Manager. She stated some concerns were being addressed such as the lack of documentation related to medication administration and staffing. However, there had not been much time to get into other areas of concern because there was no cooperation or help from the clinical staff on the floor to assist with overseeing the process related to following up on audits, mock survey, etc. Additionally, she stated she expected all staff to adhere to the facility's policy and procedures related to all aspects of resident care. 1. On 03/07/18, the facility failed to ensure Resident #3's environment remained as free from accidents and hazards as possible when Certified Nurse Aides (CNA) #9 and CNA #13 transferred Resident #3 with a new lift without any training on the proper use of the lift. The CNA's used the old lift sling which resulted in the resident falling out of the sling onto the floor. The facility failed to educate staff on proper use of the new lift and the type sling to be used on residents with a lift. In addition, after the incident the facility failed to ensure all staff were notified not to use the new lift until they were educated on it; and failed to reinservice all staff on the lift use and using the proper sling. 2. On 02/13/18, Resident #51 had orders for a Urinalysis and Culture and Sensitivity (C&S); however, the facility failed to ensure the C & S results were obtained and the Physician was notified of the results. According to laboratory documentation, the facility was notified by facsimile (fax) on 02/15/18 of the C & S results; however, there was no documented evidence the facility made the Physician aware of the results. On 02/28/18 (approximately two {2} weeks later), the resident was noted to not respond verbally, not follow with his/her pupils and his/her eyes were dilated. In addition, the resident had a temperature of 95 degrees Fahrenheit. The resident was hospitalized with [DIAGNOSES REDACTED]. 3. On 04/05/18 at 3:35 PM, observation revealed staff provided dressing changes to Resident #64's three (3) Stage IV Pressure Ulcers: the left buttock, the right buttock, and sacrum; and two (2) unstagable pressure ulcers: left and right heels due to necrosis. Licensed staff failed to provide pain medication prior to the dressing changes. The resident called out repeatedly in pain and the licensed staff stated (He/She) always screams like that, as they continued to fill the deep wounds in the resident's back side. The resident was ordered [MEDICATION NAME] every three (3) hours and [MEDICATION NAME] and Tylenol, as needed (PRN) for pain. In addition, the dressing to the right torso, dated 04/03/18, had a moderate amount of thick green, foul smelling drainage, that covered the nine inch by nine inch dressing and was seeping from under the dressing site and on to the resident's gown. Necrotic areas at both heels were cleaned with a skin prep solution and placed back into blood splattered heel boots, while the resident begged the staff tearfully not to place them back into the boots. 4. Resident #56 was admitted with a burn to the right lower leg on 02/20/18 and was assessed, care planned and had physician orders [REDACTED]. However, observations, interviews, and review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the resident's treatments were not being completed as care planned and ordered. On 04/04/18, Resident #56 went to the wound clinic and returned with an order to shower daily with soap and water, pat the wound dry and then apply treatment to ensure the treatments were completed daily to prepare wound for skin graphs. However, review of the Nurse's Notes, (MONTH) (YEAR) TAR, Care Plan and shower sheet, on 04/07/18 at 2:00 PM revealed the order was not transcribed for the daily showers to be completed. 5. Licensed staff failed to administer [MEDICATION NAME] and blood thinners, Insulin, blood pressure medication, [MEDICAL CONDITION] medication, and/or Antipsychotics to Residents #2, #13, #20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #57, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, #625. 6. Licensed staff failed to document if they administered Residents #2, #13, #20, #29, #30, #35, #40 ,#43, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #67. #73, #74, #125, #275, #575 and #625 medications/treatments so staff would know whether the residents had received his/her medications/treatments or not. Interview with the Medical Director, on 04/07/15 at 8:45 PM, revealed he believed the biggest problem was turnover in staffing related to the Director of Nursing (DON) as the facility had three (3), four (4) or five (5) in the past year and there had not been a steady rudder for the ship. He revealed there had been no consistency in leadership of the facility and there was not a good flow to the system. Interview with the Regional Nurse Manager, on 04/07/18 at 8:40 PM, revealed the Chief Nursing Officer was aware of the facility's concerns and there was a lot of dead weight in the building; however, there had not been any significant changes to correct the concerns with the operation of the facility. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure sore management; medication administration in regards to documentation and timeliness; HIPPA (privacy); use of lifts/slings; lock out/tag out system for mechanical lifts; implementation and revision of care plans; and the responsibilities and job duties of a licensed nurses. Interview with Certified Medication Tech (CMT) #2 on 04/20/18 at 11:05 AM, revealed she had received education related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident (TRUNCATED)

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure residents were free of any significant medication errors for twenty-six (26) of thirty-six (36) sampled residents (Residents #2, #13, #20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, ). Licensed staff failed to provide Resident #56's treatments to debride the resident's burn wound to his/her right leg to prepare for skin graphs. In addition, staff failed to provide treatments and pain medication to Resident #64 related to three (3) Stage IV wounds which caused the resident to scream out in pain. The facility's failure to ensure residents were free of any significant medication errors has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, the licensed staff failed to administer [MEDICATION NAME] and blood thinners, Insulin, blood pressure medication, [MEDICAL CONDITION] medication, and/or Antipsychotics to Residents #2, #13, #20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #57, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, #625. The findings include: Review of the facility's policy for Medication Administration, dated (MONTH) 2012, revealed the individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record), immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. If a dose of a regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. 1. Record review revealed the facility admitted Resident #64 on 09/15/17 and readmitted the resident from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #64's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of the (MONTH) (YEAR) Physicians' Orders revealed three (3) Stage IV Pressure Ulcers, to the right and left buttock and sacral areas, which were to be cleansed with Dial Soap and water, packed with one-quarter (1/4) strength Dakin's Solution, (made from diluted bleach,) covered with gauze and secured with tape. The two Stage IV areas to the bilateral heels were to be treated with Skin-Prep (a liquid, film-forming agent that forms a protective film around intact skin) and left open to air. All dressings were ordered to be changed twice a day (BID.) A foam dressing was to be applied to a scar on the resident's right chest; and changed weekly on Fridays. Further review revealed to obtain accuchecks twice a day; and administer [MEDICATION NAME] 10 milligrams (mg) twice a day for Depression, [MEDICATION NAME] 15 mg twice a day for [MEDICAL CONDITION], [MEDICATION NAME] 30 mg at bedtime for Failure to Thrive, [MEDICATION NAME] one (1) mg every six (6) hours as needed for Anxiety, and [MEDICATION NAME] 7.5 mg/325 mg every four (4) hours as needed for pain. Review of Resident #64's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In addition, accuchecks were not obtained twice a day (BID) from 04/01-06/18, except one time on 04/04/18 at 8:00 PM for a result of 230 mg/dl (milligram/deciliter). Additionally, [MEDICATION NAME] was not administered twice a day on 04/01-02/18 and the evening dose was missed on 04/03/18; [MEDICATION NAME] was not administered on 04/01/18 or 04/02/18; and [MEDICATION NAME] was omitted on 04/01/18, 04/02/18 and 04/03/18. Interviews with Licensed Practical Nurse (LPN) #7 on 04/03/18 at 4:00 PM, revealed she was responsible for the treatments and the dressing changes for Resident #64 and they had not been completed. LPN#7 stated the treatments and dressing changes were completed, When he/she will let me. The LPN stated the resident refuses all the time, and they were short staffed. LPN #7 stated she I have asked for help. Interview with Registered Nurse (RN) #2 on 04/04/18 at 10:54 AM, revealed she had been the wound care nurse and had been taken off this position for budgeting concerns. She stated there were concerns the pressure sore treatments were not being completed as ordered; had not been changed for several days; and not done at all on the week-ends related to short staffing. She also stated the staff would ask the resident if he/she would like the dressings changed, instead of saying, We are going to change your dressings now., to which the resident usually complied. Interview with the Director of Nursing (DON), on 04/06/18 at 4:20 PM, revealed she had been hired in (MONTH) (YEAR) and due to staff walking out and being terminated, she was having to work the hallways and stated she had to work the evening shift all Easter weekend on the floor, because there was no one to take her place. She stated the treatment nurse was fired on 03/28/18 and the Administrator stated the charge nurses were responsible for the dressing changes after this. She stated she was not aware until recently that they were not being completed. Interview with the Administrator on 04/05/18 at 1:58 PM, revealed she was recently made aware of an observation on 04/03/18 at 5:18 PM, that revealed the dressings had not been changed since 04/02/18. She stated she was not aware the dressings had not been completed, as ordered until the last couple of days. The Administrator stated she would have expected the staff to have notified the physician when medications and treatments were not administered, as ordered. 2. Record review revealed the facility admitted Resident #56 on 02/20/18, with [DIAGNOSES REDACTED]. Review of the Resident #56's Physicians' Orders dated 03/08/18, revealed to apply Santyl ([MEDICATION NAME] ointment) to the right lower leg after washing with soap and water. Pat dry, and cover with nickel thick ointment, then cover with moist gauze, then dry gauze, then roll gauge, then ace wrap. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TAR) revealed there was no documentation the staff applied the Santyl on 03/30/18, 03/31/18, 04/04/18 and 04/02/18; and on 04/03/18 on the morning shift. Observation and interview on 04/03/18 at 1:09 PM, revealed Resident #56 lying in bed with a large amount of green drainage, noted on the dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before. Observation of the dressing change on 04/03/18 at 2:31 PM revealed copious amounts of green, bloody drainage with a foul smell. Observation revealed there was not a date or time provided on the old dressing. 3. Record review revealed the facility admitted Resident #2 on 10/27/17, with [DIAGNOSES REDACTED]. Review of Resident #2's (MONTH) and (MONTH) (YEAR) Physicians Orders revealed to administer [MEDICATION NAME] 50 mg 1 tablet by mouth twice daily for blood pressure, [MEDICATION NAME] DR 125 mg Cap sprinkles give 2 capsules (250 mg) by mouth four times a day for [MEDICAL CONDITION], Klonopin 0.5 mg tablet one tablet by mouth twice daily, Aripiprazole 2 mg tablet 1 tablet by mouth at bedtime, and [MEDICATION NAME] 10 mg tablet take one tablet by mouth every night for mood stabilization. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]{4} doses of each medication over 4 days). 4. Record review revealed the facility admitted Resident #30 on 01/04/18, with [DIAGNOSES REDACTED]. Review of Resident #30's (MONTH) (YEAR) Physicians' Order revealed to administer [MEDICATION NAME] 5 mg tablet one three times a day, [MEDICATION NAME] 10 mg give one tablet by mouth daily at bedtime, Quetiapine [MEDICATION NAME] 25 mg tab one tablet by mouth at night, [MEDICATION NAME] 300 mg capsule one tablet twice daily, Magnesium Oxide 400 mg tablet one tablet orally twice daily, [MEDICATION NAME] HCL 10 mg tablet 10 mg PO two times daily, and [MEDICATION NAME] 160-4.5 MCG inhaler inhale 2 puffs two times daily. In addition, [MEDICATION NAME] 0.125 mg tablet one tablet one time a day was ordered. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In addition, there was no documentation [MEDICATION NAME] 0.125 mg was administered on 04/01/18 and 04/02/18 at 6:00 AM. 5. Record review revealed the facility admitted Resident #57 on 02/20/18, with [DIAGNOSES REDACTED]. Review of Resident #57 (MONTH) (YEAR) and (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] 5 mg tablet one PO at bedtime and [MEDICATION NAME] HCL 30 mg tablet one tablet by mouth at bedtime for depression. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. 6. Record review revealed the facility admitted Resident #74 on 08/30/17, and readmitted on [DATE] at 3:28 PM with [DIAGNOSES REDACTED]. Review of Resident #74 (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] HCL 4 mg tablet give one tablet by mouth twice a day for muscle spasms, [MEDICATION NAME] 300 mg capsule give one capsule by mouth every 8 hours for [MEDICAL CONDITION], [MEDICATION NAME] HCL 100 mg tab give one tablet by mouth daily at bedtime for depression, and [MEDICATION NAME] 50 mg tablet give one tablet by mouth daily at bedtime for [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 7. Record review revealed the facility admitted Resident #47 on 01/17/17, and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47 (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' Orders revealed to administer Eliquis 2.5 mg tablet give one tablet by mouth twice daily for anticoagulation. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. 8. Record review revealed the facility admitted Resident #67 on 03/15/18, with [DIAGNOSES REDACTED]. Review of Resident #67's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' orders revealed an order for [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. 9. Record review revealed the facility readmitted Resident #20 on 12/13/17, with [DIAGNOSES REDACTED]. Review of Resident #20's (MONTH) (YEAR) Physicians' Order revealed to administer [MEDICATION NAME] 300 mg capsule take one capsule by mouth three times daily for [MEDICAL CONDITION], [MEDICATION NAME] HCL 15 mg tablet take one tablet by mouth three times daily for mood stabilization, [MEDICATION NAME] 3 mg tablet take one tablet by mouth every bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 150 mg tablet two (2) tablets (300 mg) by mouth every night at bedtime for [MEDICAL CONDITION], Quetiapine [MEDICATION NAME] 300 mg tab take one tablet by mouth every bedtime for [MEDICAL CONDITION], Memantine HCL 10 mg tablet take one tablet by mouth two times daily for Alzheimer's, Carvedilol 6.25 mg tablet take one tablet by mouth two times daily for hypertension, Potassium CL ER 20 mEq tablet take one tablet by mouth two times daily for supplement, Ducosate Sodium 100 mg softgel give one softgel by mouth twice daily for constipation, [MEDICATION NAME] HCL 25 mg tab take one tablet by mouth at bedtime for nerve pain/antidepressant, and Donepezil HCL 10 mg tablet take one tablet by mouth every bedtime for Alzheimer's. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 10. Record review revealed the facility admitted Resident #65 on 02/10/17 with [DIAGNOSES REDACTED]. Review of Resident #65's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' Order revealed an order for [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. 11. Record review revealed the facility admitted Resident #44 on 02/02/18, with [DIAGNOSES REDACTED]. Review of Resident #44's (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] 30 mg tablet one tablet by mouth every night for A-Fib, Eliquis 5 mg tablet one tablet two times a day by mouth, [MEDICATION NAME] sodium 100 mg capsule one by mouth twice a day, [MEDICATION NAME] 250 mg capsule one capsule by mouth twice daily [MEDICATION NAME] 100 units/ml vial inject 10 units subcutaneous every night. and to obtain Accuchecks before meals and at bedtime and record results. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 12. Record review revealed the facility readmitted Resident #31 on 09/24/17 with [DIAGNOSES REDACTED]. Review of Resident #31 (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] Sodium 20 mg tab one tablet by mouth once daily for [MEDICAL CONDITION]; to check oxygen saturation (O2 Sat) every shift and PRN, notify physician if O2 sat less than 90%; and wanderguard-check placement every shift. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. 13. Record review revealed the facility readmitted Resident #43 on 02/02/18 with [DIAGNOSES REDACTED]. Review of Resident #43 (MONTH) (YEAR) and (MONTH) (YEAR) Physician order [REDACTED]. Review of the (MONTH) and (MONTH) MAR indicated [REDACTED]. 14. Record review revealed the facility admitted Resident #50 on 02/12/18, with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]{3} days). 15. Record review revealed the facility admitted Resident #53 on 12/12/15, with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 16. Record review revealed the facility admitted Resident #63 on 12/08/17 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 17. Record review revealed Resident #275 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 18. Record review revealed the facility admitted Resident #73 on 03/06/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 03/23/18, revealed the facility assessed Resident # 73's cognition as severely impaired with a Brief Interview for Mental Status (BIMS') score of five (5), which indicated the resident was not interviewable. Review of Resident #73's (MONTH) (YEAR) Physicians' Orders revealed to administer Quetiapine [MEDICATION NAME] (antipsychotic) 100 MG Tab give (1) one tablet by mouth three (3) times daily, [MEDICATION NAME] Succ ER (Blood pressure) 200 mg give (1) tablet by mouth twice (2) daily, [MEDICATION NAME] 250-50 Diskus (breathing medication) inhale one (1) puff twice (2) daily for [MEDICAL CONDITION], [MEDICATION NAME] ER (anti-diabetic) 2.5 MG tablet (1) tablet by mouth once daily before breakfast, [MEDICATION NAME] (blood pressure) 100 MG tab (2) tablets by mouth every 12 hours' *Hold for heart rate below 60 for hypertension, [MEDICATION NAME] (Alzheimer's) 5 MG tablet give (1) tablet by mouth at bedtime, Accuchecks twice (2) a day call MD if blood sugar <60 or >400, and Wander guard-check (monitoring device) placement, function (right ankle) ordered every shift. Review of Resident #73's (MONTH) (YEAR) MAR, revealed Quetiapine [MEDICATION NAME] Succ ER, [MEDICATION NAME] 250-50 Diskus [MEDICATION NAME] 100 MG tab, [MEDICATION NAME] 5 MG tablet were not documented as administered at 9 PM on 04/01/18, 04/02/18 and 04/03/18. In addition, [MEDICATION NAME] ER 2.5 MG was not documented as given at 6:00 AM on 04/01/01-04/03/18. Further review revealed accuchecks twice (2) a day were not documented as being obtained at 6:30 AM and 8:00 PM on 04/01-03/18; and Wander guard-check placement, function (right ankle) once a shift was not documented as being completed at 7:00 AM and 7:00 PM on 04/01-03/18. However, further review of the record on 04/04/18, revealed no documented evidence in the Nurse's Notes, or on the MARs/TAR's, as to why the medication and treatments were not administered as the physician ordered, or that the physician was notified of the missed medications. 19. Record review revealed the facility admitted Resident #575 on 12/19/17, with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] Prop 50 micrograms (mcg) spray, 1 spray each nostril every night at bedtime; [MEDICATION NAME] Sodium 20 mg tab, give one tablet by mouth daily at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] (antipsychotic) 5 mg tablet, 1 tablet by mouth three times a day for [MEDICAL CONDITION]; and, Levetiracetam 500 mg tablet, 1 tablet by mouth twice daily for [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with Resident #575 on 04/07/18 at 9:00 AM revealed he/she believes he/she has not been receiving his/her medications at night. He/She stated he/she didn't understand why he/she didn't get them. He/She also stated he/she did not ask anyone about not getting the medications. Resident #575 stated that he/she figured if they wanted him/her to have his/her medications, they would have given them to him/her. Interview with LPN #3 on 04/03/18 at 5:25 PM revealed on the morning of 04/03/18, she was covering the 100 and 200 Halls, and when she went over to the 300 Hall (above residents), she found the nurse to be sleeping ( the nurse responsible for the above noted residents). She stated when the nurse was awakened she was very fidgety and talking to herself and making weird demonic noises and talking in different voices. She stated she called the Director of Nursing (DON) to ask what she should do and the DON told her to take the keys away from the nurse, but the nurse refused to give them up, so she just kept a close eye on her until the DON got to the facility and walked her out of the facility. The facility requested the nurse do a drug test but the nurse refused. Interview with Certified Medication Technician (CMT) #8 on 04/05/18 at 11:30 AM, revealed LPN #7 told her to say there was not enough time to give the medications due to not enough help. CMT #8 stated what actually happened was LPN #7 called her To come in to work on 04/03/18 at about 7:30 PM to help give the 6:00 PM medications and other night time medications on 300 Hall (above residents). She stated by the time she got to the facility, the 8:00 PM medications were late and the residents were begging for their medications so the two (2) of them passed the medications together to get them passed faster. She revealed after the medications were passed, she went back home because LPN #7 stated she would sign out the medications, but she did not. CMT #8 stated she did not sign out any medications, even though she administered medications. She further revealed she knew she should of signed out the medications that she gave but trusted LPN #7 to because it was the LPN's shift and she was just helping her out. She stated about a month ago the CMT's were pulled to work as CNA's and the nurses had to start passing their own medications. CMT #8 stated the nurses were very frustrated because they had to give their own medications. Continued interview revealed some of the nurses had drug and alcohol problems and were on the CARES Program (cannot give narcotics due to drug use history). She stated if the medications were not signed out as given, then they were not given. Interview with the Director of Nursing on 04/06/18 at 2:00 PM revealed she expected to be notified if medications or treatment were not received or refused. She stated if the MAR/TAR was not initialed then it was right to assume the medication or treatment had not been administered. She stated the nurse that had worked the first and second shift was escorted out of the facility at 4:00 AM, on the morning of 04/03/18 due to being under the influence of something. The DON stated the nurse was to impaired to do the narcotic count before leaving, so she was unsure if the medications were given or not. 20. Record review revealed the facility admitted Resident #61 on 09/27/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/14/18, revealed the facility assessed Resident #61's cognition as moderately impaired with a BIMS score of twelve (12) which indicated the resident was interviewable. Review of (MONTH) (YEAR) physician's orders [REDACTED].#61 [MEDICATION NAME] 70-30, 30 units subcutaneous twice a day for Diabetes; finger stick blood glucose checks before meals and at bedtime with sliding scale parameters for administering Humalog (insulin). Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of Resident #61's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with Resident #61 on 04/05/18 at 1:59 PM revealed the resident did not recall getting insulin and/or a finger stick on 04/04/18. 21. Record review revealed the facility admitted Resident #60 on 09/27/15, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/12/18 revealed the facility assessed Resident #60's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of (MONTH) (YEAR) physician's orders [REDACTED].#60 finger stick blood glucose checks before meals and at bed time; Humalog 10 units subcutaneous with meals for Diabetes. Review of Resident #60's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with Resident #60 on 04/05/18 at 9:53 AM revealed there had been times when he/she had not received his/her Insulin or finger sticks. The resident stated he/she did not receive Insulin or finger sticks on the morning of 04/04/18. 22. Record review revealed the facility admitted Resident #125 on 03/20/18 with [DIAGNOSES REDACTED]. Review of Resident's Brief Interview of Mental Status (BIMS) score on admission revealed the facility assessed Resident #125's cognition as intact with a score of fifteen (15) which indicated the resident was interviewable. However, after brief conversation with the resident, it was determined information obtained was not reliable. The Admission Minimum Data Set (MDS) assessment had not been completed due to a hospital admission on 03/31/18 related to [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED].#125 finger stick blood glucose checks before meals and at bed time with sliding scale parameters for administering Humalog; and, [MEDICATION NAME] 15 units subcutaneously with meals for Diabetes. Review of Resident #125's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #3 on 04/04/18 at

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to have an effective system to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of thirty-six (36) sampled residents (Resident #64). Resident #64 was assessed, care planned and had physician orders for dressing changes twice a day (BID). However, the resident failed to receive twice a day (BID) dressing changes for five (5) Stage IV Pressure Ulcers, from 04/01-05/18, which promoted increasing and unnecessary pain and a worsening of the resident's pressure areas and condition, causing mental anguish and serious physical harm. The facility's failure to provide the necessary treatment and services, consistent with the professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Skin System Policy and Procedure, last revised (MONTH) 2014, revealed all resident will be assessed on admission, readmission and quarterly and with each change of condition for their individual risks for skin compromise. Care planning starts on admission a baseline assessment is developed for each resident. Upon completion of the Admission Data Set, the nurse will implement the ADL Care Guide and provide instructions to the nursing assistants regarding the care of the resident. The Interact System is utilized for assessment, documentation, change of condition and any possible transfer. Notify the physician and responsible party of the skin/wound impairment. Note of the 24 Hour Report and the TAR and notify the assigned nurse manager, nursing assessment coordinator and Skin Committee of the change in the resident's condition, requiring additional oversight and monitoring. Review of the facility's policy titled, Dressings, Dry/Clean, last revised (MONTH) 2013, revealed after verifying the physician's order, reviewing the resident's care plan and checking the treatment record, the licensed staff was to have assembled their equipment and explained the procedure to the resident. The resident was to have been positioned correctly and the staff was to have washed their hands, put on clean gloves and removed the old dressing and discarded. They were then to have washed their hands and put on clean gloves. Record review revealed the facility admitted Resident #64 on 09/15/17 and readmitted the resident from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment dated [DATE], revealed the facility assessed Resident #64's cognition as intact with a Brief Interview for Mental Status (BIMS score of thirteen (13)which indicated the resident was interviewable. In addition, the resident required extensive assist of two (2) staff for Activities of Daily Living (ADLs). Review of the Wound Healing Progress Report, dated 02/16/18, upon readmission from the hospital, revealed the resident had five (5) Stage IV Pressure Sores: the left buttock, measuring a length of four centimeters (4.0 cm) by a width of 4.0 cm by a depth of 1.5 cm; the right buttock measured 7.0 cm by 7.0 cm by 0.4 cm; the area to the sacrum measured 4.0 cm by 4.2 cm by 3.7 cm; the left heel was un-stageable, due to necrosis (a thick, black/brown scabbed area) and measured 7.0 cm by 7.0 cm by 0.1 cm; the right heel was also un-stageable, also due to necrosis and measured 4.0 cm by 4.0 cm by 0.1. Additionally, the resident required a protective dressing to a scar to the upper right torso, the site measured 4.0 cm by 4.0 cm, with no depth noted. Review of the Comprehensive Care Plan for Impaired Skin Integrity, dated 02/23/18, revealed interventions for treatments, as ordered; turning and repositioning every two (2) hours and as needed and as will allow; pain medications 30 minutes prior to dressing changes; a low air loss mattress; and staff were to report any signs or symptoms of infection (odor, increased drainage, pain or redness) and to notify the physician, family or responsible party of any changes. Review of the (MONTH) (YEAR) Physician Orders revealed three Stage IV Pressure Ulcers, to the right and left buttock and sacral areas, were to have been cleansed with Dial Soap and water, packed with one-quarter (1/4) strength Dakin's Solution, (made from diluted bleach,) covered with gauze and secured with tape. The two Stage IV areas to the bilateral heels were to have been treated with Skin-Prep (a liquid, film-forming agent that forms a protective film around intact skin) and left open to air. All dressings were ordered to have been changed twice a day (BID.) A foam dressing was to have been applied to a scar on the resident's right chest and was to have been changed weekly on Fridays. Review of the Medication Administration Records (MARS) and Treatment Administration Records (TAR's) for (MONTH) (YEAR), revealed there was no evidence that any of the three Stage IV dressing changes, to the resident's bottom, had been completed for 7:00 AM and 7:00 PM, from 04/01/18-04/05/18, except for one (1) entry on 04/04/18 at 7:00 AM. Interview with Resident #64 on 04/03/18 at 03:39 PM, revealed the pressure areas to the sacral area and bilateral buttocks, felt like they were to his/her rectum, and stated honey, it feels like they are running electric wires up inside me when they do that, when asked about the pressure sore dressings. She also stated, it just hurts too bad to turn over. Observation of Resident #64's dressings to the sacral area on 04/03/18 at 5:18 PM, with the Staff Development Coordinator (SDC) and CNA #10, revealed the resident called out with turning, but tolerated the procedure well. The dressing site to sacral area, had visible dampness and was not secured, was dated 04/02/18 even though the resident was supposed to receive dressing changes two (2) times a day, and a darkened area was noted below the dressing site. Observations on 04/04/18 at 10:15 AM, 12:15 PM, 2:20 PM, 4:40 PM and 5:18 PM and throughout the five-day survey, on 04/03-05/18, revealed there were multiple observations of the resident lying supine. The resident was not observed to have been repositioned off her backside, except for two (2) brief periods for observation of pressure areas and stayed supine with head of the bed elevated 30 degrees for five days. Observation of the dressing change on 04/05/18 at 3:35 PM, with RN #1 and LPN #7, revealed the the left buttock wound measured five (5.0) cm by four (4.0) cm by three (3.0) cm; the right buttock wound measured six (6.0) cm by four (4.0) cm by four (4.0) cm; the sacrum wound measured five (5.0) cm by four (4.0) cm by two (2.0) cm; the necrotic left heel was four (4.0) cm by six (6.0) with no visible depth; and the necrotic right heel measured three (3.0) cm by three (3.0) cm with no depth determined. The area to the right chest, from a AAA repair at his/her right chest that never properly healed, revealed a protective dressing dated 04/03/18, a green, foul smelling drainage, and measured six (6.0) cm by four (4.0) cm with bright red, shiny skin noted at the site. The slimy, green drainage covered the nine (9.0) inch by (9.0) nine inch dressing and was seeping from under the dressing site and on to the resident's gown. The measurements revealed all wounds had increased in depth to where the bone was visible at the right lower buttock wound. Necrotic (black/brown scabbed areas) at both heels were cleaned with a skin prep solution. As RN #1 and LPN #7 filled the three Stage IV Pressure areas to the right and left buttock and sacral areas with a bleach solution soaked gauze, the resident was calling out You are hurting me!' and this pain makes me so sick! and you don't know how much that hurt!. Further observation revealed the staff never washed their hands in between glove changes and RN #1 stated In an ideal world, we would have changed them in between each wound dressing and washed our hands, but she is in too much pain. Additionally, during the dressing change on 04/05/18, it was noted the resident's heel boots had blood splatters and other debris. Observation on 04/06/18 at 8:30 AM, revealed the resident was still wearing the gown with the green drainage on the front. In addition, the heel boots that had blood splatters and other debris, still remained on the resident at the end of the survey on 04/07/18. Interview with Certified Nurse Aide (CNA) #5 on 04/04/18 at 2:25 PM, revealed Resident #64 refuses to turn side-to-side, off the buttocks and sacral area and the CNA stated they were unable to enter any times of repositioning on the care plan documentation, because of the resident's refusals. She stated she had reported this to the licensed staff repeatedly. Interview with CNA #10 on 04/04/18 at 2:40 PM, revealed Resident #64 lies supine all day long and refuses to turn, screaming until he/she is placed back in a supine position because it hurts him/her too bad. Interview with CNA #10 on 04/05/18 at 4:35 PM, revealed the resident remained in the same hospital gown, dampened with the green-colored drainage from the dressing to the resident's right chest. The CNA stated she had started her shift at 2:30 PM, yet had not been in the room to check on the resident, due to being short of staff and stated the previous shift CNA failed to mention anything about this and stated she was a new girl and did not know her name. Interview with CNA #3 and observation of Resident #64 on 04/06/18 at 8:30 AM, revealed the resident was still wearing the same hospital gown with the green drainage on the front and the blood and debris speckled heel boots and the CNA stated if I saw it, I would have reported it, and was not made aware of the drainage or heel boots until this time. Interview with Licensed Practical Nurse (LPN) #7 on 04/03/18 at 4:00 PM, revealed she was responsible for the treatments and the dressing changes for Resident #64 and they had not been completed and were completed when he/she will let me. The LPN stated the resident refuses all the time, because it hurts the resident too bad, and they were short staffed and she had asked for help. Interview with Registered Nurse (RN) #2 by phone, on 04/04/18 at 10:54 AM, revealed she had been the wound care nurse and had been taken off this position for budgeting concerns on 03/28/18. She stated there were concerns the pressure sore treatments were not being completed as ordered, due to short staffing and had not been changed for several days and not done at all on the week-ends. She also stated the staff ask the resident if he/she would like the dressings changed, instead of saying we are going to change your dressings now, to which the resident usually complied. Interview with the Director of Nursing (DON) on 04/06/18 at 4:20 PM, revealed she would have expected the staff to have changed their gloves and washed their hands. Interview with RN #1 on 04/05/18 at 3:50 PM, revealed she was unaware of any problems with the torso dressing, as she had been off work for a week and stated the torso wound was from an old surgical wound that was healed and this dressing was only there for protection. Interview with Resident #64's Physician on 04/04/18 at 1:50 PM, revealed he did not foresee these pressure ulcers healing as the resident was not cooperative with the required care and the resident had her own mind. The physician was not aware the resident was not medicated prior to the dressing changes. Interview with the Physician on 04/05/18 at 4:50 PM, revealed he was not aware of the green-colored drainage to Resident #64's right chest and stated this was supposedly healed. Interview with the Administrator on 04/05/18 at 1:58 PM, revealed she was recently made aware of the resident not having been turned, repositioned, gotten out of bed, or moved off his/her buttocks, and recently made aware of the observation on 04/03/18 at 5:18 PM, that revealed the dressings had not been changed since 04/02/18. The Administrator stated she was not aware the dressings had not been completed, as ordered until the last couple of days. She also stated the charge nurses were responsible to complete the dressings, as the facility no longer employed a wound care nurse. The Administrator stated she would have expected the resident's refusal would not be the nurses' sole attempt to complete the dressing changes and the nurses should have proceeded to find out why the resident was refusing and take a step to eliminate the reason and maybe try another staff member the resident would be more willing to allow to help. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders starting on 04/10/18 and to be completed by 04/18/18 or will not be allowed to work until educated. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders revealed they were updated as well. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included Physician's Orders by order type, Treatment Records, Oxygen Orders, Tube Feeding Orders, Lab Orders Audit, Elopement Audit, Dietary, Skin Audits, TB Audits, Falls, Care Plan Review/Update, and Code Status review. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders starting on 04/10/18 and to be completed by 04/18/18 or the employee will not work until t (TRUNCATED)

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure one (1) of thirty-six (36) sampled residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan (Resident #56). Resident #56 was admitted with a burn to the right lower leg on 02/20/18 and was assessed, care planned and had physician orders [REDACTED]. However, observations, interviews, and review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the resident's treatments were not being completed as care planned and ordered. On 04/04/18, Resident #56 went to the wound clinic and returned with an order to shower daily with soap and water, pat the wound dry and then apply treatment. However, review of the Nurse's Notes, (MONTH) (YEAR) TAR, Care Plan and shower sheet, on 04/07/18 at 2:00 PM revealed the order was not transcribed for the daily showers to be completed. The facility's failure to ensure resident's received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the policy titled, Dressings, Dry/Clean dated 09/2013 revealed: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage 3. The name and title of the individual changing the dressing. 4. The type of dressing used and the wound care given. 5. All assessment data obtained when inspecting the wound. 6. How the resident tolerated the procedure. 7. Any problems or complaints (pain or discomfort) made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for the refusal and the resident's response to the explanation of the risk of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. 9. The signature and title of the person recording the data. Reporting: Notify the supervisor if the resident refuses the dressing change, and report other information in accordance with facility policy and procedure and professional standards of practice. Policy review titled Medication Administration, General Guidelines, dated 12/12 revealed medications are administered as prescribed in accordance with manufacturers, specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. 1. The individual who administers the medication dose, records the administration on the resident's MAR indicated [REDACTED]. 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication is withheld or refused, the physician is notified. 4. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the care center's master employee signature log. Record review revealed the facility admitted Resident #56 on 02/20/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 02/27/18, revealed the facility assessed Resident #56's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of Resident #56's (MONTH) (YEAR) physician's orders [REDACTED]. Pat dry, and cover with nickel thick ointment, then cover with moist gauze, then dry gauze, then roll gauge, then ace wrap. This was to be done two (2) times a day (BID). In addition, the resident was to be showered every other day with dressing off the right lower leg with dial soap and water, rinse well, and make sure dressing was changed two times a day (BID). Review of Resident #56 Comprehensive Care Plan for Impaired Skin Integrity and Risk for Alteration in Comfort related to Burn to right lower leg/foot, dated 02/20/18 revealed report any signs and symptoms of infection (odor, increased drainage, pain, or redness), shower every other day, remove dressing to the right leg, use dial soap and water, rinse well; and, ensure the dressing was changed two (2) times a day, was added on 03/14/18. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARs) revealed the resident should be showered every other day; however, further review of the TAR's revealed Resident #56 had not been provided a shower per the care plan from 03/29/18 through 04/04/18 which indicated he/she went without a shower for five (5) days and there was no documentation as to why this occurred. Further review of the (MONTH) and (MONTH) (YEAR) TAR revealed there was no documentation the dressing was changed per the care plan on 03/30/18, 03/31/18, 04/01/18 and 04/02/18 on either shift. Review of the Departmental Notes revealed Resident #56 refused treatments on, 03/22/18, 03/24/18, and 03/30/18. The notes further revealed on 03/21/18 the resident was educated on the importance of treatment needing to be done per MD orders, Observation and interview on 04/03/18 at 1:09 PM revealed Resident #56 was lying in bed with a large amount of green drainage noted on dressing and a pool of green drainage noted on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before even though it was supposed to be changed twice a day per the care plan. Observation of the dressing change on 04/03/18 at 2:31 PM revealed there was copious amounts of green, bloody drainage with foul smell and the dressings were not dated when applied. Observation on 04/04/18 at 10:00 AM revealed Resident #56 went out to the wound clinic on 04/04/18. Review of physician's orders [REDACTED]. However, review of the Nurse's Notes, (MONTH) (YEAR) TAR, Care Plan and shower sheet, on 04/07/18 at 2:00 PM revealed the order was not documented for the daily showers to be completed. Interview with CNA's #10 and #14 on 04/07/18 at 3:00 PM revealed they were not aware Resident #56 was to have a daily shower, that the resident usually just washed him/her self off in the room. Interview with LPN #7, on 04/05/18 at 11:15 AM, revealed she did not remember any dressing changes for Resident #56 on day shift. She stated she thought the dressing changes were done when the resident went to the wound clinic. She further revealed there was not enough staff and now that the Certified Medication Technicians (CMT's) were pulled to the floor working as CNA's, the licensed staff had to pass their own medications, and there just was not enough time to complete all tasks. Interview with hall 300 Charge Nurse, LPN #7 on 04/04/18 at 11:15 PM revealed she was not aware of a scheduled shower or dressing change for day shift, the shift that she worked. She stated the nurses are having to pass the medications instead of the Certified Medication Techs (CMT's), and there was not enough time to complete all the assigned tasks assigned. Interview with the Clinical Coordinator from the wound clinic on 04/09/18 at 10:00 AM revealed they were trying to prepare Resident's #56's burn wound for a skin graph. She stated when the resident was at the wound center on 04/04/18, new orders were sent to the facility that specified to shower daily. She revealed on the 03/14/18 visit, the dressing was dated 03/11/18, so she felt the dressing had not been getting changed as it should be so she added shower every other day to the orders to help ensure the dressing was getting done more frequently. Further interview on 04/09/18 at 3:30 PM, revealed the wound clinic had never been notified the resident was refusing dressing changes, of the amount of drainage, or the foul odor. Interview with the Director of Nursing on 04/06/18 at 2:00 PM revealed she expected to be notified, as well as, the Physician if treatments were not received or refused. She further stated if the MAR/TAR was not initialed then it was right to assume the treatment was not administered. Interview with the Attending Physician/Medical Director on 04/10/18 at 9:07 AM revealed if any resident missed their treatment, he expected to be notified. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure s (TRUNCATED)

Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise care plans based on changing goals, preferences, needs, and in response to current interventions for four (4) of thirty-six (36) sampled residents (Residents #3, #5, #62 and #73). On 03/07/18, Resident #3 was transferred by a new lift, with staff, Certified Nurse Aides (CNA) #9 and #13, using the incorrect sling. This transfer resulted in the resident falling out of the sling onto the floor. The facility failed to revise the resident's care plan to ensure the correct lift and sling were used on Resident #3. In addition, Resident #5 and #62's care plans, which required the use of a lift, were not revised to include the type of lift and sling staff were to use for care. The facility's failure to revise the care plan has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, the facility failed to revise the care plan to address Resident #73's exit seeking behavior identified and the resident exiting the building unsupervised on 03/27/18. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated (MONTH) (YEAR) and last revised (MONTH) (YEAR), revealed the comprehensive care plan will be revised by the interdisciplinary team after each comprehensive, significant change of condition and quarterly Minimum Data Sets (MDS) assessment. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of the facility's policy, Incident & Accident Process, dated 10/15, revealed the resident Care Plan is to be updated as interventions are implemented. Record review revealed the facility admitted Resident #3 on 05/28/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/16/18, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of Resident #3 Self Care Deficit Care Plan, dated 09/27/16, revealed the resident required assist of two (2) for bed mobility and transfers and mechanical lift total was documented on the plan with no date. Review of Risk for Injury related to Falls Care Plan dated 09/27/16, revealed transfers assist of two (2). Review of the Certified Nurse Aide (CNA) care plan that was located on the resident's closet door on 03/27/18 revealed to transfer with mechanical lift with assist of two (2). However, further review of the care plans revealed there was no intervention to address which lift and sling were to be used on the resident. Review of Nurse's Notes on 03/07/18 at 11:00 AM, late entry for 10:10 AM, and interviews on 03/27/18 with CNA #9 at 2:17 PM, and CNA #13 at 2:43 PM, revealed Resident #3 was being transferred from the bed to the wheelchair with a new lift and the old lift sling by CNA #13 and #9. The CNAs reported the resident was agitated during the transfer due to fear of missing an activities event. The resident shifted to the left side while the lift was approximately four (4) foot in the air. The resident fell to the floor hitting his/her head with no injury. Both CNAs stated they had not received any education on the new lift and were not aware the old sling could not be used on the new lift. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 02/24/18, revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further record review revealed there was no documented evidence the resident was assessed to determine the type of lift or sling size to use for the resident. Review of Resident #5 Self Care Deficit Care Plan, dated 07/07/16, revealed the resident required assist of two (2) with transfers with a mechanical lift. Review of Risk for Injury related to Falls Care Plan dated 09/01/16, revealed the resident required the assist of two (2) with transfers with a mechanical lift. No CNA care plan was provided by the facility. However, further review of the care plans revealed there was no intervention to address the type of lift or sling to use with the resident. 3. Record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change assessment, dated 03/15/18, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Review of the Self Care Deficit Care Plan, dated 01/23/18, updated 03/20/18, revealed a sit to stand lift for transfers and assist of two (2). Review of Risk for Injury related to Falls Care Plan dated 11/22/17, updated 03/20/18, revealed to transfer with a mechanical lift assist of two (2). No CNA care plan was provided by the facility. However, further review of the care plans revealed there was no intervention to address the type of lift or sling to use with the resident. Interview with Licensed Practical Nurse (LPN) #8 on 03/26/18 at 5:03 PM revealed she expected staff to provide care according to the care plan, but if the information was not on the care plan, they would need to ask someone. Observation of the 100 Hall nurse's station with LPN #8 revealed some CNA care plans were in a binder at the desk, but the LPN was not sure where the rest were located. Resident #3's CNA care plan was not in the binder. Interview with CNA #2 on 03/26/18 at 5:06 PM revealed she goes by what she was told to do as there were no CNA care plans on the 100 Hall. Interview with CNA #15 on 03/27/18 at 11:48 AM and Certified Medication Aide (CMA)/CNA on 03/28/18 at 2:09 PM revealed the CNA care plan to determine what sling to use for each resident were located at the desk. However, review of the CNA care plans on the 300 Hall revealed no information regarding which lift or slings to use. The CMA and CNA stated they would not know what sling to use on a resident with a lift. Interview with LPN #7 on 03/28/18 at 9:48 AM and CNA #14 on 03/27/18 at 4:25 PM, revealed they would look at the CNA care plan to determine what type of sling and lift to use for a resident. However, observations, with the CNA and the LPN revealed a care plan of a resident on the 300 Hall, who required a lift; however, the lift type nor sling were on the CNA's care plan. In addition, they were unable to locate any information at the desk of the type of sling and lift to use for any residents requiring a lift. Interview with CNA #9 on 03/27/18 at 2:17 PM, revealed the CNAs use the computer to know how many staff to use for care but not which lift or sling, as it was not listed in the computer. Interview with CNA #13 on 03/27/18 at 2:43 PM revealed CNA care plans were on the resident's closet doors and in a book at the nurse's station on 300 Hall. Interview with Registered Nurse (RN) #2 on 03/27/18 at 2:00 PM revealed the CNAs do not have CNA care plans in a book or on the closet doors. However, there may still be some care plans on the closet doors. She stated the CNAs need to look at the Nursing Care Plan for care. Interview with the MDS Coordinator on 03/27/18 at 9:08 AM revealed CNAs do not have care plans as they look on the computer for the amount of care to provide; however, which lift and sling to use on each resident was not in the computer. Interview with RN #1 on 03/28/18 at 10:00 AM revealed there were two (2) different lifts and she did not know much about the different types of slings. She stated the Administrative staff discussed on 03/27/18 about adding the color of the sling (size of the sling) to the care plan. Interview with the Staff Development Coordinator (SDC) on 03/28/18 at 10:45 AM revealed the CNAs really do not have care plans/Kardex for care. Therefore she was going to make resident kardexs and put at the nurse's station for the staff with the sling and lift type. Interview with the Director of Nursing (DON) on 03/29/18 at 9:38 AM, revealed previously the Comprehensive Care Plan was the care plan everyone was to refer to; however, the information of the slings and lifts were not updated on those care plans. She stated the DON was responsible to determine which lift and sling to use, by using the resident's weight. The DON stated there was no system in place to communicate this information to the staff. The DON also revealed the MDS Coordinator was responsible to update the care plan for the lifts and pads; and, the nurses were responsible to supervise the CNAs to ensure they were following the care plan. Interview with the Regional Corporate Nurse on 03/28/18 at 3:12 PM revealed after the incident not all comprehensive care plans were updated to include the type of lift and which sling to use. She stated the CNAs go by the computer for the type of assistance to provide a resident, but the computer did not have sling or lift type. 4. Review of the facility's policy titled, Elopement Protocol, origination date (MONTH) (YEAR), revealed Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The care plan is to be updated with the resident specific information to promote resident's safety. Any change of condition including elopement, elopement attempts or exit seeking behaviors will be reassessed for need of further intervention to reduce the risk of elopement. The nurse or social worker/designee will complete the Elopement/Wandering Risk Data Set; the nurse will follow up with the physician. Immediate interventions for Resident safety: 4. Interventions to reduce the risk of elopement will be updated to the resident's Care Plan and communicated with staff. Record review revealed the facility admitted Resident #73 on 03/10/18, with [DIAGNOSES REDACTED]. Review of the fourteen (14) day MDS assessment, dated 03/23/18, revealed the facility assessed Resident #73's cognition as severely impaired with a BIMS' score of five (5), which indicated the resident was not interviewable. Review of the Comprehensive Nursing care plan, with problem onset date of 03/16/18 for Exhibits Alteration in mood/behavior, revealed wander guard placement to right ankle (no date), and monitor whereabouts when wandering and redirect as needed, maintain low stimulus environment such as soft music, dim lighting, close exterior blinds when agitated and document response to decreased in external stimulus, secure unit and positive reinforcement for appropriate behavior. Review of the most recent Elopement/Wandering Risk Data set, dated 03/20/18, revealed Resident #73 had poor safety environmental awareness, oriented to person only, increased confusion in the PM, was at risk for elopement and had a wander guard device on his/her right ankle. Review of Nurses Notes written by LPN #5 dated 03/27/18 at 5:34 AM, revealed Resident #73 was becoming increasingly agitated throughout the PM shift with exit seeking behavior. The resident became combative with nursing and dietary staff and was wandering in and out of rooms. Fluids and snacks were offered. The resident continued to self-ambulate up and down the hall. Review of a Nurses Note, dated 03/27/18 at 7:37 AM, and interviews on 04/03/18 with CNA #4, at 7:58 PM, and LPN #4 at 10:17 AM, revealed the resident was brought back inside from the door on the end of wing three (3) after staff heard the wanderguard alarm sounding. Resident #73 was in his/her wheel chair sitting on the sidewalk, wearing gray jogging pants, a gray stripped shirt, socks and shoes, with a blanket wrapped around him/her. The resident was alert, confused, with no injury noted. Head to toe assessment completed. The resident was placed on fifteen (15) minutes checks and a SBAR (Situation, Background, Appearance, Review) communication form was completed. The Son and MD were notified. However, further review of the care plan, revealed no documented evidence the care plan was updated after Resident #73 was having exit seeking behaviors on 03/27/18 at 5:34 AM or after he/she exited the facility on 03/27/18 at 6:30 AM, to reflect new interventions to help prevent Resident #73 from exiting the building unsupervised again, per facility policy. Observations on 04/03/18 at 4:13 PM, revealed Resident #73 was up in his/her wheelchair sitting in the doorway to his/her room with the wander guard (monitoring device) located on his/her right ankle; the resident was no longer on fifteen (15) minute checks. The fifteen minute checks were discontinued on 03/29/18 at 5:00 PM. Further interview with LPN #4 on 04/3/18 at 10:17 AM, revealed she did not update the care plan with date Resident #73 exited the building unsupervised and she did not add the new intervention of the fifteen (15) minutes checks to the care plan, as she was so busy she did not even think about it. Interview with the DON on 04/06/18 10:23 AM, revealed she would expect the nurse to update the care plans to reflect the date of the exit, and new interventions to be added to the care plan to avoid other exits. She stated care plans should be updated by the nurse anytime there was a change with the resident's care needs. Interview with the Administrator on on 04/05/18 at 1:42 PM, revealed she would have expected the care plan to be updated with the new exit seeking behavior and the date the exit occurred, labs that were ordered and with the new (15) minute checks that had taken place. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. The Nurse Aides (2) involved in the incident were re-educated on 03/07/18 and 03/08/18 by the Regional Quality Manager. Education included reviewing the care plan for transfer status and selecting appropriate weight capacity for the lift, assuring all pieces of equipment, lift and sling, were properly assembled and in good working order, using slings manufactured for the lnvacare Total Lift, use of the lnvacare Total Lift with demonstration and competency performance validation. 2. Resident #3 was evaluated on 03/08/18 by Occupational Therapy. Resident #3's care plan was revised to include type of mechanical lift and type of sling on 03/07/18 by Director of Nursing. 3. All 13 residents requiring a lift to transfer were screened and/or evaluated by Physical Therapist or Occupational Therapist, beginning 03/08/18, and completed by 03/29/18. The care plan was revised for all 13 residents requiring a lift to transfer to include the type of mechanical lift and type of sling by 03/29/18 by the Nurse Management Team. 4. Education was initiated on 03/07/18 and completed for all nursing staff regarding lift competencies demonstration/return demonstration with completion on 03/31/18 by the Director of Nursing (DON), Staff Development Coordinator (S[NAME]),and/or the Assistant Director of Nursing (ADON) for the lnvacare lift. Mechanical Lift Management Education will be provided during Nursing staff orientation, at least annually, and as indicated by the Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing. 5. The Tolles Lift was placed out of use with lock out/tag out system by the maintenance assistant pending receipt of training materials from the manufacturer on 03/27/18. The lift will not be utilized until all nursing staff have been trained. 6. An AdHoc Quality Assurance (OA) Meeting was held on 03/07/18 to discuss the IJ and develop an action plan. Attendees included the Administrator, Regional Quality Manager, Director of Nurses, Staff Development, MDS (2), Rehabilitation Manager, Social Services, and Activity Director. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action items to be initiated. 7. The Regional Quality Manager provided education to the Director of Nurses or Administrator on 03/29/18 that education must be completed for all nursing staff prior to placing new equipment on the floor which included lifts. The training for the lifts must include demonstration/return demonstration. The Director of Nursing and or the Administrator will review any new lift equipment that has arrived and confirm that the equipment was properly locked out until education was completed. 8. The Regional Maintenance Director re-educated the Maintenance Assistant regarding the Lock out/Tag out system on 03/27/18. 9. The Maintenance Assistant was educated on 03/07/18 by the Regional Quality Manager to use the lock out/tag out system for all new medical equipment until notified by the Director of Nursing and/or the Administrator to unlock. 10. All staff were notified that all new mechanical lifts will be placed into lock out/tag out until education on the use of the mechanical lift is completed. The Maintenance Assistant began re-education for all nursing staff on lock¿ out/tagout policy on 04/05/18. Reeducation was completed with 36 staff, with 21 remaining. Remaining staff will not work until reeducated on the process developed to identify and re-educate to assure staff. Staff are not to clock in prior to re-education. 11. New orders will be reviewed, by the MDS Coordinator, daily for changes. 12. A new communication book was developed to reflect the most current lift and sling that each resident is safe to use by the Director of Nursing and the Regional Quality Manager and put in place on 03/29/18. The Communication books will be updated by the MDS Coordinators quarterly and upon admission, and with any potential change of condition that would alter the lift need. 13. The MDS Coordinators were re-educated by the Regional Quality Manager and the Director of Nursing on 03/29/18 regarding the necessity of updating the care plans and the communication book at each nurses' station to reflect the most current lift and sling that each resident is safe to use quarterly and upon admission, and with any potential change of condition that would alter the lift need. 14. The Director of Nursing, Staff Development Coordinator or Nurse Manager will review new admissions daily for one (1) week and two (2) times a week for four (4) weeks and ongoing monthly beginning 03/29/18 to ensure that all residents have up-to-date care plans related to lift status. 15. Post-test will be completed for all nursing staff and nursing orientees regarding return demonstration of proper use of lifts and slings three (3) times a week for four (4) weeks and three (3) per month ongoing by the Director of Nursing or Nurse Manager. 16. The Audit of the care plans related to lifts and the post-test results will be reviewed at a minimum of weekly at the weekly QA meeting with a member of the Regional team in attendance for review and any needed recommendation, until substantial compliance is achieved. 17. On 03/29/18, the QA Committee met to discuss the Information outlined in the notice of Immediate Jeopardy and to develop action plans to abate the jeopardy. Attendees included the Administrator, Regional Quality Manager, Director of Nurses, Staff Development, MDS (2), Rehabilitation Manager, Social Services, and Activity Director. The Medical Director was contacted via phone by the Administrator on this date to review the IJ citing and the action plan status. 18. A QA meeting will be held a minimum of weekly until substantial compliance is achieved and monthly thereafter. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA Meeting. This team includes at a minimum the Administrator, Director of Nursing, Social Services, C.N.A and Charge Nurse. **The State Survey Agency validated the corrective actions implemented by the facility as follows: 1. Review of the education provided to the two (2) CNAs, who were involved in the incident as well as all staff was verified with the starting date of 03/07/18 and ending date of 03/31/18, by the DON, SDC, and /or the ADON, regarding use of Invacare lifts and proper use of the correct sling for the lift with return demonstrations completed. Review of competency validations revealed all staff were trained and met competency requirements. 2. Review of an Occupational Therapist (OT) Evaluation, dated 03/08/18, revealed Resident #3 was evaluated for use of the mechanical lift and it was determined the mechanical lift was the safest mode of transfers for nursing to complete. Otherwise, due to the documented physical impairments and associated functional deficits, the resident was at risk for falls. Review of Resident #3's care plan, revised 03/29/18, revealed the care plan was updated with an intervention of the use of a mechanical lift (Invacare) with a purple sling. Transfers to be completed with assist x two (2) staff with a mechanical lift. 3. Review of therapy evaluations, dated 03/08/18 through 03/29/18, revealed all residents who required the use of a mechanical lift received PT and OT screening and evaluations for the use of the lifts. Review of all 13 residents' care plans, who required a lift to transfer, revealed all 13 care plans were reviewed and revised by the Nurse Management Team to include the use of a mechanical lift and the appropriate color and size of sling to be used. 4. Review of education documentation, dated 03/07/18, by the DON, SDC and/or the ADON, revealed all nursing staff was educated on lift competencies with a return demonstration required after the training on use of the Invacare Lift. 5. Observation of the Tollos lift on, 04/20/18 at 1:15 PM, revealed it was placed out of use with lock/tag out system by the Maintenance Assistant pending receipt of training materials from the manufacturer. 6. Review of the AdHoc meetings notes, dated 03/07/18 revealed a meeting was held with the Administrator, Regional Quality Manager, Director of Nurses, Staff Development, MDS (2), Rehabilitation Manager, Social Services, and Activity Director. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action items to be initiated. 7. Review of education to the DON and the Administrator, by the Regional Quality Manager dated 03/29/18, revealed education was provided related to any new equipment being locked out until appropriate education to staff could be conducted related to the use of the equipment 8. Review of the inservice sign in sheet, dated 03/27/18 revealed the Regional Maintenance Director re-educated the Maintenance Assistant regarding the lock out/tag out system. Interview with the Maintenance Director on 04/19/18 at 10:26 AM, revealed he was educated by the acting maintenance director before him. He stated he was also educated on 03/07/18 by the Regional Maintenance Director. He stated he then, in turn educated all staff related to the lock/out tag out system with competencies skills completed afterwards. He stated if new equipment arrived when he was not at the facility, staff were to call him immediately and not use the equipment until they were trained. If the equipment was something they have already been trained on then they were allowed to use it, but not on any new piece of equipment. 9. Review of education provided related to the Lock out; Tag out policy for lifts revealed it was started on 04/05/18 and completed on 04/06/18 by the Maintenance Assistant Director to all nursing staff. The inservice included immediate maintenance notification related to any lifts that needed to be locked out. 10. Review of audits revealed new physician's orders [REDACTED]. Interview with the MDS Nurse, on 04/19/18 at 10:00 AM revealed she was educated on reviewing Physicians' Orders daily. 11. Review of the new communication book revealed a list of residents who required the use of a mechanical lift, the sling size and color to be used and a guide to CNAs. The book had been updated daily since it was initiated on 03/29/18. 12. Interview with the MDS Nurse, on 04/19/18 at 10:00 AM revealed she had been inserviced/educated related to updating the care plans and the new communication book and updating the CNA kiosk record related to which lift a resident was using, the size and color of the sling to be used as well. She stated the care plans were to be reviewed and revised when the lift in use was discontinued and the book was updated, as well as the CNA kiosk. 13. Review of the resident roster, dated 04/20/18, revealed there were no new admission to the facility. 14. Review of Resident Handling Observation Forms revealed all CNAs working Unit 2 and Unit 3 (where lifts are used) were completed three (3) times related to use of the mechanical lift, use of proper body mechanics, and overall handling performance standards the weeks of 03/07/18 through 03/31/18. 16. Review of the audit of the care plans related to lift use revealed they had been revised with the appropriate sling size and color for each resident requiring the use of a lift on 03/29/18. Review of the audits of the post test revealed they were being reviewed at a minimum of weekly.

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to develop or implement a Comprehensive Care Plan for nine (9) of thirty-six (36) sampled residents (Residents #2, #30, #35, #40, #49, #56, #64, #51, and #67). Resident #64 was care planned for staff to turn and reposition every two (2) hours, administer pain medications thirty (30) minutes prior to the extensive dressing changes for five (5) Stage IV Pressure Ulcers; if the resident complained of pain during this treatment, the staff were to have stopped the treatment and after ensuring the resident was safe, sought pain relief and returned when the pain was reported as acceptable; and to report any unrelieved or unacceptable levels of pain to the physician. Additionally, there was an intervention to administer [MEDICATION NAME] every three hours. However, observations on 04/04/18 at 10:15 AM, 12:15 PM, 2:20 PM, 4:40 PM and 5:18 PM and throughout the survey, on 04/03-05/18, revealed there were multiple observations of the resident lying supine. Additionally, observation of dressing changes on 04/05/18 at 3:35 PM, revealed staff failed to administer pain medication prior to or during the dressing changes and the resident screamed at the staff how bad he/she was hurting, tears were in his/her eyes, and he/she had facial grimacing. The facility's failure to implement the care plan has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, staff failed to assess Resident #67's and Resident #49's [MEDICAL TREATMENT] shunt sites per care plan; failed to transfer Resident #51 with assist of two (2) staff and a mechanical lift resulting in a fall with no injury; and, failed to provide oxygen to Residents' #2, #30, #35, #40, and #56 per care plan. The findings include: Review of the facility's policy Baseline Care Plan Standard of Practice, dated (MONTH) (YEAR), revealed the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards for quality care. It must include any services and treatments to be administered by the facility and personnel acting on behalf of the facility and any updated information based on the details of the initial comprehensive care plan, as necessary. Review of the facility's policy, Comprehensive Care Plans Standards of Practice, dated (MONTH) (YEAR), revealed it was the practice of this facility to develop and implement person-centered care plans for each resident, consistent with resident's rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The facility will ensure residents who display or are diagnosed with [REDACTED]. The facility will attempt alternate methods for refusal of treatment and/or services and document such attempts in the clinical record, including discussions with the resident and/or the resident's representative. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, significant change of condition and Quarterly Minimum Data Set (MDS) assessment. 1. Record review revealed the facility admitted Resident #64 on 09/15/17 and readmitted the resident from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE], revealed the facility assessed Resident #64's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of Resident #64's Comprehensive Care Plan for Pain dated 09/15/17, revealed interventions to report any unrelieved or unacceptable levels of pain to the physician, as needed and [MEDICATION NAME] (opioid pain medication) was to have been administered, as ordered. Review of the Comprehensive Care Plan for Alteration in Skin Integrity dated 02/23/18, revealed interventions to medicate the resident for pain, prior to the extensive dressing changes; and if the resident complained of pain an alternative method should have been sought, and the physician should have been made aware; and, to turn and reposition every two hours, and as needed. However, observations on 04/04/18 at 10:15 AM, 12:15 PM, 2:20 PM, 4:40 PM and 5:18 PM and throughout the survey, on 04/03-05/18, revealed the resident was lying on his/her back. In addition, observation of a dressing change on 04/05/18 at 3:35 PM until 4:10 PM revealed Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #7 failed to offer the resident pain medication prior to the dressing change and continued on with the dressing changes, discussing how they wished they had bigger gloves and continued to fill the three (3) Stage IV Pressure areas to the right and left buttock and sacral areas with a bleach solution soaked gauze, all the while the resident was calling out, You are hurting me!' and This pain makes me so sick! and You don't know how much that hurt! Interviews on 04/04/18 with Certified Nurse Aide (CNA) #5 at 2:25 PM, CNA #10 at 2:40 PM, and CNA #1 at 4:31 PM, revealed the resident screams and hollers when they move him/her or try to position the resident on his/her side. The CNAs stated the resident will continue to scream until they place him/her back on his/her back. However, review of the clinical record revealed there was no evidence anyone was made aware of the resident's pain. Interview with RN #1 and LPN #7 during the dressing change on 04/05/18 at 3:35 PM, revealed LPN #7 stated she medicated the resident for pain with [MEDICATION NAME] at 1:00 PM and the resident was not due again until 4:00 PM. She stated she was aware the resident also had additional as needed medications for pain, but they had not been administered. Interview with the Hospice RN on 04/06/18 at 4:45 PM, revealed up to one week ago, she felt the resident's pain was in good control. She stated there had been no requests from staff for any more pain medications until the evening of 04/05/18. She stated she would have expected the facility to medicate 20-30 minutes prior to a dressing change, as per the care plan. Interview with the Physician on 04/05/18 at 4:45 PM, revealed he was unaware of Resident #64's unrelieved pain and that what was ordered was not sufficient. He stated he . had no problem assisting with the resident's pain control. Interview with the Administrator on 04/05/18 at 1:58 PM, revealed she was unaware the care plan had not been followed. She stated she was aware of the resident's refusals for dressing changes and repositioning. Further interview on 04/07/18 at 10:00 AM, revealed she expected the staff to follow the plan of care and the physician's orders for this resident. 2. Record review revealed the facility admitted Resident #56 on 02/20/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 02/27/18, revealed the facility assessed Resident #56's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #56 Comprehensive Care Plan for Impaired Skin Integrity and Risk for Alteration in Comfort related to Burn to right lower leg/foot, dated 02/20/18, revealed interventions to identify location and rate of pain prior to and after interventions, report any signs and symptoms of infection (odor, increased drainage, pain, or redness), pain assessment per protocol, medicate as ordered, shower every other day, remove dressing to the right leg, use dial soap and water, rinse well; and, ensure the dressing is changed two (2) times a day, was added on 03/14/18. Observation and interview on 04/03/18 at 1:09 PM revealed Resident #56 was lying in bed with a large amount of green drainage noted on the dressing and a pool of green drainage noted on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before even though it was supposed to be changed twice a day per care plan. In addition, observation of the dressing change on 04/03/18 at 2:31 PM revealed there was a copious amount of green, bloody drainage with a foul smell. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARs) revealed the resident should be showered every other day; however, further review of the TAR's revealed Resident #56 had not been provided a shower, per care plan from 03/29/18 through 04/04/18 which indicated he/she went without a shower for five (5) days and there was no documentation as to why this occurred. Further review of the (MONTH) and (MONTH) (YEAR) TAR's revealed there was no documentation the dressing was changed per care plan on 03/30/18, 03/31/18, 04/01/18, and 04/02/18 on either shift. Interview with CNA's #10 and #14 on 04/07/18 at 3:00 PM, revealed they were not aware of Resident #56 having to have a daily shower. They stated the resident usually just washed himself/herself off in the room. The CNA's stated they had not heard him/her complain of pain. Interview with LPN #7 on 04/05/18 at 11:15 AM, revealed she did not remember any dressing changes for Resident #56 on day shift. She stated she thought the dressing changes were done when the resident went to the wound clinic. LPN #7 stated there was not enough staff and now that the Certified Medication Technicians (CMT's) were pulled to the floor working as CNA's, the licensed staff had to pass their own medications, and there just was not enough time to complete all the tasks. 3. Record review revealed the facility admitted Resident #51 on 01/04/18, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/10/18, revealed the facility assessed Resident #51's cognition as moderately impaired with a BIMS score of nine (9) which indicated the resident was interviewable. However, after brief conversation, it was determined information obtained from resident was not reliable. Review of the Resident #51's Comprehensive Care Plan for risk for injury related to falls, initiated 01/04/18, revealed an intervention to transfer with assist of two (2) with mechanical lift. However, review of a facility Investigation Report dated 02/27/18, revealed CNA #7 transferred Resident #51 from the wheelchair to the bed without the use of a lift or the assistance of another staff as care planned. The resident's knees became weak and the resident was lowered to the floor during the transfer. No injury was noted. Attempts were made to contact CNA #7 on 04/06/18 at 8:32 AM and on 04/07/18 at 9:00 AM, without success. Interview with Director of Nursing (DON), on 04/06/18 at 9:10 AM, revealed the CNA should not have been transferring the resident without the mechanical lift and assist of another CNA. The DON could not provide any further information regarding any disciplinary action for CNA #7 and in-services provided. The DON stated she expected the CNA's to follow the care plans when providing care. 4. Record review revealed the facility readmitted Resident #49 on 02/24/18, with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 03/06/18, revealed the facility assessed Resident #49's cognition as moderately impaired with a BIMS score of ten (10), indicating the resident was interviewable. Review of a Comprehensive Care Plan for Resident #49 initiated 01/26/18, revealed to check site for bruit, thrill, and signs of complications every shift and upon return to facility from [MEDICAL TREATMENT]. However, review of the January, February, and (MONTH) (YEAR) TAR's revealed there was no documented evidence staff were assessing Resident #49's shunt per the care plan. Interview with Resident #49 at 10:45 AM on 04/04/18 revealed staff check the [MEDICAL TREATMENT] site sometimes but, not often. Resident #49 stated he/she has had the shunt since admission to the facility. Interview with Registered Nurse (RN) # 1 on 04/04/18 at 10:45 AM, revealed she did not know why this information would not be on the Treatment Administration Record (TAR) as it was on the Care Plan. Interview with Licensed Practical Nurse (LPN) #1 on 04/07/18 at 10:30 AM revealed [MEDICAL TREATMENT] shunt sites should be checked every shift for thrill, bruit, and any signs/symptoms of infection per the Care Plan. 5. Record review revealed the facility admitted Resident #67 on 03/15/18, with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Residents #67's cognition as intact with a BIMS' score of fifteen (15), which indicated this resident was interviewable. Review of Resident #67's Comprehensive Care Plan for Potential for alteration in elimination related to end stage [MEDICAL CONDITION], [MEDICAL TREATMENT] shunt right antecubital/[MEDICAL TREATMENT], dated 03/15/18 revealed an intervention for the nurse to observe the [MEDICAL TREATMENT] shunt site for signs and symptoms of infection and notify physician, if noted. However, review of the (MONTH) and (MONTH) (YEAR) Electronic Treatment Administration Record (e-TAR) revealed there was no documented evidence the shunt was assessed for signs and symptoms of infection on 03/25/18, 03/27/18, 03/30/18, 03/31/18, 04/01/18, 04/02/18, and 04/03/18 per the care plan. Interview with Resident #67 on 04/06/18 at 9:55 AM, revealed the staff do not check his/her shunt regularly only sometimes. 6. Record review revealed the facility admitted Resident #2 on 09/28/17 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 10/05/17 revealed the facility assessed Resident #2's cognition as intact with a BIMS' score of fifteen (15), which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Potential for Alteration in Circulation/Oxygenation related to [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION], dated 10/09/17 and (MONTH) (YEAR) Physician's Order, revealed an intervention to administer O2 at 2 liters per minute (LPN) nightly (initiated on 02/20/18). However, observations on 03/29/18 at 3:35 PM and 03/29/18 at 10:41 PM, revealed there was no O2 concentrator in Resident #2's room . On 03/29/18 at 10:41 PM, the resident was lying in bed awake. During interview with RN #6 she stated the resident was not to have O2. The resident's O2 Saturation was 91%. Further interview with RN #6 revealed she he did not work the 300 Hall much. 7. Record review revealed the facility admitted Resident #30 on 01/04/18 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, dated [DATE], revealed the facility assessed Resident #30's cognition as intact with a BIMS' score of fourteen (14), which indicated the resident was interviewable. Further review of the Minimum Data Set revealed it did not indicate the resident required therapy at that time. Review of Potential for Alteration in Circulation related to Hypertension, [MEDICAL CONDITIONS], Chronic [MEDICAL CONDITION] Comprehensive Care Plan, dated 01/04/18 revealed the care plan was updated on 03/15/18 to include O2 which was increased to three (3) (liters per minute) LPM per nasal cannula. However, observation on 03/29/18 at 10:25 PM with Registered Nurse (RN) #6 revealed Resident #30 did not have his/her O2 cannula in his/her nose; it was lying on his/her chest. The resident's O2 saturation was 82% mm/Hg (millimeters of mercury normal is 95-100%). Further observation revealed the concentrator was set on two (2) LPM, instead of the ordered three (3) LPM. 8. Record review revealed the facility readmitted Resident #35 on 05/24/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/16/18, revealed the facility assessed Resident #35's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was non-interviewable. Review of the Comprehensive Care Plan for Potential for Alteration in Circulation/Oxygen exchange related to [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION], Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) machine, dated 10/04/16, and review of the (MONTH) (YEAR) Physician Orders revealed to check O2 Saturation every shift on room air and record the results, if O2 less than 90% restart O2 at two (2) LPM via nasal cannula. Further review revealed to administer [MEDICAL CONDITION] nightly with O2 concentrator to [MEDICAL CONDITION] at six (6) LPM. However, review of the (MONTH) (YEAR) TAR revealed O2 saturations were not obtained on 03/02/18-03/05/18, 03/07/18-03/10/18, 03/14/18, 03/16/18-03/18/18, and 03/20/18-03/23/18 (total of sixteen {16} days), twice daily as ordered per the care plan. In addition, observation on 03/29/18 at 3:40 PM revealed there was no O2 concentrator in Resident #35's room. Observation with RN #6, on 03/29/18 at 10:28 PM revealed Resident #35 was lying in bed with eyes closed without his/her [MEDICAL CONDITION] on his/her face and no O2 concentrator in the room connected to the [MEDICAL CONDITION] per the care plan. RN #6 stated the resident was not to have O2 with his/her [MEDICAL CONDITION]. O2 Saturation was obtained by the RN and was 99%. 9. Record review revealed the facility admitted Resident #40 on 01/11/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/20/18, revealed the facility assessed Resident #40's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Potential for Alteration in Circulation/Oxygen Exchange related to Heart Failure, Hypertension, Chronic Artery Disease (CAD), [MEDICAL CONDITION], Chronic [MEDICAL CONDITION], and O2 use, dated 01/09/17, and (MONTH) (YEAR) Physician Orders revealed to administer at three (3) LPM per nasal cannula during the night for [MEDICAL CONDITION]/[MEDICAL CONDITIONS]. However, observation on 03/29/18 at 11:25 PM, with Licensed Practical Nurse (LPN) #6 revealed Resident #40 was lying in the bed without the O2 cannula in the resident's nose and it was laying in the trash can in a bag. The O2 concentrator was not turned on. Interview with Resident #40, on 03/29/18 at 11:25 PM revealed when Certified Nurse Aide (CNA) #2 put him/her to bed after supper she forgot to place the O2 on him/her. Further observation at this time revealed LPN #6 checked the resident's O2 sat.which was 92% and stated the CNA should have placed the O2 on the resident when the resident went to bed. The LPN placed the cannula of the tubing that was in the trash can on the resident and no O2 was coming out of the tubing. The LPN changed the tubing and still no O2 was coming out for the resident. The nurse tested the tubing in a cup of water and no bubbles formed. Interview with Certified Nurse Aide (CNA) #2 on 03/31/18 at 9:41 PM revealed she always places O2 on Resident #40 before he/she goes to bed; however, she was not sure about the night of the 29th. She stated the resident was immobile and could not turn off the O2 himself/herself if he/she was in the bed. Interview with LPN #6 on 03/29/18 at 11:15 revealed the nurse's are ultimately responsible to ensure the care plan is implemented. 10. Record review revealed the facility admitted Resident #56 on 02/20/18 with [DIAGNOSES REDACTED].#56's cognition as intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Potential for Alteration in Circulation /Oxygenation related to [MEDICAL CONDITIONS], Hypertension, and [MEDICAL CONDITION], dated 03/01/18 and (MONTH) (YEAR) Physician Orders revealed to administer O2 at two (2) LPM per nasal cannula nightly. However, observation at 03/29/18 at 3:37 PM, revealed there was no O2 concentrator in Resident #56's room. Further observation with RN #6 on 03/29/18 at 10:35 PM revealed there was still no O2 concentrator in Resident #56's room. RN #6 stated he did not know much about the resident as he/she was a newer admit, but he did not think the resident was ordered O2. Observation revealed the resident's O2 saturation was obtained by the RN and was 97%. On 03/29/18 at 10:41 PM, RN #6 read through the orders on the computer with the State Survey Agency Surveyor and saw that Resident #2 was ordered O2 at 2 LPM nightly. Observation revealed there was no O2 in the room. Resident #30 was to receive O2 at 3 LPM; however, the resident was on 2 LPM. Continued review of the orders revealed Resident #56 was to receive 2 LPM of O2 nightly. Observation revealed there was no O2 in the room. Interview with LPN #5 on 03/29/18 at 2:13 PM, revealed half of the O2 concentrators were broke. She stated residents have orders for O2 and [MEDICAL CONDITION] machines for O2, but there were not enough concentrators in the building; therefore, the residents do not receive the O2 or [MEDICAL CONDITION]. She stated she has looked everywhere in the building and was unable to find the O2 concentrators for the residents. LPN #5 stated recently the residents affected were Residents #2, #35, and #56. She stated she would check the O2 saturations and they would be above 90%, but if not she would have hooked up the resident to portable O2. Interview with LPN #7 on 03/30/18 at 10:17 AM revealed the night nurse would report to her of the need for O2 concentrators and would write it on the twenty-four (24) hour report sheet. She stated she had even verbally told the Assistant Director of Nursing (ADON), as she was the one who picked up the twenty-four (24) hour report sheets every morning, and she would say that was not her concern. Interview with RN #7 on 03/31/18 at 9:25 PM and RN #1 on 04/05/18 at 5:20 PM, revealed they expected the nurses to follow the care plan. Interview with the Director of Nursing (DON) on 04/06/18 at 9:40 AM revealed that if the intervention was on the care plan, the nurses should follow the care plan. Interview with the MDS Nurse on 04/07/18 at 12:50 PM revealed she expected staff to follow the care plan, and nurses to know if a resident had orders for oxygen, and to apply the O2, as ordered. Interview with the Director of Nursing on 04/06/18 at 10:00 AM revealed she expected the staff to follow the residents' Care Plans. Interview with the Regional Nurse Consultant on 04/07/18 at 12:19 PM revealed she expected staff to follow the physician's orders and care plan for oxygen. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders starting on 04/10/18 and to be completed by 04/18/18 or will not be allowed to work until educated. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants

Based on interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of thirty-six (36) sampled residents was free of verbal, mental, and physical abuse (Resident #15). On 03/24/18, Certified Nurse Aides (CNA's) #1 and #19 used a lift to transfer Resident #15 against his/her will. Resident #15 grabbed the grab bars of the bed so not to be transferred in the lift. The two (2) CNA's pried his/her hands off the grab bar and forced him/her to use the lift. The resident ended up in the lift without a call light and he/she panics without a call light. The resident had a sore right hand the next day with bruising noted on the right second and third knuckle. Resident #15 stated it was very demeaning. The facility's failure to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Prohibition Standards of Practice, last revised (MONTH) (YEAR) revealed each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free of mistreatment, neglect and misappropriation of property. The following standards of practice will be operational in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family member or legal guardian, friends, or other individuals. Further review of the policy revealed the definition of abuse is any willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Also includes the deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. This includes verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, including abuse facilitated or enabled through the use of technology. Record review revealed the facility admitted Resident #15 on 01/20/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 01/27/18 revealed the facility assessed Resident #15's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. The MDS further revealed the resident required the extensive assistance of two (2) for transfer. Review of the Daily Care Guide, not dated, which is used by the CNA's to care for the residents, revealed Resident #15 required two (2) person assist for transfer and toileting. Further review revealed there was no intervention to use a mechanical lift for transfers. Review of the facility's investigation, dated 03/26/18, revealed Resident #15 reported the two (2) CNA's forced him/her to use the mechanical lift for transfer against his/her will. The two (2) CNA's were both immediately suspended and all appropriate personnel were notified. CNA #1 stated the resident refused the lift and asked to talk with the Director of Nursing (DON), who was not available, so this was reported to the Assistant Director of Nursing (DON) who told them to use the lift. The ADON was also suspended because of her direction to the staff. Further review revealed CNA#19 did not return the Administrator's phone calls, so she was unable to talk with her. All alert and oriented residents were interviewed and during the interviews both CNA #1's and CNA #19's names were mentioned in negative context. Reports were made that they were rude when they were together, and they both responded to call lights and would say, I will be right back. but never return. One of the residents stated he/she felt this was a command of control over the residents. In conclusion, the facility substantiated the alleged allegation occurred for the following reasons: 1. Multiple residents voiced concerns during the interviews related to both CNA #1 and CNA #19. 2. A second allegation against CNA #19 was made that had not previously been reported to staff. 3. The ADON did not properly assess the situation and ensure the resident was agreeable to the use of a mechanical lift or determine the proper equipment that was needed given that he/she would be agreeable for transfer. Further review of the resident's record and the facility's investigation revealed there was no documented evidence the resident was assessed for any injuries immediately after the incident. Review of a Skin Assessment Report, dated 03/30/18, revealed Resident #15's skin was intact (six {6} days after the incident). Interview with Resident #15 on 04/06/18 at 10:00 AM revealed he/she was an assist of two (2) for transfer without a mechanical lift. The resident stated two (2) Certified Nurse Aids (CNA's) told him/her they did not want to hurt their backs, so they were going to use the mechanical lift. The resident stated he/she refused the lift stating it just took him/her a few minutes to loosen up then he/she could assist with the transfer. Resident #15 stated the CNA's then tried to get him/her to use the bed pan but he/she told the CNA's he/she could not use the bed pan. The resident further stated the CNA's continued to argue with him/her and said,Then you can use the bed pan, lift, or go in your pants. Resident #15 stated he/she grabbed the bars of the bed so not to be transferred by the lift. The two (2) CNA's pried his/her hands off the grab bar and forced him/her to use the lift against his/her will and he/she ended up in the lift without a call light. He/she stated he/she panics without his/her call light. Resident #15 further stated the next day his/her right hand hurt, for about a day. The resident stated he/she noticed a bruise to the right, second and third knuckle. He/she stated it was very demeaning, and also he/she was scared to death of CNA #1. He/she further stated he/she will absolutely never be forced to use it (the lift) again. Interview with CNA #1 on 04/08/18 at 10:08 AM, revealed she and CNA #19 worked together the day Resident #15 kept pushing the call light and wanting to get up in his/her wheelchair. CNA #1 stated they tried to get the resident up but he/she would not help them at all. CNA #1 stated she had a bad back and she told the resident they could not keep tugging and pulling on him/her because it was hard on them, and they didn't want to hurt him/her either. She stated the resident could be very stubborn and he/she refused to help. CNA #1 revealed they asked the nurse on the unit to come down and she talked to the resident and she still refused to help them. CNA #1 stated the ADON was approached and she said for the staff's safety and safety of the resident they would have to use the lift if the resident would not help. CNA #1 revealed the resident eventually agreed to let us use the lift, but he/she refused to hang on to the bars. The resident just left his/her hands at his/her side when they transferred him/her from the bed to the wheelchair. CNA #1 stated she and CNA # 19 never pried the resident's hands from anything, as he/she kept them at his/her side. Further interview with CNA #1 revealed normally it takes two (2) staff to get Resident #15 up, but when he/she was not wanting to help they had no choice but to use the lift or leave him/her in bed. CNA #1 stated when the resident was in bed, he/she would stay on the light until staff got him/her up. She stated staff had caught the resident transferring himself/herself a couple of times out of bed. CNA #1 stated she did not understand why she and the other CNA were suspended because they did not do anything wrong as they were told to use the lift because the resident would not help with the transfer. CNA #1 stated the Administrator suspended her the following Monday night and told her to write a statement when she came back to work, but she had not been back and no one has called them about their jobs. She stated the resident never stated that they had hurt him/her, or that there was bruising. CNA #1 further stated the resident always bragged if they did not do this or that she/she would call State on us. CNA #1 stated the resident used a lift when he/she first came to the facility, but she was not sure if it was on the CNA care plan or not. CNA #19 no longer worked at the facility. Attempts to interview CNA #19 by phone on 04/07/18 at 9:40 AM and 1:50 PM were unsuccessful. The ADON no longer worked at the facility and attempts to interview the ADON by phone on 04/07/18 at 9:43 AM and 1:52 PM were unsuccessful. Interview with Certified Medical Technician (CMT)/CNA #13 on 04/07/18 at 2:15 PM revealed CNA # 1 and CNA #19 could be very harsh and rude to the residents. She stated there had been multiple complaints reported when the two (2) CNA's worked together. She stated they used a very harsh tone of voice and were very bossy to the residents. She stated the CNA's would provide the care when they (the CNA's,) were ready to do it especially if the resident required extra time during care. She stated the Administrator had told the two (2) CNA's to tone it down multiple times but the CNA's continued as before. She further revealed she did not report the CNA's continued to behave that way because she did not like to cause trouble, or get a co-worker in trouble but knew the Administrator and other administrative staff were aware. Review of the personnel records for CNA #1 and CNA #2 did not reveal any disciplinary actions or write ups in relation to resident care. Review of inservice training revealed the last inservice on abuse for staff was provided on 02/02/18 related to residents' rights, abuse allegations, cell phone use, social media policy, and reporting abuse/allegations of abuse immediately. Interview with the Administrator on 04/06/18 at 3:00 PM revealed, after investigating the incident, they felt there was enough evidence to suspend the two (2) CNA's and also the Assistant Director of Nursing (ADON) due to the CNA's working under her guidance. She stated all the residents were interviewed on the 300 Hall after the incident which revealed multiple negative comments concerning those two (2) CNA's. The Administrator stated one of the CNA's was really good and she hated to see her go, but then she teamed up with the other CNA, and they would feed off each other so she felt the right decision was made. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to notify the Physician when medications and treatments were not administered according to Physician orders [REDACTED].#2, #13, #15, #16, ,#20, #29, #30, #31, #40, #43, #44, #47, #50, #53, #56, #57, #59, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, and #625). The medications included insulin's, blood thinners, [MEDICAL CONDITION] medications, antipsychotics, and treatments for pressure ulcers and burn wounds. Resident #64 was assessed to have three (3) Stage IV Pressure Ulcers: the left buttock, the right buttock, and sacrum; and two (2) unstagable pressure ulcers: left and right heels due to necrosis. In addition, the resident was ordered [MEDICATION NAME] every three (3) hours and [MEDICATION NAME] and Tylenol, as needed (PRN) for pain. There was no evidence the resident was provided treatments on 04/01/18-04/06/18 at 7:00 AM and 7:00 PM, except for one entry on 04/04/18 at 7:00 AM. However, record review revealed there was no evidence the physician or wound care center was made aware of the treatments not being completed. Resident #56 had orders to apply Santyl (chemical debrider) ointment to the lower right [MEDICAL CONDITION] washing with soap and water and to receive showers every other day to prepare the burn wounds for skin graph. Resident #56 did not receive a shower from 03/29/18 through 04/04/18 and dressing changes on 03/30/18, 03/31/18, 04/01/18 and 04/02/18 on either shift. However, record review revealed the wound clinic or physician was made aware the treatment or showers were not competed. On 04/03/18, Resident #56 was observed lying in bed with a large amount of green drainage on dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed. The facility's failure to ensure the physician was notified of omissions of significant medication and treatments including Insulin's, [MEDICATION NAME] and blood thinners, [MEDICAL CONDITION] medications, Antipsychotics, and treatments for pressure and burn wounds has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy Change of Condition Process, dated (MONTH) (YEAR) revealed to ensure the optimal outcome for the resident, the nursing process of assessment, plan, intervention and evaluation will be used and physician involvement is always required. Review of the policy titled, Medication Administration: General Guidelines, not dated, revealed medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of the facility's policy titled Identifying and Managing Medication Errors and Adverse Consequences, dated (MONTH) 2007, revealed the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's attending physician. Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. Notify the nurse supervisor or the physician if the resident refuses the treatment 1. Record review revealed the facility admitted Resident #64 on 09/15/17 and readmitted the resident from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #64's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. In addition, the resident required extensive assist of two (2) staff for Activities of Daily Living (ADLs). Review of the (MONTH) (YEAR) Physicians' Orders revealed three (3) Stage IV Pressure Ulcers, to the right and left buttock and sacral areas, which were to be cleansed with Dial Soap and water, packed with one-quarter (1/4) strength Dakin's Solution, (made from diluted bleach,) covered with gauze and secured with tape. The two Stage IV areas to the bilateral heels were to be treated with Skin-Prep (a liquid, film-forming agent that forms a protective film around intact skin) and left open to air. All dressings were ordered to be changed twice a day (BID.) A foam dressing was to be applied to a scar on the resident's right chest; and changed weekly on Fridays. Further review revealed to obtain accuchecks twice a day; and administer [MEDICATION NAME] 10 milligrams (mg) twice a day for Depression, [MEDICATION NAME] 15 mg twice a day for [MEDICAL CONDITION], [MEDICATION NAME] 30 mg at bedtime for Failure to Thrive, [MEDICATION NAME] one (1) mg every six (6) hours as needed for Anxiety, and [MEDICATION NAME] 7.5 mg/325 mg every four (4) hours as needed for pain. Review of Resident #64's (MONTH) (YEAR) Medication Administration Records (MAR's,) Treatment Administration Records (TAR's) , revealed dressing changes for the five (5) Stage IV sites, ordered BID, had not been signed as completed from 04/01/18-04/06/18 at 7:00 AM and 7:00 PM, except for one entry on 04/04/18 at 7:00 AM. In addition, accuchecks were not obtained twice a day (BID) from 04/01-06/18, except one time on 04/04/18 at 8:00 PM with a result of 230 mg/dl (milligram/deciliter). Additionally, [MEDICATION NAME] was not administered twice a day on 04/01-02/18 and the evening dose was missed on 04/03/18; [MEDICATION NAME] was not administered on 04/01/18 or 04/02/18; and [MEDICATION NAME] was omitted on 04/01/18, 04/02/18 and 04/03/18. However, further review of the Nursing Note Entries from 03/31/18 until 04/04/18 revealed there was no documented evidence the physician or the Hospice Nurse were made aware of any omitted treatments/medications. Interviews with Licensed Practical Nurse (LPN) #7 on 04/03/18 at 4:00 PM, revealed she was responsible for the treatments and the dressing changes for Resident #64 and they had not been completed but were completed when he/she will let me. The LPN stated the resident refuses all the time, and they were short staffed. LPN #7 stated she had asked for help. When asked if she should have notified the Physician she just looked down and shook her head. Interview with Registered Nurse (RN) #2 on 04/04/18 at 10:54 AM, revealed she had been the wound care nurse and had been taken off this position for budgeting concerns. She stated there were concerns the pressure sore treatments were not being completed as ordered; had not been changed for several days; and not done at all on the week-ends related to short staffing. She also stated the staff would ask the resident if he/she would like the dressings changed, instead of saying, we are going to change your dressings now, to which the resident usually complied. Interview with the Director of Nursing (DON) on 04/06/18 at 4:20 PM revealed she had recently been hired and was not aware licensed staff were not doing what they should. She was unable to provide how the licensed staff were monitored to ensure the care was provided to the residents. Interview with the Administrator on 04/05/18 at 1:58 PM, revealed she was recently made aware of an observation on 04/03/18 at 5:18 PM, that revealed the dressings had not been changed since 04/02/18. She stated she was not aware the dressings had not been completed, as ordered until the last couple of days. Interview with Resident #64's Physician on 04/04/18 at 1:50 PM, revealed he did not foresee these pressure ulcers healing as the resident was not cooperative with the required care and the resident had (his/her) own mind He stated the pressure ulcers were unavoidable due to the resident's non-compliance with turning, repositioning and refusals of care; however, he was not aware the resident's pain medication was not given or that pain medications were not effective. 2. Record review revealed the facility admitted Resident #56 on 02/20/18 with [DIAGNOSES REDACTED]. Review of the Resident #56's Physicians' Orders dated 03/08/18, revealed to apply Santyl ([MEDICATION NAME] ointment) to the right lower leg after washing with soap and water. Pat dry, and cover with nickel thick ointment, then cover with moist gauze, then dry gauze, then roll gauge, then ace wrap. This was to be done two (2) times a day (BID). Review of Physicians' Orders dated 03/14/18, revealed to shower every other day, with dressing off the right lower leg, with Dial soap and water, rinse well, and make sure dressing is changed BID. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TAR's) revealed the resident should be showered every other day; however, further review of the TAR's revealed Resident #56 had not been provided a shower per the care plan from 03/29/18 through 04/04/18. In addition, there was no documentation the dressing was changed per the care plan on 03/30/18, 03/31/18, 04/01/18 and 04/02/18 on either shift. Review of the Departmental Notes revealed treatment was refused on 03/22/18, 03/24/18, and 03/30/18 related to the resident's pain. However, further review of the (MONTH) and (MONTH) (YEAR) Departmental Notes revealed there was no documented evidence the Physician or wound clinic was made aware the resident was not receiving treatments/showers Observation and interview on 04/03/18 at 1:09 PM, revealed Resident #56 lying in bed with a large amount of green drainage, noted on the dressing and a pool of green drainage on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before. Observation of the dressing change on 04/03/18 at 2:31 PM revealed copious amounts of green, bloody drainage with a foul smell. Observation revealed there was not a date or time provided on the old dressing. Interview with the Clinical Coordinator from the wound clinic on 04/09/18 at 10:00 AM and 3:30 PM revealed they were trying to prepare Resident's #56's burn wound for a skin graph. She stated the wound clinic had never been notified the resident was not receiving/refusing dressing changes/showers, of the amount of drainage, or the foul odor. In addition, she the she thought the wound was improving and she saw no signs of infection on 04/04/18. Interview with the Attending Physician/Medical Director on 04/10/18 at 9:07 AM revealed if any resident missed their treatment, he expected to be notified. 3. Record review revealed the facility admitted Resident #625 on 04/02/18, with [DIAGNOSES REDACTED]. Review of Resident #625's (MONTH) (YEAR) Physician order [REDACTED]. two times a day (BID) in the PM; [MEDICATION NAME] (Insulin) 100 units/ml vial, inject 30 units sub-qutanious (sub-q) nightly; and, Keflex (Antibiotic) 500 mg, two (2) capsules by mouth every twelve (12) hours for seven (7) days for [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) MAR and count of the medications revealed the resident had not been received the Wednesday dose of [MEDICATION NAME] on 04/04/18. Further review of the MAR revealed two (2) morning (AM), one afternoon (PM) and one (1) bedtime (HS) accu check (blood sugar check), were not obtained on 04/03/18; and one dose of [MEDICATION NAME] had not been administered at 8:00 PM; and, one (1) dose of [MEDICATION NAME] was not administered on 03/03/18 at 9:00 PM In addition, review of the MAR and a count of the Keflex revealed fourteen (14) capsules should have been given but only eleven (11) were gone from the blister pack. The MAR revealed the Keflex had not been initialed as administered on 04/03/18 at 9:00 AM and 9:00 PM. However, review of the record on 04/07/18, revealed there was no documented evidence in the Nurses Notes or on the MAR's/TAR's, as to why the medication and treatments were not administered as the physician ordered, or that the physician was notified of the missed medications. 4. Record review revealed the facility readmitted Resident #59 on 11/17/17 with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment revealed the facility assessed Resident #59's cognition to be intact with a BIMS' score of fifteen (15) which indicated the resident was interviewable. Review of Resident #59's (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR revealed this medication was not administered on 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. However, review of the record on 04/04/18, revealed there was no documented evidence in the Nurses' Notes or on the MAR's as to why the medications were not administered as the physician ordered, or that the physician was notified of the missed medications. Interview with Resident #59 on 04/04/18 at 10:00 AM revealed he/she knew he/she did get the three (3) little medications (he/she) gets at bedtime. He/she stated he/she knew one of the pills was for anxiety. 5. Record review revealed the facility admitted Resident #15 on 01/20/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, 01/27/18 revealed the facility assessed Resident #15's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. Review of Resident #15's (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR revealed there was no documentation the medication was administered at 6:00 AM on 04/01/18-04/03/18; and, at 10:00 PM on 04/02/18 and 04/03/18. However, review of the record on 04/04/18, revealed there was no documented evidence in the Nurses Notes or on the MAR's as to why the medications were not administered as the physician ordered, or that the physician was notified of the missed medications. Interview with Resident #15 on 04/05/18 at 9:15 AM revealed she didn't remember missing any of his/her medications but sometimes does not get his/her HS medications until 12:00 AM to 2:30 AM. 6, Record review revealed the facility admitted Resident #73 on 03/06/18 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 03/23/18, revealed the facility assessed Resident # 73's cognition as severely impaired with a Brief Interview for Mental Status (BIMS') score of five (5), which indicated the resident was not interviewable. Review of Resident #73's (MONTH) (YEAR) Physician order [REDACTED]. daily before breakfast, [MEDICATION NAME] (blood pressure) 100 MG tab (2) tablets by mouth every 12 hours *Hold for heart rate below 60 for hypertension, [MEDICATION NAME] (Alzheimer's) 5 MG tablet give (1) tablet by mouth at bedtime, Accuchecks twice (2) a day call MD if blood sugar <60 or >400, and Wander guard-check (monitoring device) placement, function (right ankle) ordered every shift. Review of Resident #73's (MONTH) (YEAR) MAR, revealed Quetiapine [MEDICATION NAME] Succ ER, [MEDICATION NAME] 250-50 Diskus [MEDICATION NAME] 100 MG tab, [MEDICATION NAME] 5 MG tablet were not documented as administered at 9:00 PM on 04/01/18, 04/02/18 and 04/03/18. In addition, [MEDICATION NAME] ER 2.5 MG was not documented as given at 6:00 AM on 04/01/18-04/03/18. Further review revealed accuchecks twice (2) a day were not documented as being obtained at 6:30 AM and 8:00 PM on 04/01-03/18; and Wander guard-check placement, function (right ankle) once a shift was not documented as being completed at 7:00 AM and 7:00 PM on 04/01-03/18. However, further review of the record on 04/04/18, revealed no documented evidence in the Nurses' Notes or on the MAR's/TAR's, as to why the medication and treatments were not administered as the physician ordered, or that the physician was notified of the missed medications. 7. Record review revealed the facility admitted Resident #575 on 12/19/17 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Review of the (MONTH) (YEAR) MAR revealed there was no documentation [MEDICATION NAME] Prop 50 mcg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] Sodium 20 mg and Levetiracetam 500 mg were administered on 04/03/18 and 04/0418 at 10:00 PM. However, review of the record on 04/04/18, revealed there was no documented evidence in the Nurses' Notes or on the MAR/TAR's, as to why the medication and treatments were not administered as the physician ordered, or that the physician was notified of the missed medications. Interview with Resident #575 on 04/07/18 at 9:00 AM revealed he/she has not been receiving his medications at night. The resident stated he/she does not understand why he/she didn't get them. The resident also revealed he/she did not ask anyone about not getting the medications as (he/she) figured if they wanted him to have his/her medications, they would have given them to (him/her). 8. Record review revealed the facility admitted Resident #2 on 10/27/17, with [DIAGNOSES REDACTED]. Review of Resident #2's (MONTH) and (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] 50 mg 1 tablet by mouth twice daily for blood pressure, Atorvastatin 20 mg one tablet by mouth daily at HS for cholesterol, [MEDICATION NAME] DR 125 mg, Cap sprinkles give 2 capsules (250 mg) by mouth four (4) times a day for [MEDICAL CONDITION], [MEDICATION NAME] 0.05% eye [MEDICATION NAME] place 1 drop in each eye every 12 hours to enhance tear production, Klonopin 0.5 mg tablet one tablet by mouth twice daily, Aripiprazole 2 mg tablet 1 tablet by mouth at bedtime, and [MEDICATION NAME] 10 mg tablet take one tablet by mouth every night for mood stabilization. Review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation the [MEDICATION NAME], Atorvastatin, [MEDICATION NAME], Klonopin, Aripiprazole and [MEDICATION NAME] were administered on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, 8:00 PM, or 9:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 9. Record review revealed the facility admitted Resident #30 on 01/04/18 with [DIAGNOSES REDACTED]. Review of Resident #30's (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] 5 mg tablet one three times a day, [MEDICATION NAME] 10 mg give one tablet by mouth daily at bedtime, Quetiapine [MEDICATION NAME] 25 mg tab one tablet by mouth at night, [MEDICATION NAME] 300 mg capsule one tablet twice daily, Magnesium Oxide 400 mg tablet one tablet orally twice daily, [MEDICATION NAME] ER 600 mg tablet 1 tablet by mouth twice daily for cough/congestion, [MEDICATION NAME] HCL 10 mg tablet 10 mg PO two times daily, and [MEDICATION NAME] 160-4.5 MCG inhaler inhale 2 puffs two times daily with no documentation the medication was administered on 04/01/18, 04/02/18, and 04/03/18. In addition, [MEDICATION NAME] 0.125 mg tablet one tablet one time a day was ordered but there was no documentation the medication was administered on 04/01/18 and 04/02/18. Review of the (MONTH) (YEAR) MAR revealed no documentation that [MEDICATION NAME], Quetiapine [MEDICATION NAME] 300 mg, Magnesium Oxide 400 mg, [MEDICATION NAME] ER 600 mg, [MEDICATION NAME] HCL 10 mg, Seenna 8.6 mg, and [MEDICATION NAME] 160-4.5 MCG, were administered on 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, or 10:00 PM . In addition, there was no documentation [MEDICATION NAME] 0.125 mg was administered on 04/01/18 and 04/02/18 at 6:00 AM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 10. Record review revealed the facility admitted Resident #57 on 02/20/18 with [DIAGNOSES REDACTED]. Review of Resident #57's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' Order revealed to administer [MEDICATION NAME] 5 mg tablet one Po (by mouth) at bedtime and [MEDICATION NAME] HCL 30 mg tablet one tablet by mouth at bedtime for depression. Review of the (MONTH) and (MONTH) (YEAR) MAR's revealed there was no documentation the [MEDICATION NAME] was administered on 03/25/18, 03/26/18, 03/27/18, 03/28/18, 03/30/18, 04/01/18, 04/02/18, and 04/03/18 at bedtime and that the [MEDICATION NAME] HCL was administered on 04/01/18, 04/02/18, and 04/03/18 at bedtime. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 11. Record review revealed the facility admitted Resident #74 on 08/30/17 and readmitted on [DATE] at 3:28 PM with [DIAGNOSES REDACTED]. Review of Resident #74's (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] EC 325 mg tablet give one tablet by mouth twice daily for [MEDICAL CONDITION], [MEDICATION NAME] HCL 4 mg tablet give one tablet by mouth twice a day for muscle spasms, Atorvastatin 40 mg tablet give one tablet by mouth daily at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 300 mg capsule give one capsule by mouth every 8 hours for [MEDICAL CONDITION], [MEDICATION NAME] HCL 100 mg tab give one tablet by mouth daily at bedtime for depression, and [MEDICATION NAME] 50 mg tablet give one tablet by mouth daily at bedtime for [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) MAR revealed there was no documentation [MEDICATION NAME], [MEDICATION NAME], Atorvastatin, [MEDICATION NAME], and [MEDICATION NAME] were administered on 04/02/18 and 04/03/18 at 9:00 PM or 10:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 12. Record review revealed the facility readmitted Resident #47 on 03/11/17 with [DIAGNOSES REDACTED]. Review of Resident #47's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' Order revealed to administer Eliquis 2.5 mg tablet give one tablet by mouth twice daily for anticoagulation. Review of the (MONTH) and (MONTH) (YEAR) MAR revealed there was no documentation the Eliquis 2.5 mg tablet was administered on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 13. Record review revealed the facility admitted Resident #67 on 03/15/18 with [DIAGNOSES REDACTED]. Review of Resident #67's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' order revealed an order for [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) MAR's revealed no documentation the [MEDICATION NAME], was administered on 03/27/18, 04/01/18, 04/02/18, and 04/03/18 at 9:00 AM and 9:00 PM; and the [MEDICATION NAME] Mes and Atorvastatin was administered on 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 14. Record review revealed the facility readmitted Resident #20 on 12/13/17 with [DIAGNOSES REDACTED]. Review of Resident #20's (MONTH) (YEAR) Physicians' Order revealed to administer [MEDICATION NAME] 300 mg capsule take one capsule by mouth three times daily for [MEDICAL CONDITION], [MEDICATION NAME] HCL 15 mg tablet take one tablet by mouth three times daily for mood stabilization, [MEDICATION NAME] 3 mg tablet take one tablet by mouth every bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 150 mg tablet two (2) tablets (300mg) by mouth every night at bedtime for [MEDICAL CONDITION], Quetiapine [MEDICATION NAME] 300 mg tab take one tablet by mouth every bedtime for [MEDICAL CONDITION], Memantine HCL 10 mg tablet take one tablet by mouth two times daily for Alzheimer's, Carvedilol 6.25 mg tablet take one tablet by mouth two times daily for hypertension, Potassium CL ER 20 mEq tablet take one tablet by mouth two times daily for supplement, DOK 100 mg softgel give one softgel by mouth twice daily for constipation, [MEDICATION NAME] HCL 25 mg tab take one tablet by mouth at bedtime for nerve pain/antidepressant, and Donepezil HCL 10 mg tablet take one tablet by mouth every bedtime for Alzheimer's. Review of the (MONTH) (YEAR) MAR revealed no documentation the [MEDICATION NAME], Quetiapine [MEDICATION NAME], Memantine HCL, Carvedilol, Potassium CL ER, DOK, [MEDICATION NAME] HCL, and Donepezil HCL were administered on 04/01/18, 04/02/18, 04/03/18 at 7:00 PM or 10:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 15. Record review revealed facility admitted Resident #65 on 02/10/17 with [DIAGNOSES REDACTED]. Review of Resident #65's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians order revealed an order for [REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) MAR revealed there was no documentation [MEDICATION NAME] and Xarelto were administered on 03/30/18, 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, 9:00 PM, or 10:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 16. Record review revealed the facility readmitted Resident #16 on 05/04/17 with [DIAGNOSES REDACTED]. Review of Resident #16's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' orders revealed to administer [MEDICATION NAME] 300 mg capsule one capsule by mouth three times daily for [MEDICAL CONDITION] pain, [MEDICATION NAME] 0.5 mg tablet one tablet by mouth at bedtime for anxiety, [MEDICATION NAME] 50 mg tablet one tablet by mouth at bedtime for depression, [MEDICATION NAME] 100 units/ml vial give 30 units subcutaneous daily at bedtime, and Humalog 100 units/ml vial accu checks QID (four times per day) S/S (sliding scale) coverage. Review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation the [MEDICATION NAME], and [MEDICATION NAME] were administered on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, and 10:00 PM. Blood sugars were not obtained on 04/02/18, 04/03/18 at 4:30 PM and 8:00 PM to determine the needed amount of sliding scale insulin. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 17. Record review revealed the facility readmitted Resident #31 on 09/24/17 with [DIAGNOSES REDACTED]. Review of Resident #31 (MONTH) (YEAR) and (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] Sodium 20 mg tab one tablet by mouth once daily for [MEDICAL CONDITION]; to check oxygen saturation (O2 Sat) every shift and PRN, notify physician if O2 sat less than 90%; and wanderguard-check placement every shift. Review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation [MEDICATION NAME] Sodium was administered or O2 SATs or wanderguard checks were completed on 03/30/18, 03/31/08, 04/01/18, 04/02/18, and 04/03/18 at 7:00 AM, 7:00 PM or 9:00 PM. However, further review of the record revealed there was no documentation the physician was made aware of the missed doses of medication. 18. Record review revealed the facility admitted Resident #44 on 02/02/18 with [DIAGNOSES REDACTED]. Review of Resident #44's (MONTH) (YEAR) Physicians' Orders revealed to administer [MEDICATION NAME] 30 mg tablet one tablet by mouth every night for A-Fib, Eliquis 5 mg tablet one tablet two times a day by mouth, [MEDICATION NAME] sodium 100 mg capsule one by mouth twice a day, [MEDICATION NAME] 250 mg capsule one capsule by mouth twice daily [MEDICATION NAME] 100 unit

Based on interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of thirty-six (36) sampled residents (Resident #15), had the right to choose aspects of his/her life in the facility that were significant to him/her. On 03/24/18, Certified Nurse Aides (CNA's) #1 and #19 transferred Resident #15 with a lift even though the resident was care planned for the assist of two (2) for transfers and he/she refused to be transferred with the lift. Resident #15 stated he /she was forced to use the lift against his/her will, which was very frightful and demeaning. The facility's failure to ensure the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Self-determination, dated (MONTH) (YEAR), revealed the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including the resident had the right to make choices about aspects of his/her life in the facility that is significant to the resident. Record review revealed the facility admitted Resident #15 on 01/20/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 01/27/18 revealed the facility assessed Resident #15's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable Review of Resident #15's Comprehensive Care Plan for Risk for Alteration in Mood/Behavior, related to the [DIAGNOSES REDACTED]. However, interview with Resident #15 on 04/06/17 at 10:00 AM revealed two (2) CNA's transferred him/her with a lift even though he/she did not want to be transferred with the lift. Further interview with Resident #15 on 04/06/18 at 10:00 AM revealed the two (2) CNA's told him/her they did not want to hurt their backs, so they were going to use the mechanical lift. The resident stated he/she refused the lift and grabbed the grab bars of the bed so not to be transferred by the lift. Resident #15 stated the two CNA's continued with the lift, and pried his/her hands off the grab bar and forced him/her to use the lift against his/her will. He/She stated he/she ended up in the lift without a call light, and he/she panics without his/her call light. Resident #15 further stated his/her right hand hurt for about a day, and he/she noticed a bruise to the right, second and third knuckles; however, review of the resident's clinical record revealed no documentation of a bruise identified on the resident's knuckles. He/she stated it was very demeaning, and he/she was scared to death of CNA #1. Resident #15 further stated, I will absolutely never be forced to use it again. Interview with CNA #1 on 04/08/18 at 10:08 AM, revealed Resident #15 refused to help them transfer him/her without the lift. CNA #1 stated the nurse on the hall came and tried to get the resident to help with the transfer unsuccessfully so the Assistant Director of Nursing (ADON) was approached. According to CNA #1, the ADON said for the staff's safety and safety of the resident, they would have to use the lift, if the resident would not help. CNA #1 stated the resident eventually agreed to let them use the lift, but he/she refused to hang on to the bars, and just left his/her hands at his/her side when they transferred him/her from the bed to the wheelchair. CNA #1 stated she and CNA #19 never pried the resident's hands from anything, as he/she kept them at his/her side. CNA #1 further stated normally it takes two (2)staff to get Resident #15 up, but when he/she was not wanting to help, . we had no choice but to use the lift or leave (him/her) in bed. CNA #1 stated when the resident was in bed, he/she would stay on the light until staff got him/her up or would attempt to transfer on his/her own. CNA #19 no longer worked at the facility and attempts to interview CNA #19 by phone on 04/07/18 at 9:40 AM and 1:50 PM were unsuccessful. The ADON no longer worked at the facility and attempts to interview the ADON by phone on 04/07/18 at 9:43 AM and 1:52 PM were unsuccessful. Interview with the Administrator on 04/06/18 at 3:00 PM revealed, after investigating the incident, they felt there was enough evidence to suspend the two (2) CNA's and also the Assistant Director of Nursing (ADON) due to the CNA's working under her guidance. She stated all the residents were interviewed on the 300 Hall after the incident which revealed multiple negative comments concerning these two (2) CNA's. The Administrator stated one of the CNA's was really good and she hated to see her go, but then she teamed up with the other CNA, they would feed off each other so she felt the right decision was made. She further stated the two (2) CNA's should have never transferred the resident against his/her will and should have honored the resident's choices per facility policy. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. Review of medication records to identify and address medication errors for Residents #29, 43, 73, 20, 61, 2, 57, 125, 47, 53, 62, 64, 575, 67, 74, 65, 60, 63, 13, 40, 30, 275 and 16 was performed by 04/18/18. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure sore management; medication administration in regards to documentation and timeliness; HIPPA (privacy); use of lifts/slings; lock out/tag out system for mechanical lifts; implementation and revision of care plans; and the responsibilities and job duties of a licensed nurses. Interview with Certified Medication Tech (CMT) #2 on 04/20/18 at 11:05 AM, revealed she had received education related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination); HIPPA (privacy); and medication administration in regards to documentation and timeliness. 13. Review of the newly adapted ADL competency check list revealed all CNA's were educated by the RN Nurse Consultants on the new check list and ADL competencies were being evaluated and completed by 04/18/18 as alleged. 14. Review of the audit log sheets, dated 04/09/18, revealed MAR and TAR audits initiated on and had been conducted daily from 04/09/18 through 04/17/18. 15. Review of audit documentation revealed lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 16. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 17. Review of the Clinical QAPI process Form revealed it was updated by RN nurse consultant to include monitoring of pain management control. Review of the action plan for pain management (no date) revealed the goal was to reach optimum pain management of identified clients and prevent other clients in the facility from being at risk for the occurrence. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 18. Review of the contract agreements, titled Prime Time Health Care, dated 04/09/18, Healthcare Staffing Agreement, dated 04/09/18, and Tru Staff for travel personal staffing agreement, dated 04/19/18 revealed the facility had obtained contracts with staffing agencies and was utilizing staff from sister facilities for licensed staff to ensure appropriate staffing levels by 04/18/18 as alleged in the AoC. 19. Review of the daily stand up meeting sign in sheets revealed the DON and Administrator attended the daily morning meetings. Interviews with the Administrator and Interim DON, on 04/20/18 at 2:30 PM, revealed they were both attending the daily stand up meetings. 20. Review of QA Committee Privileged, QA meeting on 04/10/18; revealed Agenda discussed; Discuss Survey IJ Outcome, Discuss Plan of correction, Discuss organization and of evaluations, auditing and monitoring, Discussed in-service and training, and competency checks, Discussed daily plan for monitoring, Discussed consult reviews, Obtained feedback from Medical Director, QA Committee will meet again 04/17/18 to review status plan of the current issues at the facility. 21. Review of QA meeting notes dated 04/17/18, revealed the Regional Director of Operations/Interim Administrator; Acting DON, Interim Social Worker; Activities Director; Rehab Manager, MDS Nurse; Business Office Manager; Human Resources Manager; Medical Director; Quality and Compliance Specialist were present. Both the administrator and DON will be participating in daily stand up meetings, weekly QA, and regular reporting to the Governing body regarding achieving an maintaining ongoing substantial compliance. (TRUNCATED)

Based on observation, interview, and record review, it was determined the facility failed to ensure one (1) of thirty-six (36) sampled residents (Resident #51), received the appropriate care to prevent a Urinary Tract Infection [MEDICAL CONDITION] from worsening leading to hospitalization . On 02/12/18, Resident #51 presented with symptoms of a UTI with complaints of burning with urination, bladder pain, and strong odor of the urine with orders received from the physician to obtain a urine specimen for urinalysis (UA) with culture and sensitivity (C&S). Results of the UA were received on 02/15/18 with the physician noting he was waiting for the C&S results before prescribing any treatment. The C&S results were faxed to the facility on [DATE], however, there were no C&S results in the chart and no evidence the physician was made aware of the results. In addition, there was no evidence the nurse contacted the laboratory to obtain the results. Certified Nurse Assistants (CNA's) reported the resident continued to complain of symptoms and this was reported to nurses; however, there was no documented evidence of on-going assessments of the resident by the nurses. On 02/28/18 (sixteen 16} days after the resident was identified with symptom of a possible UTI) the resident was noted to be non-verbal, pupils dilated and non-reactive with a temperature of 95 degrees Fahrenheit. The resident was hospitalized from [DATE] through 03/03/18 with [DIAGNOSES REDACTED]. The resident returned to the facility with orders to continue antibiotic two (2) times per day for five (5) days. The facility's failure to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator on 04/06/18 at 4:56 PM, revealed the facility did not have policies for bowel and bladder or Urinary Tract Infections. Review of facility's policy titled, Change of Condition, dated (MONTH) (YEAR), revealed change of condition in a resident should target many areas of Interdisciplinary Team (IDT) function. Skill, assessment, and intervention to any change of condition will vary depending on that change and involvement of the IDT when necessary. To ensure the optimal outcome for the resident, nursing process of Assessment, Plan, Intervention, and Evaluation will be used. Physician involvement is always required for following the Interaction process without exclusion of the Licensed Professional's judgment, as is follow-up assessment per Federal Regulatory Guidelines. The resident care plan is to be updated as interventions are implemented. Process: INTERACT system is to be followed. All forms are to be completed in the entirely, signed and dated as needed, and kept per medical records retention or QA committee, as indicated. All new nursing staff shall have this included in their new hire orientation. Protocal: Stop and Watch: early detection tool shall be used by Certified Nurse Assistants (CNA's) and other staff as needed. Charge Nurse will do follow-up assessment as soon as possible if not immediately when the tool is utilized by CNA. Change in Condition Assessment Guidelines will be followed by the licensed nurse for the initial and when necessary, the follow-up assessment to detect change of condition by symptoms and categories. All information triggers in this reference will be used when notifying the physician/Nurse Practitioner. Situation-Background-Assessment/Appearance-Request (SBAR) form is to be used for documentation prior to notifying the Physician/Nurse Practitioner. This form will contain information gathered when doing assessment/evaluation and it to be utilized as nursing note in the medical record. The SBAR is a continuation of the nursing notes with narrative documentation area on the reverse side. Review of the policy titled, Lab, Radiology and other Diagnostic Testing Serviced, Standard of Practice, last revised (MONTH) (YEAR), revealed it is the practice of the facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab, radiology and other diagnostic results. Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering physician per physician orders. Documentation of diagnostic tests, the results and date/time of physician notification will be maintained in the resident's clinical record. All diagnostic test results will be filed in the resident's clinical record. The policy lists the process, step four (4) states each shift will monitor for receipt of lab results and notify lab if not received within twenty-four (24) hours or as indicated (except Culture and Sensitivity labs take longer than twenty-four (24) hours. Step five (5) - Notify supervisor and physician of any delays in receipt of lab results, follow-up. Record review revealed the facility admitted Resident #51 on 01/04/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/10/18 revealed the facility assessed Resident #51's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. However, after brief conversation, it was determined information obtained from Resident #51 was not reliable. Further review of the MDS revealed the resident required extensive assist of two (2) staff for toileting and hygiene and total assist of two (2) staff with transfers; and, the resident was always incontinent of urine. The MDS also revealed a [DIAGNOSES REDACTED]. Review of Resident #51's Comprehensive Care Plan for Alteration in Elimination related to incontinent of bowel and bladder, dated 01/04/18, revealed interventions to report changes to characteristics of urine such as color, odor, sediment. Review of Departmental Notes by Licensed Practical Nurse (LPN) #3 dated 02/12/18 at 10:47 PM, revealed Resident #51 had complaints of pain in the bladder and a strong odor from the urine was noted. The physician was notified and orders were received to obtain a urine for urinalysis (UA) and culture and sensitivity (C&S). The specimen was obtained and the resident tolerated the procedure well. Review of the Comprehensive Care Plan for Alteration in Elimination related to incontinent of bowel and bladder, dated 01/04/18, revealed the care plan was revised on 02/12/18 to note Strong urine odor present and to Obtain urine for routine and Culture and Sensitivity. In addition, a note was added on 03/16/18, Recent UTI. Review of the Departmental Notes by Registered Nurse (RN) #10, dated 02/15/18 at time at 11:52 AM, revealed the results of UA were received by the facility on 02/15/18 and faxed to the physician. Review of the UA Lab Report, dated 02/15/18, revealed the urine had 5-10 White Blood Cells present with trace bacteria. Urine culture and sensitivity is pending was noted on the UA lab slip. A hand written note by LPN #3 on the lab results indicated the Physician was aware and was waiting on the C&S results. However, further review of the resident's clinical record revealed there was no Laboratory Report of the C&S results or any documented evidence the physician was notified of the results. Further review of the Departmental Notes dated 02/16/18 through 02/28/18, revealed there was no documented evidence the resident had any more complaints of bladder pain and no evidence licensed staff conducted ongoing assessments due the resident's possible UTI. Review of facility's SBAR Communication form dated 02/28/18 at 6:20 AM, revealed vital signs were checked: blood pressure: 150/90 (normal: 120/80-140/90), pulse; 92 (normal: 60-100), Respirations: 16 (normal: 12-20), temperature 95 degrees (normal 98.7) Fahrenheit, and blood sugar was 196 (normal 70-120); and a mental status evaluation indicated the resident was not responding verbally, not following with pupils, eyes were dilated. Urine Evaluation indicated Resident #51's urine had a strong odor. Neurologic Evaluation indicated the resident's pupils were dilated, rolling tongue, and not following directions, not verbal. Physician on-call for resident's primary care physician was notified at 6:25 AM and orders to transfer to the hospital were received. Review of the Departmental Notes revealed on 02/28/18 at 7:01 AM, Resident #51 was noted to have twitching of the left leg, pupils dilated and eyes not tracking to sound well; no speech, but some moaning sounds; and vital signs to include: blood pressure: 150/90 (normal: 120/80-140/90), pulse; 92 (normal: 60-100), Respirations: 16 (normal: 12-20), temperature 95 degrees (normal 98.7) Fahrenheit, and blood sugar was 196 (normal 70-120). Review of the SBAR Communication Form, dated 02/28/18, revealed the resident's urine had a strong odor. The resident was transported to the local hospital for evaluation and treatment. Review of the Hospital Discharge Summary dated 03/03/18, revealed Resident #51 was hospitalized [DATE] through 03/03/18 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the Laboratory (lab) Manager on 04/06/18 at 4:21 PM revealed the C&S results were reported to the facility via facsimile (fax) on 02/15/18. Review of the final C&S report, dated 02/15/18, revealed the report was faxed to the facility on [DATE] and the results were Gram Negative Bacilli, 1,000-9,999 Colony Forming Unit (cfu) per milliliter (mL), was growing in resident's urine. Interview with Certified Nurse Aide (CNA) #17 on 04/07/18 at 9:10 AM revealed Resident #51 complained of burning with urination prior to being sent to the hospital on [DATE]. CNA #17 stated she reported the complaints to the nurse at that time. The CNA was unable to recall the dates of the complaints or the date she reported the resident's complaints. Interview with CNA #11 on 04/07/18 at 9:35 AM revealed Resident #51 had complained to her regarding burning with urination prior to hospitalization . CNA #11 stated she reported the complaints to Registered Nurse (RN) #10. Telephone interview with Registered Nurse #10 on 04/07/18 at 9:45 AM revealed she could not remember if anyone reported UTI symptoms for Resident #51. RN #10 stated the resident expressed complaints of symptoms often and frequently asked for a bed pan or his/her adult brief to be changed. She stated she did not recall any signs or symptoms being present before hospitalization . RN #10 further stated she usually follows up on labs, UA, C&S results for her assigned residents, but she did not this particular time. Telephone interview with Licensed Practical Nurse (LPN) #3 on 04/07/18 at 11:50 AM revealed the facility never received the C&S results before the resident went to the hospital. LPN #3 stated the resident did not have symptoms of a UTI until he/she went to the hospital. The LPN denied any reports of symptoms from CNA's. However, LPN #3 stated the resident reported minimal burning with urination but she did not think the minimal burning was significant enough to report or follow up on. Attempts to contact the resident's primary care physician were unsuccessful. A phone call was made on 04/06/18 at 1:13 PM with no answer; on 04/09/18 at 9:30 AM with a message with call back information left on answering machine; and on 04/19/18 at 2:30 PM with no answer. Interview with the Director of Nursing (DON) on 04/06/18 at 9:20 AM revealed lab culture results should be back to the nursing facility within seventy-two (72) hours after sending the specimen to the lab. The DON stated if the results had not been received within seventy-two (72) hours, the nurse on duty should be calling to check the lab to check on the results. She stated at one a nurse was assigned to follow up on the labs but she was terminated. The DON further stated she expected the nurses to follow up on the labs for their assigned residents and she would have expected the nurses to continue to assess the resident for on-going symptoms of urinary tract infection [MEDICAL CONDITION]. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse con (TRUNCATED)

Based on interview, record review and facility policy review, it was determined the facility failed to ensure the physician was notified of abnormal lab results in a timely manner for two (2) of thirty-six (36) sampled residents (Residents #51 and #23). On 02/12/18, Resident #51 had orders for a Urinalysis and Culture and Sensitivity (C&S); however, the facility failed to ensure the C & S results were obtained and the Physician was notified of the results. According to laboratory documentation, the facility was notified by facsimile (fax) on 02/15/18 of the C & S results; however, there was no documented evidence the facility made the Physician aware of the results. On 02/28/18 (approximately two {2} weeks later), the resident was noted to not respond verbally, not follow with his/her pupils and his/her eyes were dilated. In addition, the resident had a temperature of 95 degrees Fahrenheit. The resident was hospitalized with [DIAGNOSES REDACTED]. The facility's failure to ensure the physician was notified of abnormal lab results in a timely manner has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, on 03/25/18, Resident #23 had orders for a Culture and Sensitivity (C&S) of penile drainage. The facility failed to ensure the C & S results were obtained and the Physician was notified of the results. According to laboratory documentation, the facility was notified by fax on 03/30/18 of the C & S results; however, there was no evidence the facility made the Physician aware of the results. The findings include: Review of the facility's policy titled, Lab, Radiology and other Diagnostic Testing Serviced, Standard of Practice, last revised November, (YEAR), revealed it was the practice of the facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab, radiology and other diagnostic testing findings. Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering physician per physician orders. Documentation of diagnostic tests, the results and date/time of physician notification will be maintained in the resident's clinical record. All diagnostic test results will be filed in the resident's clinical record. The policy lists the process: Step 4- Each shift will monitor for receipt of lab results and notify lab if not received within twenty-four (24) hours or as indicated (except Culture and Sensitivity labs take longer than twenty-four (24) hours. Step five - Notify supervisor and physician of any delays in receipt of lab results, follow-up. 1. Record review revealed the facility admitted Resident #51 on 01/04/18, with [DIAGNOSES REDACTED]. Review of the Resident #51's UA Lab Report, dated 02/13/18, revealed the resident's urine had 5-10 White Blood Cells present with trace bacteria. Urine culture and sensitivity is pending was noted on the UA lab slip. A hand written note on the lab results indicated the Physician was aware and was waiting on C &S results. However, further review of the resident's clinical record revealed there were no Laboratory Report of the C&S results or documented evidence the physician was notified of the results. Review of facility's Situation-Background-Assessment/Appearance Request (SBAR) Communication form dated 02/28/18 at 6:20 AM, revealed the resident's temperature was 95 degrees Fahrenheit (normal 98.6 degrees); was not responding verbally, not following with pupils, eyes were dilated, urine had a strong odor, the resident's tongue was rolling, and he/she was not following directions. The physician on-call for the resident's primary care physician was notified at 6:25 AM and orders to transfer to the hospital were received. Review of hospital records revealed Resident #51 was admitted to the hospital on [DATE] through 03/03/18 for [MEDICATION NAME] Urinary Tract Infection [MEDICAL CONDITION], Acute [MEDICAL CONDITION], Dehydration, and Multi-drug resistant organism, proteus mirabilis, in the urine. Resident #51 was discharged with orders to continue on oral antibiotics two (2) times per day for five (5) days. Interview with the Lab personnel on 04/06/18 at 4:21 PM and, review of the Lab Report dated 02/15/18 provided by the lab, revealed the C&S results were reported to the facility via fax on 02/15/18 and the results were Gram Negative Bacilli, 1,000-9,999 Colony Forming Unit (cfu) per milliliter (mL), growing in resident's urine. Telephone interview with Registered Nurse (RN) #10 on 04/07/18 at 9:45 AM revealed she usually follows up on labs, UA, and C&S results for her assigned residents, but she did not this particular time. 2. Record review revealed the facility admitted Resident #23 on 09/16/13 with [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders dated 03/25/18, revealed to obtain swab of penis discharge and send out. However, further review of the resident's clinical record revealed there was no Laboratory Report of the C&S results or documented evidence the physician was notified of the results. Interview with Lab personnel on 04/06/18 at 4:10 PM, and review of the Lab Report dated 03/30/18 provided by the lab, revealed the C&S results were reported to the facility via fax on 03/30/18 and the results were Rare [MEDICATION NAME] cells; Morphologically resembling squamous cells; Moderate Gram Positive Cocci in pairs and clusters; Numerous Gram Positive Bacilli; Numerous Gram Negative Bacilli; and Morganella Morganii growing in the specimen. Interview with LPN #8 on 04/05/18 at 9:10 AM revealed she had not had time to call the lab for the results. Further review with LPN #8 on 04/06/18 08:40 AM revealed she forgot to check on the culture yesterday after interview with State Surveyor. Interview with the Director of Nursing (DON) on 04/06/18 at 9:20 AM revealed if the C & S results have not been received within seventy-two (72) hours, the nurse on duty should call the lab to check on the results. The DON further stated she expected the nurses to follow up on the labs for their assigned residents. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. Review of medication records to identify and address medication errors for Residents #29, 43, 73, 20, 61, 2, 57, 125, 47, 53, 62, 64, 575, 67, 74, 65, 60, 63, 13, 40, 30, 275 and 16 was performed by 04/18/18. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure sore management; medication administration in regards to documentation and timeliness; HIPPA (privacy); use of lifts/slings; lock out/tag out system for mechanical lifts; implementation and revision of care plans; and the responsibilities and job duties of a licensed nurses. Interview with Certified Medication Tech (CMT) #2 on 04/20/18 at 11:05 AM, revealed she had received education related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination); HIPPA (privacy); and medication administration in regards to documentation and timeliness. 13. Review of the newly adapted ADL competency check list revealed all CNA's were educated by the RN Nurse Consultants on the new check list and ADL competencies were being evaluated and completed by 04/18/18 as alleged. 14. Review of the audit log sheets, dated 04/09/18, revealed MAR and TAR audits initiated on and had been conducted daily from 04/09/18 through 04/17/18. 15. Review of audit documentation revealed lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 16. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 17. Review of the Clinical QAPI process Form revealed it was updated by RN nurse consultant to include monitoring of pain management control. Review of the action plan for pain management (no date) revealed the goal was to reach optimum pain management of identified clients and prevent other clients in the facility from being at risk for the occurrence. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 18. Review of the contract agreements, titled Prime Time Health Care, dated 04/09/18, Healthcare Staffing Agreement, dated 04/09/18, and Tru Staff for travel personal staffing agreement, dated 04/19/18 revealed the facility had obtained contracts with staffing agencies and was utilizing staff from sister facilities for licensed staff to ensure appropriate staffing levels by 04/18/18 as alleged in the AoC. 19. Review of the daily stand up meeting sign in sheets revealed the DON and Administrator attended the daily morning meetings. Interviews with the Administrator and Interim DON, on 04/20/18 at 2:30 PM, revealed they were both attending the daily stand up meetings. 20. Review of QA Committee Privileged, QA meeting on 04/10/18; revealed Agenda discussed; Discuss Survey IJ Outcome, Discuss Plan of correction, Discuss organization and of evaluations, auditing and monitoring, Discussed in-service and training, and competency checks, Discussed daily plan for monitoring, Discussed consult reviews, Obtained feedback from Medical Director, QA Comm (TRUNCATED)

Based on interview, record review, and facility policy review, it was determined the facility failed to have laboratory reports filed in three (3) of thirty-six (36) sampled residents' clinical records (Residents #51, #23, and #72). On 02/12/18, Resident #51 had orders for a Urinalysis and Culture and Sensitivity (C&S); however, the facility failed to ensure the C & S results were obtained to file in the chart. Resident #51 was found on 02/28/18 (approximately two {2} weeks later), with a temperature of 95 degrees Fahrenheit, unresponsive, and his/her eyes were dilated. The resident was hospitalized with [DIAGNOSES REDACTED]. The facility's failure to ensure abnormal lab results were in the chart in a timely manner has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, the facility failed to ensure Resident #23's 03/30/18 Culture and Sensitivity (C&S) laboratory reports; and, Resident #72's laboratory reports were filed in each resident's clinical record. The findings include: Review of the policy titled, Lab, Radiology and other Diagnostic Testing Serviced, Standard of Practice, last revised November, (YEAR), revealed documentation of diagnostic tests, the results and date/time of physician notification will be maintained in the resident's clinical record. All diagnostic test results will be filed in the resident's clinical record. 1. Record review revealed the facility admitted Resident #51 on 01/04/18 with [DIAGNOSES REDACTED]. Review of the Resident #51's UA Lab Report, dated 02/13/18, revealed a hand written note on the lab results indicated the Physician was aware and was waiting on C &S results. However, further review of the resident's clinical record revealed there were no Laboratory Report of the C&S results in the record. Review of facility's Situation-Background-Assessment/Appearance Request (SBAR) Communication form dated 02/28/18 at 6:20 AM, revealed Resident #51 was found to have a temperature of 95 degrees Fahrenheit (normal 98.6 degrees); was unresponsive, not following with pupils, eyes were dilated, urine had a strong odor, the resident's tongue was rolling, and he/she was not following directions. The physician on-call for the resident's primary care physician was notified at 6:25 AM and orders to transfer to the hospital were received. Review of hospital records revealed Resident #51 was admitted to the hospital on [DATE] through 03/03/18 with [DIAGNOSES REDACTED]. Resident #51 was discharged with orders to continue on oral antibiotics two (2) times per day for five (5) days. Interview with the Lab personnel on 04/06/18 at 4:21 PM and, review of the Lab Report dated 02/15/18 provided by the lab, revealed the C&S results were reported to the facility via fax on 02/15/18 and the results were Gram Negative Bacilli, 1,000-9,999 Colony Forming Unit (cfu) per milliliter (mL), growing in resident's urine. Telephone interview with Registered Nurse (RN) #10 on 04/07/18 at 9:45 AM revealed she usually follows up on labs, UA, and C&S results for her assigned residents, but she did not this particular time. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders dated 03/25/18 revealed to obtain swab of penis discharge and send out. Review of the Laboratory Report revealed the culture was collected at the facility on 03/27/18 and received in the lab that same day. However, further review of the resident's clinical record revealed there was no laboratory report of the C&S obtained on 03/27/18. Review of the lab results provided by the laboratory dated 03/30/18 and interview with Lab Manager #1 on 04/06/18 at 4:10 PM revealed the C & S lab results were sent to the facility per fax on 03/30/18. 3. Record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].#72 revealed an order for [REDACTED]. Review of the clinical record revealed the labs were drawn in (MONTH) (YEAR), however, the lab results were not filed in Resident #72's clinical record. Further interview with Lab Manager #1 on 04/07/18 at 10:50 AM, revealed the facility nursing staff has access to an online portal in which they could log onto and view and print lab results for each resident. He stated critical labs were called into the facility within fifteen (15) minutes when the results were obtained by the lab. He stated lab results were also faxed to the facility. Interview with Registered Nurse (RN) #1 on 04/07/18 at 2:48 PM, revealed she had been responsible for tracking and logging labs, however, with her added duties she just didn't have time to take care of three (3) units. Interview with the Director of Nursing (DON) on 04/06/18 at 9:20 AM revealed lab culture results should be back to the nursing facility within seventy-two (72) hours after sending the specimen to the lab. The DON stated if the results have not been received within seventy-two (72) hours, the nurse on duty should call the lab to check on the results. The DON stated once the labs are obtained by the facility, they should be placed on the chart. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. Review of medication records to identify and address medication errors for Residents #29, 43, 73, 20, 61, 2, 57, 125, 47, 53, 62, 64, 575, 67, 74, 65, 60, 63, 13, 40, 30, 275 and 16 was performed by 04/18/18. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders [REDACTED]. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders [REDACTED]. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included physician's orders [REDACTED]. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders [REDACTED]. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination). Interviews on 04/20/18 with the Divisional Director of Operations at 1:15 PM, MDS Nurse #2 at 3:30 PM and the Interim Administrator at 4:30 PM, revealed they had been educated by the QA Compliance Consultant regarding the QA process and the role of the interdisciplinary (IDT) team. Staff interviews conducted on 04/20/18 with Licensed Practical Nurses (LPNs) #8 at 10:28 AM, #11 at 1:56 PM, #2 at 2:05 PM, and #1 at 3:01 PM; Registered Nurses (RN's) #10 at 1:46 PM and #3 at 3:14 PM; and Minimum Data Set (MDS) Nurse #2 at 9:39 PM, revealed they had received education by the RN Nurse Consultants related to residents' rights; abuse/neglect; infection control; head to toe assessments; acknowledging and reporting change in condition of a resident; reporting and documenting lab results; ensuring documentation in the medical record; conducting pain assessments; wound assessment and pressure sore management; medication administration in regards to documentation and timeliness; HIPPA (privacy); use of lifts/slings; lock out/tag out system for mechanical lifts; implementation and revision of care plans; and the responsibilities and job duties of a licensed nurses. Interview with Certified Medication Tech (CMT) #2 on 04/20/18 at 11:05 AM, revealed she had received education related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infection control; use of mechanical lifts in regards to using two (2) person assist and which sling size and color to use; and resident rights (self-determination); HIPPA (privacy); and medication administration in regards to documentation and timeliness. 13. Review of the newly adapted ADL competency check list revealed all CNA's were educated by the RN Nurse Consultants on the new check list and ADL competencies were being evaluated and completed by 04/18/18 as alleged. 14. Review of the audit log sheets, dated 04/09/18, revealed MAR and TAR audits initiated on and had been conducted daily from 04/09/18 through 04/17/18. 15. Review of audit documentation revealed lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 16. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 17. Review of the Clinical QAPI process Form revealed it was updated by RN nurse consultant to include monitoring of pain management control. Review of the action plan for pain management (no date) revealed the goal was to reach optimum pain management of identified clients and prevent other clients in the facility from being at risk for the occurrence. Review of a reference tool in use as of 04/10/18, revealed daily monitoring of change of condition/pain management and reporting. 18. Review of the contract agreements, titled Prime Time Health Care, dated 04/09/18, Healthcare Staffing Agreement, dated 04/09/18, and Tru Staff for travel personal staffing agreement, dated 04/19/18 revealed the facility had obtained contracts with staffing agencies and was utilizing staff from sister facilities for licensed staff to ensure appropriate staffing levels by 04/18/18 as alleged in the AoC. 19. Review of the daily stand up meeting sign in sheets revealed the DON and Administrator attended the daily morning meetings. Interviews with the Administrator and Interim DON, on 04/20/18 at 2:30 PM, revealed they were both attending the daily stand up meetings. 20. Review of QA Committee Privileged, QA meeting on 04/10/18; revealed Agenda discussed; Discuss Survey IJ Outcome, Discuss Plan of correction, Discuss organization and of evaluations, auditing and monitoring, Discussed in-service and training, and competency checks, Discussed daily plan for monitoring, Discussed consult reviews, Obtained feedback from Medical Director, QA Committee will meet again 04/17/18 to review status plan of the current issues at the facility. 21. Review of QA meeting notes dated 04/17/18, revealed the Regional Director of Operations/Interim Administrator; Acting DON, Interim Social Worker; Activities Director; Rehab Manager, MDS Nurse; Business Office Manager; Human Resources Manager; Medical Director; Quality and Compliance Specialist were present. Both the administrator and DON will be participating in daily stand up meetings, weekly QA, and regular reporting to the Governing body regarding ach (TRUNCATED)

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the clinical records were accurate and complete related to documentation on the Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for twenty-five (25) of thirty-six (36) residents (Residents #2, #13, #20, #29, #30, #35, #40 ,#43, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #67. #73, #74, #125, #275, #575 and #625). Resident #56 had orders to shower every other day and apply santyl ointment [MEDICAL CONDITION] right lower leg to prepare wound for skin graph. However, there was no documented evidence on the MAR/TAR the showers were completed on 04/01/18-04/05/18 and the treatments were completed on 03/30/18, 03/31/18, 04/01/18, and 04/02/18. In addition, orders were received on 04/04/18 to shower daily with soap and water, pat wound dry then apply treatment to ensure the treatments would be completed as ordered; however, the order was not transcirbed to MAR, TAR, shower sheets or Comprehensive Care Plan so staff would be aware to give daily showers. Observation on 04/03/18, revealed Resident #56 in bed with a large amount of green drainage, noted on the dressing and a pool of green drainage noted on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before. The facility's failure to ensure medical records were complete and accurately documented, has caused or was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, Licensed staff failed to document if they administered Residents #2, #13, #20, #29, #30, #35, #40 ,#43, #47, #50, #53, #56, #57, #60, #61, #62, #63, #64, #67. #73, #74, #125, #275, #575 and #625 medications/treatments to include Counadin, Insulin, blood pressure medication, accu-checks, [MEDICAL CONDITION] medication and antipsychotics so staff would know whether the residents had received his/her medications/treatments or not. The findings include: Review of the facility's policy, Medication Administration General Guidelines, dated 12/12 from Nursing Care Center Pharmacy Policy & Procedure Manual- 2007 PharMerica Corp revealed, The individual who administers the medications dose, records the administration on the resident's MAR immediately following the medication being given.If dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee log. 1. Record review revealed the facility admitted Resident #56 on 02/20/18 with [DIAGNOSES REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) Physician order [REDACTED].#56's lower leg were not documented as completed, or a N indicating refused or withheld on either shift on 03/30/18, 03/31/18, 04/01/18, and 04/02/18 and on the morning shift on 04/03/18. In addition, orders were received on 04/04/18 to shower daily with soap and water, pat wound dry then apply treatment; however, there was no documentation on the MAR, TAR, shower sheets or Comprehensive Care Plan so staff would be aware to give daily showers. Observation and interview on 04/03/18 at 1:09 PM, revealed Resident #56 lying in bed with a large amount of green drainage, noted on the dressing and a pool of green drainage noted on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before. There was not a date or time provided on the old dressing. Interview with the Clinical Coordinator from the wound clinic on 04/09/18 at 10:00 AM revealed for the resident's visit on 04/04/18, new orders were sent to the facility that specified to shower daily. She stated on the 03/14/18 visit, the dressing was dated 03/11/18, so she felt the dressing had not been getting changed as it should, so she added shower every other day to the orders to help ensure the dressing was getting done more frequently. She further revealed at 3:30 PM the wound clinic had never been notified related to refusing of the dressing changes 2. Record review revealed the facility admitted Resident #64 on 09/15/17 and was readmitted from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of Resident #64's Medication Administration Records (MAR's,) Treatment Administration Records (TAR's,) and the Nursing Notes for (MONTH) (YEAR), revealed the dressing changes for the five (5) Stage IV sites, ordered BID, had not been signed as completed, or a N for refused or withheld from 04/01-05/18, except for one entry on 04/04/18 at 7:00 AM. In addition, [MEDICATION NAME] ordered every three hours for pain, had several unsigned areas on the MAR even though every dose of [MEDICATION NAME] was accounted for on the Narcotic Count Sheet. [MEDICATION NAME] and [MEDICATION NAME], ordered by the physician for a [DIAGNOSES REDACTED]. Additionally, there was no Nursing Note entries from 03/31/18 until 04/04/18 and no evidence in the chart the physician or the Hospice Nurse was made aware of any omitted or refused medications or treatments. 3. Record review revealed the facility admitted Resident #35 on 07/01/12 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's (MONTH) (YEAR) physician's orders [REDACTED]. the MAR/TAR and did not indicate if the medication was administered, withheld, or refused on 04/01/18, 04/02/18, and 04/03/18. 4. Record review revealed the facility admitted Resident #625 on 04/02/18 with [DIAGNOSES REDACTED]. Review of Resident #35's (MONTH) (YEAR) physician's orders [REDACTED]. However, the boxes next to the [MEDICATION NAME] were blank on the MAR and did not indicate if the medication had been administered, withheld, or refused on 04/01/18 at 5:00 PM. 5. Record review revealed the facility readmitted Resident #20 on 12/13/17 with [DIAGNOSES REDACTED]. Review of Resident #20's (MONTH) (YEAR) Physicians' Order and MAR revealed to administer [MEDICATION NAME] 300 mg capsule take one capsule by mouth three times daily for [MEDICAL CONDITION], [MEDICATION NAME] HCL 15 mg tablet take one tablet by mouth three times daily for mood stabilization, [MEDICATION NAME] 3 mg tablet take one tablet by mouth every bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 150 mg tablet two (2) tablets (300 mg) by mouth every night at bedtime for [MEDICAL CONDITION], Quetiapine [MEDICATION NAME] 300 mg tab take one tablet by mouth every bedtime for [MEDICAL CONDITION], Memantine HCL 10 mg tablet take one tablet by mouth two times daily for Alzheimer's, Carvedilol 6.25 mg tablet take one tablet by mouth two times daily for hypertension, Potassium CL ER 20 meq tablet take one tablet by mouth two times daily for supplement, Ducosate Sodium 100 mg softgel give one softgel by mouth twice daily for constipation, [MEDICATION NAME] HCL 25 mg tab take one tablet by mouth at bedtime for nerve pain/antidepressant, Donepezil HCL 10 mg tablet take one tablet by mouth every bedtime for Alzheimer's. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM or 10:00 PM. 6. Record review revealed the facility admitted Resident #2 on 10/27/17 with [DIAGNOSES REDACTED]. Review of Resident #2's (MONTH) (YEAR) Physicians Orders and MAR revealed to administer [MEDICATION NAME] 50 mg 1 tablet by mouth twice daily for blood pressure, Atorvastatin 20 mg one tablet by mouth daily at HS for cholesterol, [MEDICATION NAME] DR 125 mg Cap sprinkles give 2 capsules (250 mg) by mouth four times a day for [MEDICAL CONDITION], [MEDICATION NAME] 0.05% eye [MEDICATION NAME] place 1 drop in each eye every 12 hours to enhance tear production, Klonopin 0.5 mg tablet one tablet by mouth twice daily, Aripiprazole 2 mg tablet 1 tablet by mouth at bedtime, [MEDICATION NAME] 10 mg tablet take one tablet by mouth every night for mood stabilization. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, 8:00 PM, or 9:00 PM. 7. Record review revealed the facility admitted Resident #30 on 01/04/18 with [DIAGNOSES REDACTED]. Review of Resident #30's (MONTH) (YEAR) Physicians Order and MAR revealed to administer [MEDICATION NAME] 5 mg tablet one three times a day, [MEDICATION NAME] 10 mg give one tablet by mouth daily at bedtime, Quetiapine [MEDICATION NAME] 25 mg tab one tablet by mouth at night, [MEDICATION NAME] 300 mg capsule one tablet twice daily, Magnesium Oxide 400 mg tablet one tablet orally twice daily, [MEDICATION NAME] ER 600 mg tablet 1 tablet by mouth twice daily for cough/congestion, [MEDICATION NAME] HCL 10 mg tablet 10 mg PO two times daily, and [MEDICATION NAME] 160-4.5 MCG inhaler inhale 2 puffs two times daily. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, or 10:00 PM. In addition, further review of the (MONTH) (YEAR) Physician order [REDACTED]. 8. Record review revealed the facility readmitted Resident #43 on 02/02/18 with [DIAGNOSES REDACTED]. Review of Resident #43's (MONTH) (YEAR) and (MONTH) (YEAR) Physician order [REDACTED]. However, the boxes were blank next to the medications on the MAR and did not indicate if the medications were administered, withheld, or refused on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM. 9. Record review revealed the facility admitted Resident #57 on 02/20/18 with [DIAGNOSES REDACTED]. Review of Resident #57's (MONTH) and (MONTH) (YEAR) Physicians Order and MAR revealed to administer [MEDICATION NAME] 5 mg tablet one PO (by mouth) at bedtime; however, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 03/25/18, 03/26/18, 03/27/18, 03/28/18, 03/30/18, 04/01/18, 04/02/18, and 04/03/18 at bedtime. Further review of the (MONTH) and (MONTH) (YEAR) Physicians Order and MAR revealed to administer [MEDICATION NAME] HCL 30 mg by mouth at bedtime for depression; however, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 04/01/18, 04/02/18, and 04/03/18 at bedtime 10. Record review revealed the facility admitted Resident #74 on 08/30/17 and readmitted on [DATE] at 3:28 PM with [DIAGNOSES REDACTED]. Review of Resident #74's (MONTH) (YEAR) Physicians Order and MAR revealed to administer [MEDICATION NAME] [MEDICATION NAME] Coated (EC) 325 mg tablet give one tablet by mouth twice daily for [MEDICAL CONDITION], [MEDICATION NAME] HCL 4 mg tablet give one tablet by mouth twice a day for muscle spasms, Atorvastatin 40 mg tablet give one tablet by mouth daily at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 300 mg capsule give one capsule by mouth every 8 hours for [MEDICAL CONDITION], [MEDICATION NAME] HCL 100 mg tab give one tablet by mouth daily at bedtime for depression, and [MEDICATION NAME] 50 mg tablet give one tablet by mouth daily at bedtime for [MEDICAL CONDITION]. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 04/02/18, and 4/03/18 at 9:00 PM or 10:00 PM. 11. Record review revealed the facility readmitted Resident #47 on 03/11/17 with [DIAGNOSES REDACTED]. Review of Resident #47's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians Order and MAR revealed to administer Eliquis 2.5 mg tablet give one tablet by mouth twice daily for anticoagulation. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. 12. Record review revealed the facility admitted Resident #67 on 03/15/18 with [DIAGNOSES REDACTED]. Review of Resident #67 (MONTH) (YEAR) and (MONTH) (YEAR) Physicians Order and MAR revealed an order for [REDACTED]. However, the boxes next to the medication were blank and did not indicate the [MEDICATION NAME], Trazadone, and [MEDICATION NAME] was administered, withheld, or refused on 03/27/18, 04/01/18, 04/02/18, and 04/03/18; the [MEDICATION NAME] Mea was administered, withheld or refused on 04/01/18, 04/02/18, and 04/03/18; and, the Atorvastatin was administered, withheld or refused on 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. In addition, review of the Physician order [REDACTED]. 03/25/18, 03/27/18, 03/30/18, 03/31/18, 04/01/18, 04/02/18, and 04/03/18. Interview with Licensed Practical Nurse (LPN) #7 on 04/05/18 at 5:25 PM revealed the shunt might have been assessed, but just did not get charted, but the order should have been followed and documented. 13. Record review revealed the facility admitted Resident #50 on 02/12/18 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. 14. Record review revealed the facility admitted Resident #53 on 12/12/15 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused for the PM doses of [MEDICATION NAME] Succ ER, [MEDICATION NAME] HCL, and [MEDICATION NAME], on 04/01/18 through 04/03/18. 15. Record review revealed the facility admitted Resident #63 on 12/08/17 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused for the PM dose of [MEDICATION NAME], and [MEDICATION NAME] on 04/01/18 through 04/03/18. 16 Record review revealed Resident #275 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused for the PM dose of [MEDICATION NAME], Trazadone, and [MEDICATION NAME] on 04/01/18 through 04/03/18. 17. Record review revealed the facility admitted Resident #61 on 09/27/16 with [DIAGNOSES REDACTED]. Review of Resident #61's (MONTH) (YEAR) Physician order [REDACTED]. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused at 6:30 AM/7:00 AM on 04/04/18. 18. Record review revealed the facility admitted Resident #60 on 09/27/15 with [DIAGNOSES REDACTED]. Review of Resident #60's (MONTH) (YEAR) Physician order [REDACTED]. However, the boxes next to the medications on the MAR were blank and did not indicate if the medication was administered, withheld, or refused at 6:30 AM/7:00 AM on 04/04/18. 19. Record review revealed the facility admitted Resident #125 on 03/20/18 with [DIAGNOSES REDACTED]. Review of Resident #125's (MONTH) (YEAR) physician's orders [REDACTED]. However, the boxes next to the finger stick on the MAR were blank and did not indicate if the fingerstick was obtained, withheld, or refused at 9:00 PM on 04/01/18 or at 6:00 AM and 11:00 AM on 04/04/18. In addition, the boxes next to the [MEDICATION NAME] on the MAR were blank and did not indicate if the medication was administered, withheld, or refused on on 04/04/18. 20. Record review revealed the facility readmitted Resident #13 on 03/27/18 with [DIAGNOSES REDACTED]. Review of Resident #13's (MONTH) (YEAR) Physician order [REDACTED].= 1250 mg; [MEDICATION NAME] (overactive bladder)10 mg tablet by mouth every night; [MEDICATION NAME] ([MEDICAL CONDITION]) 325 mg tablet (1) tablet by mouth twice daily; Pro-stat Sugar free liquid pkt give 60ml (2 pkts) by mouth twice daily r/t wound healing; [MEDICATION NAME] (blood pressure) 50 mg tab give (1) tablet by mouth (2) times daily; Xarelto (blood thinner)15 mg tablet by mouth at bedtime; Quetiapine ([MEDICAL CONDITION]) 100 mg tablet (1) tablet by mouth every night *give with 25 mg to = 125 mg; and Quetiapine ([MEDICAL CONDITION]) 25 mg (1) by mouth every night * give with 100 mg to = 125 mg. However, the boxes next to the Atorvastatin 10 mg, [MEDICATION NAME] 500 mg two tablets, [MEDICATION NAME] 250 mg, [MEDICATION NAME] 10 MG, [MEDICATION NAME] 325 mg tablet, Pro-stat Sugar free liquid 60 ml, Xarelto 15 mg, Quetiapine 100 mg tablet and 25 mg; were blank and did not indicate if the medication was administered, withheld or refused at 7:00 PM on 04/02/18. In addition, the box next to [MEDICATION NAME] 50 mg was blank at 9:00 PM on 04/02/18. 21. Record review revealed the facility admitted Resident #40 on 01/11/17 with [DIAGNOSES REDACTED]. Review of Resident #40's (MONTH) (YEAR) Physician order [REDACTED].) 0.1 mg twice (2) daily; [MEDICATION NAME] (anxiety) 7.5 mg tablet give (1) tablet twice daily; Klonopin (anxiety)1 mg tablet give (1) tablet by mouth twice a day; [MEDICATION NAME] ([MEDICAL CONDITION]) 500 mg tablet give (1) tablet by mouth every (12) hours; [MEDICATION NAME] ([MEDICAL CONDITION]) 400 mg capsule give (1) capsule by mouth three time a day; [MEDICATION NAME] cream: apply to bilateral feet twice a day; and Oxygen Saturations to be checked at night, while on and off oxygen. However, the boxes next to DOK 100 mg soft gel, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 0.1 mg, [MEDICATION NAME] 7.5 mg, [MEDICATION NAME] DR 500 mg, and [MEDICATION NAME] 400 mg were blank and did not indicate if the medication was administered, withheld or refused on 04/03/18 at 9:00 PM; the boxes next to the [MEDICATION NAME] 90 mcg were blank on 04/02-03/18 at 9:00 PM, and the boxes next to the Levetiracetam 500 mg and Klonopin 1 mg were blank on 04/03/18 at 7:00 PM. In addition, the box next to the [MEDICATION NAME] cream was blank on 04/03/18 at 9:00 PM; and Oxygen Saturations box was blank on 04/01-03/18 for the 7:00 PM shift. 22. Record review revealed the facility admitted Resident #73 on 03/06/18 with [DIAGNOSES REDACTED]. Review of Resident #73's (MONTH) (YEAR) Physician order [REDACTED]. mouth every 12 hours' *Hold for heart rate below 60 for hypertension, [MEDICATION NAME] (Alzheimer's) 5 mg tablet at bedtime, Accuchecks twice (2) a day call MD if blood sugar <60 or >400, and Wander guard-check (monitoring device) placement, function (right ankle) ordered every shift. However, the boxes next to Quetiapine [MEDICATION NAME] Succ ER, [MEDICATION NAME] 250-50 Diskus, [MEDICATION NAME] were blank and did not indicate if the medication was administered, withheld, or refused at 9:00 PM on 04/01/18-04/03/18. In addition, the boxes next to [MEDICATION NAME] ER were blank at 6:00 AM on 04/01/18-04/03/18, the boxes next to the accuchecks twice (2) a day were blank at 6:30 AM and 8:00 PM on 04/01/18-04/03/18; and the boxes next to Wander guard-checks were blank on the 7:00 AM and 7:PM shift on 4/01/18-04/03/18. 23. Record review revealed the facility admitted Resident #62 on 11/22/17 with [DIAGNOSES REDACTED]. Current [DIAGNOSES REDACTED]. Review of Resident #62's (MONTH) (YEAR) Physician order [REDACTED]. Donepezil Hcl (memory enhancer) 5 mg tab per [DEVICE] at bedtime, [MEDICATION NAME] (calorie replacement) 1.2 at 60 cc/hr times 22 hours per [DEVICE]. However, the boxes next to the [MEDICATION NAME], Donepezil, Atorvastatin, [MEDICATION NAME] Acid were blank and did not indicated if the medication was withheld, administered or refused on 04/02/18 and 04/04/18 at 9:00 PM. In addition, the boxes next to the Potassium [MEDICATION NAME] Granules, the [DEVICE] flushes, check [DEVICE] for residual, assess [DEVICE] site, and check [DEVICE] placement were blank at 7:00 PM on 04/02/18 and 04/04/18. 24. Record review revealed the facility admitted Resident #29 on 07/01/12, with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Give contents of 1U-D Vial via mini nebulizer every 8 hours for [MEDICAL CONDITION]; however, the boxes next to the medications were blank and did not indicate if the medication was administered, withheld, or refused on 04/02/18, 04/03/18 and 04/04/18 at 6:00 AM and on 04/03/18 and 04/04/18 at 10 PM. Interview with Licensed Practical Nurse #10 on 04/06/18 revealed she could not answer question as to why the nebulizers were not recorded but she had given them. Interview with Registered Nurse (RN) #6 revealed that Resident #29 would refuse the nebulizer in the morning at times if the resident was sleepy and didn't want to wake up and take the nebulizer. She also revealed per policy, she charts on the MAR that the resident refused. 25. Record review revealed the facility admitted Resident #575 on 12/19/17 with [DIAGNOSES REDACTED]. Review of (MONTH) (YEAR) Physician order [REDACTED]. In addition, the boxes next to Levetiracetam were blank on 04/03/18 and 04/04/18. Interview with Director of Nursing on 04/06/18 at at 10:23 AM and 3:45 PM revealed the medication administration policy should be followed by Nurses and Medication Techs. She stated if a resident was not given medication because it was withheld, refused etc, then a N should be documented as not given and a reason documented as why it was not given. She revealed each staff was responsible for signing their own medications out with no exceptions. She stated there should be no blanks on the MAR's or TAR's and if the medications were not initialed, she could not say with certainty the medications were given. Interview with the Administrator on 04/07/18 at 10:03 AM and 10:40 AM, revealed she would have expected the staff to document correctly in the resident's clinical record when medications and treatments were omitted, refused, administered or not administered and the nursing notes were utilized for further explanation of care and physician notification. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 0

Based on interview, record review, review of hospital Emergency Department Record, review of the lift manufacture guidelines, and facility policy review, it was determined the facility failed to have an effective system in place to train staff on new equipment; train on the lock out tag out system; and communicate to staff which lift and sling to be used on each resident to ensure the resident's environment remains as free from accidents and hazards as possible; or to ensure adequate supervision was provided while transferring with a lift for two (2) of thirty-six (36) sampled residents (Resident #3 and #51). On 03/07/18, the facility failed to ensure Resident #3's environment remained as free from accidents and hazards as possible when Certified Nurse Aides (CNA) #9 and CNA #13 transferred Resident #3 with a new lift without any training on the proper use of the lift. The CNA's used the old lift sling which resulted in the resident falling out of the sling onto the floor. The facility failed to educate staff on proper use of the new lift and the type sling to be used on residents with a lift. In addition, after the incident the facility failed to ensure all staff were notified not to use the new lift until they were educated on it; and failed to reinservice all staff on the lift use and using the proper sling. The facility's failure to ensure residents' environment was as free from accidents and hazards as possible has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/02/18 and determined to exist on 03/07/18. The facility was notified of the Immediate Jeopardy on 04/02/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In addition, Resident #51 was assessed and care planned to require the assist of two (2) staff and mechanical lift for transfer. However, on 02/27/18, Certified Nurse Aide (CNA) #7 transferred the resident without the use of a mechanical lift and the assistance of another staff. The resident's legs became weak and had to be lowered to the floor with no injury sustained. The findings include: Review of the facility's policy, Incident & Accident Process, dated (MONTH) (YEAR), revealed the purpose of the Incident and Accident Process is to ensure the facility's environment was as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines. Review of the Safe Patient Handling and Transfer Policy, dated (MONTH) 2013, revealed mechanical lifting equipment and/or other handling aids should be used to prevent the manual lifting and handling of patients except when absolutely necessary. It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and patients during patient handling activities by following this policy. Use available mechanical lifting devise and other approved handling aids for high-risk patient handling and movement when appropriate. Use mechanical lifting devices and other approved handling aids in accordance with instructions and training. Non-compliance may indicate a need for disciplinary action. In conjunction with the initial resident assessment or when otherwise appropriate, an analysis of the risk of injury to the resident, nurse and direct-care staff posed by the resident's movement and handling needs and the facility's physical environment will be performed. Care planning needs may include transfers. Staff will complete and document training initially, annually, and as needed for proper equipment use and understanding of safe resident handling and movement. The facility's Administrator will ensure that mechanical lifting devices and other equipment/aids are accessible to direct care staff. All patient transfers with mechanical lifts will be done with a minimum of two (2) persons or as specified in the patient's plan of care. 1. Interview with the Administrator on 03/29/18 at 3:52 PM revealed the facility does not have a lift policy. She stated they use the Manufacture Guidelines for the proper use of the lifts. She further stated the facility is a no lift (by staff) facility and they use the Safe Patient Handling and Transfer Policy. Review of the Tollos Combi Sling Operating Instructions (new lift), dated (MONTH) 2014, revealed each resident should be assessed on an individual basis for proper sling sizing. Use correct sling size and attach properly and securely. Visibly inspect sling prior to each use to ensure sling is the correct type, size and design to handle lifting. In addition, practice with the sling before using it in regular service. Furthermore, ensure caregivers are trained and have read and understand the user manual and have demonstrated proper usage. Test each trainee's understanding of the lift and keep training records. Using the lift requires a minimum of one (1) trained operator. Most accidents occur from wrong sling size or type. Sling failure or wrong sling size may cause serious injury. Make certain staff understand how to select, attach, inspect and test slings. Untrained operators can cause injury or be injured. Review of the Invacare Electric Portable Patient Lift Owner's Operator Manual (old lift), dated 2011, revealed the Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system. Review of the facility's policy, Lockout/Tagout Program, dated 01/24/07, revealed to notify all affected employees that the machine or equipment must be shut down and locked and/or tagged out to perform servicing or maintenance. All employees shall receive training regarding the Lockout/Tagout Program. Different levels of training will be provided based upon the involvement of the employee program. All employees shall be specifically notified and made aware of the Lockout/Tagout Program. This will include instructions not to start or attempt to activate any machine, piece of equipment, or process that is locked or tagged out. Affected employees must be notified before and after lockout/tagout devices are/have been applied. After servicing and/or maintenance is complete and equipment is ready for normal operations, the authorized employee must notify affected employees that the servicing or maintenance is completed and the machine or equipment is ready for use. Record review revealed the facility admitted Resident #3 on 05/28/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 02/16/18, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required assist of two (2) with bed mobility and transfers. Review of Resident #3 Self Care Deficit Care Plan, dated 09/27/16, revealed the resident required assist of two (2) for bed mobility and transfers and mechanical lift total was documented on the plan with no date. Review of Risk for Injury related to Falls Care Plan dated 09/27/16, revealed transfers assist of two (2). Review of a CNA care plan that was on the resident's closet door revealed to use a mechanical lift for transfers. Review of the Therapy Evaluation, dated 02/12/18 revealed Therapy evaluated the resident due to readmission to the facility on [DATE], and determined the resident required transfers with a mechanical lift; however, the assessment did not include the type of lift or sling to be used. Review of Nurse's Notes dated 03/07/18 at 11:00 AM, late entry for 10:10 AM revealed Resident #3 was being transferred from the bed to the wheelchair by the lift with two (2) CNA's. The CNA's reported the resident was agitated during transfer due to fear of missing an activities event. The resident shifted to the left side while the lift was approximately four (4) feet in the air. Further review revealed the nurse saw from her peripheral vision that the resident shifted his/her weight, resulting in him/her slipping out of the sling between the upper and lower portion of lift pad. The resident fell to the floor hitting his/her head. The nurse assessed the resident and determined the resident was oriented to self and place and had no laceration or raised areas on head; however, the resident complained of pain to the head and neck. The resident was laying on the floor, across the legs of lift with his/her head between the bed and the right leg of the lift; and his/her lower extremities were across the left leg of the lift. Vital signs were assessed. The Assistant Director of Nursing (ADON) came to the resident's room. The resident was transferred from the floor to the bed per direction of the ADON while awaiting ambulance. Review of the Emergency Department Record, dated 03/07/18 at 10:48 AM, revealed the resident came in with [DIAGNOSES REDACTED]. A cat-scan of the head, lumbar spine, [MEDICATION NAME] spine, and x-ray of the right ankle were negative. The resident returned to the facility on [DATE]. Interview with CNA #9 on 03/27/18 at 2:17 PM revealed Resident #3 doesn't like to be late; however, it was not care planned to honor the resident's request to get up early for activities. CNA #9 stated on 03/07/18, Resident #3 was getting agitated as it was 9:55 AM and church service started at 10:00 AM. She stated she and CNA #13 placed the resident in the new lift with an old sling and the resident began leaning to the left, which was normal for him/her. Further interview revealed the resident flipped over and out of the sling and fell to the floor head first. She stated the Assistant Director of Nursing (ADON) came into the room and stated they needed to get the resident back into the bed. The resident was complaining of pain in his/her head and neck. She stated they moved the lift out of the way and CNA #13 and the ADON lifted the resident back in the bed. She further stated prior to Resident #3's falls there was a list at the desk that stated what sling to use on each resident. She stated the facility had purchased a new lift a couple months ago for a larger resident, but they had not received in-service on the new lift. CNA #9 stated the staff used the new lift with the old slings as they had not been told any different. Further interview revealed they did not know what sling to use with the new lift. She stated there was only one (1) or two (2) working lifts in the building. The CNA stated one (1) of the controllers on the lift did not work and the legs on the other lift did open half the time. She further stated it was hard to get everyone up that requires a lift to activities, meals, and therapy on time. Interview with CNA #9 on 03/28/18 at 10:30 AM revealed if the equipment was not working they would tell the nurse and the nurse would put in a work order for Maintenance. She stated the lift with the controller not working, sat at the end of 100 Hall for a couple of weeks and was finally removed on 03/25/18. She stated she had not received inservicing on the new lift prior to using it. Interview with CNA #13 on 03/27/18 at 2:43 PM revealed the slings for the lift were determined by weight. She stated she used the new lift to transfer Resident #3 and did not know what lift sling to use with the new lift, as she was not aware there was any difference. She stated the only lift she could find was the new lift to transfer the resident. CNA #13 stated she and CNA #9 transferred the resident with the new lift and the old lift sling. She stated once the resident was in the lift sling it seemed the resident was trying to get comfortable and leaned to the left, which was normal for the resident. She further stated the resident then slid out of the lift pad head first. CNA #13 stated the ADON assessed the resident and told them to put him/her back in the bed. She stated she questioned putting the resident back in the bed as he/she had fallen and had pain. The CNA stated four (4) of them cradled the resident and picked him/her up and placed him/her back in the bed. She stated the staff was not using the new lift now as there were no slings to use with the lift. Interview with Registered Nurse (RN) #2 on 03/27/18 at 11:09 AM revealed she was outside Resident #3's door in the hallway and saw out of her peripheral vision that CNA's #9 and #13 were transferring Resident #3 with a lift. She stated she saw the resident shift his/her weight, the sling twist, and the resident landed part on the lift bar legs and the rest of his/her body on the floor. She further stated the resident hit so hard she heard the resident's head hit the lift bar legs and she was concerned with a head injury and did not want to move the resident. RN #2 stated the Assistant Director of Nursing (ADON) came to the room while she called the ambulance and when she reentered the room, the ADON stated she moved the resident's neck and the resident was not hurt so they lifted the resident back into bed. RN #2 stated she was not sure what intervention was put in place after the fall. She further stated she thought therapy determined what lift pad a resident was to use as they performed the lift assessment. In addition, she stated there was nothing in place for the staff to know what lift or sling to use on the residents. She stated there was not information on the care plan to communicate to staff the correct sling or lift to use with each resident requiring a lift. Review of the facility's investigation determined root cause of the fall on 03/07/18 revealed the staff needed reeducation on the lift. Further review revealed the facility began an Action Plan on 03/07/18, which identified improper use of the mechanical lift and lift pad. The plan revealed all residents requiring lift transfers would be screened for appropriate transfer technique; educate nursing staff and restorative aides on use of the mechanical lift and the appropriate lift and slings by 03/30/18; competency validation completed on all nursing staff ongoing; return demonstration on the use of lift and slings to be completed on all nursing staff, ongoing, bariatric (obese) lift to be removed from the floor on 03/08/18; residents requiring the lift reflect residents that will be transferred using the new lift, all nursing staff to be educated and return demonstration prior to using new lift when lift pads arrive; care plans to be audited and completed on appropriate use of lift/slings by 03/28/18. However, review of the In-Service Record for the lift training revealed as of 03/28/18, seventeen (17) nursing staff had not received education on the lifts or slings. In addition, further review of Resident #3 Self Care Deficit Care Plan, and Risk for Injury related to Falls Care Plan on 03/28/18, dated 09/27/16, revealed the care plan was updated on 03/07/18 to include transfer with assist of two with mechanical lift, and the falls care plan was updated on 03/08/18 to re-educate staff on mechanical lift use and competencies on all CNA's and licensed nurses on the mechanical lift. However, further review revealed there was no documented evidence the care plan was updated to include the type of lift and sling. Interview with CNA #3 on 03/28/18 at 10:55 AM, revealed when she began work at the facility a couple weeks ago she received education on lift transfers and to use the appropriate sling according to weight. She stated the Administrative staff had told us a couple weeks ago they were making us a list of what color pad to use for each resident with a lift. She stated she told them she needed a list as she was not familiar with the residents and did not know which sling to use. Observation (during this interview) of the old shower room, with the CNA, revealed the new lift had no indicators for non-use. CNA #3 plugged the lift in and turned the lift on and stated she was not for sure what was wrong or why the lift was in the room. She noticed the battery was low. Interview with the Maintenance Director on 03/28/18 at 10:45 AM and 2:45 PM revealed the DON told him to look over the new lift after the incident and ensure everything was working and remove it from the floor. He stated he placed the lift in the old shower room and placed a sign on the new lift stating Do Not Use, he stated he should have applied the Lock Out Tag Out plug to ensure the lift could not be plugged in and used. He further stated he thought he was doing what was best when he put the lift behind locked doors, although if staff needed an item in the old shower room storage they had the code to go into the room. He stated he usually puts a sign on the equipment if it was not in use and removed it from the floor. Interview with CNA #4 on 03/30/18 at 11:09 AM revealed restorative staff obtain weights for the building. She stated she had not been trained on the new lift. She stated the DON told them they could use the new lift after the incident to obtain weights on residents continuing to use the same old lift pads. She further stated the new lift stayed in the old shower room; however, staff would come in the room and get the lift. Interview with CNA #5 on 03/30/18 at 11:25 AM, revealed she had not received training on the new lift. She stated when the new lift came to the building everyone used the lift. She stated Resident #3 fell from the new lift on a day she was off work. CNA #5 stated the DON allowed Restorative to use the new lift to obtain weights on residents. She further stated she was not aware she could not use the old lift slings with the new lift. Interview with Licensed Practical Nurse (LPN) #7 on 03/28/18 at 9:48 AM revealed the sling size for each resident on a lift should be on the shower sheet or the care plan. However, review of the shower sheets and care plans with the LPN revealed no sling sizes were on the sheets and care plans. She stated the lifts use all the same lift pads. LPN #7 stated she had not received any education related to lifts since the incident had occurred. Interview with LPN #6 on 03/29/18 at 2:13 PM revealed she had not received in-service on the new lift or education of lift use after the incident on 03/07/18 until 03/28/18. She stated that in-service revealed not to use the old lift slings with the new lift and a new book was at the desk for staff to access to determine which residents required which lift and which sling. She stated prior to 03/28/18 she did not know what sling or lift to use on a resident. LPN #6 further stated half the lifts didn't work and those lifts would be placed in storage and then magically reappear on the floor. She stated she was not aware of the Lock Out Tag Out procedure by the facility. She stated nurses placed notes on equipment, Out of Order, but they never get fixed. Interview with LPN #8 on 03/26/18 at 11:42 AM, and CNA #15 on 03/27/18 at 11:55 AM revealed there was a paper at the desk that told the staff according to weight what sling to use with the new lift, but it was no longer there. Interview with CNA #16 on 03/27/18 at 4:15 PM revealed she was not sure where to find information on what sling to use for a resident with a lift. She stated if she had to get someone up with a lift now, she would not know what sling to use. Interview with CNA #14 on 03/27/18 at 4:25 PM revealed he would look at the CNA care plan to determine what type of sling to use on a resident. However when he observed the CNA care plan the sling nor lift type was on the care plan. He stated he would use the sling he had always used for a resident. Interview with CNA/Certified Medication Aide (CMA) on 03/28/18 at 2:09 PM revealed she was not aware of what sling to use for a resident and would have to ask someone. She stated there was no list on what lift sling to use or type of lift. Interview with LPN #1 on 03/29/18 at 10:21 AM revealed the slings were used according to weight, if the resident was small use a small sling, if the resident was large use a larger sling. She stated to gauge the size of the person to determine the sling. She further stated when the new lift was on the floor she was not aware the slings from the old pad could not be used on the new lift. Interview with RN #1 on 03/28/18 at 10:00 AM, revealed she was not familiar with the lift pads. She stated based on a resident's weight, she would determine which color pad to use. She stated the department managers discussed yesterday about placing the color of the sling on the care plans for staff as there was no current communication to staff on what type of lift or pad to use. She further stated if she had to use a lift she would have to figure out what sling to use. RN #1 stated she had not received any training on the new lift prior to the incident on 03/07/18. Interview with the Therapy Program Director on 03/27/18 at 11:45 AM revealed therapy only determines if a resident requires a lift for transfers, but did not determine what sling they needed to use. Interview with the Staff Development Coordinator (SDC) on 03/28/18 at 10:45 AM, revealed she had begun last night (03/27/18) making a CNA Sling Size and Color for Transfer book for the staff. She stated the book included the resident's name, sling size, color of sling, and type of lift. The SDC further stated only four (4) residents in the building should be using the new lift. She stated they had begun education on lift transfer but it had not been completed. Further interview on 03/28/19 at 2:39 PM, revealed the new lift was bought for bariatric residents and should be used on four (4) residents and the other lift should be used on eleven residents with a total of fifteen (15) residents in need of the use of a lift for transfers. She stated the Administrator stated the new lift was removed from the floor as the facility did not have slings to go with the new lift. Observation on 03/28/18 at 2:45 PM, revealed another lift sitting in the hallway with one lift sling. Interview with the DON on 03/28/18 at 2:53 PM, revealed she was not aware of why another lift was in the building as it just showed up. Observation at 3:00 PM revealed the other lift was gone from the hall. Interview on 03/28/18 at 3:00 PM with the DON revealed the Administrator requested a rental lift on 03/07/18 to replace the new lift until the new slings for the lift came to the facility. She stated the Regional Nurse Consultant pulled the other lift off the floor until staff could be educated on the rented lift. Interview with the DON on 03/29/18 at 9:38 AM revealed she came to the facility in (MONTH) (YEAR). She stated she was responsible to determine which lift and sling the resident was to use by the resident's weight. However, there was no system in place to communicate this information to staff. She stated there was a list for the color of sling to use according to the resident's weight for the old lift, but not a list with the new lift. However, there were no slings in the building to use for the new lift. The DON stated the new lift came to the facility in (MONTH) (YEAR), and she would have expected education of staff prior to use of the lift and with new hires. She stated she would have expected the slings to be available for staff to use with the new lift. She stated she had not, nor had the facility, identified the old lift slings were not interchangeable with the new lift; education had not been completed on the new lift for all staff including new employees; and there were no slings for the new lift prior to the incident on 03/07/18. The DON stated when the incident occurred on 03/07/18, she thought she told the Maintenance Director to remove the lift from the building and then she found out on 03/28/18 by the State Survey Agency that the lift was still in the building. She stated if the lift was left in the building the Tag Out System should have been used. Further interview revealed they had started education with nursing staff and it may be completed today. Interview on 03/29/18 at 11:45 AM revealed therapy began screening residents with lift on 03/07/18. She stated there were about eleven (11) staff members left to educate on the proper use of the lift. The DON stated therapy screened the residents for the best mode of transfer and if they required a lift, she or the SDC would determine the sling size for the residents. Interview with the Regional Nurse Consultant on 03/28/18 at 3:12 PM revealed the staff had not received education on the new lift prior to use. She stated the facility did not have slings for the new lift and it should not have been available for staff use. She stated the SDC had started a book for the staff which would communicate the color of sling and type of lift to be used on all residents with a lift. She stated not all care plans were updated with the correct sling size or lift. She further stated she had requested Maintenance to Lock Out/Tag Out the new sling the other day. Further interview on 03/28/18 at 3:45 PM revealed the facility identified the staff did not use the right lift and the slings could not be interchanged with other lifts. She stated the facility had started education on lift transfers on 03/07/18; however, not all staff had been inserviced. Interview with the Administrator on 03/28/18 at 3:30 PM and 4:15 PM revealed the new lift should not have been on the floor without the proper equipment. She stated different equipment and procedures require education of staff. She stated since the new lift was not in use, if a resident required the use of a bariatric lift she would need to borrow one from a sister facility until the slings arrived. Further interview with the Administrator on 03/29/18 at 11:20 AM, revealed on 03/15/18 a request was made to rent a lift until the slings for the new lift were delivered. Interview at 3:52 PM revealed the new lift pads were ordered on [DATE] and eleven (11) staff members were left to in-service on the lift procedure. 2. Record review revealed the facility admitted Resident #51 on 01/04/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/10/18 revealed the facility assessed Resident #51's cognition as moderately impaired with a Brief Interview for Mental Status score of nine (9) which indicated the resident was interviewable. However, after brief conversation, on 04/03/18 at 1:08 PM, it was determined information obtained from the resident was not reliable. Further review of the MDS revealed the resident required total assist of two (2) staff for transfers and he/she was not ambulatory. The facility assessed Resident #51 to have functional limitations of the upper extremity on one side, and lower extremity on one side; Surface to surface transfer (transfer between bed and chair or wheel chair) not steady only able to stabilize with human assistance. The MDS further indicated the resident had no falls prior or since admission to the facility. Review of the Comprehensive Care Plan for Risk for Injury related to Falls, initiated 01/04/18 revealed an intervention to transfer the resident with assist of two (2) with mechanical lift. Review of the facility's Investigation Report dated 02/27/18, revealed Certified Nursing Assistant (CNA) #7 was transferring Resident #51 from the wheelchair to the bed. During the transfer the resident's knees became weak and the resident was lowered to the floor. No injury was noted per the note. Attempts to contact CNA #7 on 04/06/18 at 8:32 AM and on 04/07/18 at 9:00 AM, were unsuccessful. The State Survey Agency called both numbers provided by the facility with no answer at either number. Interview with Director of Nursing (DON), on 04/06/18 at 9:10 AM, revealed the CNA should not have been transferring the resident without the mechanical lift and assist of another CNA. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. The Nurse Aides (2) involved in the incident were re-educated on 03/07/18 and 03/08/18 by the Regional Quality Manager. Education included reviewing the care plan for transfer status and selecting appropriate weight capacity for the lift, assuring all pieces of equipment, lift and sling, were properly assembled and in good working order, using slings manufactured for the lnvacare Total Lift, use of the lnvacare Total Lift with demonstration and competency performance validation. 2. Resident #3 was evaluated on 03/08/18 by Occupational Therapy. Resident #3's care plan was revised to include type of mechanical lift and type of sling on 03/07/18 by Director of Nursing. 3. All 13 residents requiring a lift to transfer were screened and/or evaluated by Physical Therapist or Occupational Therapist, beginning 03/08/18, and completed by 03/29/18. The care plan was revised for all 13 residents requiring a lift to transfer to include the type of mechanical lift and type of sling by 03/29/18 by the Nurse Management Team. 4. Education was initiated on 03/07/18 and completed for all nursing staff regarding lift competencies demonstration/return demonstration with completion on 03/31/18 by the Director of Nursing (DON), Staff Development Coordinator (S[NAME]),and/or the Assistant Director of Nursing (ADON) for the lnvacare lift. Mechanical Lift Management Education will be provided during Nursing staff orientation, at least annually, and as indicated by the Director of Nursing (DON), Staff Development Coordinator (SDC) and Assistant Director of Nursing. 5. The Tolles Lift was placed out of use with lock out/tag out system by the maintenance assistant pending receipt of training materials from the manufacturer on 03/27/18. The lift will not be utilized until all nursing staff have been trained. 6. An AdHoc Quality Assurance (OA) Meeting was held on 03/07/18 to discuss the IJ and develop an action plan. Attendees included the Administrator, Regional Quality Manager, Director of Nurses, Staff Development, MDS (2), Rehabilitation Manager, Social Services, and Activity Director. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action items to be initiated. 7. The Regional Quality Manager provided education to the Director of Nurses or Administrator on 03/29/18 that education must be completed for all nursing staff prior to placing new equipment on the floor which included lifts. The training for the lifts must include demonstration/return demonstration. The Director of Nursing and or the Administrator will review any new lift equipment that has arrived and confirm that the equipment was properly locked out until education was completed. 8. The Regional Maintenance Director re-educated the Maintenance Assistant regarding the Lock out/Tag out system on 03/27/18. 9. The Maintenance Assistant was educated on 03/07/18 by the Regional Quality Manager to use the lock out/tag out system for all new medical equipment until notified by the Director of Nursing and/or the Administrator to unlock. 10. All staff were notified that all new mechanical lifts wi (TRUNCATED)

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to ensure effective pain management was provided to one (1) of thirty-six) sampled residents (Resident #64). Staff failed to recognize when pain could have been anticipated and treated for [REDACTED]. This resulted in the resident experiencing pain, and screaming at the staff how bad he/she was hurting with tearing and facial grimacing. The facility's failure to provide pain management has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and was determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled Pain Management Process, date 10/2015 revealed; the facility recognizes that each resident has the right to maintain their quality of life. The facility also recognizes that each resident reacts to pain in different ways, and that narcotics carry a significant risk with use including side effects and abuse. The facility will react to the resident's pain control needs based on the resident's goal for pain relief and the resident's goals for functional ability. The facility's goal is to measure all residents receive appropriate pain relief measures to assure that the resident pain does not affect their ability to function within their designated goals for functional ability. The resident's goal for pain control will be met by the use of medications and alternative methods to reduce pain as outlined in the Federal Regulatory Requirements for Long Term Care. This system will suggest necessary evaluations, interventions, and re-evaluations as a standard care practice for licensed nurses. Also, Physician and family will be notified when pain levels are outside normal levels for each individual resident. Residents who have received PRN pain medication more than three times in the last week or having a pain scale greater than seven (7) will be reviewed weekly by the pain management Committee. This will comply with the IDT approach to pain management for each individual. Review of the facility policy titled, Wound Treatment Administration Review, dated (MONTH) 2014, revealed the staff were to have attended to the resident's comfort, repositioning needs and addressed pain throughout the procedure. Record review revealed the facility admitted Resident #64 on 09/15/17 and readmitted the resident from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #64's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. In addition, the resident required extensive assist of two (2) staff for Activities of Daily Living (ADLs). Review of the most recent Pain Assessment, dated 03/16/18, revealed frequent pain, rated as a nine (9) on the zero to ten (0-10) scale and had mild relief with pain medication. Observation and interview with Resident #64 on 04/03/18 at 1:00 PM and 3:21 PM, revealed the resident lying supine in bed, with the head of bed up 30 degrees, with a flat affect and stated glad to meet you, now if you don't mind, I'm trying to eat my lunch, and no I just want to lay here. I've been at (a psychiatric facility) for years and I got sick last year in (MONTH) and they said I had an adrenal gland problem and I went to the hospital and stated he/she had been in the facility about 65 days. There were no visible signs of distress or discomfort and the resident denied any pain at this time. Review of Resident #64's Comprehensive Care Plan for Pain dated 09/15/17, revealed a goal of the resident voicing relief from pain interventions, within one half hour from administration of the medication and of the pain not interfering with the daily routine, with a goal date of 12/31/17. Further review revealed interventions were to report any unrelieved or unacceptable levels of pain to the physician, as needed and [MEDICATION NAME] as ordered; utilize pain medications thirty minutes prior to dressing changes, if needed; and, if the resident complained of pain during the treatment, the staff was to stop the treatment, leave the resident safe, seek pain relief and return when the pain was reported as acceptable. Review of the (MONTH) and (MONTH) (YEAR) Physician's Orders revealed Resident #64's five (5) Stage IV dressings were ordered to be changed twice a day (BID) and to administer [MEDICATION NAME], routinely, one (1) mg every three (3) hours for pain. [MEDICATION NAME] 7.5/325 mg every four hours, as needed (PRN) for pain, and Tylenol 650 mg Suppository, every six hours, PRN for pain. Additionally, the resident had [MEDICATION NAME] one (1) mg every eight hours for Anxiety, PRN. Further review revealed the resident was ordered Hospice on 03/12/18, to assist with pain control. Review of the Wound Healing Progress Report, dated 02/16/18, upon readmission from the hospital, revealed the resident had five (5) Stage IV Pressure Sores: the left buttock, measuring a length of four centimeters (4.0 cm) by a width of 4.0 cm by a depth of 1.5 cm; the right buttock measured 7.0 cm by 7.0 cm by 0.4 cm; the area to the sacrum measured 4.0 cm by 4.2 cm by 3.7 cm; the left heel was un-stageable, due to necrosis and measured 7.0 cm by 7.0 cm by 0.1 cm; and, the right heel was also un-stageable, also due to necrosis and measured 4.0 cm by 4.0 cm by 0.1 cm. Additionally, the resident required a protective dressing to a scar to the upper right torso, from a previous surgery and the site measured 4.0 cm by 4.0 cm, with no depth noted. Observation of Resident #64's dressings to the sacral area on 04/03/18 at 5:18 PM, with the Staff Development Coordinator (SDC) and CNA #10, revealed the resident's legs were contracted with the knees slightly bent and the heels covered with heel boots. The resident called out in pain with turning, but tolerated the procedure well. The dressing site to sacral area dated 04/02/18, had visible dampness, was not secured, and a darkened area was noted below the dressing site. On 04/05/18 at 8:53 AM, there were multiple observations of the resident lying supine and requests to observe the actual dressing change, requested from RN #1 and LPN #7, who stated the resident refused. Observation of the dressing changes on 04/05/18 at 3:35 PM, revealed RN #1 had not pre-medicated the resident, prior to the dressing changes and LPN #3 stated it was not time and she was not due another dose of [MEDICATION NAME] until 4:00 PM, and they had not considered using any other PRN or as needed medication for pain, or calling the physician for an earlier dose and continued on with the dressing changes. The resident called out repeatedly in pain, You don't know how bad this hurts me! and begged staff to be easy with me! and stated this pain makes me so sick! while RN #1 and LPN #2 discussed how they wished they had brought in a box of larger gloves as the medium gloves were too tight and stated she always screams like that, as they continued to fill the deep wounds in the resident's back side with a quarter strength (¼) bleach solution soaked kerlix gauze and pad the bed with 4 by 4's to absorb the blood and drainage oozing from the wounds. The staff never washed their hands in between glove changes and RN #1 stated In an ideal world, we would have changed them in between each wound dressing and washed our hands, but she is in too much pain. When questioned about the pain medication administration, LPN #3 stated we did medicate him/her for pain, at 1:00 PM. The resident was tearing and asking why did you let them hurt me? after the procedure and was medicated with [MEDICATION NAME] at 4:10 PM, by LPN #3, and the resident stated it felt like hot electric wires up my rectum. Review of the Controlled Drug Records and the MARS for (MONTH) (YEAR) revealed [MEDICATION NAME] was not administered until 04/04/18 at 9:00 PM and twice on 04/05/18 at 3:00 AM and 8:00 PM. The [MEDICATION NAME] 7.5/325 mg tablets had no entries on the MAR. However, there were ten (10) doses administered from 04/01/18-04/05/18 but none of those doses were administered on 04/03/18, when the dressing changes were observed. Interviews with the Certified Nurse Aides (CNA's) #10 and #11 revealed the resident would scream out in pain, anytime they would try to reposition off of his/her back and when pillowed for comfort, would scream until they had to remove the pillows and reposition the resident, to his/her back. Interview with CNA/Certified Medication Assistant (CMA) #1 on 04/07/18 at 9:45 AM, revealed she was able to get the resident to allow the CNA/CMA to take his/her medications and complete the resident's care needs but stated I have to be insistent. Interview with LPN #7 on 04/03/18 at 4:00 PM, revealed the nurse changed Resident #64's dressings when (he/she) will let me, and stated (he/she) refuses all the time. because it hurts too bad and she's Hospice. Interview with the Hospice Nurse RN #7 on 04/06/18 at 4:45 PM and the Physician on 04/05/18 at 4:45 PM, revealed they were not aware the resident had unrelieved pain and not aware the resident was not medicated prior to dressing changes. They stated they would have expected the resident to be medicated prior to dressing changes and any concerns to be reported to them. Additionally, the physician ordered and wrote out, on a prescription pad, an order for [REDACTED].#64's shoulder revealed the patch was not administered to the resident until 04/07/18 at 11:00 AM. Observation and interview with the resident on 04/07/18 at 2:35 PM, revealed the resident stated he/she had received the pain patch this morning and pointed to his/her left shoulder. The patch was dated 04/07/18 at 11:00 AM. The resident stated I'd like to rest now. You know how that wears me out, and referred to dressing changes and stated pain was better. Interview with the Director of Nursing (DON) on 04/06/18 at 4:20 PM, revealed she would have expected the staff to stop the dressings and medicate the resident for pain, prior to completing the dressing changes and to call Hospice with any concerns that his/her pain regimen was not effective. Interview with the Physician, on 04/07/18 at 10:25 AM and the Hospice Nurse, on 04/06/18 at 4:45 PM, revealed they would have expected the facility to obtain the patch from the local back-up pharmacy, in a timelier manner. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #15 was reassessed on 04/06/18 by Physical Therapy regarding refusal of the lift due to inconsistent and variable levels of assistance with transfers and also assessed for abuse regarding the use of the lift. A care plan meeting was held on 04/11/18, and the Care Plan was updated. Physician was notified. The Social Services Consultant assessed Resident #15 and completed an interview and observation of the resident on 04/10/18. 2. A head to toe evaluation was completed for Residents #56 and #64 by the nurse management team on 04/09/18 and 04/10/18 with findings reported to the physician; care plans were updated for pain management and pressure wounds. These residents received a shower, dressing change and medication review. In addition, a pain assessment was completed on Residents #56 and #64. The physician was notified of the results. 3. Resident #51's Physician was notified of lab results on 04/15/18. Resident #51 was assessed including review of signs of urinary tract infection, and ordered labs as indicated. The physician was notified. Orders and care plan updated as needed. A head to toe evaluation and review of labs was completed on 04/12/18 for Resident #51 4. The Primary Care Physician (Medical Director) was notified regarding medication and treatment omissions for Residents #16, 275, 30, 40, 13, 63, 60, 65, 74, 625, 67, 59, 575, 64, 62, 53, 5, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, 43, and 29 by the Administrator, Director of Nursing, Regional Quality Manager, Staff Development, MDS, Social Services, and Activity Director on 04/05/18. A head to toe evaluation was completed for Residents #16, 275, 30, 40, 23, 13, 63, 60, 65, 74, 625, 67, 59, 53, 15, 47, 125, 57, 56, 35, 2, 61, 20, 73, and 43 by the nurse management team on 04/10-12/18 with findings reported to the physician. Orders and care plans were updated as needed. review of medication records [REDACTED]. Physicians were notified and corrective action was taken. Residents #16, #275, #30, #40, #13, #63, #60, #65, #74, #625, #67, #59, #53, #15, #47, #125, #57, #56, #35, #2, #61, #20, #73 and #43 had the accuracy of their clinical record including, but not limited to, their MARS and TARS reviewed and updated. The Physician was notified as needed. 5. The facility's Governing Body is comprised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. The Governing Body is instrumental in developing and implementing all elements of the plan of correction and will be overseeing compliance on an ongoing basis. 6. A head to toe assessment/evaluation was completed for all current residents by the nurse management team with findings reported to the physician. A chart review for each resident was completed by RN Nurse Consultants beginning 04/10/18 and were completed by 04/18/18. Nurse management notified physicians, obtained orders and updated care plans as needed. The evaluation included signs and symptoms of UTI and assessment of risks/benefits. Physicians notified, orders obtained and care plans updated as needed. 7. A resident interview and observation was completed and care plans updated by the Social Services Consultant for all residents on 04/09/18 through 04/10/18. 8. All residents with wounds were assessed on 04/11-12/18 by certified wound nurse consultant and the physician was notified of any changes. No new wounds were identified. 9. The shower schedule was reviewed by RN nurse consultant and any residents that had not received their shower timely was offered a shower and/or rescheduled per their preference. 10. MARS/TARS for all residents were reviewed by the nurse management team and nurse consultants by 04/18/18. 11. A review of current labs for all residents was completed by the nurse management by 04/12/18 and all labs were reviewed by the physician. 12. On 04/08/18, education was provided by counsel regarding the regulations governing licensed nurses, nurse aides and KMA's which included, but was not limited to, repercussions for willfully or negligently not carrying out assigned duties and will be completed by the nurse management team and Regional Director of Operations and Administrator by 04/18/18 or will not be allowed to work until educated. The interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director has been educated regarding QA Process, and role of the IDT team by the QA Compliance Consultant by 04/18/18. All staff were educated regarding Abuse and Neglect and Resident Rights by the RN Consultants, training was started by 04/10/18 and was completed by 04/18/18 or will not be allowed to work until educated. All staff were re-educated regarding resident rights of self-determination by RN Consultants and the Nurse Management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and completed by 04/18/18 or employee will not be allowed to work until educated. All licensed nurses were educated regarding standards of practice for Abuse and Neglect, Resident Rights, Infection Control, Changes of Condition, Lab Process, Pain Process, Skin System, updating care plans for change of condition, and Care planning by the RN nurse consultant team beginning 04/10/18 and completed 04/18/18 or will not be allowed to work until educated. Newly hired licensed staff and agency staff will be educated regarding standards of practice, regulations governing licensed nurses/KMA, and medication procedures prior to providing care. All licensed nurses were educated regarding pain management by 04/18/18 or will not be allowed to work until educated. Reeducation regarding pain management including dressing changes for all licensed nurses and KMA was initiated and competency evaluated. All licensed nurses were educated regarding timely reporting lab results and the updated lab process by the nurse management team and the RN Nurse Consultants by 04/18/18 or the employee will not be allowed to work until education is complete. All licensed nurses and KMA's were provided education by the nurse management team (Interim Director of Nurses, Interim Assistant Director of Nurses, Staff Development Coordinator, Regional Quality Manager) and the RN Consultants (8) on medication administration including signing out medications timely, documentation of PRN's when given and with follow-ups, medication administration and treatment administration with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment errors, insulin administration, documentation of wound care, and following physician orders starting on 04/10/18 and to be completed by 04/18/18 or will not be allowed to work until educated. All licensed nurses, KMA's, and nurse aides were educated regarding the QA Infection Control Standard of Practice and Changes of Condition Process by nurse consultant team on 04/12/18 and will be completed by 04/18/18 or the employee will not work until educated. All nurses/KMA/Aides were reeducated on perineal care including infection control and signs and symptoms of UTI by 04/18/18 or the employee will not be allowed to work until educated. Return demonstration and/or competency confirmation obtained. Education for nurses/nurse aides on the QA Skin System for wound care, to include Stop and Watch, INTERACT and bathing was initiated on 04/12/18 by clinical nurse consultants and is to be completed by 04/18/18 or will not be allowed to work until educated. 13. An ADL Care Competency Checklist was developed for CNA's (Exhibit) by RN nurse consultants and will be completed by 04/18/18. All CNA's, including newly hired, received education and demonstrated competency for each area. The checklist specifically identified whether each individual met competency in each category. If that individual did not, he or she will be retrained and observed again prior to caring for residents. All new nurses, KMA's, nurse aides and RAs will be checked off prior to working with residents. 14. An audit was completed for missing medication and treatments via review of the MARS/TARS effective 04/09/18. An ongoing audit will be completed daily for three (3) weeks. Results to be forwarded to QAPI monthly for review. 15. Labs will be audited 3 x per week for 3 weeks; and, monthly thereafter for MD review and in the clinical record. 16. Change of condition and pain management will be audited 3 x week for 3 weeks and monthly thereafter. 17. The Clinical QAPI process regarding pharmacy/medications was implemented. The monitoring will include the Clinical QAPI process which has a monitoring task list including pharmacy issues. These monitoring forms will be completed by the Interdisciplinary team and reported in weekly QA meetings by the Administrator and DON. The monitoring will be performed and reported to the QA committee weekly for 3 months or until substantial compliance is obtained. 18. The facility has obtained contracts with staffing agencies and is utilizing staff from sister facilities for licensed nursing staff to ensure appropriate staffing levels by 04/18/18. 19. Both the Administrator and the Director of Nursing will be participating in daily stand up meetings, weekly QA meetings, the clinical meeting using the Clinical QAPI Daily Review Form (Exhibit), and weekly through the QA Pain Committee process with regular reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. Ongoing Pain Management Control will be monitored by the DON and Administrator and discussed during the daily clinical meeting, and during the weekly QA Pain Meeting using the QA Pain reference tool (Exhibit), interdisciplinary care plan meetings and report results to the QA Committee monthly for 3 months or until substantial compliance is achieved. 20. A QA meeting was conducted on 04/10/18 to develop a plan for removal of Immediate Jeopardy. The Administrator, Director of Nursing, Regional Quality Manager, staff development, MDS, Rehabilitation Manager, Social Services, Activity Director and Medical Director were directly involved in the process. Additionally, the Medical Director has participated in ongoing QA meetings, communicated with and advised the facility daily regarding the ongoing corrective action process and regularly come onsite. 21. On 04/17/18, the QA Committee met to review the audit results and follow-up as needed. The QA Committee will meet weekly thereafter for three months and monthly ongoing. In addition to the facility QA team, a member of the Regional Team will be in attendance for the weekly QA meetings as well. 22. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. 23. Members of the Governing Body will regularly be onsite at the facility on a schedule. The Governing Body will consult with the Compliance Department monthly for three months to ensure the facility is adequately managed. The Governing Body will rely on the Compliance Department to assist them with meeting regulations. 24. The facility hired a new Administrator effective 04/18/18 and Director of Nursing on 04/11/18. The new Administrator began his official duties on 04/18/18. The Administrator's onboarding process included orientation by the Regional Director of Operations. Additionally, he is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. The Director of Nursing onboarding process included orientation by the RN Consultants and the Regional Quality Manager, and Quality Compliance Specialist. Additionally, she is fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of PT Evaluation and Plan of Treatment Record dated 04/06/18, revealed Resident #15 was assessed per PT. Review of Care Plan Meeting Notes dated 04/11/18, revealed Resident #15 was in attendance with noted changes to care plan. Review of Resident Interview and Observation form dated 04/10/18, revealed the resident assessment was completed by the Social Services Consultant. 2. Review of head to toe assessments revealed evaluation, pressure ulcer/wound assessment, and pain assessments were completed for Resident #56 and Resident #64 on 04/10/18 and 04/11/18. In addition, review of the comprehensive care plans for Residents #56 and #64 revealed they had been revised with new interventions for pain management and wound care on 04/11/18. A review of a list of residents signed off as seen by the physician revealed he was notified of the results of the pain assessments for Residents #56 and #64. Review of Resident #56's TAR revealed a shower was given on 04/10/18. Review of the TAR for Resident #64 revealed dressing changes were completed on 04/09/18 and 04/10/18. Review of the bath day roster dated 04/07/18 through 04/17/18 revealed Resident #64 received sponge baths on 04/08/18 and 04/09/18 and tub baths on 04/10/18, 04/13/18, and 04/14/18. Review of medication reviews revealed Resident #56 & #64 had medications reviewed. 3. Review of Departmental Notes revealed the physician was notified of the urinalysis results on 04/15/18 for Resident #51. Review of the head to toe assessment and labs for Resident #51 revealed they were completed on 04/12/18 and he/she was assessed for signs and symptoms of a UTI on 04/11/18. The physician was notified of the results of the assessment. Review of the care plan and physician orders revealed they were updated as well. 4. Review of the facility documentation revealed the physician was notified regarding medications and treatment omissions for thirty-one (31) residents on 04/15/18. Review of head to toe assessments revealed all residents were assessed and the MD was notified on 04/11/18. The assessments were completed on 04/10-04/12/18 by the nurse management team. Orders and care plans were updated as needed. 5 Interview with the Interim Administrator revealed the Governing Body was compromised of the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director. 6. Review of head to toe skin assessments dated 04/10/18 through 04/18/18 revealed an assessment was completed for all residents in a census of seventy-four (74) residents with any changes in condition reported to the physician. All residents were assessed for signs and symptoms of a UTI. Review of the comprehensive care plan documentation revealed all care plans were reviewed on 04/18/18. Further review of the Resident Interview & Resident Observation Forms revealed consults were completed for all residents on 04/09/18 to 04/10/18. Chart reviews were conducted by the RN Nurse Consultants which included Physician's Orders by order type, Treatment Records, Oxygen Orders, Tube Feeding Orders, Lab Orders Audit, Elopement Audit, Dietary, Skin Audits, TB Audits, Falls, Care Plan Review/Update, and Code Status review. Review of the Care plan Review list provided by the facility revealed the care plans were reviewed by the Social Services Consultant on 04/09/18 to 04/10/18. 7. Review of the Resident Interview and Resident Observation Forms revealed consults for all residents were completed for all residents on 04/09/18 to 04/10/18. 8. Review of Nursing Notes dated 04/10-04/11/18 revealed all residents were evaluated by the certified wound nurse consultant for wounds and physician notifications were made as needed. 9. Review of shower schedules revealed any resident who had not received a shower was offered one and rescheduled if desired. 10. Review of the records revealed all MAR's and TAR's for all residents were reviewed by 04/18/18. 11. Review of documentation provided revealed Lab audits were completed on 04/12/18 and labs for all residents were reviewed by the physician. 12. Review of in-service records revealed training was provided to all nursing staff and KMA's for Promoting Skin Health, Preventing Pressure Ulcer/Skin Breakdown, Ensuring Proper MD Orders for Skin Care on 04/16/18; Wound Treatments Administration Review on 04/18/18; medication administration completed on 04/18/18. Review of inservice sign in sheets, dated 04/10/18, revealed education was provided to all licensed nursing staff by the nurse management team related to medication and treatment administration and ADL documentation with attention to pain, signing off orders, notification of physician for any late medication/treatments including dressing changes as well as proper documentation for medication and treatment. Review of inservice sign in sheets and a list of licensed employees revealed education was provided to all licensed nurses on standards of practice, abuse and neglect, resident rights, infection control, changes of condition, lab process, pain process, skin system, and care planning which began on 04/10/18 and was completed on 04/18/18 by the Nurse Management team and RN Nurse Consultants Review of inservice sign in sheets revealed education was provided by counsel to all licensed nursing staff regarding the regulations governing nurses and KMA's and the possible repercussions for willfully not carrying out assigned duties on 04/04/18 through 04/12/18. Review of the inservice sign in sheets dated 04/10/18 through 04/18/18, revealed all licensed Nurses/KMA were reeducated by the nurse management team regarding signing off orders, documentation of wound care as well as proper documentation for medication and treatment errors. Review of inservice sign in sheets revealed the nursing consultant team provided training to all licensed nurses and KMA's regarding medication orders and administration including signing out medications timely, documentation of PRN's when given and with follow-ups, insulin administration, and following physician orders starting on 04/10/18 and to be completed by 04/18/18 or the employee will not work until trained. Review of education provided on 04/12-04/18/18 by the clinical nurse consultants revealed all NA/CNA's were educated as alleged in the AoC related to the skin care system policy, Stop and Watch forms, INTERACT forms and bathing. Review of education provided by the Staff Development Coordinator, dated 04/16/18, revealed all licensed nursing staff and KMA's were inserviced on pain management and dressing changes and competency evaluated. signs and symptoms of UTIs and the physician notified as needed. Review of education provided by the nurse consultant team, revealed all licensed nursing staff and KMA's were inserviced on the QA Infection Control Standards of Practice; pain management and dressing changes and competency evaluated, signs and symptoms of Cutis and the physician was notified as needed. All nurses/ KMA's, CNA's were reeducated on perineal care including infection control and signs and symptoms of UTI. Return demonstration and competency confirmation obtained. Review of ADL competency checklist revealed all CNA's had been checked off on Abuse and Residents Rights; Communication and Customer Service; ADL care; Documentation and Reporting; Infection Control/Handwashing and a verbal repeat demonstration and was completed by 04/18/18. Review of In-Service Records dated 04/12/18 and 04/17/18 revealed the interdisciplinary team, including the Administrator, Director of Nursing, Regional Director of Operations and the Medical Director had been educated regarding QA Process, role of the IDT team by the QA Compliance Consultant by 04/18/18. Staff interviews conducted on 04/20/18 with Certified Nursing Assistants (CNA's) #15 at 9:01 AM, #17 at 10:01 AM, #18 at 10:11 AM, #2 at 12:46 PM, #5 at 1:05 PM, #19 at 3:47 PM, and #8 at 3:57 PM; Activity Assistant #1 at 9:55 AM, revealed education had been provided to them by the Regional Corporate Nurses related to abuse/neglect in regards to when to report, types of abuse, who to report to and how to protect the resident from further abuse; monitoring skin and reporting new or worsened areas of concern to the charge nurse; use of the Stop and Watch form related to change in condition of a resident; infecti (TRUNCATED)

Based on observation, interview and facility policy review, it was determined the facility failed to ensure acceptable standards of care was provided for twenty-eight (28) of thirty-six (36) sampled residents (Residents #2, #13, #20, #29, #30, #31, #35, #40, #43, #47, #50, #53, #56, #57, #59, #60, #61, #62, #63, #64, #65, #67, #73, #74, #125, #275, #575, and #625). Record reviews revealed physician's orders were not followed for wound care and medication administration for thirty-one (31) residents. The facility's failure to ensure acceptable standards of care has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/07/18 and determined to exist on 02/15/18. The facility was notified of the Immediate Jeopardy on 04/07/18. An acceptable Credible Allegation of Compliance (A[NAME]), related to the Immediate Jeopardy, was received on 04/20/18 alleging the Immediate Jeopardy was removed on 04/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 04/19/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled, Medication Administration, General Guidelines, dated (MONTH) 2012, revealed medications are administered as prescribed in accordance with manufacturers, specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administers the report off duty without first recording the administration of the medications. 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication is withheld or refused, the physician is notified. 4. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the care center's master employee signature log. Review of the policy titled Medication Administration: General Guidelines, not dated, revealed medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. Medications are administered in accordance with written orders of the prescriber. 1. Review of the policy titled Skin System Policy & Procedure, not dated, revealed . A resident having a pressure sore receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Record review revealed the facility admitted Resident #64 on 09/15/17 and readmitted the resident from the hospital, on 02/16/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #64's cognition as intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of the Physician Orders for (MONTH) (YEAR), revealed three Stage IV Pressure Ulcers, to the right and left buttock and sacral areas, were to have been cleansed with Dial Soap and water, packed with one-quarter (1/4) strength Dakin's Solution, (made from diluted bleach,) covered with gauze and secured with tape. Two Stage IV areas to the bilateral heels were to have been treated with Skin-Prep (a liquid, film-forming agent that forms a protective film around intact skin) and left open to air. All dressings were ordered to have been changed twice a day (BID.) A foam dressing was to have been applied to a scar on the resident's right chest and was to have been changed weekly on Fridays. However, review of the (MONTH) (YEAR) Treatment Administration Records (TAR's) revealed there was no evidence the dressing changes had been completed or why they had not been completed from 04/01/18 through 04/04/18 at 7:00 AM and 7:00 PM. Observation of Resident #64's dressings to the sacral area on 04/03/18 at 5:18 PM, with the Staff Development Coordinator (SDC) and Certified Nurse Aide (CNA) #10, revealed the dressing site to sacral area, had visible dampness and was not secured, was dated 04/02/18 even though the resident was supposed to receive dressing changes two (2) times a day, and there was a darkened area noted below the dressing site. In addition, review of a Physician Order and script from the Physician, dated 04/05/18 at approximately 4:45 PM, revealed the staff were to have applied a [MEDICATION NAME] (a pain patch) 25 mg [MEDICATION NAME] every three (3) days. However, interview with Resident #64 on 04/06/18 at 4:30 PM, revealed the resident stated I'm hurting so bad, and I'm just waiting for Jesus. On 04/07/18 at 8:50 AM the resident stated I hurt all over. Interview with CMT #1, at that time, revealed the resident had still not received the [MEDICATION NAME] Pain Patch the physician ordered on [DATE] at 4:45 PM. Review of the Narcotic Count Sheet and observation of the date of the patch on Resident #64's shoulder on 04/07/18 at 2:35 PM, revealed the first patch was not administered to the resident until 04/07/18 at 11:00 AM. Interview with Licensed Practical Nurse (LPN) #7 on 04/03/18 at 4:00 PM, revealed she was responsible for the treatments and the dressing changes for Resident #64 and they had not been completed but were done when he/she will let me. The LPN stated the resident refuses all the time, and they were short staffed and she had asked for help. Interview with the Administrator on 04/05/18 at 1:58 PM, revealed she was recently made aware of the observation on 04/03/18 at 5:18 PM, that revealed the dressings had not been changed since 04/02/18. The Administrator stated she was not aware the dressings had not been completed, as ordered until the last couple of days. She also stated the charge nurses were responsible to complete the dressings, as the facility no longer employed a wound care nurse. The Administrator stated she would have expected the resident's refusal would not be the nurses sole attempt to complete the dressing changes and the nurses should have proceeded to find out why the resident was refusing and take a step to eliminate the reason and maybe try another staff member the resident would be more willing to allow to help. Interviews with Resident #64's Physician on 04/04/18 at 1:50 PM, revealed he did not foresee these pressure ulcers healing as the resident was not cooperative with the required care and the resident had her own mind. 2. Record review revealed the facility admitted Resident #56 on 02/20/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 02/27/18, revealed the facility assessed Resident #56's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the (MONTH) and (MONTH) (YEAR) Physician's Orders for Resident #56 revealed to apply Santyl ointment to the lower right leg and foot after washing with soap and water. Pat dry, and cover with nickel thick ointment, then cover with moist gauze, then dry gauze, then roll gauge, then ace wrap. This was to be done two (2) times a day (BID). However, review of the (MONTH) and (MONTH) (YEAR) TAR revealed there was no documentation the treatment had been completed on 03/30/18, 03/31/18, 04/01/18, and 04/02/18 on either shift, or on 04/03/18 on the morning shift. In addition, review of a Physician's Orders from the Wound Clinic, dated 04/04/18, revealed to shower daily with soap and water, pat wound dry then apply treatment.; however, review of the (MONTH) TAR revealed this was not added to the TAR or added to the shower sheet. Observation and interview on 04/03/18 at 1:09 PM revealed Resident #56 lying in bed with a large amount of green drainage, noted on dressing and a pool of green drainage noted on the bed sheets. The resident stated he/she was not sure the last time the dressing had been changed, either yesterday or the day before even though the Physician Order was for it to be changed twice a day. Observation of the dressing change on 04/03/18 at 2:31 PM revealed copious amounts of green, bloody drainage with a foul smell. There was not a date or time provided on the old dressing. Interview with hall 300 Charge Nurse, LPN #7 on 04/04/18 at 11:15 PM revealed she was not aware of a scheduled shower or dressing change for day shift, the shift that she worked. She stated now that the nurses are having to pass the medications instead of the CMT's there is not enough time to complete all the assigned tasks. Interview with the Clinical Coordinator from the wound clinic on 04/09/18 at 10:00 AM revealed new orders were sent to the facility at the time of the resident's visit on 04/04/18, that specified to shower daily. She stated on the 03/14/18 visit, the dressing was dated 03/11/18, so she felt the dressing had not been getting changed as it should be so she added shower every other day to the orders to help ensure the dressing was getting done more frequently. 3. Record review revealed the facility readmitted Resident #35 on 05/24/17 with [DIAGNOSES REDACTED]. Review of the annual MDS assessment, dated 08/18/17, revealed the facility assessed Resident #35's cognition as severely impaired with a BIMS score of seven (7) which indicated the resident was not interviewable. Review of the (MONTH) (YEAR) Physician Orders revealed to monitor [MEDICAL TREATMENT] access to the right [MEDICATION NAME] every shift for signs and symptoms of infection; [MEDICAL CONDITION] nightly, check tubing for leaks, O2 concentrator, BIBAP at six (6) liters per minute (LPM). However, review of the (MONTH) (YEAR) TAR revealed there was no documentation this was done on 04/01/18, 04/02/18, and 04/03/18 at 7:00 AM or 7:00 PM. 4. Record review revealed the facility admitted Resident #625 on 04/02/18 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician Orders revealed to administer Resident #625 [MEDICATION NAME] 2.5 mg on Monday, Wednesday, and Friday. However, review of the (MONTH) (YEAR) MAR and medication count revealed the [MEDICATION NAME] was not administered on 04/01/18 at 5:00 PM. 5. Record review revealed the facility admitted Resident #2 on 10/27/17 with [DIAGNOSES REDACTED]. Review of Resident #2's (MONTH) (YEAR) Physicians Orders revealed to administer [MEDICATION NAME] 50 mg 1 tablet by mouth twice daily for blood pressure, Atorvastatin 20 mg one tablet by mouth daily at HS for cholesterol, [MEDICATION NAME] DR 125 mg Cap sprinkles give 2 capsules (250 mg) by mouth four times a day for [MEDICAL CONDITION], [MEDICATION NAME] 0.05% eye [MEDICATION NAME] place 1 drop in each eye every 12 hours to enhance tear production, Klonopin 0.5 mg tablet one tablet by mouth twice daily, Aripiprazole 2 mg tablet 1 tablet by mouth at bedtime, [MEDICATION NAME] 10 mg tablet take one tablet by mouth every night for mood stabilization. However, review of the (MONTH) and (MONTH) (YEAR) MAR revealed there was no documentation the medication was administered on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, 8:00 PM, or 9:00 PM. 6. Record review revealed the facility admitted Resident #30 on 01/04/18 with [DIAGNOSES REDACTED]. Review of Resident #30's (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] 5 mg tablet one three times a day, [MEDICATION NAME] 10 mg give one tablet by mouth daily at bedtime, Quetiapine [MEDICATION NAME] 25 mg tab one tablet by mouth at night, [MEDICATION NAME] 300 mg capsule one tablet twice daily, Magnesium Oxide 400 mg tablet one tablet orally twice daily, [MEDICATION NAME] ER 600 mg tablet 1 tablet by mouth twice daily for cough/congestion, [MEDICATION NAME] HCL 10 mg tablet 10 mg PO two times daily, and [MEDICATION NAME] 160-4.5 MCG inhaler inhale 2 puffs two times daily. However, review of the (MONTH) (YEAR) TAR revealed no documentation the medication was administered on 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, or 10:00 PM . In addition, further review of the (MONTH) (YEAR) Physician Orders revealed to administer [MEDICATION NAME] 0.125 mg tablet one tablet one time a day; however further review of the (MONTH) (YEAR) MAR revealed no documentation the medication was administered on 04/01/18 and 04/02/18 at 6:00 AM. 7. Record review revealed the facility admitted Resident #57 on 02/20/18 with [DIAGNOSES REDACTED]. Review of Resident #57's (MONTH) and (MONTH) (YEAR) Physicians Order MAR revealed to administer [MEDICATION NAME] 5 mg tablet one po at bedtime; however, review of the (MONTH) and (MONTH) (YEAR) MAR revealed there was no documentation the medication was administered on 03/25/18, 03/26/18, 03/27/18, 03/28/18, 03/30/18, 04/01/18, 04/02/18, and 04/03/18 at 18 at bedtime. Further review of the (MONTH) and (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] HCL 30 mg by mouth at bedtime for depression; however, further review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation the medication was administered on 04/01/18, 04/02/18, and 04/03/18 at bedtime 8. Record review revealed the facility admitted Resident #74 on 08/30/17 and readmitted on [DATE] at 3:28 PM with [DIAGNOSES REDACTED]. Review of Resident #74's (MONTH) (YEAR) Physicians Order revealed an order for [REDACTED]. mouth daily at bedtime for depression, and [MEDICATION NAME] 50 mg tablet give one tablet by mouth daily at bedtime for [MEDICAL CONDITION]. However, review of the (MONTH) (YEAR) MAR revealed no documentation the medication was administered on 04/02/18, and 4/03/18 at 9:00 PM or 10:00 PM. 9. Record review revealed the facility readmitted Resident #47 on 03/11/17 with [DIAGNOSES REDACTED]. Review of Resident #47's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians order revealed to administer Eliquis 2.5 mg tablet give one tablet by mouth twice daily for anticoagulation. However, review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation the medication was administered on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. 10. Record review revealed the facility admitted Resident #67 on 03/15/18 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Residents #67's cognition as intact with a BIMS of fifteen (15), which indicated this resident was interviewable. Review of Resident #67 (MONTH) (YEAR) and (MONTH) (YEAR) Physicians Order revealed an order for [REDACTED]. However, review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation [MEDICATION NAME], Trazadone, and [MEDICATION NAME] was administered on 03/27/18, 04/01/18, 04/02/18, and 04/03/18; [MEDICATION NAME] Mes was administered on 04/01/18, 04/02/18, and 04/03/18; and, Atorvastatin was administered on 04/01/18, 04/02/18, and 04/03/18 at 9:00 PM. In addition, review of the Physicians Orders dated 03/15/18 and (MONTH) (YEAR) revealed to check bruit and thrill shunt right antecubital site every shift, assess surgical site right antecubital site every shift for redness/drainage. However, review of the (MONTH) and (MONTH) Electronic TAR (E-TAR) revealed there was no documentation the site was assessed every shift on 03/25/18, 03/27/18, 03/30/18, 03/31/18, 04/01/18, 04/02/18, and 04/03/18. Interview with Resident #67 on 04/06/18 at 09:55 AM revealed that the staff do not check his shunt. only sometimes. Interview with Licensed Practical Nurse (LPN) #7 on 04/05/18 at 05:25 PM revealed the shunt might have been assessed, but just did not get charted, but the order should have been followed and documented. Interview with the Director of Nursing on 04/06/18 at 09:40 AM revealed if the physician ordered the shunt to be assessed, the nurses should follow the physicians order, and if it was not documented, it was not done. 11. Record review revealed the facility readmitted Resident #20 on 12/13/17 with [DIAGNOSES REDACTED]. Review of Resident #20's (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] 300 mg capsule take one capsule by mouth three times daily for [MEDICAL CONDITION], [MEDICATION NAME] HCL 15 mg tablet take one tablet by mouth three times daily for mood stabilization, [MEDICATION NAME] 3 mg tablet take one tablet by mouth every bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 150 mg tablet two (2) tablets (300 mg) by mouth every night at bedtime for [MEDICAL CONDITION], Quetiapine [MEDICATION NAME] 300 mg tab take one tablet by mouth every bedtime for [MEDICAL CONDITION], Memantine HCL 10 mg tablet take one tablet by mouth two times daily for Alzheimer's, Carvedilol 6.25 mg tablet take one tablet by mouth two times daily for hypertension, Potassium CL ER 20 meq tablet take one tablet by mouth two times daily for supplement, Ducosate Sodium 100 mg softgel give one softgel by mouth twice daily for constipation, [MEDICATION NAME] HCL 25 mg tab take one tablet by mouth at bedtime for nerve pain/antidepressant, Donepezil HCL 10 mg tablet take one tablet by mouth every bedtime for Alzheimer's. However, review of the (MONTH) (YEAR) MAR revealed no documentation the medication was administered on 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM or 10:00 PM. 12. Record review revealed facility admitted Resident #65 on 02/10/17 with [DIAGNOSES REDACTED]. Review of Resident #65's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] HCL 0.1 mg tablet give one tablet by mouth three times daily for hypertension, [MEDICATION NAME] 25 mg tablet one tablet by mouth twice daily for hypertension, and Xarelto 20 mg tablet give one tablet by mouth daily at bedtime for A-Fib. However, review of the (MONTH) and (MONTH) (YEAR) MAR revealed no documentation the medication was administered on 03/30/18, 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM, 9:00 PM, or 10:00 PM. 13. Record review revealed the facility readmitted Resident #31 on 09/24/17 with [DIAGNOSES REDACTED]. Review of Resident #31's (MONTH) (YEAR) and (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] Sodium 20 mg tab one tablet by mouth once daily for [MEDICAL CONDITION], to check oxygen saturation (O2 Sat) every shift and PRN notify physician if O2 sat less than 90%; and wanderguard-check placement every shift. However review of the (MONTH) and (MONTH) (YEAR) MAR revealed there was no documentation the medication was administered, or the wanderguard-check was completed on 03/30/18, 03/31/08, 04/01/18, 04/02/18, and 04/03/18 at 7:00 AM, 7:00 PM or 9:00 PM. 14. Record review revealed the facility admitted Resident #44 on 02/02/18 with [DIAGNOSES REDACTED]. Review of Resident #44's (MONTH) (YEAR) Physicians Order revealed to administer [MEDICATION NAME] 30 mg tablet one tablet by mouth every night for A-Fib, Eliquis 5 mg tablet one tablet two times a day by mouth, [MEDICATION NAME] sodium 100 mg capsule one by mouth twice a day, [MEDICATION NAME] 250 mg capsule one capsule by mouth twice daily [MEDICATION NAME] 100 units/ml vial inject 10 units subcutaneous every night, and Accuchecks before meals and at bedtime and record results. However, there was no documentation the medication was administered or accuchecks were completed on 04/01/18, 04/02/18, and 04/03/18 at at 7:00 PM. 15. Record review revealed the facility readmitted Resident #43 on 02/02/18 with [DIAGNOSES REDACTED]. Review of Resident #43's (MONTH) (YEAR) and (MONTH) (YEAR) Physician order revealed an order for [REDACTED]. However, review of the (MONTH) and (MONTH) MAR revealed no documentation the medication was administered on 03/31/18, 04/01/18, 04/02/18, and 04/03/18 at 7:00 PM. 16. Record review revealed the facility admitted Resident #50 on 02/12/18 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician's Orders revealed to administer [MEDICATION NAME] 25 mg twice daily. However, review of the (MONTH) (YEAR) MAR revealed there was no documentation indicating Resident #50 was administered the PM dose of [MEDICATION NAME] (blood pressure) 25 mg on 04/01/18 through 04/03/18 (three {3} days). 17. Record review revealed the facility admitted Resident #53 on 12/12/15 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician's Orders revealed to administer [MEDICATION NAME] (blood pressure) 40 mg two (2) times a day, [MEDICATION NAME] (blood pressure) 25 mg three (3) times a day, [MEDICATION NAME] Succ ER (blood pressure) 25 mg two (2) times a day, [MEDICATION NAME] HCL (depression) 20 mg once daily at bedtime, and [MEDICATION NAME] (pain, narcotic) 7.5 mg-325 mg at 7:00 PM nightly. However, review of the (MONTH) (YEAR) MAR revealed there was no documentation the resident was administered the PM doses of [MEDICATION NAME] 40 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] Succ ER 25 mg, [MEDICATION NAME] HCL 20 mg, and [MEDICATION NAME] 7.5 mg/325 mg on 04/01/18 through 04/03/18. 18. Record review revealed the facility admitted Resident #63 on 12/08/17 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician's Orders revealed to administer [MEDICATION NAME] (antipsychotic) 1 mg at bedtime, [MEDICATION NAME] (anxiety) 1 mg twice daily, [MEDICATION NAME] (antipsychotic) 200 mg at bedtime, and [MEDICATION NAME] SOD DR (mood stabilizer) ) 250 mg three times daily. However, review of the (MONTH) (YEAR) MAR revealed there was no documentation the resident received the PM dose of [MEDICATION NAME] 1 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 200 mg, and [MEDICATION NAME] SOD DR 250 mg on 04/01/18 through 04/03/18. 19. Record review revealed Resident #275 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician's Orders MAR revealed to administer [MEDICATION NAME] (insulin, diabetes) 20 units at bedtime, [MEDICATION NAME] SUCC ER 50 mg twice daily, [MEDICATION NAME] ([MEDICAL CONDITION]) 600 mg twice daily, [MEDICATION NAME] HCL (muscle spasms) 4 mg every eight hours, [MEDICATION NAME] (antipsychotic) twice daily, and Trazadone (depression) 150 mg at bedtime. However, review of the (MONTH) (YEAR) MAR revealed there was no documentation the resident was administered the PM dose of [MEDICATION NAME] SUCC ER 50 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] HCL 4 mg, [MEDICATION NAME] 60 mg,Trazadone 150 mg, and [MEDICATION NAME] 20 units on 04/01/18 through 04/03/18. 20. Record review revealed the facility admitted Resident #73 on 03/06/18 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 03/23/18, revealed the facility assessed Resident # 73's cognition as severely impaired with a Brief Interview for Mental Status (BIMS') score of five (5), which indicated the resident was not interviewable. Review of Resident #73's (MONTH) (YEAR) Physician Orders revealed to administer Quetiapine [MEDICATION NAME] (antipsychotic) 100 MG Tab give (1) one tablet by mouth three (3) times daily, [MEDICATION NAME] Succ ER (Blood pressure) 200 mg give (1) tablet by mouth twice (2) daily, [MEDICATION NAME] 250-50 Diskus (breathing medication) inhale one (1) puff twice (2) daily for [MEDICAL CONDITION], [MEDICATION NAME] ER (anti-diabetic) 2.5 MG tablet (1) tablet by mouth once daily before breakfast, [MEDICATION NAME] (blood pressure) 100 MG tab (2) tablets by mouth every 12 hours' *Hold for heart rate below 60 for hypertension, [MEDICATION NAME] (Alzheimer's) 5 MG tablet give (1) tablet by mouth at bedtime, Accuchecks twice (2) a day call MD if blood sugar <60 or >400, and Wander guard-check (monitoring device) placement, function (right ankle) ordered every shift. However, review of Resident #73's (MONTH) (YEAR) MAR, revealed Quetiapine [MEDICATION NAME] Succ ER, [MEDICATION NAME] 250-50 Diskus [MEDICATION NAME] 100 MG tab, [MEDICATION NAME] 5 MG tablet was not documented as administered at 9 PM on 04/01/18, 04.02/18 and 04/03/18. In addition, [MEDICATION NAME] ER 2.5 MG was not documented as given at 6:00 AM on 04/01/01-04/03/18. Further review revealed accuchecks twice (2) a day were not documented as being obtained at 6:30 AM and 8:00 PM on 04/01-03/18; and Wander guard-check placement, function (right ankle) once a shift was not documented as being completed at 7:00 AM and 7:00 PM on 04/01-03/18. 21. Record review revealed the facility admitted Resident #575 on 12/19/17 with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician Orders revealed to administer [MEDICATION NAME] Prop 50 micrograms (mcg) spray, 1 spray each nostril every night at bedtime; [MEDICATION NAME] Sodium 20 mg tab, give one tablet by mouth daily at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] (antipsychotic) 5 mg tablet, 1 tablet by mouth three times a day for [MEDICAL CONDITION]; and, Levetiracetam 500 mg tablet, 1 tablet by mouth twice daily for [MEDICAL CONDITION]. However, review of the (MONTH) (YEAR) MAR revealed there was no documentation [MEDICATION NAME] Prop 50 mcg, [MEDICATION NAME] 5 mg, and [MEDICATION NAME] Sodium 20 mg and Levetiracetam 500 mg was administered on 04/03/18 and 04/0418 at 10:00 PM. Interview with Resident #575 on 04/07/18 at 9:00 AM revealed he/she has not been receiving his medications at night. The resident stated she does not understand why he/she did not get them. The resident also revealed he/she did not ask anyone about not getting the medications. The resident stated he/she figured if they wanted him/her to have his/her medications, they would have given them to him/her. Interview with LPN #3 on 04/03/18 at 5:25 PM revealed on the morning of 04/03/18, she found the nurse who was covering the 300 hall (above residents) asleep . She stated when the nurse awakened, she was very fidigity, talking to herself, making weird demonic noises, and talking in different voices. She stated she called the Director of Nursing (DON) and the DON came to the facility and escorted the nurse out of the building. Interview Certified Medication Technician (CMT) #8 on 04/05/18 revealed on 04/03/18 at about 7:30 PM, LPN #7 called her to help give the 6:00 PM medications and other night time medications on the 300 hall (above residents). She stated by the time she got to the facility, the 8:00 PM medications were late and the residents were begging for their medications so the two of them passed the medications together to get them passed faster. She further stated LPN #7 was supposed to have initialed the medications had been given to all the residents on 300 hall; however she did not. She further revealed she knew she should of signed out the medications that she gave but trusted LPN #7 to do it since it was the LPN's shift. She stated if the medications are not signed out as given, then they were not given. Interview with the Director of Nursing on 04/06/18 at 2:00 PM revealed the nurse that was covering 300 hall was escorted out of the facility at 4:00 AM, on the morning of 04/03/18 due to being under the influence of something, and was to impaired to do the narcotic count before leaving, so she was unsure if the medications were given or not on the 300 hall or not. 22 Record review revealed the facility admitted Resident #61 on 09/27/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/14/18, revealed the facility assessed Resident #61's cognition to be moderately impaired with a BIMS score of twelve (12) which indicated the resident was interviewable. Review of Resident #61's Physician Order dated April, (YEAR), revealed to administer [MEDICATION NAME] 70-30, 30 units subcutaneous twice a day for Diabetes; and obtain finger stick blood glucose checks before meals and at bedtime with Humalog sliding scale parameters. However, review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed the licensed staff failed to obtain the resident's finger stick blood glucose at 6:30 AM and failed to administer the ordered [MEDICATION NAME] 70-30 at 7:00 AM on 04/04/18. Interview with Resident #61 on 04/05/18 at 1:59 PM revealed Resident

Based on interview, record review and review of the facility's Administrator Position Description, and the facility's policy and procedures, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental and psychosocial well being for one (1) of eighteen (18) sampled residents (Resident #5). The Administer failed to ensure staff was aware of Resident #7's history of sexually inappropriate behavior; and, failed to have an effective system in place to report and investigate resident to resident sexually inappropriate behavior to make sure residents in the facility received adequate supervision to protect other residents and prevent reoccurrence. Refer to F225, F226, F279 and F323. The facility's failure to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently 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, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/02/15 and determined to exist on 05/31/15. The facility was notified of the Immediate Jeopardy on 07/02/15. An acceptable Allegation of Compliance (AoC) was received on 07/14/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 07/11/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plans of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Administrator's job description, characteristic duties and responsibilities, and essential functions revealed the Administrator is to keep actively involved in the day-to-day operation of the facility and to remain aware of potential problems and plan courses of corrective action; act as a role model by following and promoting policies and procedures in all aspects of the daily operations of the facility; and, assures that all incidents of abuse are thoroughly investigated and reported and appropriate steps are taken to prevent reoccurrence. Review of the facility's Abuse and Neglect policy, not dated, revealed the purpose is to prohibit abuse of residents from any source; promote the well-being of residents by providing a safe and supportive environment; and maintain the resident's right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. Any person who suspects that abuse, neglect, or misappropriation of property may have occurred, will immediately report the alleged violation to the facility's administration. Administration will immediately notify the Office of Inspector General, Adult protective Services and the local law enforcement authority. The administration will initiate the investigation process by interviewing appropriate staff and resident(s) having potential knowledge of the allegation. The facility's administration will complete the investigation within five (5) days of the allegation and will document all interviews, including the date, time and content of the interview. Further review of the facility's Abuse and Neglect policy revealed if an alleged perpetrator is a resident, the nursing staff will initiate interventions to provide immediate protection of residents until the interdisciplinary team can convene to review the current plan of care and make necessary revisions in order to ensure the safety of others. Trends will be identified, recommendations will be made, and action plans will be developed and follow up will ensure ongoing compliance. Review of Resident #7's History and Physical, dated 04/30/15, revealed Resident #7 was recently hospitalized due to increased confusion and aggression as well as a sexual assault accusation at previous skilled nursing facility. Patient stabilized while hospitalized and transferred to facility for continued care. Record review revealed the facility admitted Resident #7 on 04/29/15 after his/her recent hospitalization . Review of Resident #7's Interim Care Plan, dated 04/29/15, and the Comprehensive Care Plan, dated 05/11/15, revealed the facility failed to care plan the resident's aggression and inappropriate sexual behavior to ensure staff was aware of these behaviors in order for them to monitor and provide adequate supervision. Interviews with Certified Nurse Aide (CNA) #2 on 07/01/15 at 11:20 AM; and RN, #2, on 07/02/15 at 2:58 PM, revealed, on 05/31/15, they witnessed, Resident #7 rubbing the left leg of Resident #5 underneath his/her pant leg while Resident #5 was laying in his/her bed. CNA #2 stated she reported this incident to RN #2. However RN #2 stated she did not report this incident to the Administrator, as she should have reported according to the facility's policy, because the Administrator had hollered at her when she reported anther incident involving Resident #7 on 05/15/15. Interview with former Administrator, on 07/01/15 at 3:45 PM, revealed she did not ensure staff was aware of Resident #7's history of sexually inappropriate behavior because she thought the resident was stabilized at the hospital prior to admission. She stated the allegations should have been investigated and reported to appropriate agencies when she became aware of them. Further interview revealed she expected all allegations of abuse to be reported immediately and investigated at the time of notification. Interview with Interim Administrator, on 07/16/15 at 11:55 AM, revealed any allegation of abuse or neglect was a reportable event. Further interview revealed his expectation was when there was an allegation of resident to resident abuse for staff to separate the residents involved, gather information pertaining to the incident, start the investigative process, and report incident immediately to all reportable agencies. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #7 was discharged to the hospital on [DATE], with an acute onset of chest pain and will not return to the facility. The resident was discharged on [DATE]. Resident #2 was placed on increased supervision on 06/18/15 due to allegations of inappropriate contact with another resident. This increase in supervision included one to one supervision while up in the chair with fifteen (15) minute checks and a bed alarm while in bed. 2. On 06/10/15, the former Director of Nursing, Assistant Director of Nursing and Unit Managers from Hall One, Two, and Three completed skin assessments on all current residents with a BIMS' score of seven (7) or less to identify any injury of unknown origin or injury suspicious in nature. There were no injuries of unknown origin or suspicious injuries noted. 3. Beginning on 06/10/15 and completed on 06/15/15, the former Administrator and Social Services Director conducted interviews with all current residents with a BIMS' score of eight (8) or greater, to identify any concerns with Resident #7 or any allegations of abuse or neglect, with no concerns identified. Beginning on 06/18/15 and concluding on 06/22/15, the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Reimbursement Nurses, Regional Director of Sales and Marketing, Regional Director of Rehabilitation and Regional Field Accountant, completed interviews with all current residents with a BIMS' score of eight (8) or greater in regards to Resident #7 and Resident #2 as well as any concern with abuse or neglect. Four (4) concerns were identified, allegations of abuse regarding Residents #2 and #7, and a visitor (family member) and one concern with missing money. 4. Beginning on 06/10/15 and completed by 06/15/15, the former Administrator, former Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services Director completed interviews with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify any concerns with abuse and neglect. In addition, the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded on 06/22/15. There were no further residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. On 06/18/15, the Regional Reimbursement Nurse reviewed all Incident Reports for the past thirty (30) days to identify any injury of unknown origin or injury suspicious in nature; there were no concerns identified. 6. On 06/25/15, the Social Services Director reviewed all current residents' medical records to include behavior documentation and behavior assessments. She also developed or updated their care plans to reflect current known behaviors and needed interventions to meet the needs of the residents. Any required updates or care plans were added on 06/25/15. 7. On 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse assessed all current residents to determine appropriate level of supervision based on current behaviors and physical ability. No changes were required. 8. On 06/10/15, the Regional Director of Operations and Regional Quality Manager completed re-education with the Former Administrator and Former Director of Nursing on the policy and requirements for reporting an investigation as well as supervision and protection and determination of competency including BIMS' score and court ordered guardianship for competency. The former Administrator and former Director of Nursing completed a competency test on 06/10/15 with 100% pass rate. Beginning on 06/10/15 and completed on 06/16/15 the former Administrator and former Director of Nursing completed re-education with all current facility staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Maintenance and Housekeeping) on the abuse policy which included reporting and protecting of residents. A competency test was administered with no staff working without having a 100% score. Beginning on 06/18/15 and completed by 06/22/15 the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Director of Rehabilitation Operations and the Regional Reimbursement Nurse, conducted a second competency test of all current staff ( Nursing, Dietary, Social Services, Maintenance, Therapy, Housekeeping and Activities) to validate understanding of abuse, neglect and inappropriate touching, which included reporting and to whom to report to when their supervisor had not addressed the allegation. No staff worked after 06/22/15 without having received this second competency test with a validated 100% accuracy. On 06/22/15, the Divisional Director provided education to the Regional Director of Operations on Abuse and Neglect including reporting and follow up with facility staff on investigation and reporting. On 06/23/15, the Interim Administrator and Interim Director of Nursing in training were re-educated by the Regional Quality Manager on abuse and neglect including reporting, protecting and the investigation as well as evaluation of competency of the resident. The Regional Quality Manager conducted competency testing of the Interim Administrator and the Interim Director of Nursing in training with both passing with 100% accuracy. Beginning on 07/10/15, and continuing each shift the Interim Administrator, Interim Director of Nursing, Social Services Director or Unit Managers will re-educate all facility staff (Nursing, Social Services, Activity, Dietary, Housekeeping, Maintenance and Therapy and Administration) on abuse and neglect including reporting, protection and supervision. They will also administer a competency test to validate understanding with no staff working after 07/10/15 without having had this education and competency test with 100% accuracy. Abuse and Neglect education and competency test were incorporated into the facility's orientation program on 06/23/15, with no staff beginning job duties until this education and competency test was complete and 100% accuracy testing. There are no agency staff employed at the facility. On 07/10/15, the Divisional Director of Operations provided re-education to the Interim Administrator and Interim Director of Nursing on abuse and neglect including reporting, investigating and providing appropriate supervision to protect residents during the investigation. They were given a competency test to validate understanding; they both scored 100% on the test. The Interim Administrator and Interim Director of Nursing re-educated the Social Services Director, Assistant Director of Nursing and Unit Managers on 07/10/15 on abuse and neglect. This training included reporting and protection and supervision. The training with competency testing administered with 100% accuracy for validation. 9. On 06/25/15, the Regional Quality Manager re-educated the Social Services Director on completion of the Social Services admission assessment to identify any known behaviors or known history of behaviors and development of a plan of care. In the Social Services Director's absence, beginning on 06/29/15, the Administrator will designate a qualified person (Director of Nursing, Assistant Director of Nursing, Unit Manager or MDS Nurse) to complete the Social Services Admission assessment and development of plans of care to address any known behaviors. Beginning 07/10/15, the Director of Nursing, Assistant Director of Nursing, MDS Nurse and Unit Managers were educated on the Social Services Admission Assessment to identify any known behaviors or known history of behaviors and development of the plan of care when designated to complete in the Social Services Director's absence. This education was completed by the Regional Quality Manager. 10. On 07/10/15, the Regional Quality Manager re-educated the Social Services Director on reviewing in the daily stand up meeting Monday-Friday any behaviors, per the Behavior Monitoring Report and updating the resident care plan for new behaviors or changes in behaviors. 11. All current Licensed Nurses were re-educated on the initiation of a behavior plan of care on admissions for residents with known behaviors. They were re-educated on the initiation of behavior monitoring for admissions with known behaviors during the admission process. This was added to the Admission Packet on 07/06/15 by medical records. The education was completed by the Regional Quality Manager, Director of Nursing or Unit Manager for Units One, Two or Three. This education began on 07/06/15 with no licensed staff working after 07/10/15, without having received this re-education. 12. On 06/22/15, the Director of Nursing, Social Services Director, Regional Director of Operations, Regional Quality Manager, Unit Manager, and Interim Director of Nursing in training completed an ad hock Quality Assurance Committee Meeting with the Medical Director attending by phone to review the plans of action, with no further recommendations noted. 13. Beginning the week of 06/16/15, the Regional Director of Operations, Regional Administrator, or Regional Quality Manager conducted interviews and re-testing of ten (10) employees per week and included interviews to identify any new concerns with abuse or neglect. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance committee deems appropriate to decrease or resolve. The Quality Assurance Performance Improvement (QAPI) Committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Administrator, Dietary Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and, as needed. 14. The Administrator will review with the Social Services Director or the Director of Nursing, Unit Manager or MDS Nurse in the absence of the Social Services Director, weekly for at least twelve (12) weeks all new admissions to ensure behavior plans of care are developed. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday- Friday with Monday's review to include Saturday and Sunday reports to ensure care plans for behaviors are updated with new or changes in behaviors. The results of the reviews will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. 15. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday-Friday to ensure care plans for behaviors are updated with new behaviors or changes in behavior. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. 16. The former Administrator was relieved of job duties on 06/22/15 by the Regional Director of Operations. The Interim Administrator was re-educated on abuse, neglect, reporting, protection, supervision and investigation as well as competency by the Regional Quality Manager on 06/24/15. A competency test was administered by the Regional Quality Manager on 06/24/15 with a passing score of 100%. 17. On 06/25/15, the Regional Director of Operations educated the Interim Administrator on the requirement that the Administrator administer the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 18. The Regional Director of Operations or Regional Quality Manager will evaluate the facility's Administrator weekly for at least twelve (12) weeks to validate that the Administrator is administering the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 19. Beginning the week of 06/26/15 the Regional Director of Operations, or Regional Quality Manager will review all abuse and neglect monitoring of allegations to validate that allegations are reported timely, protection of the resident occurs including appropriate supervision and thorough investigation was conducted. 20. The Regional Director of Operations or Regional Quality Manager will observe the daily stand up meeting at least weekly for twelve (12) weeks to validate that behaviors are being reviewed and the plan of care updated with new or changes in behaviors to provide protection and appropriate supervision of the residents. The results of these validations will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #7's Physician order [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's Supervision Flow Sheet revealed the resident was placed on one to one supervision 06/18/15 while awake. Further review revealed Resident #2 was on every fifteen (15) minute observation and a bed alarm was used while the resident is in bed. 2. Review of skin assessments, dated 06/10/15-06/15/15 and 06/30/15 through 07/01/15, revealed all residents with a BIMS' score of seven (7) and below had skin assessments completed twice with no concerns identified. 3. Review of interviews, dated 06/10/15 through 06/15/15; and, 06/18/15 through 06/22/15, revealed all residents with a BIMS' score of eight (8) or greater were interviewed twice with no concerns identified. Review of interview logs, dated 06/18/15 through 06/22/15, revealed residents with a BIMS of eight (8) or greater and staff were interviewed, with other concerns of abuse identified concerning Residents #2 and #7 and a visitor. 4. Review of the facility's investigation initiated 06/10/15 revealed the former Administrator, former DON, former ADON, Unit Managers and SSD completed interviews on 06/10/15 through 06/15/15, with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify concerns of abuse and neglect. Review of the facility's investigation revealed the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded 06/22/15. There were no further identified residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. Review of the facility's Incident Reports beginning 05/15/15 revealed no concerns of injuries of unknown origin or injuries suspicious in nature. 6. Review of care plans of current residents listed in the abuse allegation (Residents #2, #5, #6, #8, #9, #10, and Unsampled Resident A), validated that care plans were updated and staff was monitoring for signs and symptoms of abuse. 7. Review of a Resident Log, revealed on 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse reviewed all current residents to determine their appropriate level of supervision based on the resident's current behaviors and physical ability. No changes were required. 8. Review of Inservice Logs, dated 06/10/15, revealed the former Administrator and former DON were in serviced and re-educated on the facility's Abuse and Neglect policy, reportable incidents, investigating, supervision, and court ordered guardianship for competency. Review of Inservice logs and post test, dated 06/10/15 through 06/15/15, revealed staff on all shifts were in serviced on the Abuse and Neglect with 100% accuracy on the post test. Interview with Dietary Aide #10, on 07/02/15 at 8:40 AM, revealed she was in serviced and re-educated by the former Administrator, on 06/11/15, on Abuse and Neglect, reporting, whom to report to, and when to report. Review of the Inservice Log, dated 07/10/15, revealed the Interim Administrator and Interim DON were re-educated by the DDO on abuse and neglect including reporting, investigating and providing appropriate supervision to protect the residents during the investigation. Review of the Inservice Log, dated 07/10/15, revealed the SSD, ADON, and Unit Managers were inserviced by the DDO. Review of the competency test administered validated 100% accuracy. Interviews with Dietary Aide (DA) #11 on 07/02/15 at 8:40 AM; DA #10 on 07/15/15 at 10:35 AM; the MDS Coordinator on 07/15/15 at 2:05 PM; the Maintenance Supervisor on 07/15/15 at 2:55 PM; the Activities Director on 07/15/15 at 3:45 PM; the Housekeeper on 07/15/15 at 4:10 PM; CNA #12 on 07/16/15 at 8:10 AM; RN #3 (Unit Manager) on 07/16/15 at 8:25 AM; Laundry Aide #1 on 07/16/15 at 8:40 AM, and the Therapy Director, on 07/16/15 at 10:20 AM revealed inservicing had been provided by the former Administrator, Interim Administrator, RQM, former DON, interim DON, and Interim ADON on Abuse and Neglect to include identifying and reporting abuse and neglect. Interviews with staff revealed what constitutes abuse and neglect, when to report, and who to report. Interview with the former DON, on 07/01/15 at 3:05 PM, revealed she was in serviced on 06/10/15 by the RQM and the Director of Clinical Operations (DCO) on the facility's Abuse and Neglect policy, reportable incidents, investigation, residents that may require increased supervision, and investigating allegations of residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. Interview with MDS Coordinator, on 07/15/15 at 2:05 PM, revealed she was in serviced on 07/13/15 by the Interim Administrator on Abuse and Neglect. Interview with the former Administrator, on 07/02/15 at 1:20 PM, revealed she was in serviced and re-educated on 06/10/15 by the RQM and DCO regarding the facility's Abuse and Neglect policy, reportable incidents, investigation, residents with behaviors requiring increased supervision, and investigating allegations of abuse with residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. In addition, she stated she was re-educated to always notify the resident's Guardian, POA, family, or responsible person in any allegation of abuse and initiate an investigation. Interview with Regional Quality Manager (RQM), on 07/16/15 at 8:50 AM, revealed in servicing with the former Administrator, former DON, former ADON and Unit Managers was completed on 06/15/15. Further interview revealed on 06/18/15 through 06/22/15, the Regional Team conducted interviews and post testing on abuse and neglect with all staff. Inservice logs were reviewed to validate. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was in serviced and re-educated, on 07/10/15, by the Interim Administrator related to abuse and neglect, monitoring and reporting. Interview with CNA #3 (works 6:30 AM to 2:30 PM), on 07/01/15 at 12:30 PM, revealed she was in serviced and tested on Abuse and Neglect in June (unable to give a date) by the former Administrator and DON. Further interview revealed she was in serviced again approximately (2) weeks later by Corporate staff and was required to score 100% on post test. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced and reeducated on Abuse and Neglect, what, when and to whom to report abuse allegations. Further interview revealed she was in serviced by the former Administrator and DON in June and in serviced again on 07/10/15 by the Interim Administrator. Interview with the Maintenance Director, on 07/15/15 at 2:55 PM, revealed he was in serviced, on 07/10/15 and again on 07/13/15, by the Interim Administrator on Abuse and Neglect. Further interview revealed he took a post test after each inservice and was required to score 100%. Interview with the Activities Director (AD), on 07/15/15 at 3:45 PM, revealed she was reeducated and in serviced on Abuse and Neglect by the Interim Administrator on 07/10/15 and on 07/13/15. She stated she took a post test after each in service and passed with a score of 100%. Further interview revealed the AD was able to identify types of abuse, when to report abuse or possible abuse, and to whom to report the allegation of abuse. The AD revealed she also was the Resident Council Facilitator. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced again on 07/10/15 by Interim Administrator on Abuse and Neglect. She stated she took a post test and was required to score 100%. Interview with the Therapy Director, on 07/16/15 at 10:20 AM, revealed she has been inserviced three (3) times on Abuse and Neglect starting in mid June. She stated her last inservice training on Abuse and Neglect was 0713/15. She took a post test, with 100% pass rate required. Review of the facility's inservice and post test, dated 06/23/15, revealed the Interim Administrator and Interim DON were educated by the RQM on abuse and neglect which included reporting, protecting, and investigating. Review of the POS [REDACTED]. Interview with the Interim DON, on 07/16/15 at 11:20 AM, and the Interim Administrator, on 07/16/15 at 11:55 AM, revealed they were inserviced on abuse and neglect; and on 06/23/15, an inservice was given by the RQM on abuse and neglect, reporting, protecting, and investigating. Further interview revealed they took a post test with 100% accuracy required and were able to identify reportable events. Review of a documented telephone interview, dated 06/22/15, revealed the DCO was inserviced by the Divisional Director of Operations (DDO) on Abuse and Neglect policy, timeliness of reporting incidents, investigating, and follow up to allegations. Review of post test revealed 100% accuracy. Interview with DCO, on 07/02/15 at 1:00 PM, revealed he was in serviced on 06/22/15 by the DDO on Abuse and Neglect, protecting, reporting, and investigating. Review of the facility's New Employee Checklist - KY, implemented on 06/23/15, revealed reporting allegations of abuse acknowledgement was incorporated into the facility's orientation program and no staff will begin job duties until educated on Abuse and Neglect and a competency test has been completed with 100% accuracy. 9. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was reeducated by the RQM, on 06/25/15. Further interview revealed when conducting Social Service Admission Assessments, any residents identified with behaviors or history of behaviors, the SSD will care plan the resident for the behaviors and they will be reviewed in the daily stand up meetings. Interview with Interim Administrator, on 07/16/15 at 11:55 AM, revealed the SSD will assess residents for a history of behaviors during the Social Service Admission Assessment. Further interview revealed in absence of the SSD, the Administrator will designate the DON, ADON, Unit Manager, or MDS Coordinator to complete the SSD Admission Assessment and implement care plans to address any identified behaviors. 10. Interview with SSD, on 07/15/15 at 2:25 PM, revealed she was inserviced and reeducated, on 07/10/15 by the RQM, related to reviewing any resident's behaviors identified, per the Behavior Monitoring Report in the daily stand up meetings Monday through Friday. She was also inserviced on updating the resident's care plan for new behaviors or changes in the resident's behavior. Interview with the SSD on 07/15/15 at 2:25 PM and RN #3 (Unit Manager), on 07/16/15 at 8:25 AM, revealed they were inserviced and educated on 07/10/15. Further interview revealed the inservice was conducted by the RQM regarding the SSD Admission Assessment, identifying residents with history of behaviors, initiating care plan to address behaviors, and reviewing residents with behaviors in the morning stand up meeting. RN #3 stated if the SSD was absent, the Administrator will designate another qualified staff member to conduct the Social Services Admission Assessments. 11. Interview with LPN # 3, on 07/15/15 at 1:35 PM, revealed she was in serviced on implementing behavior care plans beginning with the admission process. Further interview revealed she received re-education by the RQM and that the SSD will assess residents for behaviors with the Social Services Admission screening. LPN #3 revealed any resident identified to have behaviors would be addressed in the daily stand up meeting Monday through Friday. Interview with the ADON, on 07/16/15 at 11:35 AM, revealed she was in serviced by the RQM, on 07/06/15, regarding assessi

Based on interview, record review and review of the facility's Abuse and Neglect policy and procedure, it was determined the facility failed to report and investigate an incident of possible abuse for one (1) of eighteen (18) sampled residents (Resident #5). The facility admitted Resident #7 on 04/29/15 from an acute care hospital where he/she had been treated for [REDACTED]. On 05/31/15, Resident #7 was observed rubbing Resident #5's leg underneath the resident's pant leg while the resident was in bed; however, Registered Nurse (RN) #2 failed to report the incident to the Administrator. In addition, during an investigation by the facility related to another incident involving Resident #7, the facility identified staff had witnessed and not reported possible sexually inappropriate behavior by Resident #2 towards Resident #5 when he/she kissed the resident. The facility's failure to have an effective system in place to ensure allegation of abuse was investigated and reported timely has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/02/15 and determined to exist on 05/31/15. The facility was notified of the Immediate Jeopardy on 07/02/15. An acceptable Allegation of Compliance (AOC) was received on 07/14/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 07/11/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Abuse and Neglect Policy, undated, revealed staff will be trained through orientation and annually on what constitutes abuse, neglect, and misappropriation of property. Any person who suspects that abuse, neglect, or misappropriation of property may have occurred, will immediately report the alleged violation to the facility's administration. The administration will immediately notify the Office of Inspector General, Adult Protective Services and the local law enforcement authority. The administration will initiate the investigation process by interviewing appropriate staff and the resident(s) having potential knowledge of the allegation. The facility's administration will complete the investigation within five (5) days of the allegation and will document all interviews, including the date, time and content of the interview. Further review of the facility's Abuse and Neglect policy revealed if an alleged perpetrator is a resident, the nursing staff will initiate interventions to provide immediate protection of residents until the interdisciplinary team can convene to review the current plan of care and make necessary revisions in order to ensure the safety of others. Trends will be identified, recommendations will be made, and action plans will be developed and follow up will ensure ongoing compliance. Record review revealed the facility admitted Resident #7 (one of the alleged perpetrators) on 04/29/15 which included [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) assessment, dated 05/06/15, revealed the facility assessed Resident #7's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. However, further review revealed the resident had a State Guardian and had a history of [REDACTED]. Interview with the former Administrator, on 07/01/15 at 3:45 PM, revealed she was aware of Resident #7's sexual assault accusations prior to admission to the facility. However, the facility failed to ensure a system was implemented to monitor Resident #7 for these sexually inappropriate behaviors. Record review revealed the facility readmitted Resident #2 (the other alleged perpetrator) on 11/12/14 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 05/04/15, revealed the facility assessed Resident #2 as cognitively intact with a BIMS' score of fifteen (15) which indicated the resident was interviewable. Further record review revealed Resident #2 had a State Guardian. Interviews were attempted with Resident #2's State Guardian without success three (3) times: 07/07/15 at 10:30 AM by cell phone number provided, on 07/09/15 at 9:30 AM by work number provided; and, on 07/21/15 at 9:00 AM (Post Survey) by cell number provided. Record review revealed the facility admitted Resident #5 (alleged victim) on 03/14/15 with [DIAGNOSES REDACTED]. Review of an Initial MDS Assessment, dated 03/21/15, revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS' score of three (3) which indicated the resident was not interviewable. Further review revealed Resident #5 had a State Guardian. Review of a written statement by Certified Nurse Aide (CNA) #2, dated 06/10/15, and interview with CNA #2 on on 07/01/15 at 11:20 AM, revealed she witnessed Resident #7 rubbing the left leg of Resident #5 underneath his/her pant leg on 05/31/15. CNA #2 stated she walked to the door of Resident #5's room and noticed Resident #5 was reading a book while the alleged perpetrator, Resident #7, was rubbing Resident #5's left leg underneath his/her pant. CNA #2 stated she was not exactly sure whether or not Resident #5 was aware of Resident #7 rubbing on his/her leg because Resident #5 kept reading and did not seem to notice that she was standing at the door. CNA #2 further stated she did not think Resident #5 was in danger because the resident was not responding to the touching and kept reading so she walked away, leaving the residents alone and went to tell a nurse. She stated she reported the incident to RN #2. Interview with RN #2, on 07/02/15 at 2:58 PM, revealed she did not report the incident involving Resident #7 and Resident #5 due to her previously reporting an incident to the former Administrator about Resident #7 and another resident on 05/15/15 and the Administrator had hollered at her. She stated the staff separated Resident #7 and Resident #5 and placed Resident #7 on fifteen (15) minute checks 05/31/15 until he/she went to the hospital on [DATE]. Interview with Dietary Aide (DA) #11, on 07/02/15 at 8:55 AM, revealed she witnessed Resident #2 kiss Resident #5 within the last two (2) to three (3) weeks. Further interview revealed she did not report the incident to the Dietary Manager or a Supervisor. Interview with Resident #5's State Guardian, on 06/30/15 at 4:05 PM, revealed Resident #5 could not make decisions for himself/herself. She stated the facility made her aware Resident #7 had rubbed Resident #5's legs and she gave the directive for the facility to keep Resident #7 away from Resident #5. She stated she did not remember the date she was notified but the person who called from the facility stated they had already taken care of the situation because Resident #7 was no longer in the facility. Interview with the former Administrator, on 07/01/15 at 3:45 PM, revealed she was aware of Resident #7's sexual assault accusations prior to admission and failed to ensure a system was implemented to monitor Resident #7 for sexually inappropriate behaviors. Interview with the former Director of Nursing (DON), on 07/01/15 at 3:05 PM, revealed all abuse allegations were initiated and reported to the appropriate agencies by the Administrator. She stated she and the former Administrator were made aware of Resident #2's and Resident #7's behavior toward Resident #5 during another facility investigation initiated on 06/10/15. The DON stated We (facility) were in the process of our investigation when we were made aware of Resident #2's and Resident #7's behaviors towards Resident #5. She stated we (facility) should have investigated and reported the allegations at that time. Interview with the former Administrator, on 07/01/15 at 3:45 PM, revealed the incidents should have been investigated and reported to the appropriate agencies when she became aware of them. She stated she expected all allegations of abuse to be reported immediately and investigated at the time of notification. However, she did not report the incidents. Interview with the Regional Quality Manager (RQM), on 07/01/15 at 3:45 PM, revealed on 06/10/15 the former ADON and former Administrator were instructed to initiate an investigation on 06/10/15 due to another allegation of abuse. The RQM stated she entered the facility on 06/16/15, and she, the former Administrator and former DON and, through information gathering and interviews it was revealed Resident #2 was witnessed by staff kissing Resident #5. Resident #7 was witnessed rubbing Resident #5's leg underneath his/her pant leg. The RQM stated she expected the former Administrator to investigate the allegations as instructed on 06/10/15 related to the reportable incident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #7 was discharged to the hospital on [DATE], with an acute onset of chest pain and will not return to the facility. The resident was discharged on [DATE]. Resident #2 was placed on increased supervision on 06/18/15 due to allegations of inappropriate contact with another resident. This increase in supervision included one to one supervision while up in the chair with fifteen (15) minute checks and a bed alarm while in bed. 2. On 06/10/15, the former Director of Nursing, Assistant Director of Nursing and Unit Managers from Hall One, Two, and Three completed skin assessments on all current residents with a BIMS' score of seven (7) or less to identify any injury of unknown origin or injury suspicious in nature. There were no injuries of unknown origin or suspicious injuries noted. 3. Beginning on 06/10/15 and completed on 06/15/15, the former Administrator and Social Services Director conducted interviews with all current residents with a BIMS' score of eight (8) or greater, to identify any concerns with Resident #7 or any allegations of abuse or neglect, with no concerns identified. Beginning on 06/18/15 and concluding on 06/22/15, the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Reimbursement Nurses, Regional Director of Sales and Marketing, Regional Director of Rehabilitation and Regional Field Accountant, completed interviews with all current residents with a BIMS' score of eight (8) or greater in regards to Resident #7 and Resident #2 as well as any concern with abuse or neglect. Four (4) concerns were identified, allegations of abuse regarding Residents #2 and #7, and a visitor (family member) and one concern with missing money. 4. Beginning on 06/10/15 and completed by 06/15/15, the former Administrator, former Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services Director completed interviews with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify any concerns with abuse and neglect. In addition, the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded on 06/22/15. There were no further residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. On 06/18/15, the Regional Reimbursement Nurse reviewed all Incident Reports for the past thirty (30) days to identify any injury of unknown origin or injury suspicious in nature; there were no concerns identified. 6. On 06/25/15, the Social Services Director reviewed all current residents' medical records to include behavior documentation and behavior assessments. She also developed or updated their care plans to reflect current known behaviors and needed interventions to meet the needs of the residents. Any required updates or care plans were added on 06/25/15. 7. On 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse assessed all current residents to determine appropriate level of supervision based on current behaviors and physical ability. No changes were required. 8. On 06/10/15, the Regional Director of Operations and Regional Quality Manager completed re-education with the Former Administrator and Former Director of Nursing on the policy and requirements for reporting an investigation as well as supervision and protection and determination of competency including BIMS' score and court ordered guardianship for competency. The former Administrator and former Director of Nursing completed a competency test on 06/10/15 with 100% pass rate. Beginning on 06/10/15 and completed on 06/16/15 the former Administrator and former Director of Nursing completed re-education with all current facility staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Maintenance and Housekeeping) on the abuse policy which included reporting and protecting of residents. A competency test was administered with no staff working without having a 100% score. Beginning on 06/18/15 and completed by 06/22/15 the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Director of Rehabilitation Operations and the Regional Reimbursement Nurse, conducted a second competency test of all current staff ( Nursing, Dietary, Social Services, Maintenance, Therapy, Housekeeping and Activities) to validate understanding of abuse, neglect and inappropriate touching, which included reporting and to whom to report to when their supervisor had not addressed the allegation. No staff worked after 06/22/15 without having received this second competency test with a validated 100% accuracy. On 06/22/15, the Divisional Director provided education to the Regional Director of Operations on Abuse and Neglect including reporting and follow up with facility staff on investigation and reporting. On 06/23/15, the Interim Administrator and Interim Director of Nursing in training were re-educated by the Regional Quality Manager on abuse and neglect including reporting, protecting and the investigation as well as evaluation of competency of the resident. The Regional Quality Manager conducted competency testing of the Interim Administrator and the Interim Director of Nursing in training with both passing with 100% accuracy. Beginning on 07/10/15, and continuing each shift the Interim Administrator, Interim Director of Nursing, Social Services Director or Unit Managers will re-educate all facility staff (Nursing, Social Services, Activity, Dietary, Housekeeping, Maintenance and Therapy and Administration) on abuse and neglect including reporting, protection and supervision. They will also administer a competency test to validate understanding with no staff working after 07/10/15 without having had this education and competency test with 100% accuracy. Abuse and Neglect education and competency test were incorporated into the facility's orientation program on 06/23/15, with no staff beginning job duties until this education and competency test was complete and 100% accuracy testing. There are no agency staff employed at the facility. On 07/10/15, the Divisional Director of Operations provided re-education to the Interim Administrator and Interim Director of Nursing on abuse and neglect including reporting, investigating and providing appropriate supervision to protect residents during the investigation. They were given a competency test to validate understanding; they both scored 100% on the test. The Interim Administrator and Interim Director of Nursing re-educated the Social Services Director, Assistant Director of Nursing and Unit Managers on 07/10/15 on abuse and neglect. This training included reporting and protection and supervision. The training with competency testing administered with 100% accuracy for validation. 9. On 06/25/15, the Regional Quality Manager re-educated the Social Services Director on completion of the Social Services admission assessment to identify any known behaviors or known history of behaviors and development of a plan of care. In the Social Services Director's absence, beginning on 06/29/15, the Administrator will designate a qualified person (Director of Nursing, Assistant Director of Nursing, Unit Manager or MDS Nurse) to complete the Social Services Admission assessment and development of plans of care to address any known behaviors. Beginning 07/10/15, the Director of Nursing, Assistant Director of Nursing, MDS Nurse and Unit Managers were educated on the Social Services Admission Assessment to identify any known behaviors or known history of behaviors and development of the plan of care when designated to complete in the Social Services Director's absence. This education was completed by the Regional Quality Manager. 10. On 07/10/15, the Regional Quality Manager re-educated the Social Services Director on reviewing in the daily stand up meeting Monday-Friday any behaviors, per the Behavior Monitoring Report and updating the resident care plan for new behaviors or changes in behaviors. 11. All current Licensed Nurses were re-educated on the initiation of a behavior plan of care on admissions for residents with known behaviors. They were re-educated on the initiation of behavior monitoring for admissions with known behaviors during the admission process. This was added to the Admission Packet on 07/06/15 by medical records. The education was completed by the Regional Quality Manager, Director of Nursing or Unit Manager for Units One, Two or Three. This education began on 07/06/15 with no licensed staff working after 07/10/15, without having received this re-education. 12. On 06/22/15, the Director of Nursing, Social Services Director, Regional Director of Operations, Regional Quality Manager, Unit Manager, and Interim Director of Nursing in training completed an ad hock Quality Assurance Committee Meeting with the Medical Director attending by phone to review the plans of action, with no further recommendations noted. 13. Beginning the week of 06/16/15, the Regional Director of Operations, Regional Administrator, or Regional Quality Manager conducted interviews and re-testing of ten (10) employees per week and included interviews to identify any new concerns with abuse or neglect. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance committee deems appropriate to decrease or resolve. The Quality Assurance Performance Improvement (QAPI) Committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Administrator, Dietary Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and, as needed. 14. The Administrator will review with the Social Services Director or the Director of Nursing, Unit Manager or MDS Nurse in the absence of the Social Services Director, weekly for at least twelve (12) weeks all new admissions to ensure behavior plans of care are developed. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday- Friday with Monday's review to include Saturday and Sunday reports to ensure care plans for behaviors are updated with new or changes in behaviors. The results of the reviews will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. 15. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday-Friday to ensure care plans for behaviors are updated with new behaviors or changes in behavior. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. 16. The former Administrator was relieved of job duties on 06/22/15 by the Regional Director of Operations. The Interim Administrator was re-educated on abuse, neglect, reporting, protection, supervision and investigation as well as competency by the Regional Quality Manager on 06/24/15. A competency test was administered by the Regional Quality Manager on 06/24/15 with a passing score of 100%. 17. On 06/25/15, the Regional Director of Operations educated the Interim Administrator on the requirement that the Administrator administer the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 18. The Regional Director of Operations or Regional Quality Manager will evaluate the facility's Administrator weekly for at least twelve (12) weeks to validate that the Administrator is administering the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 19. Beginning the week of 06/26/15 the Regional Director of Operations, or Regional Quality Manager will review all abuse and neglect monitoring of allegations to validate that allegations are reported timely, protection of the resident occurs including appropriate supervision and thorough investigation was conducted. 20. The Regional Director of Operations or Regional Quality Manager will observe the daily stand up meeting at least weekly for twelve (12) weeks to validate that behaviors are being reviewed and the plan of care updated with new or changes in behaviors to provide protection and appropriate supervision of the residents. The results of these validations will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #7's Physician order [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's Supervision Flow Sheet revealed the resident was placed on one to one supervision 06/18/15 while awake. Further review revealed Resident #2 was on every fifteen (15) minute observation and a bed alarm was used while the resident is in bed. 2. Review of skin assessments, dated 06/10/15-06/15/15 and 06/30/15 through 07/01/15, revealed all residents with a BIMS' score of seven (7) and below had skin assessments completed twice with no concerns identified. 3. Review of interviews, dated 06/10/15 through 06/15/15; and, 06/18/15 through 06/22/15, revealed all residents with a BIMS' score of eight (8) or greater were interviewed twice with no concerns identified. Review of interview logs, dated 06/18/15 through 06/22/15, revealed residents with a BIMS of eight (8) or greater and staff were interviewed, with other concerns of abuse identified concerning Residents #2 and #7 and a visitor. 4. Review of the facility's investigation initiated 06/10/15 revealed the former Administrator, former DON, former ADON, Unit Managers and SSD completed interviews on 06/10/15 through 06/15/15, with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify concerns of abuse and neglect. Review of the facility's investigation revealed the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded 06/22/15. There were no further identified residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. Review of the facility's Incident Reports beginning 05/15/15 revealed no concerns of injuries of unknown origin or injuries suspicious in nature. 6. Review of care plans of current residents listed in the abuse allegation (Residents #2, #5, #6, #8, #9, #10, and Unsampled Resident A), validated that care plans were updated and staff was monitoring for signs and symptoms of abuse. 7. Review of a Resident Log, revealed on 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse reviewed all current residents to determine their appropriate level of supervision based on the resident's current behaviors and physical ability. No changes were required. 8. Review of Inservice Logs, dated 06/10/15, revealed the former Administrator and former DON were in serviced and re-educated on the facility's Abuse and Neglect policy, reportable incidents, investigating, supervision, and court ordered guardianship for competency. Review of Inservice logs and post test, dated 06/10/15 through 06/15/15, revealed staff on all shifts were in serviced on the Abuse and Neglect with 100% accuracy on the post test. Interview with Dietary Aide #10, on 07/02/15 at 8:40 AM, revealed she was in serviced and re-educated by the former Administrator, on 06/11/15, on Abuse and Neglect, reporting, whom to report to, and when to report. Review of the Inservice Log, dated 07/10/15, revealed the Interim Administrator and Interim DON were re-educated by the DDO on abuse and neglect including reporting, investigating and providing appropriate supervision to protect the residents during the investigation. Review of the Inservice Log, dated 07/10/15, revealed the SSD, ADON, and Unit Managers were inserviced by the DDO. Review of the competency test administered validated 100% accuracy. Interviews with Dietary Aide (DA) #11 on 07/02/15 at 8:40 AM; DA #10 on 07/15/15 at 10:35 AM; the MDS Coordinator on 07/15/15 at 2:05 PM; the Maintenance Supervisor on 07/15/15 at 2:55 PM; the Activities Director on 07/15/15 at 3:45 PM; the Housekeeper on 07/15/15 at 4:10 PM; CNA #12 on 07/16/15 at 8:10 AM; RN #3 (Unit Manager) on 07/16/15 at 8:25 AM; Laundry Aide #1 on 07/16/15 at 8:40 AM, and the Therapy Director, on 07/16/15 at 10:20 AM revealed inservicing had been provided by the former Administrator, Interim Administrator, RQM, former DON, interim DON, and Interim ADON on Abuse and Neglect to include identifying and reporting abuse and neglect. Interviews with staff revealed what constitutes abuse and neglect, when to report, and who to report. Interview with the former DON, on 07/01/15 at 3:05 PM, revealed she was in serviced on 06/10/15 by the RQM and the Director of Clinical Operations (DCO) on the facility's Abuse and Neglect policy, reportable incidents, investigation, residents that may require increased supervision, and investigating allegations of residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. Interview with MDS Coordinator, on 07/15/15 at 2:05 PM, revealed she was in serviced on 07/13/15 by the Interim Administrator on Abuse and Neglect. Interview with the former Administrator, on 07/02/15 at 1:20 PM, revealed she was in serviced and re-educated on 06/10/15 by the RQM and DCO regarding the facility's Abuse and Neglect policy, reportable incidents, investigation, residents with behaviors requiring increased supervision, and investigating allegations of abuse with residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. In addition, she stated she was re-educated to always notify the resident's Guardian, POA, family, or responsible person in any allegation of abuse and initiate an investigation. Interview with Regional Quality Manager (RQM), on 07/16/15 at 8:50 AM, revealed in servicing with the former Administrator, former DON, former ADON and Unit Managers was completed on 06/15/15. Further interview revealed on 06/18/15 through 06/22/15, the Regional Team conducted interviews and post testing on abuse and neglect with all staff. Inservice logs were reviewed to validate. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was in serviced and re-educated, on 07/10/15, by the Interim Administrator related to abuse and neglect, monitoring and reporting. Interview with CNA #3 (works 6:30 AM to 2:30 PM), on 07/01/15 at 12:30 PM, revealed she was in serviced and tested on Abuse and Neglect in June (unable to give a date) by the former Administrator and DON. Further interview revealed she was in serviced again approximately (2) weeks later by Corporate staff and was required to score 100% on post test. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced and reeducated on Abuse and Neglect, what, when and to whom to report abuse allegations. Further interview revealed she was in serviced by the former Administrator and DON in June and in serviced again on 07/10/15 by the Interim Administrator. Interview with the Maintenance Director, on 07/15/15 at 2:55 PM, revealed he was in serviced, on 07/10/15 and again on 07/13/15, by the Interim Administrator on Abuse and Neglect. Further interview revealed he took a post test after each inservice and was required to score 100%. Interview with the Activities Director (AD), on 07/15/15 at 3:45 PM, revealed she was reeducated and in serviced on Abuse and Neglect by the Interim Administrator on 07/10/15 and on 07/13/15. She stated she took a post test after each in service and passed with a score of 100%. Further interview revealed the AD was able to identify types of abuse, when to report abuse or possible abuse, and to whom to report the allegation of abuse. The AD revealed she also was the Resident Council Facilitator. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced again on 07/10/15 by Interim Administrator on Abuse and Neglect. She stated she took a post test and was required to score 100%. Interview with the Therapy Director, on 07/16/15 at 10:20 AM, revealed she has been inserviced three (3) times on Abuse and Neglect starting in mid June. She stated her last inservice training on Abuse and Neglect was 0713/15. She took a post test, with 100% pass rate required. Review of the facility's inservice and post test, dated 06/23/15, revealed the Interim Administrator and Interim DON were educated by the RQM on abuse and neglect which included reporting, protecting, and investigating. Review of the POS [REDACTED]. Interview with the Interim DON, on 07/16/15 at 11:20 AM, and the Interim Administrator, on 07/16/15 at 11:55 AM, revealed they were inserviced on abuse and neglect; and on 06/23/15, an inservice was given by the RQM on abuse and neglect, reporting, protecting, and investigating. Further interview revealed they took a post test w

Based on interview, record review and review of the facility's Abuse and Neglect policy and procedure, it was determined the facility failed to ensure staff implemented written procedures to prohibit mistreatment, neglect and abuse per the facility's policy for one (1) of eighteen (18) sampled residents (Resident #5). The facility admitted Resident #7 on 04/29/15, from an acute care hospital where he/she had been treated for [REDACTED]. On 05/31/15, Resident #7 was observed by a Certified Nursing Assistant (CNA) rubbing on Resident #5's leg underneath his/her pants while Resident #5 was in bed. The CNA reported the incident to Registered Nurse (RN) #2; however, RN #2 failed to report the incident to the Administrator. Further investigation by the facility revealed staff had witnessed possible sexually inappropriate behavior by Resident #2 towards Resident #5 when he/she kissed Resident #5. The staff did not report it to the Administrator per facility policy. The facility's failure to implement its policy and procedures related to reporting and investigating possible abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/02/15 and determined to exist on 05/31/15. The facility was notified of the Immediate Jeopardy on 07/02/15. An acceptable Allegation of Compliance (AOC) was received on 07/14/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 07/11/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Abuse and Neglect Policy, undated, revealed staff will be trained through orientation and annually on what constitutes abuse neglect, and misappropriation of property. Any person who suspects that abuse, neglect, or misappropriation of property may have occurred will immediately report the alleged violation to the facility's administration. The facility's administration will immediately notify the Office of Inspector General, Adult protective Services and local law enforcement authority. The administration will initiate the investigation process by interviewing appropriate staff and residents having potential knowledge of the allegation. The facility's administration will complete the investigation within five (5) days of the allegation and will document all interviews, including the date, time and content of the interview. Further review of the facility's Abuse and Neglect policy revealed if an alleged perpetrator is a resident, the nursing staff will initiate interventions to provide immediate protection of residents until the interdisciplinary team can convene to review the current plan of care and make necessary revisions in order to ensure the safety of others. Trends will be identified, recommendations will be made, and action plans will be developed and follow up will ensure ongoing compliance. Record review revealed the facility admitted Resident #7, (an alleged perpetrator) on 04/29/15 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) assessment, dated 05/06/15, revealed the facility assessed Resident #7's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review revealed the resident had a State Guardian; and had a history of [REDACTED]. of aggression and sexually inappropriate behavior. Record review revealed the facility admitted Resident #5 (alleged victim) on 03/14/15 with [DIAGNOSES REDACTED]. Review of the Initial MDS assessment, dated 03/21/15, revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS' score of three (3) which indicated the resident was not interviewable. Review of a statement written by Certified Nurse Aide (CNA) #2, dated 06/10/15, and interviews with CNA #2 on 07/01/15 at 11:20 AM, and RN #2, on 07/02/15 at 2:58 PM, revealed, on 05/31/15, CNA #2 witnessed, Resident #7 rubbing the left leg of Resident #5 underneath his/her pant leg while Resident #5 was laying in his/her bed. CNA #2 stated she reported this incident to RN #2. Interview with RN #2 revealed she did not report the incident to the Administrator, as she should have reported according to the facility's policy, because the Administrator had hollered at her when she reported an incident between Resident #7 and another resident on 05/15/15. During review of the facility's investigation of the incident between Resident #7 (the alleged perpetrator) and another resident, it was revealed a Dietary Aide (DA) had witnessed Resident #2 kissing Resident #5. There was no evidence the DA reported the incident to the Administrator. Interview with the former Director of Nursing (DON), on 07/01/14 at 3:05 PM, revealed all abuse allegations were initiated and reported to appropriate agencies by the Administrator. She stated she and the former Administrator were made aware of an incident that staff had observed Resident #2 kiss Resident #5. The DON stated, We (facility) were in the process of our investigation of another incident when we were made aware of the incident with Resident #2 and Resident #5 and looking back, we (facility) should have investigated and reported the allegation at that time. Interview with the former Administrator, on 07/01/15 at 3:45 PM, revealed she was aware of Resident #7's sexual assault accusations prior to the resident's admission. The Administrator stated she failed to ensure a system was implemented to monitor Resident #7 for sexually inappropriate behaviors. She stated the incidents should have been investigated and reported to the appropriate agencies when she became aware of them, per the facility's policy. She stated she expected all allegations of abuse to be reported immediately and investigated at the time of notification. Interview with the Regional Quality Manager (RQM), on 07/01/15 at 3:45 PM, revealed she was informed of another incident on 06/10/15. The RQM stated she instructed the former Administrator to initiate an investigation at that time related to that incident. Further interview revealed the RQM entered the facility on 06/16/15, and the former Administrator and former DON initiated a more thorough investigation on 06/18/15 and through information gathering and interviews it was revealed Resident #2 was witnessed by staff kissing Resident #5. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #7 was discharged to the hospital on [DATE], with an acute onset of chest pain and will not return to the facility. The resident was discharged on [DATE]. Resident #2 was placed on increased supervision on 06/18/15 due to allegations of inappropriate contact with another resident. This increase in supervision included one to one supervision while up in the chair with fifteen (15) minute checks and a bed alarm while in bed. 2. On 06/10/15, the former Director of Nursing, Assistant Director of Nursing and Unit Managers from Hall One, Two, and Three completed skin assessments on all current residents with a BIMS' score of seven (7) or less to identify any injury of unknown origin or injury suspicious in nature. There were no injuries of unknown origin or suspicious injuries noted. 3. Beginning on 06/10/15 and completed on 06/15/15, the former Administrator and Social Services Director conducted interviews with all current residents with a BIMS' score of eight (8) or greater, to identify any concerns with Resident #7 or any allegations of abuse or neglect, with no concerns identified. Beginning on 06/18/15 and concluding on 06/22/15, the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Reimbursement Nurses, Regional Director of Sales and Marketing, Regional Director of Rehabilitation and Regional Field Accountant, completed interviews with all current residents with a BIMS' score of eight (8) or greater in regards to Resident #7 and Resident #2 as well as any concern with abuse or neglect. Four (4) concerns were identified, allegations of abuse regarding Residents #2 and #7, and a visitor (family member) and one concern with missing money. 4. Beginning on 06/10/15 and completed by 06/15/15, the former Administrator, former Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services Director completed interviews with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify any concerns with abuse and neglect. In addition, the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded on 06/22/15. There were no further residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. On 06/18/15, the Regional Reimbursement Nurse reviewed all Incident Reports for the past thirty (30) days to identify any injury of unknown origin or injury suspicious in nature; there were no concerns identified. 6. On 06/25/15, the Social Services Director reviewed all current residents' medical records to include behavior documentation and behavior assessments. She also developed or updated their care plans to reflect current known behaviors and needed interventions to meet the needs of the residents. Any required updates or care plans were added on 06/25/15. 7. On 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse assessed all current residents to determine appropriate level of supervision based on current behaviors and physical ability. No changes were required. 8. On 06/10/15, the Regional Director of Operations and Regional Quality Manager completed re-education with the Former Administrator and Former Director of Nursing on the policy and requirements for reporting an investigation as well as supervision and protection and determination of competency including BIMS' score and court ordered guardianship for competency. The former Administrator and former Director of Nursing completed a competency test on 06/10/15 with 100% pass rate. Beginning on 06/10/15 and completed on 06/16/15 the former Administrator and former Director of Nursing completed re-education with all current facility staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Maintenance and Housekeeping) on the abuse policy which included reporting and protecting of residents. A competency test was administered with no staff working without having a 100% score. Beginning on 06/18/15 and completed by 06/22/15 the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Director of Rehabilitation Operations and the Regional Reimbursement Nurse, conducted a second competency test of all current staff ( Nursing, Dietary, Social Services, Maintenance, Therapy, Housekeeping and Activities) to validate understanding of abuse, neglect and inappropriate touching, which included reporting and to whom to report to when their supervisor had not addressed the allegation. No staff worked after 06/22/15 without having received this second competency test with a validated 100% accuracy. On 06/22/15, the Divisional Director provided education to the Regional Director of Operations on Abuse and Neglect including reporting and follow up with facility staff on investigation and reporting. On 06/23/15, the Interim Administrator and Interim Director of Nursing in training were re-educated by the Regional Quality Manager on abuse and neglect including reporting, protecting and the investigation as well as evaluation of competency of the resident. The Regional Quality Manager conducted competency testing of the Interim Administrator and the Interim Director of Nursing in training with both passing with 100% accuracy. Beginning on 07/10/15, and continuing each shift the Interim Administrator, Interim Director of Nursing, Social Services Director or Unit Managers will re-educate all facility staff (Nursing, Social Services, Activity, Dietary, Housekeeping, Maintenance and Therapy and Administration) on abuse and neglect including reporting, protection and supervision. They will also administer a competency test to validate understanding with no staff working after 07/10/15 without having had this education and competency test with 100% accuracy. Abuse and Neglect education and competency test were incorporated into the facility's orientation program on 06/23/15, with no staff beginning job duties until this education and competency test was complete and 100% accuracy testing. There are no agency staff employed at the facility. On 07/10/15, the Divisional Director of Operations provided re-education to the Interim Administrator and Interim Director of Nursing on abuse and neglect including reporting, investigating and providing appropriate supervision to protect residents during the investigation. They were given a competency test to validate understanding; they both scored 100% on the test. The Interim Administrator and Interim Director of Nursing re-educated the Social Services Director, Assistant Director of Nursing and Unit Managers on 07/10/15 on abuse and neglect. This training included reporting and protection and supervision. The training with competency testing administered with 100% accuracy for validation. 9. On 06/25/15, the Regional Quality Manager re-educated the Social Services Director on completion of the Social Services admission assessment to identify any known behaviors or known history of behaviors and development of a plan of care. In the Social Services Director's absence, beginning on 06/29/15, the Administrator will designate a qualified person (Director of Nursing, Assistant Director of Nursing, Unit Manager or MDS Nurse) to complete the Social Services Admission assessment and development of plans of care to address any known behaviors. Beginning 07/10/15, the Director of Nursing, Assistant Director of Nursing, MDS Nurse and Unit Managers were educated on the Social Services Admission Assessment to identify any known behaviors or known history of behaviors and development of the plan of care when designated to complete in the Social Services Director's absence. This education was completed by the Regional Quality Manager. 10. On 07/10/15, the Regional Quality Manager re-educated the Social Services Director on reviewing in the daily stand up meeting Monday-Friday any behaviors, per the Behavior Monitoring Report and updating the resident care plan for new behaviors or changes in behaviors. 11. All current Licensed Nurses were re-educated on the initiation of a behavior plan of care on admissions for residents with known behaviors. They were re-educated on the initiation of behavior monitoring for admissions with known behaviors during the admission process. This was added to the Admission Packet on 07/06/15 by medical records. The education was completed by the Regional Quality Manager, Director of Nursing or Unit Manager for Units One, Two or Three. This education began on 07/06/15 with no licensed staff working after 07/10/15, without having received this re-education. 12. On 06/22/15, the Director of Nursing, Social Services Director, Regional Director of Operations, Regional Quality Manager, Unit Manager, and Interim Director of Nursing in training completed an ad hock Quality Assurance Committee Meeting with the Medical Director attending by phone to review the plans of action, with no further recommendations noted. 13. Beginning the week of 06/16/15, the Regional Director of Operations, Regional Administrator, or Regional Quality Manager conducted interviews and re-testing of ten (10) employees per week and included interviews to identify any new concerns with abuse or neglect. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance committee deems appropriate to decrease or resolve. The Quality Assurance Performance Improvement (QAPI) Committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Administrator, Dietary Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and, as needed. 14. The Administrator will review with the Social Services Director or the Director of Nursing, Unit Manager or MDS Nurse in the absence of the Social Services Director, weekly for at least twelve (12) weeks all new admissions to ensure behavior plans of care are developed. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday- Friday with Monday's review to include Saturday and Sunday reports to ensure care plans for behaviors are updated with new or changes in behaviors. The results of the reviews will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. 15. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday-Friday to ensure care plans for behaviors are updated with new behaviors or changes in behavior. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. 16. The former Administrator was relieved of job duties on 06/22/15 by the Regional Director of Operations. The Interim Administrator was re-educated on abuse, neglect, reporting, protection, supervision and investigation as well as competency by the Regional Quality Manager on 06/24/15. A competency test was administered by the Regional Quality Manager on 06/24/15 with a passing score of 100%. 17. On 06/25/15, the Regional Director of Operations educated the Interim Administrator on the requirement that the Administrator administer the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 18. The Regional Director of Operations or Regional Quality Manager will evaluate the facility's Administrator weekly for at least twelve (12) weeks to validate that the Administrator is administering the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 19. Beginning the week of 06/26/15 the Regional Director of Operations, or Regional Quality Manager will review all abuse and neglect monitoring of allegations to validate that allegations are reported timely, protection of the resident occurs including appropriate supervision and thorough investigation was conducted. 20. The Regional Director of Operations or Regional Quality Manager will observe the daily stand up meeting at least weekly for twelve (12) weeks to validate that behaviors are being reviewed and the plan of care updated with new or changes in behaviors to provide protection and appropriate supervision of the residents. The results of these validations will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #7's Physician order [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's Supervision Flow Sheet revealed the resident was placed on one to one supervision 06/18/15 while awake. Further review revealed Resident #2 was on every fifteen (15) minute observation and a bed alarm was used while the resident is in bed. 2. Review of skin assessments, dated 06/10/15-06/15/15 and 06/30/15 through 07/01/15, revealed all residents with a BIMS' score of seven (7) and below had skin assessments completed twice with no concerns identified. 3. Review of interviews, dated 06/10/15 through 06/15/15; and, 06/18/15 through 06/22/15, revealed all residents with a BIMS' score of eight (8) or greater were interviewed twice with no concerns identified. Review of interview logs, dated 06/18/15 through 06/22/15, revealed residents with a BIMS of eight (8) or greater and staff were interviewed, with other concerns of abuse identified concerning Residents #2 and #7 and a visitor. 4. Review of the facility's investigation initiated 06/10/15 revealed the former Administrator, former DON, former ADON, Unit Managers and SSD completed interviews on 06/10/15 through 06/15/15, with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify concerns of abuse and neglect. Review of the facility's investigation revealed the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded 06/22/15. There were no further identified residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. Review of the facility's Incident Reports beginning 05/15/15 revealed no concerns of injuries of unknown origin or injuries suspicious in nature. 6. Review of care plans of current residents listed in the abuse allegation (Residents #2, #5, #6, #8, #9, #10, and Unsampled Resident A), validated that care plans were updated and staff was monitoring for signs and symptoms of abuse. 7. Review of a Resident Log, revealed on 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse reviewed all current residents to determine their appropriate level of supervision based on the resident's current behaviors and physical ability. No changes were required. 8. Review of Inservice Logs, dated 06/10/15, revealed the former Administrator and former DON were in serviced and re-educated on the facility's Abuse and Neglect policy, reportable incidents, investigating, supervision, and court ordered guardianship for competency. Review of Inservice logs and post test, dated 06/10/15 through 06/15/15, revealed staff on all shifts were in serviced on the Abuse and Neglect with 100% accuracy on the post test. Interview with Dietary Aide #10, on 07/02/15 at 8:40 AM, revealed she was in serviced and re-educated by the former Administrator, on 06/11/15, on Abuse and Neglect, reporting, whom to report to, and when to report. Review of the Inservice Log, dated 07/10/15, revealed the Interim Administrator and Interim DON were re-educated by the DDO on abuse and neglect including reporting, investigating and providing appropriate supervision to protect the residents during the investigation. Review of the Inservice Log, dated 07/10/15, revealed the SSD, ADON, and Unit Managers were inserviced by the DDO. Review of the competency test administered validated 100% accuracy. Interviews with Dietary Aide (DA) #11 on 07/02/15 at 8:40 AM; DA #10 on 07/15/15 at 10:35 AM; the MDS Coordinator on 07/15/15 at 2:05 PM; the Maintenance Supervisor on 07/15/15 at 2:55 PM; the Activities Director on 07/15/15 at 3:45 PM; the Housekeeper on 07/15/15 at 4:10 PM; CNA #12 on 07/16/15 at 8:10 AM; RN #3 (Unit Manager) on 07/16/15 at 8:25 AM; Laundry Aide #1 on 07/16/15 at 8:40 AM, and the Therapy Director, on 07/16/15 at 10:20 AM revealed inservicing had been provided by the former Administrator, Interim Administrator, RQM, former DON, interim DON, and Interim ADON on Abuse and Neglect to include identifying and reporting abuse and neglect. Interviews with staff revealed what constitutes abuse and neglect, when to report, and who to report. Interview with the former DON, on 07/01/15 at 3:05 PM, revealed she was in serviced on 06/10/15 by the RQM and the Director of Clinical Operations (DCO) on the facility's Abuse and Neglect policy, reportable incidents, investigation, residents that may require increased supervision, and investigating allegations of residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. Interview with MDS Coordinator, on 07/15/15 at 2:05 PM, revealed she was in serviced on 07/13/15 by the Interim Administrator on Abuse and Neglect. Interview with the former Administrator, on 07/02/15 at 1:20 PM, revealed she was in serviced and re-educated on 06/10/15 by the RQM and DCO regarding the facility's Abuse and Neglect policy, reportable incidents, investigation, residents with behaviors requiring increased supervision, and investigating allegations of abuse with residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. In addition, she stated she was re-educated to always notify the resident's Guardian, POA, family, or responsible person in any allegation of abuse and initiate an investigation. Interview with Regional Quality Manager (RQM), on 07/16/15 at 8:50 AM, revealed in servicing with the former Administrator, former DON, former ADON and Unit Managers was completed on 06/15/15. Further interview revealed on 06/18/15 through 06/22/15, the Regional Team conducted interviews and post testing on abuse and neglect with all staff. Inservice logs were reviewed to validate. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was in serviced and re-educated, on 07/10/15, by the Interim Administrator related to abuse and neglect, monitoring and reporting. Interview with CNA #3 (works 6:30 AM to 2:30 PM), on 07/01/15 at 12:30 PM, revealed she was in serviced and tested on Abuse and Neglect in June (unable to give a date) by the former Administrator and DON. Further interview revealed she was in serviced again approximately (2) weeks later by Corporate staff and was required to score 100% on post test. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced and reeducated on Abuse and Neglect, what, when and to whom to report abuse allegations. Further interview revealed she was in serviced by the former Administrator and DON in June and in serviced again on 07/10/15 by the Interim Administrator. Interview with the Maintenance Director, on 07/15/15 at 2:55 PM, revealed he was in serviced, on 07/10/15 and again on 07/13/15, by the Interim Administrator on Abuse and Neglect. Further interview revealed he took a post test after each inservice and was required to score 100%. Interview with the Activities Director (AD), on 07/15/15 at 3:45 PM, revealed she was reeducated and in serviced on Abuse and Neglect by the Interim Administrator on 07/10/15 and on 07/13/15. She stated she took a post test after each in service and passed with a score of 100%. Further interview revealed the AD was able to identify types of abuse, when to report abuse or possible abuse, and to whom to report the allegation of abuse. The AD revealed she also was the Resident Council Facilitator. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced again on 07/10/15 by Interim Administrator on Abuse and Neglect. She stated she took a post test and was required to score 100%. Interview with the Therapy Director, on 07/16/15 at 10:20 AM, revealed she has been inserviced three (3) times on Abuse and Neglect starting in mid June. She stated her last inservice training on Abuse and Neglect was 0713/15. She took a post test, with 100% pass rate required. Review of the facility's inservice and post test, dated 06/23/15, revealed the Interim Administrator and Interim DON were educated by the RQM on abuse and neglect which included reporting, protecting, and investigating. Review of the POS [REDACTED]. Interview with the Interim DON, on 07/16/15 at 11:20 AM, and the Interim Administrator, on 07/16/15 at 11:55 AM, revealed they were inserviced on abuse and neglect; and on 06/23/15, an inservice was given by the RQM on abuse and neglect, reporting, protecting, and investigating. Further interview revealed they took a post test with 100% accuracy required and were able to identify reportable events. Review of a documented telephone interview, dated 06/22/15, revealed the DCO was inserviced by the Divisional Director of Operations (DDO) on Abuse and Neglect policy, timeliness of reporting incidents, investigating, and follow up to allegations. Review of post test revealed 100% accuracy. Interview with DCO, on 07/02/15 at 1:00 PM, revealed he was in serviced on 06/22/15 by the DDO on Abuse and Neglect, protecting, reporting, and investigating. Review of the facility's New Employee Checklist - KY, implemented on 06/23/15, revealed reporting allegations of abuse acknowledgement was incorporated into the facility's orientation program and no staff will begin job duties until educated on Abuse and Neglect and a competency test has been completed with 100% accuracy. 9. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was reeducated by the RQM, on 06/25/15. Further interview revealed when conducting Social Service Admission Assessments, any residents identified with behaviors or history of behaviors, the SSD will care plan the resident for the behaviors and they will be reviewed in the daily stand up meetings. Interview with Interim Administrator, on 07/16/15 at 11:55 AM, revealed the SSD will assess residents for a history of behaviors during the Social Service Admission Assessment. Further interview revealed in absence of the SSD, the Administrator will designate the DON, ADON, Unit Manager, or MDS Coordinator to complete the SSD Admission Assessment and implement care plans to address any identified behaviors. 10. Interview with SSD, on 07/15/15 at 2:25 PM, revealed she was inserviced and reeducated, on 07/10/15 by the RQM, related to reviewing any resident's behaviors identified, per the Behavior Monitoring Report in the daily stand up meetings Monday through Friday. She was also inserviced on updating the resident's care plan for new behaviors or changes in the resident's behavior. Interview with the SSD on 07/15/15 at 2:25 PM and RN #3 (Unit Manager), on 07/16/15 at 8:25 AM, revealed they were inserviced and educated on 07/10/15. Further interview revealed the inservice was conducted by the RQM regarding the SSD

Based on interview, record review, facility policy review and review of facility staff's written statements related to allegations of abuse, it was determined the facility failed to develop a comprehensive care plan related to the resident's history of inappropriate sexual behaviors for one (1) of eighteen (18) sampled residents (Resident #7). The facility admitted Resident #7 on 04/29/15. The facility was aware the resident had been hospitalized prior to admission due to aggression and a possible sexual assault. However, the facility failed to develop an Interim Care Plan or Comprehensive Care Plan that addressed the resident's prior history of this behavior to ensure staff was aware to monitor for this behavior; and, aware of what actions to take if the resident exhibited this behavior. On 05/31/15, he/she was found rubbing Resident #5's leg underneath the resident's pant while Resident #5 was in bed. After the 05/31/15 incident, the resident was placed on fifteen (15) checks until he/she left the facility for an emergency evaluation on 06/02/15 (due to low ammonia levels) and was later discharged from the facility on 06/13/15. The facility's failure to develop a comprehensive care plan for Resident #7 to address his/her known sexually abusive behaviors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/02/15 and determined to exist on 05/31/15. An acceptable Allegation of Compliance (AOC) was received on 07/14/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 07/11/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Guidelines Resident Comprehensive Care Plans, dated 09/08, revealed the resident's Comprehensive Care Plan should be viewed as an Interdisciplinary approach in managing the acute and chronic needs of the resident living in the facility. It further revealed the comprehensive care plan should always have realistic goals and approaches/interventions to address the residents' needs. Review of the facility's policy titled, Clinical QAPI Daily Review Process, dated 08/01/14, revealed the admission charts/readmission charts are to be reviewed for the completion for the Clinical QAPI daily review meeting. In addition, the Nurse Assessment Coordinator and ADON/DON/Designee will ensure appropriate updates to the comprehensive care plan and Accunurse Activities of Daily Living Care Plan are carried out and communicated to the direct care staff and Interdisciplinary Team. Record review revealed the facility admitted Resident #7 on 04/29/15 with [DIAGNOSES REDACTED]. Review of an Initial Minimum Data Set (MDS) assessment, dated 05/06/15, revealed the facility assessed Resident #7's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. The resident has a State Guardian. Review of Resident #7's History and Physical, dated 04/30/15, revealed the resident was hospitalized after he/she displayed increased confusion and aggression, as well as an sexual assault accusation at a previous skilled nursing facility. Further review revealed the resident was stabilized while hospitalized and was transferred to this facility for continued care. Review of Resident #7's Interim Care Plan, dated 04/29/15, and the Comprehensive Care Plan, dated 05/11/15, revealed the care plans did not address the resident's history of aggression or sexual assault to ensure staff was aware to monitor for this behavior and what actions to take if the resident exhibited this behavior. Further review revealed the Comprehensive Care Plan did address Resident #7 making sexual inappropriate comments. Interview with Licensed Practical Nurse (LPN) #1, on 07/02/15 at 2:21 PM, revealed she was the Admission Nurse for Resident #7. LPN #1 stated she was not aware of Resident #7's history of sexual inappropriate behavior and aggression. She stated she would have expected any one admitting residents or making the interim care plans to have placed these behaviors on the care plan to ensure the right services were provided to the residents. Review of Certified Nursing Assistant (CNA) #2 written statement, dated 06/10/15, and interview with Certified Nurse Aide (CNA) #2, on 07/01/15 at 11:20 AM, revealed she witnessed Resident #7 rubbing the left leg of Resident #5 underneath his/her pant leg while Resident #5 was in bed on 05/31/15. Interview with Assistant MDS Coordinator, on 07/09/15 at 1:08 PM, revealed she had developed Resident #7's care plan on 05/11/15 and she had no knowledge of Resident #7 having any inappropriate sexual behaviors, prior to admission. She stated she would not place anything involving behaviors on the care plan normally unless it had to do with refusal of care or resisting care and she would place that on the Activities of Daily Living (ADL) care plan. She stated Social Services or Nursing would and should have added inappropriate sexual behavior to the resident's care plan so it could be updated and addressed. She further stated during the time Resident #7 allegedly was having issues with behaviors, the Social Services Staff was out on leave and the Administrator was acting in that role and other staff would assist when they could. Interview with Social Services Director, on 07/13/15 at 8:27 AM, revealed she was only around Resident #7 for a few days due to her being on leave. She stated she had not observed any new behaviors while she was there and the Administrator and several other staff took over her responsibilities while she was on leave. In addition, she stated it would have been her responsibility to update the care plan if new behaviors were observed by Resident #7 to address those behaviors. Interview with the Director of Nursing (DON), on 07/01/15 at 3:05 PM, revealed even though Resident #7 had previous sexual inappropriate behaviors, there was nothing on the care plan to reflect these behaviors. She stated she was mislead by the hospital when they were discussing placing the resident at their facility. She stated she, . was lead to believe Resident #7 no longer exhibited the sexual inappropriate behaviors due to hospitalization and medication changes. The DON stated she had gone to see Resident #7 and he/she did not appear to exhibit any behaviors so she discussed it with the Administrator and they decided since there were no behaviors exhibited and the hospital claimed he/she (the resident) was stabile, there was no reason to address the behaviors with the admission's staff or place sexual inappropriate behavior on the resident's care plan. Further interview with the DON revealed she now realized that Resident #7's behaviors should have been placed on his/her care plan. Interview with the former Administrator, on 07/01/15 at 3:45 PM, revealed she believed the hospital when they claimed Resident #7 was stabilized. She stated she did not have staff place anything on the resident's care plans to reflect any sexual behaviors due to the resident not exhibiting any sexual behaviors when he/she was visited by the Director of Nursing, prior to admission. She further stated she did not share with staff Resident #7's previous sexual inappropriate behavior or the potential for the resident to be sexually inappropriate, eliminating the opportunity for staff to intervene if needed. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #7 was discharged to the hospital on [DATE], with an acute onset of chest pain and will not return to the facility. The resident was discharged on [DATE]. Resident #2 was placed on increased supervision on 06/18/15 due to allegations of inappropriate contact with another resident. This increase in supervision included one to one supervision while up in the chair with fifteen (15) minute checks and a bed alarm while in bed. 2. On 06/10/15, the former Director of Nursing, Assistant Director of Nursing and Unit Managers from Hall One, Two, and Three completed skin assessments on all current residents with a BIMS' score of seven (7) or less to identify any injury of unknown origin or injury suspicious in nature. There were no injuries of unknown origin or suspicious injuries noted. 3. Beginning on 06/10/15 and completed on 06/15/15, the former Administrator and Social Services Director conducted interviews with all current residents with a BIMS' score of eight (8) or greater, to identify any concerns with Resident #7 or any allegations of abuse or neglect, with no concerns identified. Beginning on 06/18/15 and concluding on 06/22/15, the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Reimbursement Nurses, Regional Director of Sales and Marketing, Regional Director of Rehabilitation and Regional Field Accountant, completed interviews with all current residents with a BIMS' score of eight (8) or greater in regards to Resident #7 and Resident #2 as well as any concern with abuse or neglect. Four (4) concerns were identified, allegations of abuse regarding Residents #2 and #7, and a visitor (family member) and one concern with missing money. 4. Beginning on 06/10/15 and completed by 06/15/15, the former Administrator, former Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services Director completed interviews with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify any concerns with abuse and neglect. In addition, the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded on 06/22/15. There were no further residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. On 06/18/15, the Regional Reimbursement Nurse reviewed all Incident Reports for the past thirty (30) days to identify any injury of unknown origin or injury suspicious in nature; there were no concerns identified. 6. On 06/25/15, the Social Services Director reviewed all current residents' medical records to include behavior documentation and behavior assessments. She also developed or updated their care plans to reflect current known behaviors and needed interventions to meet the needs of the residents. Any required updates or care plans were added on 06/25/15. 7. On 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse assessed all current residents to determine appropriate level of supervision based on current behaviors and physical ability. No changes were required. 8. On 06/10/15, the Regional Director of Operations and Regional Quality Manager completed re-education with the Former Administrator and Former Director of Nursing on the policy and requirements for reporting an investigation as well as supervision and protection and determination of competency including BIMS' score and court ordered guardianship for competency. The former Administrator and former Director of Nursing completed a competency test on 06/10/15 with 100% pass rate. Beginning on 06/10/15 and completed on 06/16/15 the former Administrator and former Director of Nursing completed re-education with all current facility staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Maintenance and Housekeeping) on the abuse policy which included reporting and protecting of residents. A competency test was administered with no staff working without having a 100% score. Beginning on 06/18/15 and completed by 06/22/15 the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Director of Rehabilitation Operations and the Regional Reimbursement Nurse, conducted a second competency test of all current staff ( Nursing, Dietary, Social Services, Maintenance, Therapy, Housekeeping and Activities) to validate understanding of abuse, neglect and inappropriate touching, which included reporting and to whom to report to when their supervisor had not addressed the allegation. No staff worked after 06/22/15 without having received this second competency test with a validated 100% accuracy. On 06/22/15, the Divisional Director provided education to the Regional Director of Operations on Abuse and Neglect including reporting and follow up with facility staff on investigation and reporting. On 06/23/15, the Interim Administrator and Interim Director of Nursing in training were re-educated by the Regional Quality Manager on abuse and neglect including reporting, protecting and the investigation as well as evaluation of competency of the resident. The Regional Quality Manager conducted competency testing of the Interim Administrator and the Interim Director of Nursing in training with both passing with 100% accuracy. Beginning on 07/10/15, and continuing each shift the Interim Administrator, Interim Director of Nursing, Social Services Director or Unit Managers will re-educate all facility staff (Nursing, Social Services, Activity, Dietary, Housekeeping, Maintenance and Therapy and Administration) on abuse and neglect including reporting, protection and supervision. They will also administer a competency test to validate understanding with no staff working after 07/10/15 without having had this education and competency test with 100% accuracy. Abuse and Neglect education and competency test were incorporated into the facility's orientation program on 06/23/15, with no staff beginning job duties until this education and competency test was complete and 100% accuracy testing. There are no agency staff employed at the facility. On 07/10/15, the Divisional Director of Operations provided re-education to the Interim Administrator and Interim Director of Nursing on abuse and neglect including reporting, investigating and providing appropriate supervision to protect residents during the investigation. They were given a competency test to validate understanding; they both scored 100% on the test. The Interim Administrator and Interim Director of Nursing re-educated the Social Services Director, Assistant Director of Nursing and Unit Managers on 07/10/15 on abuse and neglect. This training included reporting and protection and supervision. The training with competency testing administered with 100% accuracy for validation. 9. On 06/25/15, the Regional Quality Manager re-educated the Social Services Director on completion of the Social Services admission assessment to identify any known behaviors or known history of behaviors and development of a plan of care. In the Social Services Director's absence, beginning on 06/29/15, the Administrator will designate a qualified person (Director of Nursing, Assistant Director of Nursing, Unit Manager or MDS Nurse) to complete the Social Services Admission assessment and development of plans of care to address any known behaviors. Beginning 07/10/15, the Director of Nursing, Assistant Director of Nursing, MDS Nurse and Unit Managers were educated on the Social Services Admission Assessment to identify any known behaviors or known history of behaviors and development of the plan of care when designated to complete in the Social Services Director's absence. This education was completed by the Regional Quality Manager. 10. On 07/10/15, the Regional Quality Manager re-educated the Social Services Director on reviewing in the daily stand up meeting Monday-Friday any behaviors, per the Behavior Monitoring Report and updating the resident care plan for new behaviors or changes in behaviors. 11. All current Licensed Nurses were re-educated on the initiation of a behavior plan of care on admissions for residents with known behaviors. They were re-educated on the initiation of behavior monitoring for admissions with known behaviors during the admission process. This was added to the Admission Packet on 07/06/15 by medical records. The education was completed by the Regional Quality Manager, Director of Nursing or Unit Manager for Units One, Two or Three. This education began on 07/06/15 with no licensed staff working after 07/10/15, without having received this re-education. 12. On 06/22/15, the Director of Nursing, Social Services Director, Regional Director of Operations, Regional Quality Manager, Unit Manager, and Interim Director of Nursing in training completed an ad hock Quality Assurance Committee Meeting with the Medical Director attending by phone to review the plans of action, with no further recommendations noted. 13. Beginning the week of 06/16/15, the Regional Director of Operations, Regional Administrator, or Regional Quality Manager conducted interviews and re-testing of ten (10) employees per week and included interviews to identify any new concerns with abuse or neglect. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance committee deems appropriate to decrease or resolve. The Quality Assurance Performance Improvement (QAPI) Committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Administrator, Dietary Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and, as needed. 14. The Administrator will review with the Social Services Director or the Director of Nursing, Unit Manager or MDS Nurse in the absence of the Social Services Director, weekly for at least twelve (12) weeks all new admissions to ensure behavior plans of care are developed. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday- Friday with Monday's review to include Saturday and Sunday reports to ensure care plans for behaviors are updated with new or changes in behaviors. The results of the reviews will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. 15. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday-Friday to ensure care plans for behaviors are updated with new behaviors or changes in behavior. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. 16. The former Administrator was relieved of job duties on 06/22/15 by the Regional Director of Operations. The Interim Administrator was re-educated on abuse, neglect, reporting, protection, supervision and investigation as well as competency by the Regional Quality Manager on 06/24/15. A competency test was administered by the Regional Quality Manager on 06/24/15 with a passing score of 100%. 17. On 06/25/15, the Regional Director of Operations educated the Interim Administrator on the requirement that the Administrator administer the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 18. The Regional Director of Operations or Regional Quality Manager will evaluate the facility's Administrator weekly for at least twelve (12) weeks to validate that the Administrator is administering the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 19. Beginning the week of 06/26/15 the Regional Director of Operations, or Regional Quality Manager will review all abuse and neglect monitoring of allegations to validate that allegations are reported timely, protection of the resident occurs including appropriate supervision and thorough investigation was conducted. 20. The Regional Director of Operations or Regional Quality Manager will observe the daily stand up meeting at least weekly for twelve (12) weeks to validate that behaviors are being reviewed and the plan of care updated with new or changes in behaviors to provide protection and appropriate supervision of the residents. The results of these validations will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #7's Physician order [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's Supervision Flow Sheet revealed the resident was placed on one to one supervision 06/18/15 while awake. Further review revealed Resident #2 was on every fifteen (15) minute observation and a bed alarm was used while the resident is in bed. 2. Review of skin assessments, dated 06/10/15-06/15/15 and 06/30/15 through 07/01/15, revealed all residents with a BIMS' score of seven (7) and below had skin assessments completed twice with no concerns identified. 3. Review of interviews, dated 06/10/15 through 06/15/15; and, 06/18/15 through 06/22/15, revealed all residents with a BIMS' score of eight (8) or greater were interviewed twice with no concerns identified. Review of interview logs, dated 06/18/15 through 06/22/15, revealed residents with a BIMS of eight (8) or greater and staff were interviewed, with other concerns of abuse identified concerning Residents #2 and #7 and a visitor. 4. Review of the facility's investigation initiated 06/10/15 revealed the former Administrator, former DON, former ADON, Unit Managers and SSD completed interviews on 06/10/15 through 06/15/15, with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify concerns of abuse and neglect. Review of the facility's investigation revealed the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded 06/22/15. There were no further identified residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. Review of the facility's Incident Reports beginning 05/15/15 revealed no concerns of injuries of unknown origin or injuries suspicious in nature. 6. Review of care plans of current residents listed in the abuse allegation (Residents #2, #5, #6, #8, #9, #10, and Unsampled Resident A), validated that care plans were updated and staff was monitoring for signs and symptoms of abuse. 7. Review of a Resident Log, revealed on 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse reviewed all current residents to determine their appropriate level of supervision based on the resident's current behaviors and physical ability. No changes were required. 8. Review of Inservice Logs, dated 06/10/15, revealed the former Administrator and former DON were in serviced and re-educated on the facility's Abuse and Neglect policy, reportable incidents, investigating, supervision, and court ordered guardianship for competency. Review of Inservice logs and post test, dated 06/10/15 through 06/15/15, revealed staff on all shifts were in serviced on the Abuse and Neglect with 100% accuracy on the post test. Interview with Dietary Aide #10, on 07/02/15 at 8:40 AM, revealed she was in serviced and re-educated by the former Administrator, on 06/11/15, on Abuse and Neglect, reporting, whom to report to, and when to report. Review of the Inservice Log, dated 07/10/15, revealed the Interim Administrator and Interim DON were re-educated by the DDO on abuse and neglect including reporting, investigating and providing appropriate supervision to protect the residents during the investigation. Review of the Inservice Log, dated 07/10/15, revealed the SSD, ADON, and Unit Managers were inserviced by the DDO. Review of the competency test administered validated 100% accuracy. Interviews with Dietary Aide (DA) #11 on 07/02/15 at 8:40 AM; DA #10 on 07/15/15 at 10:35 AM; the MDS Coordinator on 07/15/15 at 2:05 PM; the Maintenance Supervisor on 07/15/15 at 2:55 PM; the Activities Director on 07/15/15 at 3:45 PM; the Housekeeper on 07/15/15 at 4:10 PM; CNA #12 on 07/16/15 at 8:10 AM; RN #3 (Unit Manager) on 07/16/15 at 8:25 AM; Laundry Aide #1 on 07/16/15 at 8:40 AM, and the Therapy Director, on 07/16/15 at 10:20 AM revealed inservicing had been provided by the former Administrator, Interim Administrator, RQM, former DON, interim DON, and Interim ADON on Abuse and Neglect to include identifying and reporting abuse and neglect. Interviews with staff revealed what constitutes abuse and neglect, when to report, and who to report. Interview with the former DON, on 07/01/15 at 3:05 PM, revealed she was in serviced on 06/10/15 by the RQM and the Director of Clinical Operations (DCO) on the facility's Abuse and Neglect policy, reportable incidents, investigation, residents that may require increased supervision, and investigating allegations of residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. Interview with MDS Coordinator, on 07/15/15 at 2:05 PM, revealed she was in serviced on 07/13/15 by the Interim Administrator on Abuse and Neglect. Interview with the former Administrator, on 07/02/15 at 1:20 PM, revealed she was in serviced and re-educated on 06/10/15 by the RQM and DCO regarding the facility's Abuse and Neglect policy, reportable incidents, investigation, residents with behaviors requiring increased supervision, and investigating allegations of abuse with residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. In addition, she stated she was re-educated to always notify the resident's Guardian, POA, family, or responsible person in any allegation of abuse and initiate an investigation. Interview with Regional Quality Manager (RQM), on 07/16/15 at 8:50 AM, revealed in servicing with the former Administrator, former DON, former ADON and Unit Managers was completed on 06/15/15. Further interview revealed on 06/18/15 through 06/22/15, the Regional Team conducted interviews and post testing on abuse and neglect with all staff. Inservice logs were reviewed to validate. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was in serviced and re-educated, on 07/10/15, by the Interim Administrator related to abuse and neglect, monitoring and reporting. Interview with CNA #3 (works 6:30 AM to 2:30 PM), on 07/01/15 at 12:30 PM, revealed she was in serviced and tested on Abuse and Neglect in June (unable to give a date) by the former Administrator and DON. Further interview revealed she was in serviced again approximately (2) weeks later by Corporate staff and was required to score 100% on post test. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced and reeducated on Abuse and Neglect, what, when and to whom to report abuse allegations. Further interview revealed she was in serviced by the former Administrator and DON in June and in serviced again on 07/10/15 by the Interim Administrator. Interview with the Maintenance Director, on 07/15/15 at 2:55 PM, revealed he was in serviced, on 07/10/15 and again on 07/13/15, by the Interim Administrator on Abuse and Neglect. Further interview revealed he took a post test after each inservice and was required to score 100%. Interview with the Activities Director (AD), on 07/15/15 at 3:45 PM, revealed she was reeducated and in serviced on Abuse and Neglect by the Interim Administrator on 07/10/15 and on 07/13/15. She stated she took a post test after each in service and passed with a score of 100%. Further interview revealed the AD was able to identify types of abuse, when to report abuse or possible abuse, and to whom to report the allegation of abuse. The AD revealed she also was the Resident Council Facilitator. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced again on 07/10/15 by Interim Administrator on Abuse and Neglect. She stated she took a post test and was required to score 100%. Interview with the Therapy Director, on 07/16/15 at 10:20 AM, revealed she has been inserviced three (3) times on Abuse and Neglect starting in mid June. She stated her last inservice training on Abuse and Neglect was 0713/15. She took a post test, with 100% pass rate required. Review of the facility's inservice and post test, dated 06/23/15, revealed the Interim Administrator and Interim DON were educated by the RQM on abuse and neglect which included reporting, protecting, and investigating. Review of the POS [REDACTED]. Interview with the Interim DON, on 07/16/15 at 11:20 AM, and the Interim Administrator, on 07/16/15 at 11:55 AM, revealed they were inserviced on abuse and neglect; and on 06/23/15, an inservice was given by the RQM on abuse and neglect, reporting, protecting, and investigating. Further interview revealed they took a post test with 100% accuracy required and were able to identify reportable events. Review of a documented telephone interview, dated 06/22/15, revealed the DCO was inserviced by the Divisional Director of Operations (DDO) on Abuse and Neglect policy, timeliness of reporting incidents, investigating, and follow up to allegations. Review of post test revealed 100% accuracy. Interview with DCO, on 07/02/15 at 1:00 PM, revealed he was in serviced on 06/22/15 by the DDO on Abuse and Neglect, protecting, reporting, and investigating. Review of the facility's New Employee Checklist - KY, implemented on 06/23/15, revealed reporting allegations of abuse acknowledgement was incorporated into the facility's orientation program and no staff will begin job duties until educated on Abuse and Neglect and a competency test has been completed with 100% accuracy. 9. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was reeducated by the RQM, on 06/25/15. Further interview revealed when conducting Social Service Admission Assessments, any residents identified with behaviors or history of behaviors, the SSD will care plan the resident for the behaviors and they will be reviewed in the daily stand up meetings. Interview with Interim Administrator, on 07/16/15 at 11:55 AM, revealed the SSD will assess residents for a history of behaviors during the Social Service Admission Assessment. Further interview revealed in absence of the SSD, the Administrator wil

Based on interview, record review, review of the facility's investigation, and review of the facility's policy for Abuse and Neglect, it was determined the facility failed to ensure staff was aware of Resident #7's history of sexually inappropriate behavior and, aware of the need to monitor and provide adequate supervision to ensure two (2) of eighteen (18) sampled residents (Resident #7 and Resident #2) did not exhibit sexually inappropriate behavior towards other residents. On 04/29/15, the facility admitted Resident #7 from an acute hospital where he/she was treated for [REDACTED]. The facility failed to develop a care plan with interventions to ensure staff was aware of these behaviors in order to monitor and report these behaviors. On 05/31/15, staff observed Resident #7 rubbing Resident #5's leg underneath the resident's pant leg while Resident #5 was in bed. Registered Nurse (RN) #2 did not report the incident because the Administrator did take any action after another incident involving anther resident. In addition, staff observed Resident #2 kissing Resident #5, however, staff failed to report the behavior and failed to provide adequate supervision to ensure a safe environment for the residents. The facility's failure to monitor and provide adequate supervision has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 07/02/15 and determined to exist on 05/31/15. The facility was notified of the Immediate Jeopardy on 07/02/15. An acceptable Allegation of Compliance (AOC) was received on 07/14/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 07/11/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed the resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Review of the facility's Abuse and Neglect policy, (no date), revealed if an alleged perpetrator is a resident, the nursing staff will initiate interventions to provide immediate protection of residents until the interdisciplinary team can convene to review the current plan of care and make necessary revisions in order to ensure the safety of others. 1. Review of Resident #7's History and Physical dated 04/30/15, revealed Resident #7 was recently hospitalized due to increased confusion and aggression as well as a sexual assault accusation at previous skilled nursing facility. Patient stabilized while hospitalized and transferred to facility for continued care. Record review revealed the facility admitted Resident #7 on 04/29/15, from the acute hospitalization , with [DIAGNOSES REDACTED]. Review of an Initial Minimum Data Set (MDS) assessment, dated 05/06/15, revealed the facility assessed Resident #7's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Resident #7 had a State Guardian. Review of the physician's orders [REDACTED]. The resident was discharged from the facility on 06/13/15. Review of Resident #7's Interim Care Plan, dated 04/29/15, and the Comprehensive Care Plan, dated 05/11/15, revealed there was no care plan with interventions to address the resident's aggression and inappropriate sexual behavior to ensure staff was aware of these behaviors in order to monitor and provide adequate supervision. Interview with the Assistant MDS Coordinator, on 07/09/15 at 1:08 PM, revealed she had developed Resident #7's care plan on 05/11/15 and she had no knowledge of Resident #7 having any inappropriate sexual behavior prior to admission. She further stated during the time when Resident #7 allegedly was having issues with behaviors the Social Services staff was out on leave and the Administrator was acting in that role and other staff would assist when they could. Review of Certified Nursing Assistant (CNA) #2 written statement, dated 06/10/15, and interview with Certified Nurse Aide (CNA) #2, on 07/01/15 at 11:20 AM, revealed she witnessed Resident #7 rubbing the left leg of Resident #5 underneath his/her pant leg while Resident #5 was in bed on 05/31/15. She stated she reported the incident to RN #2. Interview with Registered Nurse (RN) #2/Charge Nurse, on 07/02/15 at 2:38 PM, revealed when CNA #2 reported the incident related to Resident #7 rubbing Resident #5's leg she didn't report it because of the Administrator's response to another incident involving the resident. However, Resident #5's (who has a BIMS' score of 3) Guardian stated the resident could not give consent. Interview with the Director of Nursing (DON), on 07/01/15 at 3:05 PM, revealed even though Resident #7 had previous sexual inappropriate behaviors, there was no care plan and interventions developed to ensure staff was aware of these behaviors, so they could monitor and provide adequate supervision to identify any sexually inappropriate behaviors. The DON stated when she discussed Resident #7 with the hospital staff, she believed Resident #7 no longer exhibited sexually inappropriate behaviors due to his/her hospitalization and medication changes. She stated the hospital claimed the resident was stable so there was no reason to address these behaviors with the admission staff or place sexually inappropriate behaviors on the care plan. The DON stated she now sees that Resident #7's behaviors should have been placed on the care plan. Interview with the former Administrator, on 07/01/15 at 3:45 PM, revealed she was aware of Resident #7's sexual assault accusations prior to admission. She stated she did not take any action to ensure staff was aware of these behaviors and knew how to supervise/monitor Resident #7 for socially inappropriate behaviors. She stated she believed the hospital when they said Resident #7 was stabilized. Further interview revealed she did not have staff place anything on the care plans to reflect any sexual behaviors due to the resident not exhibiting any sexual behaviors when he/she was visited by the Director of Nursing prior to admission. The Administrator further stated she did not share with staff Resident #7's previous sexual inappropriate behavior or the potential for Resident #7 to be sexually inappropriate, eliminating the opportunity for staff to intervene, if needed, to provide a safe environment. 2. Record review revealed the facility readmitted Resident #2 on 11/12/14 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 05/04/15, revealed the facility assessed Resident #2's cognition as intact with a BIMS' score of fifteen (15) which indicated the resident was interviewable. Review of Resident #2's physician's orders [REDACTED].#2 was started on Paxil (antidepressant) 10 milligrams (mg) for ten (10) days and then it was increased to 20 mg by mouth at bedtime for sexual obsessiveness. On 06/18/15, Resident #2 was placed on every fifteen (15) minute monitoring, and a care plan was initiated for sexually inappropriate behaviors. On 06/19/15, Resident was placed on continuous supervision (1:1). Review of a facility investigation initiated on 06/10/15, revealed the facility identified staff observed Resident #2 kiss Resident #5, in the last several weeks. However, staff failed to report this behavior to ensure adequate supervision could be provided to prevent further incidents. Interview with the former Director of Nursing (DON), on 07/01/15 at 3:05 PM, revealed the facility did not have a policy for increased supervision. Further interview revealed she would expect any discipline of staff to report inappropriate activity between residents to their immediate supervisor, and resident to resident abuse/mistreatment should be investigated to ensure the safety of residents. Interview with former Administrator, on 07/01/15 at 3:45 PM, revealed allegations were to be investigated when reported. Further interview revealed she expected residents identified with sexually inappropriate behaviors be provided adequate supervision to ensure the safety of all residents. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #7 was discharged to the hospital on [DATE], with an acute onset of chest pain and will not return to the facility. The resident was discharged on [DATE]. Resident #2 was placed on increased supervision on 06/18/15 due to allegations of inappropriate contact with another resident. This increase in supervision included one to one supervision while up in the chair with fifteen (15) minute checks and a bed alarm while in bed. 2. On 06/10/15, the former Director of Nursing, Assistant Director of Nursing and Unit Managers from Hall One, Two, and Three completed skin assessments on all current residents with a BIMS' score of seven (7) or less to identify any injury of unknown origin or injury suspicious in nature. There were no injuries of unknown origin or suspicious injuries noted. 3. Beginning on 06/10/15 and completed on 06/15/15, the former Administrator and Social Services Director conducted interviews with all current residents with a BIMS' score of eight (8) or greater, to identify any concerns with Resident #7 or any allegations of abuse or neglect, with no concerns identified. Beginning on 06/18/15 and concluding on 06/22/15, the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Reimbursement Nurses, Regional Director of Sales and Marketing, Regional Director of Rehabilitation and Regional Field Accountant, completed interviews with all current residents with a BIMS' score of eight (8) or greater in regards to Resident #7 and Resident #2 as well as any concern with abuse or neglect. Four (4) concerns were identified, allegations of abuse regarding Residents #2 and #7, and a visitor (family member) and one concern with missing money. 4. Beginning on 06/10/15 and completed by 06/15/15, the former Administrator, former Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services Director completed interviews with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify any concerns with abuse and neglect. In addition, the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded on 06/22/15. There were no further residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. On 06/18/15, the Regional Reimbursement Nurse reviewed all Incident Reports for the past thirty (30) days to identify any injury of unknown origin or injury suspicious in nature; there were no concerns identified. 6. On 06/25/15, the Social Services Director reviewed all current residents' medical records to include behavior documentation and behavior assessments. She also developed or updated their care plans to reflect current known behaviors and needed interventions to meet the needs of the residents. Any required updates or care plans were added on 06/25/15. 7. On 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse assessed all current residents to determine appropriate level of supervision based on current behaviors and physical ability. No changes were required. 8. On 06/10/15, the Regional Director of Operations and Regional Quality Manager completed re-education with the Former Administrator and Former Director of Nursing on the policy and requirements for reporting an investigation as well as supervision and protection and determination of competency including BIMS' score and court ordered guardianship for competency. The former Administrator and former Director of Nursing completed a competency test on 06/10/15 with 100% pass rate. Beginning on 06/10/15 and completed on 06/16/15 the former Administrator and former Director of Nursing completed re-education with all current facility staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Maintenance and Housekeeping) on the abuse policy which included reporting and protecting of residents. A competency test was administered with no staff working without having a 100% score. Beginning on 06/18/15 and completed by 06/22/15 the Regional Team consisting of the Regional Director of Operations, Regional Quality Manager, Regional Director of Rehabilitation Operations and the Regional Reimbursement Nurse, conducted a second competency test of all current staff ( Nursing, Dietary, Social Services, Maintenance, Therapy, Housekeeping and Activities) to validate understanding of abuse, neglect and inappropriate touching, which included reporting and to whom to report to when their supervisor had not addressed the allegation. No staff worked after 06/22/15 without having received this second competency test with a validated 100% accuracy. On 06/22/15, the Divisional Director provided education to the Regional Director of Operations on Abuse and Neglect including reporting and follow up with facility staff on investigation and reporting. On 06/23/15, the Interim Administrator and Interim Director of Nursing in training were re-educated by the Regional Quality Manager on abuse and neglect including reporting, protecting and the investigation as well as evaluation of competency of the resident. The Regional Quality Manager conducted competency testing of the Interim Administrator and the Interim Director of Nursing in training with both passing with 100% accuracy. Beginning on 07/10/15, and continuing each shift the Interim Administrator, Interim Director of Nursing, Social Services Director or Unit Managers will re-educate all facility staff (Nursing, Social Services, Activity, Dietary, Housekeeping, Maintenance and Therapy and Administration) on abuse and neglect including reporting, protection and supervision. They will also administer a competency test to validate understanding with no staff working after 07/10/15 without having had this education and competency test with 100% accuracy. Abuse and Neglect education and competency test were incorporated into the facility's orientation program on 06/23/15, with no staff beginning job duties until this education and competency test was complete and 100% accuracy testing. There are no agency staff employed at the facility. On 07/10/15, the Divisional Director of Operations provided re-education to the Interim Administrator and Interim Director of Nursing on abuse and neglect including reporting, investigating and providing appropriate supervision to protect residents during the investigation. They were given a competency test to validate understanding; they both scored 100% on the test. The Interim Administrator and Interim Director of Nursing re-educated the Social Services Director, Assistant Director of Nursing and Unit Managers on 07/10/15 on abuse and neglect. This training included reporting and protection and supervision. The training with competency testing administered with 100% accuracy for validation. 9. On 06/25/15, the Regional Quality Manager re-educated the Social Services Director on completion of the Social Services admission assessment to identify any known behaviors or known history of behaviors and development of a plan of care. In the Social Services Director's absence, beginning on 06/29/15, the Administrator will designate a qualified person (Director of Nursing, Assistant Director of Nursing, Unit Manager or MDS Nurse) to complete the Social Services Admission assessment and development of plans of care to address any known behaviors. Beginning 07/10/15, the Director of Nursing, Assistant Director of Nursing, MDS Nurse and Unit Managers were educated on the Social Services Admission Assessment to identify any known behaviors or known history of behaviors and development of the plan of care when designated to complete in the Social Services Director's absence. This education was completed by the Regional Quality Manager. 10. On 07/10/15, the Regional Quality Manager re-educated the Social Services Director on reviewing in the daily stand up meeting Monday-Friday any behaviors, per the Behavior Monitoring Report and updating the resident care plan for new behaviors or changes in behaviors. 11. All current Licensed Nurses were re-educated on the initiation of a behavior plan of care on admissions for residents with known behaviors. They were re-educated on the initiation of behavior monitoring for admissions with known behaviors during the admission process. This was added to the Admission Packet on 07/06/15 by medical records. The education was completed by the Regional Quality Manager, Director of Nursing or Unit Manager for Units One, Two or Three. This education began on 07/06/15 with no licensed staff working after 07/10/15, without having received this re-education. 12. On 06/22/15, the Director of Nursing, Social Services Director, Regional Director of Operations, Regional Quality Manager, Unit Manager, and Interim Director of Nursing in training completed an ad hock Quality Assurance Committee Meeting with the Medical Director attending by phone to review the plans of action, with no further recommendations noted. 13. Beginning the week of 06/16/15, the Regional Director of Operations, Regional Administrator, or Regional Quality Manager conducted interviews and re-testing of ten (10) employees per week and included interviews to identify any new concerns with abuse or neglect. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance committee deems appropriate to decrease or resolve. The Quality Assurance Performance Improvement (QAPI) Committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. Members of the QAPI Committee will consist of at a minimum the Director of Nursing, Administrator, Dietary Services Director, Maintenance Director, Activity Director and Business Office Manager with the Medical Director participating at least quarterly and, as needed. 14. The Administrator will review with the Social Services Director or the Director of Nursing, Unit Manager or MDS Nurse in the absence of the Social Services Director, weekly for at least twelve (12) weeks all new admissions to ensure behavior plans of care are developed. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday- Friday with Monday's review to include Saturday and Sunday reports to ensure care plans for behaviors are updated with new or changes in behaviors. The results of the reviews will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. 15. In addition, the Interim Administrator will observe the review of behavior monitoring in the daily stand up meeting Monday-Friday to ensure care plans for behaviors are updated with new behaviors or changes in behavior. The results of these test will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. 16. The former Administrator was relieved of job duties on 06/22/15 by the Regional Director of Operations. The Interim Administrator was re-educated on abuse, neglect, reporting, protection, supervision and investigation as well as competency by the Regional Quality Manager on 06/24/15. A competency test was administered by the Regional Quality Manager on 06/24/15 with a passing score of 100%. 17. On 06/25/15, the Regional Director of Operations educated the Interim Administrator on the requirement that the Administrator administer the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 18. The Regional Director of Operations or Regional Quality Manager will evaluate the facility's Administrator weekly for at least twelve (12) weeks to validate that the Administrator is administering the facility in a manner that enables the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 19. Beginning the week of 06/26/15 the Regional Director of Operations, or Regional Quality Manager will review all abuse and neglect monitoring of allegations to validate that allegations are reported timely, protection of the resident occurs including appropriate supervision and thorough investigation was conducted. 20. The Regional Director of Operations or Regional Quality Manager will observe the daily stand up meeting at least weekly for twelve (12) weeks to validate that behaviors are being reviewed and the plan of care updated with new or changes in behaviors to provide protection and appropriate supervision of the residents. The results of these validations will be reviewed with the Quality Assurance Committee weekly. This will continue weekly for at least twelve (12) weeks and until the Quality Assurance Committee deems appropriate to decrease or resolve. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #7's Physician order [REDACTED]. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's Supervision Flow Sheet revealed the resident was placed on one to one supervision 06/18/15 while awake. Further review revealed Resident #2 was on every fifteen (15) minute observation and a bed alarm was used while the resident is in bed. 2. Review of skin assessments, dated 06/10/15-06/15/15 and 06/30/15 through 07/01/15, revealed all residents with a BIMS' score of seven (7) and below had skin assessments completed twice with no concerns identified. 3. Review of interviews, dated 06/10/15 through 06/15/15; and, 06/18/15 through 06/22/15, revealed all residents with a BIMS' score of eight (8) or greater were interviewed twice with no concerns identified. Review of interview logs, dated 06/18/15 through 06/22/15, revealed residents with a BIMS of eight (8) or greater and staff were interviewed, with other concerns of abuse identified concerning Residents #2 and #7 and a visitor. 4. Review of the facility's investigation initiated 06/10/15 revealed the former Administrator, former DON, former ADON, Unit Managers and SSD completed interviews on 06/10/15 through 06/15/15, with all current staff (Nursing, Dietary, Activities, Social Services, Administration, Therapy, Housekeeping and Maintenance) to identify concerns of abuse and neglect. Review of the facility's investigation revealed the Regional Team began interviews for all current staff (Nursing, Dietary, Social Services, Administration, Therapy, Housekeeping and Maintenance and Activity) on 06/18/15 and concluded 06/22/15. There were no further identified residents, visitors, vendors, family or staff that were identified as suspicious for having committed abuse or neglect. 5. Review of the facility's Incident Reports beginning 05/15/15 revealed no concerns of injuries of unknown origin or injuries suspicious in nature. 6. Review of care plans of current residents listed in the abuse allegation (Residents #2, #5, #6, #8, #9, #10, and Unsampled Resident A), validated that care plans were updated and staff was monitoring for signs and symptoms of abuse. 7. Review of a Resident Log, revealed on 06/22/15, the Interdisciplinary team consisting of the former Director of Nursing, former Administrator, Social Services Director, Activity Director, Assistant Director of Nursing and MDS Nurse reviewed all current residents to determine their appropriate level of supervision based on the resident's current behaviors and physical ability. No changes were required. 8. Review of Inservice Logs, dated 06/10/15, revealed the former Administrator and former DON were in serviced and re-educated on the facility's Abuse and Neglect policy, reportable incidents, investigating, supervision, and court ordered guardianship for competency. Review of Inservice logs and post test, dated 06/10/15 through 06/15/15, revealed staff on all shifts were in serviced on the Abuse and Neglect with 100% accuracy on the post test. Interview with Dietary Aide #10, on 07/02/15 at 8:40 AM, revealed she was in serviced and re-educated by the former Administrator, on 06/11/15, on Abuse and Neglect, reporting, whom to report to, and when to report. Review of the Inservice Log, dated 07/10/15, revealed the Interim Administrator and Interim DON were re-educated by the DDO on abuse and neglect including reporting, investigating and providing appropriate supervision to protect the residents during the investigation. Review of the Inservice Log, dated 07/10/15, revealed the SSD, ADON, and Unit Managers were inserviced by the DDO. Review of the competency test administered validated 100% accuracy. Interviews with Dietary Aide (DA) #11 on 07/02/15 at 8:40 AM; DA #10 on 07/15/15 at 10:35 AM; the MDS Coordinator on 07/15/15 at 2:05 PM; the Maintenance Supervisor on 07/15/15 at 2:55 PM; the Activities Director on 07/15/15 at 3:45 PM; the Housekeeper on 07/15/15 at 4:10 PM; CNA #12 on 07/16/15 at 8:10 AM; RN #3 (Unit Manager) on 07/16/15 at 8:25 AM; Laundry Aide #1 on 07/16/15 at 8:40 AM, and the Therapy Director, on 07/16/15 at 10:20 AM revealed inservicing had been provided by the former Administrator, Interim Administrator, RQM, former DON, interim DON, and Interim ADON on Abuse and Neglect to include identifying and reporting abuse and neglect. Interviews with staff revealed what constitutes abuse and neglect, when to report, and who to report. Interview with the former DON, on 07/01/15 at 3:05 PM, revealed she was in serviced on 06/10/15 by the RQM and the Director of Clinical Operations (DCO) on the facility's Abuse and Neglect policy, reportable incidents, investigation, residents that may require increased supervision, and investigating allegations of residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. Interview with MDS Coordinator, on 07/15/15 at 2:05 PM, revealed she was in serviced on 07/13/15 by the Interim Administrator on Abuse and Neglect. Interview with the former Administrator, on 07/02/15 at 1:20 PM, revealed she was in serviced and re-educated on 06/10/15 by the RQM and DCO regarding the facility's Abuse and Neglect policy, reportable incidents, investigation, residents with behaviors requiring increased supervision, and investigating allegations of abuse with residents with a BIMS' score of (8) or greater. Further interview revealed, on 06/18/15, she was in serviced and re-educated on the facility's abuse and neglect policy and given a post test by the RQM. In addition, she stated she was re-educated to always notify the resident's Guardian, POA, family, or responsible person in any allegation of abuse and initiate an investigation. Interview with Regional Quality Manager (RQM), on 07/16/15 at 8:50 AM, revealed in servicing with the former Administrator, former DON, former ADON and Unit Managers was completed on 06/15/15. Further interview revealed on 06/18/15 through 06/22/15, the Regional Team conducted interviews and post testing on abuse and neglect with all staff. Inservice logs were reviewed to validate. Interview with the SSD, on 07/15/15 at 2:25 PM, revealed she was in serviced and re-educated, on 07/10/15, by the Interim Administrator related to abuse and neglect, monitoring and reporting. Interview with CNA #3 (works 6:30 AM to 2:30 PM), on 07/01/15 at 12:30 PM, revealed she was in serviced and tested on Abuse and Neglect in June (unable to give a date) by the former Administrator and DON. Further interview revealed she was in serviced again approximately (2) weeks later by Corporate staff and was required to score 100% on post test. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced and reeducated on Abuse and Neglect, what, when and to whom to report abuse allegations. Further interview revealed she was in serviced by the former Administrator and DON in June and in serviced again on 07/10/15 by the Interim Administrator. Interview with the Maintenance Director, on 07/15/15 at 2:55 PM, revealed he was in serviced, on 07/10/15 and again on 07/13/15, by the Interim Administrator on Abuse and Neglect. Further interview revealed he took a post test after each inservice and was required to score 100%. Interview with the Activities Director (AD), on 07/15/15 at 3:45 PM, revealed she was reeducated and in serviced on Abuse and Neglect by the Interim Administrator on 07/10/15 and on 07/13/15. She stated she took a post test after each in service and passed with a score of 100%. Further interview revealed the AD was able to identify types of abuse, when to report abuse or possible abuse, and to whom to report the allegation of abuse. The AD revealed she also was the Resident Council Facilitator. Interview with Housekeeper #1, on 07/15/15 at 4:15 PM, revealed she was in serviced again on 07/10/15 by Interim Administrator on Abuse and Neglect. She stated she took a post test and was required to score 100%. Interview with the Therapy Director, on 07/16/15 at 10:20 AM, revealed she has been inserviced three (3) times on Abuse and Neglect starting in mid June. She stated her last inservice training on Abuse and Neglect was 0713/15. She took a post test, with 100% pass rate required. Review of the facility's inservice and post test, dated 06/23/15, revealed the Interim Administrator and Interim DON were educated by the RQM on abuse and neglect which included reporting, protecting, and investigating. Review of the post test revealed he scored 100%. Interview with the Interim DON, on 07/16/15 at 11:20 AM, and the Interim Administrator, on 07/16/15 at 11:55 AM, revealed they were inserviced on abuse and neglect; and on 06/23/15, an inservice was given by the RQM on abuse and neglect, reporting, protecting, and investigating. Further interview revealed they took a post test with 100% accuracy required and were able to identify reportable events. Review of a documented telephone interview, dated 06/22/15, revealed the DCO was inserviced by the Divisional Director of Operations (DDO) on Abuse and Neglect policy, timeliness of reporting incidents, investigating, and follow up to allegations. Review of post test revealed 100% accuracy. Interview with DCO, on 07/02/15 at 1:00 PM, revealed he was in serviced on 06/22/15 by the DDO on Abuse and Neglect, p

Based on interview, record review, and review of the hospital Consultation Reports and the facility's policies and procedures, it was determined the facility failed to provide services by qualified personnel according to the written plan of care for one (1) of three (3) sampled residents, (Resident #1.) On 03/13/15, Resident #1 was noted to have a decline in cognition, weight bearing, transferring, continence, and verbalization after receiving two (2) as needed (PRN) medications, [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for anxiety). Resident #1 needed the assistance of three (3) to transfer from the chair to the bed, was unable to eat his/her evening meal and staff was unable to wake up the resident. Staff and Resident #1's Spouse reported the changes to LPN #2 and they were told the resident was resting from the medications. On the morning of 03/14/15, Resident #1's change in condition was reported to Licensed Practical Nurse (LPN) #1; and, on 03/14/15 at 8:37 AM, RN #1 identified Resident #1 was unresponsive. However, there was no documented evidence Resident #1's care plan was implemented related to the documentation of medications, monitoring the effectiveness and the side effects of the medications, monitoring for confusion and behaviors, conducting neurological assessments due to pharmacological factors and reporting to the physician, as needed. On 03/14/15 at 11:00 AM, approximately eighteen (18) hours after the PRN medications were given, the resident was unresponsive and was sent out to the hospital, where it was determined the resident had a massive stroke. The resident was admitted to the Intensive Care Unit, was unresponsive, non-communicative, and required a Gastric Feeding Tube (GT), due to the inability to sustain nutrition. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/18/15 and determined to exist on 03/13/15. An acceptable Allegation of Compliance (AoC) was received on 05/22/15, alleging the IJ was removed on 05/21/15. The State Survey Agency validated the Immediate Jeopardy was removed on 05/21/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Regional Clinical Coordinator, on 05/18/15 at 6:15 PM, revealed there was no specific policy for care plans but the Interim Care Plans were generated on admission, based on the resident's diagnoses, history and Activities of Daily Living (ADL) needs, and concerns. 1. Closed record review revealed the facility admitted Resident #1 on 03/12/15 with [DIAGNOSES REDACTED]. Review of the Admission Data Set, dated 03/13/15, revealed the facility assessed the resident to be alert and oriented to person, place, and time, short and long term memory were intact, understood and understands with clear comprehension, was on a regular diabetic diet, was ambulatory with a walker, had no impairment in range of motion (ROM), and was continent of bowel and bladder. Review of the Interim Plan of Care, dated 03/12/15, revealed interventions for staff to record the effectiveness of the pain medications, monitor and record the side effects of the medications, assess for pain as needed, report pain affecting daily life to the care provider, monitor the resident's blood sugars, monitor for confusion and behaviors and report to the physician, as needed. In addition, due to a fall at home and to medical, neurological and pharmacological factors, there were interventions to implement neurological assessments, as needed. Review of a Nursing Note, dated 03/13/15 at 2:53 PM, and interview with LPN #1 on 05/15/15 at 9:55 AM; and on 05/18/15 at 3:38 PM, revealed LPN #1 administered as needed (PRN) [MEDICATION NAME] (pain) and [MEDICATION NAME] (anxiety), on 03/13/15, at approximately 2:30 PM, for the resident's complaints of nervousness and chronic pain. Interviews with Certified Nursing Assistant (CNA) #1, on 05/15/15 at 11:35 AM; CNA #2 on 05/15/15 at 11:40 AM; and, Resident #1's spouse on 05/12/15 at 9:50 AM and on 05/17/15 at 5:11 PM, revealed on 03/13/15 in the afternoon Resident #1 was asleep in a chair and would not wake up. They stated the resident would not wake up for supper. CNA #1 stated he had to have two (2) ambulance attendants assist him to put the resident to bed because he/she was dead weight. Resident #1's Spouse stated he/she informed the staff this was a change for the resident as he/she had never slept more than two (2) hours at a time due to all the pain from a previous fracture. CNA #1 and the Resident's Spouse were concerned with the resident's condition and they notified LPN #2 but were assured it was due to the (PRN) medications. Review of the Nurse's Notes, dated 03/13/15 and 03/14/15; and, review of the March 2015 Electronic Medication Administration Records (EMARs) revealed there was no documented evidence LPN #1 or LPN #2 assessed the resident to determine the effectiveness and/or side effects of the medications; assessed for any neurological changes in the resident; or monitored the resident for confusion and behaviors and reported to the physician, as stated in the plan of care. Interview with LPN #1, on 05/15/15 at 9:55 AM; and, on 05/18/15 at 3:38 PM, revealed she was unsure why the results of the effectiveness of the PRNs were not documented and stated it had been a very busy week and she probably forgot. The LPN was unable to remember if the resident had been assessed, prior to her leaving her shift at 6:00 PM. However, there was no documented evidence the resident was assessed. Interview with LPN #2, on 05/15/15 at 11:10 AM; and, on 05/16/15 at 3:28 PM, revealed she worked the 6 PM - 6 AM shift, on 03/13/15. She stated the resident was sleeping and was never fully awakened, throughout the night. LPN #2 stated the resident was resting well from receiving the PRN medications and she felt there was no change in the resident's condition to require further assessment or warrant calling the physician. LPN #2 stated no one had told her that Resident #1 had experienced a change in condition. Review of a Nursing Note, dated 03/14/15 at 8:47 AM, and interview with RN #1 on 05/15/15 at 8:25 PM and 10:40 AM; and, on 05/17/15 at 4:09 PM, revealed Resident #1 was unresponsive on 03/14/15, and he felt it was because the resident received pain medication prior to his shift. The RN stated he did an assessment of the resident at 8:47 AM and stated there was no facial drooping, yet the resident was unable to follow commands to stick out his/her tongue or grip hands. He stated he had to hold the resident's eyes open to assess the pupils, which were noted to have been sluggish. The RN stated he was aware of the need to call the physician with any changes per the care plan, but he felt the need to get a second opinion on the resident's condition from another nurse (RN #2), who came to assess the resident at approximately 11:00 AM. He stated RN #2 administered two (2) sternal rubs on the resident and the process was begun to get the resident to the ER. The RN stated looking back, I probably should have sent (him/her) out earlier. Review of the Hospital Physician Consultation Reports, dated 03/14/15, revealed the resident was diagnosed with [REDACTED]. TPA was not administered because the time the resident was last known well, was greater than three (3) hours prior to arrival. The resident was admitted to the Intensive Care Unit, was unresponsive, non-communicative, and required a Gastric Feeding Tube (GT), due to the inability to sustain nutrition. Interview with the Director of Nursing (DON), on 05/18/15 at 5:30 PM, revealed there was no evidence the staff members followed the plan of care and ensured the resident was fully assessed after the PRN medications were were administered on 03/13/14 at 2:35 PM; and, after CNA #1 and the Resident's Spouse's concerns were made to the nurses. Interview with the Administrator, on 05/18/15 at 5:05 PM, revealed staff should have assessed the resident and called the physician, when they first noticed the resident's change in cognition. He stated staff should have the followed the plan of care for the resident. 2. Record review revealed the facility readmitted Resident #1 on 03/27/15 with [DIAGNOSES REDACTED]. The facility readmitted Resident #1 again, after a hospital stay on 04/10/15, due to leakage of fluids around the [DEVICE] site. Review of the resident's Activity of Daily Living Plan of Care, dated 05/01/15, revealed the resident was unresponsive, totally dependent of staff for all care needs, NPO (nothing by mouth), and dependent on a Gastric Tube (GT) for all medications and nutrition and was incontinent of bowel and bladder. Review of the ADL plan of Care, dated 04/10/15, revealed nail care was to have been provided as needed, and oral care was required daily and PRN. Review of the care plan for Impaired Skin Integrity, dated 04/28/15, revealed due to the oral mucous membrane having a thick, brown film and the resident breathing through the mouth and rarely closing the mouth, oral care was to have been provided several times a day and the resident was to only get bed baths, due to continuous tube feeding and treatment for [REDACTED]. Review of the Physician order [REDACTED]. Interview with the hospital Certified Nurse Aide (CNA) #3, on 05/13/15 at 4:25 PM, revealed she was working in the emergency room (ER) at the hospital, when Resident #1 was admitted on [DATE]. CNA #3 stated the resident presented to the ER with a foul odor, had fingernails with blackened debris under the nailbeds and was in need of mouth care, as the resident's oral cavity was full of a crusty, cake-like build-up that took fourteen (14) pink swabs to clean. The CNA also revealed there were dark rings on the sheets and stated the Director of Nursing (DON) at the nursing facility, had been called and made aware of the hospital's concerns with this resident. Interview with hospital Registered Nurse (RN) #3, on 05/14/13 at 11:13 AM, revealed she was also working at theER on [DATE], when Resident #1 was admitted . RN #3 stated the sheets had old, dried urine rings around them and yet the resident had on a clean brief, his/her nails had brown sediment packed under the nailbeds and dried blood on the fingertips, from what looked like Accu-checks, taken for blood sugar levels. The RN described the resident's mouth as having caked-on debris in the roof of the resident's mouth and noted copious amounts of yellow, dried particles, as the resident's mouth was swabbed. Review of the ER Physician's Clinical Report, dated 05/06/15, revealed the resident arrived at the ER at approximately 7:32 AM and the resident's chief complaint was green drainage from all orifices, and report on arrival was the resident had very poor mouth care with lots of oral secretions and also some mild drainage from around the GT site, but also appeared to have very poor local care around the GT. Interviews, on 05/13/15 with CNA #8 at 1:25 PM and CNA #9 at 2:35 PM, revealed both CNAs stated the resident was bathed, mouth care was completed and the resident had clean sheets and a clean gown upon leaving the facility. CNA #8 stated she would clean the resident's mouth every time he/she was turned, approximately every two (2) hours and nail care was done with the bed bath. CNA #9 stated the resident received daily bed baths and mouth care was completed every hour and every time she went into the room, as the resident was a mouth breather and had the feeding tube and always had dried mucous in his/her mouth. Interview with LPN #1, on 05/15/15 at 10:07 AM, revealed it seemed like the more the CNAs cleaned (his/her) mouth, the more it needed cleaning. The LPN also stated the CNAs should be following the care plans and should be administering nail care each shift, when the bed bath was completed. The LPN monitored nail care during the weekly skin assessments. However, the resident's last skin assessment was completed on 05/01/15 and not due again, until 05/07/15. The resident was transported, per ambulance, to the hospital on [DATE]. Interview with RN #4, on 05/14/15 at 9:12 AM, revealed she assessed the resident prior to leaving the facility and did leave some of the bright green drainage around the resident's GT site because I wanted them to see it. The RN stated she also assisted the CNAs to clean the resident, prior to transfer and stated he/she had a fresh gown and linens and stated the resident was a mouth breather and residents with this and a GT will have a thrushy mouth. The RN stated the resident was a Full Code and she was afraid he/she had developed a massive infection of some sort and stated it did not take fifteen (15) minutes to get the resident out to the ER and she did not notice a problem with the fingernails. The RN stated she took the report from the hospital, and the hospital staff stated it took them over an hour to clean the resident up. The RN revealed she reported the call to the Director of Nursing (DON). Interview with the DON, on 05/15/15 at 12:35 PM, revealed all residents' nails would be kept clean on a daily basis and trimmed as necessary and all nails would be trimmed by the nursing assistants except for the diabetic residents and their nails would be trimmed by the licensed nurse. The DON stated she would have expected the nail and mouth care to have been completed, as specified on the care plan. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides at the facility. 2. On 05/18/15, assessments were conducted for eighty-one (81) of eighty-one (81) current residents, to determine if there were any medical needs requiring physician notification that the physician was not already aware of. This assessment included vital signs, respiratory assessment, bowel sounds, and changes in level of consciousness. There were no identified residents with a change in condition that the physician was not aware of, or that required further physician notification. 3. The DON and ADON conducted an audit of all current residents, on 05/18/15, to identify any resident who had received an as needed (PRN) pain medication, in the past twenty four hours and to ensure that a follow up to the effectiveness or adverse side effects of the PRN pain medication was completed. There were no noted adverse side effects of any PRN pain and all had effect relief of pain and there were no identified residents with a change in condition that the physician was not aware of or requiring further physician notification. 4. On 05/18/15 through 05/19/15 the DON, ADON, Unit Managers and the MDS Coordinator reviewed all current residents' plans of care to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. On 05/18/15, the Regional Quality Manager re-educated the DON, ADON, Unit Managers for all three units (Units One (1), Two (2) and Three (3) and the MDS Coordinator on Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS (Centers for Medicare and Medicare Services), to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. 6. On 05/18/15, all license staff was re-educated by the DON, ADON and Unit Managers Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS, to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. No licensed staff will work after 05/20/15 without having completed this re-education and competency test. All newly employed licensed nurses will receive this education prior to taking sole charge of a unit. On 05/18/15 and ongoing all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. In addition, re-education was provided related to reporting a change in condition to the Charge Nurse. If there are further concerns, the CNAs were then to report to the other nurse and up the chain of command. A competency test was administered to validate understanding with a minimum score of 100% accuracy and all CNAs passed with 100 % accuracy. No staff will work at the facility, after 05/20/15, without having this training and competency test with a minimum score of 100% accuracy, any staff not receiving 100% accuracy will be immediately re-educated and will not work until competency test is 100% accurate. 7. Beginning 05/18/15, the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents' conditions each shift, to determine if licensed staff were notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. This will continue on each shift including weekends until the Immediate Jeopardy is lifted, then five (5) times per week for twelve (12) weeks thereafter. 8. The DON, ADON or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 9. The DON, ADON, or Unit Managers, or the MDS Coordinator audited all narcotic records daily, to identify any PRN pain medication given and compare to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented, weekly including weekends, until the Immediate Jeopardy was lifted then five (5) times a week for twelve (12) weeks thereafter. 10. An Ad Hock Quality Assurance and Performance Improvement (QAPI) Committee was convened to review the facility investigation and concerns. An allegation of compliance was developed and reviewed with the Medical Director, who attended via phone. The results of all audits will be reviewed with the Quality Assurance and Improvement Committee weekly, until substantial compliance has been achieved, then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. The resident no longer resides at the facility. 2. Review of the 100% (81 of 81) resident assessments, dated 05/18/15, revealed the residents were assessed to determine if there were any medical needs to warrant physician notification with no concerns identified. Chart reviews were completed on Residents #4, #5 and #6 with no identified areas of concern. 3. Review of the DON and ADON conducted audits of all current residents, dated 05/18/15 to identify any resident that required a PRN medication and to ensure a follow-up assessment, monitoring for any side effect or reactions and to evaluate the effectiveness of the PRN, revealed they were completed without concerns. 4. Review of the audits dated 05/18/15 through 05/19/15 completed by the DON, ADON, Unit Managers and MDS Coordinator revealed all current residents' plans of care were reviewed to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. Materials and sign-in sheets, dated 05/18/15,were reviewed regarding in-services held by the Regional Quality Manager, for the Nursing Administration Staff and re-training on the EMAR system, documentation of PRN medications, physician notification, care planning and the INTERACT process were reviewed. Review of the Competency testing revealed staff had a 100% pass rate with no concerns noted. Interview with the DON, on 05/28/15 at 10:45 AM, revealed she and the Administrative Nurses had all had the re-education completed by the Regional Quality Manager related to assessments, implementing the care plan, change of condition, documentation of PRN medications, and physician notification and the INTERACT process. 6. Materials and sign-in sheets, dated 05/18/15-05/20/15, revealed the DON, ADON and Unit Managers re-educated all licensed staff on the same requirements with a competency test with a minimum score of 100% accuracy required. Staff interviews conducted on 05/28/15 with LPN #4 at 8:35 AM; LPN #5 at 8:51 AM; RN #2 at 10:12 AM; LPN #6 at 10:25 AM revealed the training had been completed and all the licensed staff had passed the test. On 05/18/15 through 05/20/15 all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse and notify the nurse of a change in condition and going up the chain of command. There were competency tests with a minimum score of 100% accuracy. Staff interviews on 05/28/15 with CNA #4 at 9:17 AM; CNA #5 at 9:25 AM; CNA #6 at 10:35 AM; and CNA #7 at 10:38 AM revealed the staff verified their training had been done and they had been tested regarding the care plans and notification of a change in condition. 7. Reviews of the every shift audits, dated 05/18/15 to 05/20/15, revealed the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents conditions each shift, to determine if licensed staff was notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. Interview with the DON, on 05/28/15 at 10:45 AM, revealed audits for residents' change of condition, notification of physician, and follow-up assessments were done on each shift until the AoC was accepted, and were now being done five times a week for twelve weeks. She stated the results of these audits will be reviewed in the QA Meetings. 8. Review of audits conducted by the DON, ADON or Unit Manager revealed five (5) residents' plans of care were reviewed to evaluate if interventions were in place and being followed. 9. Review of daily audits conducted by the DON, ADON, Unit Managers, or the MDS Coordinator revealed all narcotic records were audited daily, to identify any PRN pain medication administered and compared to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented. 10. A review of the QA meetings, dated 05/20/15, 05/21/15 and 05/22/15, revealed the agenda regarded concerns with the allegation deficiencies as well as the annual survey deficiencies, complaint, and facility self-reported complaints. The meeting was attended by the Administrator, DON, Activities Director, MDS Coordinator, Business Office Manager, Dietary Services Manager, Medical Records, Housekeeping and Maintenance and the Marketing Manager. Interview with the Medical Clinical Officer (MCO) revealed the Medical Director attended the 05/18/15 meeting, by phone and was kept abreast of any concerns and the meetings were to continue weekly, then monthly until resolved.

Based on observation, interview, record review, and review of the facility's policy and procedure, hospital Physician Consultation Reports, and Lippincott Manual of Nursing Practice, Ninth Edition, it was determined the facility failed to ensure necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was reported to have exhibited declines in cognition, weight bearing, transferring, continence, and verbalization, beginning 03/13/15, after as needed (PRN) medications were administered. On 03/13/15, Resident #1's change in condition was reported to the Licensed Practical Nurse (LPN) #2; however, there was no documented evidence licensed staff had conducted an assessment related to the resident's decline. Resident #1 was admitted to the hospital, on 03/14/15, with [DIAGNOSES REDACTED]. The resident never regained the cognitive status or physical abilities held prior to the event and remained non-verbal, dependent on a Gastric Feeding Tube (GT) for nutritional support, incontinent and totally dependent on staff for all care needs. The facility's failure to ensure necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care when a resident had a decline in intake and function has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/18/15 and determined to exist on 03/13/15. The facility was notified of the Immediate Jeopardy on 05/18/15. An acceptable Allegation of Compliance (AoC) was received on 05/22/15, alleging the removal of Immediate Jeopardy on 05/21/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 05/28/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy for a Resident Change of Condition, undated, revealed the facility was to have notified the physician and family immediately, if there was a significant change of condition, regardless of the time. The Nurse will use standards of clinical practice and the Interact III process to make this determination on immediacy. Review of the Interact Communication Form used for guidance Before Calling the Physician, undated, required an assessment of the resident's Situation, Background, Appearance, and Review (SBAR Form) to have been utilized when the resident experienced a change of condition and prior to calling the physician. The staff was to have assessed the resident, observing the signs and symptoms the resident had experienced, checked the vital signs, reviewed recent progress notes, labs and etc., reviewed medication changes and alerts, evaluated the mental status, behaviors, respiratory, cardiovascular, abdominal, urine outputs, skin, pain, neurological and the Activities of Daily Living (ADLs) compared to the resident's baseline status as well as reviewing the resident's code status. Interview with the Corporate Clinical Nursing Specialist, on 05/15/15 at 1:00 PM, revealed the facility had no policy for assessments but instead referred to the Lippincott Manual of Nursing Practice, Ninth Edition, for guidance. Review of the Clinical Manifestations for a stroke, Lippincott page 506, revealed signs and symptoms of a stroke included numbness, weakness or loss of motor ability, difficulty swallowing, [MEDICAL CONDITION] of loss of speech, visual difficulties, altered cognitive abilities and self care deficits. Record review revealed the facility admitted Resident #1 on 03/12/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set assessment, dated 03/13/15, revealed the facility assessed Resident #1 as alert to person, place and time; had no long term or short term memory deficits, continent of bowel and bladder, on a regular diabetic diet with no chewing or swallowing difficulties, the resident's speech was understood and the resident understood others and had no limitations in range of movement. Review of the Interim Plan of Care, dated 03/12/15, revealed interventions for staff to record the effectiveness of the pain medications; monitor and record the side effects of the medications, assess for pain, and to report pain affecting daily life, monitor the resident's blood sugars, monitor for confusion and behaviors and report to the physician, as needed. In addition, due to a fall at home and to medical, neurological and pharmacological factors, there were interventions to implement neurological assessments, as needed. Review of the Physician Orders, dated 03/12/15, revealed an order for [REDACTED]. Review of the Nursing Notes, dated 03/13/15 at 2:53 PM, revealed Licensed Practical Nurse (LPN) #1 documented the resident was awake and alert, with some confusion. Medicated times one for pain. Resident feeds self with tray set up. Appetite good. Fluids given with good results. Able to make wants and needs known. Resident is very needy and demanding. Continent of bowel and bladder. Feeds self with tray set up. However, review of the March 2015 Electronic Medication Administration Record [REDACTED]. Interview with Certified Nursing Assistant (CNA) #1, on 05/15/15 at 11:35 AM, revealed he had worked with Resident #1 on 03/13/15, on the 2:30 PM - 10:30 PM shift and noticed a change in the resident, from the previous afternoon (03/12/15.) CNA #1 stated on 03/12/15, the resident had frequently requested the bedpan and was able to roll over on his/her side and hold to the side rail and able to ambulate with a walker, after assisting the resident out of the bed or chair. CNA #1 revealed on 03/13/15, the resident was sleeping in a chair and would not wake up. The CNA stated he called on two (2) Emergency Medical Technicians (EMTs) who were in the building for another resident, to assist him to get the resident out of the chair as he/she was dead weight, and unable to assist with standing or pivoting. He also stated the spouse was visiting and stated he/she had never seen the resident like this. CNA #1 revealed vital signs were taken and were within the resident's normal range and the CNA informed the LPN #2 of his and the spouses' concerns and was assured it was due to the (PRN) medications, that were administered at approximately 3:00 PM. Interview with CNA #2, on 05/15/15 at 11:40 AM, revealed the CNA also worked the 2:30 PM - 10:30 PM shift on 03/13/15 and was told Resident #1 had just received PRN medication and the resident was up in a chair and dozing off at the start of the shift and the CNA stated she tried to wake the resident just before supper, and the resident would not wake up or eat supper. The CNA stated the resident would open his/her eyes but go right back to sleep and had to be assisted back to bed and the resident had previously been able to transfer him/herself with a walker and the CNA figured it was just the medication, and stated nobody knew much about him/her. Interview with Resident #1's Spouse, on 05/12/15 at 9:50 AM and 05/17/15 at 5:11 AM, revealed the spouse had visited the resident on 03/13/15 after supper and stated the resident never ate the supper meal. The spouse stated staff brought the tray in and sat it on the table and the food had not been touched when the staff came and picked the tray up. The spouse stated the resident looked drugged out or over-medicated. The spouse also stated it took three (3) people to get the resident back in the bed that afternoon due to the resident being so lethargic. Further interview revealed the spouse revealed two (2) ambulance personnel were in the building and the male CNA asked them to help him get the resident back to bed because he/she was not bearing weight at all. The spouse stated he/she stayed until about 9:00 PM and the resident looked like (he/she) was gone. The spouse revealed the resident had never had this type of reaction to the medication before and the resident never slept more than two (2) or three (3) hours at a time, because he/she was in so much pain all the time, from a spinal fracture in December 2014. The spouse stated he/she told two (2) or three (3) staff members he was concerned, yet was unsure exactly who was told. He/She stated he/she felt they should have gotten (the resident) out then. He requested they take the vital signs and was told they were fine and the resident was just resting from the PRN medication. Interview with LPN #1, on 05/15/15 at 9:55 AM and 05/18/15 at 3:38 PM, revealed the LPN had worked the 6:00 AM - 6:00 PM shift on 03/13/15 when the resident had repetitive complaints regarding the sheets not fitting properly and requested to place the call light in different areas and stated this was the concern with the resident's needy and demanding behaviors, that were documented in the Nursing Notes. The LPN stated she had given [MEDICATION NAME] five (5)/325 milligrams (mg) and [MEDICATION NAME] 0.5 mg, as a PRN, on 03/13/15, at approximately 2:30 PM, for the resident's and the spouse's complaints of nervousness and chronic pain and this was the first time the LPN had administered these medications to the resident. The LPN was unsure as to why the results of the effectiveness of the PRNs were not documented, except that it had been a very busy week. She stated she went by the room at approximately 5:00 PM and the resident was up in the chair talking and eating . The LPN stated it was a busy day and was able to get help from RN #4, who was the Unit Manager. Interview with RN #4, on 05/15/14 at 11:00 AM, revealed Resident #1 was a little woozy after receiving the PRNs on 03/13/15. She stated if she had been given those medications, she would have been woozy too. The RN stated the resident was helped to bed and went right to sleep, after having eaten the supper meal. However, review of the consumption records for the ADL documentation by the CNAs, dated 03/13/15-03/14/15 revealed the resident refused the dinner meal, on 03/13/15. The RN stated the results of the PRN should have been documented in the chart and EMARs. Interview with LPN #2, on 05/15/15 at 11:10 AM and on 05/16/15 at 3:28 PM, revealed the LPN worked the 6:00 PM - 6:00 AM shift, on 03/13/15 and stated the resident was sleeping when the LPN made rounds at the start of her shift and the spouse was visiting at the bedside. LPN #2 stated the resident never fully awakened, throughout the night; however, he/she pulled his/her arm away when vital signs and accuchecks, (for blood sugar testing,) were administered. The LPN denied any report from CNAs or the family regarding any concerns with the resident and felt the resident was resting well from receiving the PRN medications, as the vital signs and blood sugar levels were within the resident's normal levels and felt there was need for further assessments. However, review of March 2015 EMARS revealed the blood sugar was initialed but there was no evidence the results had been documented. Review of Nursing Notes documented by Registered Nurse (RN) #1, dated 03/14/15 at 8:47 AM, revealed Resident has been very unresponsive, I believe this to be because he/she had received pain medication prior to my shift, according to report, he/she does not react particularly well and has sluggish pupil [MEDICATION NAME]. The next entry, made by RN #1, on 03/14/15 at 11:36 AM, revealed the resident was unresponsive to two sternal rubs and sent to the emergency room (ER) at 11:34 AM. Review of the Hospital Physician Consultation Reports, dated 03/14/15, revealed the Attending Physician's clinical impression was a non-traumatic [MEDICAL CONDITION] involving a distal branch of the posterior cerebral artery. TPA was not administered because the time the patient was last known well, was greater than three hours prior to arrival. Interview with RN #1, on 05/15/15 at 8:25 PM and 10:40 AM and 05/17/15 at 4:09 PM, revealed he worked the 6:00 AM - 6:00 PM shift on 03/14/15 and the Resident #1 was mostly unresponsive when he started his shift at 6:00 AM and remained that way, until sent to the ER at 11:34 AM. He stated on 03/14/15 at approximately 8:00 AM, he had taken the resident's Pulse Oximeter reading (used to measure the oxygen saturation of the blood) and this was 96 percent, with a heart rate of 109 and the RN stated he felt he had a window of time to work in and he felt the PRN medications were still hanging around. The RN made an entry into the Nursing Notes at 8:47 AM and he had checked in on (him/her) several times and stated there was no facial drooping, yet the resident was unable to follow commands to stick out his/her tongue or grip the RN's hands, to test for grip strength and stated he had to hold (his/her) eyes open to assess the pupils, which were noted to have been sluggish. Vital signs were not taken at that time but he/she did obtain them prior to sending the resident to the hospital at 11:34 AM. The RN stated he started working on the SBAR tool, for guidance at 9:00 AM and noted the resident was drowsy and lethargic at that time. He stated he had graduated from RN school five (5)months ago and felt the need to get a second opinion on the resident's condition from another nurse working at the time. RN #2 came to assess the resident at approximately 11:00 AM, administered two sternal rubs on the resident and the process was begun to get the resident to the ER, the spouse and physician were called and the resident left the facility at 11:34 AM. The RN stated looking back, I probably should have sent (him/her) out earlier. Interview with RN #2, on 05/14/15 at 9:15 AM, revealed she was not the resident's assigned nurse on 03/14/15, but was working another area, at approximately 11:00 AM, when RN #1 asked her to come and take a look at the resident. The RN stated the resident was not responsive to sternal rubs and she assisted the staff to get the resident to the ER, as the resident was a Full Code. Interview with the Director of Nursing (DON), on 05/18/15 at 5:30 PM, revealed she was on a medical leave of absence during this time and felt if the LPN had entered the PRN medications into the EMAR, there would have been an automatic pop up to remind the nurse the follow- up assessment was due, regarding the effectiveness or possible side-effects of the PRN medications. However, this was not done, there was no evidence the resident was fully assessed after the PRN, after concerns from CNA #1 and the spouses concerns were made and prior to having unresponsiveness to two sternal rubs and being sent to the ER. Interview with the Assistant Director of Nursing (ADON), on 05/18/15 at 6:00 PM, revealed she also had medical issues during this time frame and had to be out of the facility, but would have expected the staff to have assessed the resident and called the physician with any change of condition. Interview with the Administrator, on 05/18/15 at 5:05 PM, revealed the Administrator had been made aware of the resident having been administered the PRNs, although she was unsure when and stated she talked to the spouse, who stated the resident had been having a difficult time sleeping and was glad the resident was finally getting some rest. However, she stated the staff should have assessed the resident and called the physician, when they first noticed the change in mentation. Interview with the Resident #1's attending physician at the facility, on 05/15/15 at 12:16 PM, revealed if the resident was drowsy, early on after administration of the medications was not unusual and stated it was not concerning whether or not they had called me at 8:30 AM or 11:30 AM as 90 percent (%) of [MEDICAL CONDITION] occur while sleeping. You have to look back to the last time the resident was normal before an acute intervention, as TPA, (Tissue Plasminogen Activator, a medication given to break down blood clots) could have been administered effectively and this has to be within the three hour window of time, from the last resident's normal. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides at the facility. 2. On 05/18/15, assessments were conducted for eighty-one (81) of eighty-one (81) current residents, to determine if there were any medical needs requiring physician notification that the physician was not already aware of. This assessment included vital signs, respiratory assessment, bowel sounds, and changes in level of consciousness. There were no identified residents with a change in condition that the physician was not aware of, or that required further physician notification. 3. The DON and ADON conducted an audit of all current residents, on 05/18/15, to identify any resident who had received an as needed (PRN) pain medication, in the past twenty four hours and to ensure that a follow up to the effectiveness or adverse side effects of the PRN pain medication was completed. There were no noted adverse side effects of any PRN pain and all had effect relief of pain and there were no identified residents with a change in condition that the physician was not aware of or requiring further physician notification. 4. On 05/18/15 through 05/19/15 the DON, ADON, Unit Managers and the MDS Coordinator reviewed all current residents' plans of care to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. On 05/18/15, the Regional Quality Manager re-educated the DON, ADON, Unit Managers for all three units (Units One (1), Two (2) and Three (3) and the MDS Coordinator on Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS (Centers for Medicare and Medicare Services), to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. 6. On 05/18/15, all license staff was re-educated by the DON, ADON and Unit Managers Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS, to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. No licensed staff will work after 05/20/15 without having completed this re-education and competency test. All newly employed licensed nurses will receive this education prior to taking sole charge of a unit. On 05/18/15 and ongoing all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. In addition, re-education was provided related to reporting a change in condition to the Charge Nurse. If there are further concerns, the CNAs were then to report to the other nurse and up the chain of command. A competency test was administered to validate understanding with a minimum score of 100% accuracy and all CNAs passed with 100 % accuracy. No staff will work at the facility, after 05/20/15, without having this training and competency test with a minimum score of 100% accuracy, any staff not receiving 100% accuracy will be immediately re-educated and will not work until competency test is 100% accurate. 7. Beginning 05/18/15, the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents' conditions each shift, to determine if licensed staff were notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. This will continue on each shift including weekends until the Immediate Jeopardy is lifted, then five (5) times per week for twelve (12) weeks thereafter. 8. The DON, ADON or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 9. The DON, ADON, or Unit Managers, or the MDS Coordinator audited all narcotic records daily, to identify any PRN pain medication given and compare to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented, weekly including weekends, until the Immediate Jeopardy was lifted then five (5) times a week for twelve (12) weeks thereafter. 10. An Ad Hock Quality Assurance and Performance Improvement (QAPI) Committee was convened to review the facility investigation and concerns. An allegation of compliance was developed and reviewed with the Medical Director, who attended via phone. The results of all audits will be reviewed with the Quality Assurance and Improvement Committee weekly, until substantial compliance has been achieved, then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. The resident no longer resides at the facility. 2. Review of the 100% (81 of 81) resident assessments, dated 05/18/15, revealed the residents were assessed to determine if there were any medical needs to warrant physician notification with no concerns identified. Chart reviews were completed on Residents #4, #5 and #6 with no identified areas of concern. 3. Review of the DON and ADON conducted audits of all current residents, dated 05/18/15 to identify any resident that required a PRN medication and to ensure a follow-up assessment, monitoring for any side effect or reactions and to evaluate the effectiveness of the PRN, revealed they were completed without concerns. 4. Review of the audits dated 05/18/15 through 05/19/15 completed by the DON, ADON, Unit Managers and MDS Coordinator revealed all current residents' plans of care were reviewed to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. Materials and sign-in sheets, dated 05/18/15,were reviewed regarding in-services held by the Regional Quality Manager, for the Nursing Administration Staff and re-training on the EMAR system, documentation of PRN medications, physician notification, care planning and the INTERACT process were reviewed. Review of the Competency testing revealed staff had a 100% pass rate with no concerns noted. Interview with the DON, on 05/28/15 at 10:45 AM, revealed she and the Administrative Nurses had all had the re-education completed by the Regional Quality Manager related to assessments, implementing the care plan, change of condition, documentation of PRN medications, and physician notification and the INTERACT process. 6. Materials and sign-in sheets, dated 05/18/15-05/20/15, revealed the DON, ADON and Unit Managers re-educated all licensed staff on the same requirements with a competency test with a minimum score of 100% accuracy required. Staff interviews conducted on 05/28/15 with LPN #4 at 8:35 AM; LPN #5 at 8:51 AM; RN #2 at 10:12 AM; LPN #6 at 10:25 AM revealed the training had been completed and all the licensed staff had passed the test. On 05/18/15 through 05/20/15 all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse and notify the nurse of a change in condition and going up the chain of command. There were competency tests with a minimum score of 100% accuracy. Staff interviews on 05/28/15 with CNA #4 at 9:17 AM; CNA #5 at 9:25 AM; CNA #6 at 10:35 AM; and CNA #7 at 10:38 AM revealed the staff verified their training had been done and they had been tested regarding the care plans and notification of a change in condition. 7. Reviews of the every shift audits, dated 05/18/15 to 05/20/15, revealed the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents conditions each shift, to determine if licensed staff was notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. Interview with the DON, on 05/28/15 at 10:45 AM, revealed audits for residents' change of condition, notification of physician, and follow-up assessments were done on each shift until the AoC was accepted, and were now being done five times a week for twelve weeks. She stated the results of these audits will be reviewed in the QA Meetings. 8. Review of audits conducted by the DON, ADON or Unit Manager revealed five (5) residents' plans of care were reviewed to evaluate if interventions were in place and being followed. 9. Review of daily audits conducted by the DON, ADON, Unit Managers, or the MDS Coordinator revealed all narcotic records were audited daily, to identify any PRN pain medication administered and compared to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented. 10. A review of the QA meetings, dated 05/20/15, 05/21/15 and 05/22/15, revealed the agenda regarded concerns with the allegation deficiencies as well as the annual survey deficiencies, complaint, and facility self-reported complaints. The meeting was attended by the Administrator, DON, Activities Director, MDS Coordinator, Business Office Manager, Dietary Services Manager, Medical Records, Housekeeping and Maintenance and the Marketing Manager. Interview with the Medical Clinical Officer (MCO) revealed the Medical Director attended the 05/18/15 meeting, by phone and was kept abreast of any concerns and the meetings were to continue weekly, then monthly until resolved.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to maintain clinical records that were complete and accurately documented for one (1) of three (3) sampled residents (Resident #1), related to incomplete documentation of Electronic Medication Administration Records (EMARs), assessments, accuchecks and services provided. The facility failed to document in the clinical record the as needed medications administered to Resident #1 on 03/13/15; failed to document the results and effectiveness of the PRN medications on the Electronic Medication Administration Record [REDACTED]. Review of the physician's order, dated 03/12/15, revealed accuchecks before meals (AC) and at bedtime (HS). The facility's failure to document narcotics administered in the EMARs, failure to document and complete a follow-up assessment, and failure to accurately document and assess Resident #1's condition, for approximately 18 hours, after medication administration, resulting in the failure of the resident being treated with clot busting medications, during the three hour window of time needed. The facility failed to maintain clinical records that were complete and accurately documented caused, or was likely to cause, serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on 05/18/15 and determined to exist on 03/13/15. The facility was notified of the Immediate Jeopardy on 05/18/15. The findings include: Review of the facility's policy and procedure titled, Medication Administration, undated, revealed the staff were required to indicate the reason for the administration and effectiveness of PRN medication in the chart, on the back of the MAR. Review of the facility Guidelines for Nursing Care, Clinical Quality Assessment Performance Improvement (QAPI) Daily Review Process, dated 08/01/14, revealed the purpose was to ensure the admission charts/ readmission charts; physician orders, incident reports, infections, labs, 24 hour reports, Accu-nurse Alerts, Situation, Background, Appearance and Review (SBAR) from the previous day (or week-end, if on Monday morning), are to be reviewed for completion and follow-up in the Clinical Daily Review Meeting. Record review revealed the facility admitted Resident #1 on 03/12/15 with [DIAGNOSES REDACTED]. Review of the Physician Orders, dated 03/12/15, revealed as needed (PRN) orders for [MEDICATION NAME] 0.5 milligrams (mg) orally, four times daily for anxiety; [MEDICATION NAME] five (5)/325 mg tablet orally every six (6) hours for pain; and, Accu-checks (to assess blood sugars) four (4) times a day, before meals and at bedtime. Review of the Admission/ Readmission Checklist, dated 03/12/15, revealed the medication orders were verified and signed off by two (2) nurses. Review of the Nursing Notes, dated 03/13/15 at 2:53 PM, revealed Licensed Practical Nurse (LPN) #1 administered medication for pain and the resident was awake and alert, with some confusion. Review of the Controlled Substance Proof Records for PRN [MEDICATION NAME] and [MEDICATION NAME] for Resident #1 revealed these medications were administered on 04/13/15 at 2:35 PM and there was no documented evidence they were administered on 03/13/15 at 2:53 PM. Review of Resident #1's EMARs, for 03/13/15 revealed there was no documentation [MEDICATION NAME] or [MEDICATION NAME] had been administered to Resident #1 on 03/13/15 at approximately 2:35 PM or a follow-up assessment was conducted to determine the effectiveness of the PRN medications. In addition, further review of the Nursing Notes, revealed there was no documented evidence the resident was assessed for the effectiveness of the medication Hospital record review and interview with Licensed Practical Nurse (LPN) #1, on 05/15/15 at 10:40 AM, revealed the resident was in the hospital on [DATE]. LPN #1 stated she should have dated the [MEDICATION NAME] and [MEDICATION NAME] as administered on 03/13/15 at 2:35 PM, instead of 04/13/15 at 2:35 PM. LPN #1 stated she did not know why the effectiveness of the medication was not documented but it was a busy day and Registered Nurse (RN) #4 helped her that day. Interview with RN #4, on 05/15/14 at 11:13 AM, revealed the results of the PRN should have been documented in Resident #1's chart and EMARs. RN #4 stated she assisted with chart audits; however, she did not check the nurses' documentation in the chart. Interview with the Resident #1's Family Member, on 05/17/15 at 5:11 PM revealed on 03/13/15, after the supper meal, a nurse came into the resident's room to check the resident's blood sugar and found it to be 600. The family member asked what the staff was going to do and was told they were going to give the insulin. Further review of the March 2015 EMARs revealed there were two (2) different entries for Accu-checks, one for three (3) times a day and one for four (4) times a day even though there was no physician's order to obtain blood sugar levels three times a day. In addition, there was an order to administer Humalog (insulin) 10 units SQ every day before each meal, at 6:30 AM; 1:00 PM and 6:00 PM and [MEDICATION NAME] (insulin) 30 units SQ at bedtime. Review of the March 2015 EMARs revealed there were initials indicating Accu-checks were completed four (4) times a day on 03/13/15, Humalog 10 mg was administered before each meal and [MEDICATION NAME] 30 units was administered at bedtime (9:00 PM) on 03/13/15. However, there was no documentation of the resident's blood sugar readings that were conducted four times a day on 03/13/15. Review of the consumption records for the Activities of Daily Living (ADL) documentation by the CNAs, dated 03/13/15-03/14/15 revealed the resident refused the supper meal on 03/13/15 and the breakfast meal was not consumed on 03/14/15. Interviews on 05/15/15 with LPN #1 at 9:55 AM, LPN #2 at 11:10 AM, RN #1 at 8:25 AM and RN #4 at 11:00 AM, revealed there was a computer glitch that prevented the EMAR from recording the blood sugar readings, taken on 03/13/15. The RNs and LPNs stated the resident should have eaten the supper meal before the insulin was administered and stated if the blood sugars were over 400, the physician would have been called. Interview with the Director of Nursing (DON), on 05/18/15 at 5:30 PM, revealed the DON stated if the LPN had entered the PRN medications into the EMAR, there would have been an automatic pop up to remind the nurse the follow-up assessment was due, regarding the effectiveness or possible side-effects of the PRN medications. However, this was not done, and there was no documented evidence the resident was assessed for effectiveness after the PRN medications were administered and the accuchecks should have been documented into the resident's record. Interview with the Assistant Director of Nursing (ADON), on 05/18/15 at 6:00 PM, revealed she was responsible to ensure the 24 hour admission paperwork was completed correctly and she had reviewed the form, yet she did not audit the documentation but would have expected the staff to have documented correctly in the clinical record. Interview with the Administrator, on 05/18/15 at 5:05 PM, revealed she would have expected the staff to have correctly documented in the resident's chart and on the EMARs. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. The resident no longer resides at the facility. 2. Review of the 100% (81 of 81) resident assessments, dated 05/18/15, revealed the residents were assessed to determine if there were any medical needs to warrant physician notification with no concerns identified. Chart reviews were completed on Residents #4, #5 and #6 with no identified areas of concern. 3. Review of the DON and ADON conducted audits of all current residents, dated 05/18/15 to identify any resident that required a PRN medication and to ensure a follow-up assessment, monitoring for any side effect or reactions and to evaluate the effectiveness of the PRN, revealed they were completed without concerns. 4. Review of the audits dated 05/18/15 through 05/19/15 completed by the DON, ADON, Unit Managers and MDS Coordinator revealed all current residents' plans of care were reviewed to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. Materials and sign-in sheets, dated 05/18/15,were reviewed regarding in-services held by the Regional Quality Manager, for the Nursing Administration Staff and re-training on the EMAR system, documentation of PRN medications, physician notification, care planning and the INTERACT process were reviewed. Review of the Competency testing revealed staff had a 100% pass rate with no concerns noted. Interview with the DON, on 05/28/15 at 10:45 AM, revealed she and the Administrative Nurses had all had the re-education completed by the Regional Quality Manager related to assessments, implementing the care plan, change of condition, documentation of PRN medications, and physician notification and the INTERACT process. 6. Materials and sign-in sheets, dated 05/18/15-05/20/15, revealed the DON, ADON and Unit Managers re-educated all licensed staff on the same requirements with a competency test with a minimum score of 100% accuracy required. Staff interviews conducted on 05/28/15 with LPN #4 at 8:35 AM; LPN #5 at 8:51 AM; RN #2 at 10:12 AM; LPN #6 at 10:25 AM revealed the training had been completed and all the licensed staff had passed the test. On 05/18/15 through 05/20/15 all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse and notify the nurse of a change in condition and going up the chain of command. There were competency tests with a minimum score of 100% accuracy. Staff interviews on 05/28/15 with CNA #4 at 9:17 AM; CNA #5 at 9:25 AM; CNA #6 at 10:35 AM; and CNA #7 at 10:38 AM revealed the staff verified their training had been done and they had been tested regarding the care plans and notification of a change in condition. 7. Reviews of the every shift audits, dated 05/18/15 to 05/20/15, revealed the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents conditions each shift, to determine if licensed staff was notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. Interview with the DON, on 05/28/15 at 10:45 AM, revealed audits for residents' change of condition, notification of physician, and follow-up assessments were done on each shift until the AoC was accepted, and were now being done five times a week for twelve weeks. She stated the results of these audits will be reviewed in the QA Meetings. 8. Review of audits conducted by the DON, ADON or Unit Manager revealed five (5) residents' plans of care were reviewed to evaluate if interventions were in place and being followed. 9. Review of daily audits conducted by the DON, ADON, Unit Managers, or the MDS Coordinator revealed all narcotic records were audited daily, to identify any PRN pain medication administered and compared to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented. 10. A review of the QA meetings, dated 05/20/15, 05/21/15 and 05/22/15, revealed the agenda regarded concerns with the allegation deficiencies as well as the annual survey deficiencies, complaint, and facility self-reported complaints. The meeting was attended by the Administrator, DON, Activities Director, MDS Coordinator, Business Office Manager, Dietary Services Manager, Medical Records, Housekeeping and Maintenance and the Marketing Manager. Interview with the Medical Clinical Officer (MCO) revealed the Medical Director attended the 05/18/15 meeting, by phone and was kept abreast of any concerns and the meetings were to continue weekly, then monthly until resolved.

Based on interview, record review, review of the hospital's Physician Consultation Reports, the facility's policy and procedure and the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #27 Components of Licensed Practical Nursing (LPN) Practice, it was determined the facility failed to ensure services provided by the facility met the professional standards of quality for one (1) of three (3) sampled residents (Resident #1). On 03/13/15 at 2:35 PM, Resident #1 was administered two as needed (PRN) medications, [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for anxiety.) LPN #1 failed to assess the resident according to professional standards of quality, after giving the medications and failed to document the effectiveness of the medications. LPN #2 failed to assess the resident at the beginning of the shift and also failed to assess the resident after Certified Nurse Aide (CNA) #1 and a family member complained the resident needed the assistance of three (3) staff to assist back into bed; and, when staff made the licensed nurses aware they were unable to awaken the resident. The resident continued to decline and on 03/14/15, approximately eighteen (18) hours later, he/she was unresponsive to sternal rubs and was sent out to the hospital, where it was determined the resident had a massive stroke. The facility's failure to ensure care was provided according to the professional standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/18/15 and determined to exist on 03/13/15. An acceptable Allegation of Compliance (AoC) was received on 05/22/15, alleging the IJ was removed on 05/21/15. The State Survey Agency validated the Immediate Jeopardy was removed on 05/21/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the KBN AOS #27 Components of Licensed Practical Nursing (LPN) Practice, last revised 06/2014, revealed components of the LPN practice included assessment and interpretation of data. Assessment includes observations of appearance and behavior; measurements of physical structure and physiologic function; and observations of a resident's subjective and objective signs and symptoms. Interpreting data includes recognizing existing relationships between data gathered and a resident's health status, established plan of care and medical treatment regimen; determining the resident's need for nursing intervention based upon data gathered regarding the resident's health status, ability to care for self, and established plan of care; and appropriate consultation. Review of Resident #1's closed record revealed the facility admitted the resident on 03/12/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident as being alert and oriented to person, place, and time; understood and understands with clear comprehension, on a regular diabetic diet, ambulatory with a walker, continent of bowel and bladder and the resident's short and long term memory were intact and he/she had no impairment in range of motion (ROM). Review of a Nursing Note, dated 03/13/15 at 2:53 PM, revealed LPN #1 administered medication for pain and the resident was awake and alert, with some confusion. Further review of the Nursing Notes revealed there was no documented evidence the nurse assessed the resident for the effectiveness of the medication. Review of Resident #1's March 2015 Electronic Medication Administration Records (EMARs) and further review of the Nursing Notes revealed there was no documented evidence LPN #1 assessed Resident #1 to determine the effectiveness of the PRN medication. Review of the Nurses' Notes for Resident #1, dated 03/13/15 at 2:53 PM, reveled LPN #1 documented the resident was awake and alert, with some confusion. Medicated x1 for pain. The next entry, documented by RN #1, dated 03/14/15 at 2:47 AM, revealed resident has been very unresponsive, I believe this to be because he/she had received pain medication prior to my shift, and according to report, he/she does not react well and has sluggish pupil [MEDICATION NAME]. The next entry made by RN #1, on 03/14/15 at 11:36 AM, revealed the resident was unresponsive to two (2) sternal rubs and was sent to the emergency room (ER) at 11:34 AM. Further review of the EMARs revealed no evidence of the documentation of the prn medications and no evidence of follow-up assessments of the prn medication. Interview with LPN #1, on 05/15/15 at 9:55 AM and, on 05/18/15 at 3:38 PM, revealed she worked the 6:00 AM to 6:00 PM shift on 03/13/15. LPN #1 stated the resident had repetitive complaints and both the resident and his/her spouse requested the resident have something for pain and anxiety. The LPN stated she had given [MEDICATION NAME] five (5)/325 milligrams (mg) and [MEDICATION NAME] 0.5 mg, as a PRN, on 03/13/15, at approximately 2:30 PM, for the resident's complaints of nervousness and chronic pain. LPN #1 stated this was the first time the resident had received these medications, at the facility. The LPN stated she was unsure why the [MEDICATION NAME] was not mentioned in the Nursing Notes, the medications were not documented on the EMARS and the results of the effectiveness of the PRNs were not documented. LPN #1 stated it had been a very busy week and she probably forgot. The LPN was unable to remember if the resident had been assessed, prior to her completing her shift at 6:00 PM. She stated the resident was sitting up eating supper when I left and was OK. However, review of the Meal Consumption Records for 03/13/15 revealed Resident #1 refused supper. Interview with Certified Nursing Assistant (CNA) #2, on 05/15/15 at 11:40 AM, revealed she was told Resident #1 had just received PRN medication and the resident was up in a chair and dozing off at the start of the shift. CNA #2 stated she tried to wake the resident just before supper and the resident would not wake up or eat supper. The CNA revealed the resident would open his/her eyes but go right back to sleep and had to be assisted back to bed. The CNA stated the resident had previously been able to transfer himself/herself with a walker. Interview with Certified Nurse Aide (CNA) #1, on 05/15/15 at 11:35 PM, revealed Resident #1 who had been alert, continent, able to verbalize needs and ambulate with the assistance of a walker on 03/12/15 had declined on 03/13/15 and was unable to awaken and needed the assistance of the CNA and two (2) ambulance workers to assist the resident back to bed as the resident was dead weight at approximately 6:00 PM. The CNA stated he reported this to LPN #2, who assured him, it was the PRN medication. Interview with Resident #1's Spouse, on 05/12/15 at 9:50 AM and 05/17/15 at 5:11 PM, revealed he/she had visited the resident on 03/13/15 after supper and stated the resident looked drugged out or over-medicated. The spouse stated he/she stayed until about 9:00 PM and the resident looked like (he/she) was gone. The spouse stated the resident had been on the same PRN medications at home and had never had this type of reaction to the medication before. He/She stated the resident never usually slept more than two (2) or three (3) hours at a time, because he/she was in so much pain all the time, from a spinal fracture in December 2014. Further interview revealed he/she had told two (2) or three (3) staff members of these concerns, and he/she felt they should have gotten (the resident) out then. The spouse stated he/she also requested vital signs be taken and was told they were fine and the resident was just resting from the PRN medication. Interview with LPN #2 on 05/15/15 at 11:10 AM; and, on 05/16/15 at 3:28 PM, revealed she made rounds at the start of her shift and the resident was sleeping. LPN #2 stated the resident never completely woke up during her shift, 6:00 PM to 6:00 AM on 03/13/15, yet pulled his/her arm away when vital signs and accu-checks (for blood sugar testing) were administered and these were within the resident's normal range. LPN #2 stated the resident was resting well from receiving the PRN medications and she did not feel the need for further assessments. Further review of the Nursing Notes revealed there was no documented evidence Resident #1 was assessed during her shift to determine if the resident had experienced a change in cognitive levels and responsiveness or a further investigation was conducted to determine if the resident had responded like this in the past to these medications. Review of the Meal Consumption Records revealed breakfast did not occur, on 03/14/15. Review of a Nursing Note documented by Registered Nurse (RN) #1, dated 03/14/15 at 8:47 AM, revealed the resident had been unresponsive and the RN believed it was due to the pain medication. The Notes revealed the resident had sluggish pupil [MEDICATION NAME]. However, there was no documented evidence the nurse notified the physician of the resident's change in condition or of any further assessment until 03/14/15 at 11:36 AM, when the resident was unresponsive to two (2) sternal rubs and sent to the emergency room (ER) at 11:34 AM. Interview with RN #1, on 05/15/15 at 8:25 PM and 10:40 AM; and, on 05/17/15 at 4:09 PM, revealed Resident #1 was mostly unresponsive when he started his shift at 6:00 AM and remained that way, until sent to the ER at 11:34 AM. The RN stated he did an assessment of the resident at 8:47 AM and stated there was no facial drooping, yet the resident was unable to follow commands to stick out his/her tongue or grip the RN's hands, to test for grip strength. RN #1 stated he had to hold (his/her) eyes open to assess the pupils, which were noted to have been sluggish. The RN stated he felt the need to get a second opinion on the resident's condition from another nurse working at the time. He stated RN #2, came to assess the resident at approximately 11:00 AM and administered two (2) sternal rubs to the resident and the process was begun to get the resident to the ER. Interview with RN #2, on 05/14/15 at 9:15 AM, revealed on 03/14/15 at approximately 11:00 AM, she was asked to come and take a look at Resident #1. The RN stated the resident was not responsive to sternal rubs and she assisted the staff to get the resident to the ER, as the resident was a Full Code. Review of the Hospital Physician Consultation Reports, dated 03/14/15, revealed the resident was diagnosed with [REDACTED]. TPA was not administered because the time the resident was last known well, was greater than three (3) hours prior to arrival. The resident was admitted to the Intensive Care Unit, and was unresponsive, non-communicative, and required a Gastric Feeding Tube (GT), due to the inability to sustain nutrition. Interview with the Assistant Director of Nursing (ADON), on 05/18/15 at 6:00 PM, revealed she would have expected the staff to have assessed the resident and called the physician with any change of condition. Interview with the Director of Nursing (DON), on 05/18/15 at 5:30 PM, revealed there was no evidence the resident was fully assessed after the PRN medications; nor after concerns from CNA #1 and the spouse were made to the nurses. She stated the LPNs should have assessed for a change in cognition and reported this to the physician. Interview with the Administrator, on 05/18/15 at 5:05 PM, revealed the staff should have assessed the resident and called the physician, when they first noticed the change in cognition. Interview with Resident #1's attending physician, on 05/15/15 at 12:16 PM, revealed the administration of the [MEDICATION NAME] and [MEDICATION NAME] would not have caused the stroke. He stated the resident having been drowsy, early on after the administration of the medications, would not have been unusual. However, the physician stated if the resident's condition had drastically changed, he would have expected the licensed staff to have made him aware of the change of condition. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides at the facility. 2. On 05/18/15, assessments were conducted for eighty-one (81) of eighty-one (81) current residents, to determine if there were any medical needs requiring physician notification that the physician was not already aware of. This assessment included vital signs, respiratory assessment, bowel sounds, and changes in level of consciousness. There were no identified residents with a change in condition that the physician was not aware of, or that required further physician notification. 3. The DON and ADON conducted an audit of all current residents, on 05/18/15, to identify any resident who had received an as needed (PRN) pain medication, in the past twenty four hours and to ensure that a follow up to the effectiveness or adverse side effects of the PRN pain medication was completed. There were no noted adverse side effects of any PRN pain and all had effect relief of pain and there were no identified residents with a change in condition that the physician was not aware of or requiring further physician notification. 4. On 05/18/15 through 05/19/15 the DON, ADON, Unit Managers and the MDS Coordinator reviewed all current residents' plans of care to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. On 05/18/15, the Regional Quality Manager re-educated the DON, ADON, Unit Managers for all three units (Units One (1), Two (2) and Three (3) and the MDS Coordinator on Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS (Centers for Medicare and Medicare Services), to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. 6. On 05/18/15, all license staff was re-educated by the DON, ADON and Unit Managers Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS, to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. No licensed staff will work after 05/20/15 without having completed this re-education and competency test. All newly employed licensed nurses will receive this education prior to taking sole charge of a unit. On 05/18/15 and ongoing all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. In addition, re-education was provided related to reporting a change in condition to the Charge Nurse. If there are further concerns, the CNAs were then to report to the other nurse and up the chain of command. A competency test was administered to validate understanding with a minimum score of 100% accuracy and all CNAs passed with 100 % accuracy. No staff will work at the facility, after 05/20/15, without having this training and competency test with a minimum score of 100% accuracy, any staff not receiving 100% accuracy will be immediately re-educated and will not work until competency test is 100% accurate. 7. Beginning 05/18/15, the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents' conditions each shift, to determine if licensed staff were notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. This will continue on each shift including weekends until the Immediate Jeopardy is lifted, then five (5) times per week for twelve (12) weeks thereafter. 8. The DON, ADON or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 9. The DON, ADON, or Unit Managers, or the MDS Coordinator audited all narcotic records daily, to identify any PRN pain medication given and compare to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented, weekly including weekends, until the Immediate Jeopardy was lifted then five (5) times a week for twelve (12) weeks thereafter. 10. An Ad Hock Quality Assurance and Performance Improvement (QAPI) Committee was convened to review the facility investigation and concerns. An allegation of compliance was developed and reviewed with the Medical Director, who attended via phone. The results of all audits will be reviewed with the Quality Assurance and Improvement Committee weekly, until substantial compliance has been achieved, then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. The resident no longer resides at the facility. 2. Review of the 100% (81 of 81) resident assessments, dated 05/18/15, revealed the residents were assessed to determine if there were any medical needs to warrant physician notification with no concerns identified. Chart reviews were completed on Residents #4, #5 and #6 with no identified areas of concern. 3. Review of the DON and ADON conducted audits of all current residents, dated 05/18/15 to identify any resident that required a PRN medication and to ensure a follow-up assessment, monitoring for any side effect or reactions and to evaluate the effectiveness of the PRN, revealed they were completed without concerns. 4. Review of the audits dated 05/18/15 through 05/19/15 completed by the DON, ADON, Unit Managers and MDS Coordinator revealed all current residents' plans of care were reviewed to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. Materials and sign-in sheets, dated 05/18/15,were reviewed regarding in-services held by the Regional Quality Manager, for the Nursing Administration Staff and re-training on the EMAR system, documentation of PRN medications, physician notification, care planning and the INTERACT process were reviewed. Review of the Competency testing revealed staff had a 100% pass rate with no concerns noted. Interview with the DON, on 05/28/15 at 10:45 AM, revealed she and the Administrative Nurses had all had the re-education completed by the Regional Quality Manager related to assessments, implementing the care plan, change of condition, documentation of PRN medications, and physician notification and the INTERACT process. 6. Materials and sign-in sheets, dated 05/18/15-05/20/15, revealed the DON, ADON and Unit Managers re-educated all licensed staff on the same requirements with a competency test with a minimum score of 100% accuracy required. Staff interviews conducted on 05/28/15 with LPN #4 at 8:35 AM; LPN #5 at 8:51 AM; RN #2 at 10:12 AM; LPN #6 at 10:25 AM revealed the training had been completed and all the licensed staff had passed the test. On 05/18/15 through 05/20/15 all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse and notify the nurse of a change in condition and going up the chain of command. There were competency tests with a minimum score of 100% accuracy. Staff interviews on 05/28/15 with CNA #4 at 9:17 AM; CNA #5 at 9:25 AM; CNA #6 at 10:35 AM; and CNA #7 at 10:38 AM revealed the staff verified their training had been done and they had been tested regarding the care plans and notification of a change in condition. 7. Reviews of the every shift audits, dated 05/18/15 to 05/20/15, revealed the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents conditions each shift, to determine if licensed staff was notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. Interview with the DON, on 05/28/15 at 10:45 AM, revealed audits for residents' change of condition, notification of physician, and follow-up assessments were done on each shift until the AoC was accepted, and were now being done five times a week for twelve weeks. She stated the results of these audits will be reviewed in the QA Meetings. 8. Review of audits conducted by the DON, ADON or Unit Manager revealed five (5) residents' plans of care were reviewed to evaluate if interventions were in place and being followed. 9. Review of daily audits conducted by the DON, ADON, Unit Managers, or the MDS Coordinator revealed all narcotic records were audited daily, to identify any PRN pain medication administered and compared to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented. 10. A review of the QA meetings, dated 05/20/15, 05/21/15 and 05/22/15, revealed the agenda regarded concerns with the allegation deficiencies as well as the annual survey deficiencies, complaint, and facility self-reported complaints. The meeting was attended by the Administrator, DON, Activities Director, MDS Coordinator, Business Office Manager, Dietary Services Manager, Medical Records, Housekeeping and Maintenance and the Marketing Manager. Interview with the Medical Clinical Officer (MCO) revealed the Medical Director attended the 05/18/15 meeting, by phone and was kept abreast of any concerns and the meetings were to continue weekly, then monthly until resolved.

Based on interview, record review, review of hospital consultation reports and review of the facility's policy and procedure, it was determined the facility failed to notify the physician and responsible party regarding a change in condition for one (1) of three (3) sampled residents (Resident #1). On 03/13/15 at approximately 6:00 PM, Resident #1 was noted with a decline in functional status as he/she was unable to assist with standing, needed the assistance of three (3) staff to transfer from the chair to the bed and was unable to eat his/her evening meal, after receiving two (2) as needed (PRN) medications, [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for anxiety) at 2:35 PM. Resident #1's change in condition was reported to Licensed Practical Nurse (LPN) #2 at the time; and, on 03/14/15 at 8:37 AM, Registered Nurse (RN) #1 identified Resident #1 was unresponsive; however, there was no documented evidence licensed staff notified the physician and Responsible Party. The resident continued to decline and on 03/14/15, approximately eighteen (18) hours later, he/she was unresponsive to sternal rubs and was sent out to the hospital, where it was determined the resident had a massive stroke. According to the emergency room (ER) Physician's Consult Report, dated 03/14/15, the resident was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. TPA (Tissue Plasminogen Activator), a medication given to break down blood clots, was not administered because the time the resident was last known well, was greater than three (3) hours prior to arrival. The resident was admitted to the Intensive Care Unit, was unresponsive, non-communicative, and required a Gastric Feeding Tube (GT), due to the inability to sustain nutrition. The facility's failure to notify the physician and the responsible party of a significant change in a resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/18/15 and determined to exist on 03/13/15. An acceptable Allegation of Compliance (AoC) was received on 05/22/15, alleging the Immediate Jeopardy was removed on 05/21/15, prior to exit. The State Survey Agency validated the Immediate Jeopardy was removed on 05/21/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure for the Notification of Resident Change in Condition, undated, revealed clinicians should immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status. If the change in the resident's condition is not crucial or significant, the resident's physician and family or legal representative will be notified at the earliest convenient time during regular business hours. The nurse may use the Interact Pathway/Guidelines for reference, but this should not supersede the nurses' judgment at bedside. Review of the facility's policy and procedure titled, Medication Administration, undated, revealed to notify the physician of changes in condition related to the medication regimen (improvement or decline.) Closed record review revealed the facility admitted Resident #1 on 03/12/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 03/13/15, revealed the facility assessed the resident to be alert and oriented to person, place, and time; short and long term memory were intact; he/she understood with clear comprehension, was on a regular diabetic diet, was ambulatory with a walker, had no impairment in range of motion (ROM), and was continent of bowel and bladder. Review of the Nursing Notes, dated 03/13/15 at 2:53 PM, revealed LPN #1 documented Resident #1 was awake and alert, with some confusion. Medicated times one (1) for pain. Resident feeds self with tray set up. Appetite good. Fluids given with good results. Able to make wants and needs known. Resident is very needy and demanding. Continent of bowel and bladder. Feeds self with tray set up. Interview with Certified Nurse Aide (CNA) #2, on 05/15/15 at 11:40 AM, revealed she worked the 2:30 PM -10:30 PM shift on 03/13/15. CNA #2 stated she was told Resident #1 had just received PRN medication and she observed the resident was up in a chair and dozing off at the start of the shift. CNA #2 revealed she tried to wake the resident just before supper, and the resident would not wake up or eat supper. The CNA stated the resident would open his/her eyes but go right back to sleep and had to be assisted back to bed. She stated the resident had previously been able to transfer himself/herself with a walker. Interview with CNA #1, on 05/15/15 at 11:35 AM, revealed he had worked with Resident #1 on 03/13/15, on the 2:30 PM -10:30 PM shift and noticed a change in the resident, from the previous afternoon (03/12/15.) CNA #1 stated the resident previously was able to make his/her needs known, able to move from side-to-side and hold on to the side rail to use the bedpan, and was able to ambulate with a walker, after the resident was assisted out of the bed or chair. CNA #1 stated on 03/13/15, at approximately 6:00 PM, the resident was sleeping in a chair and would not wake up. The CNA stated he called on two (2) Emergency Medical Technicians (EMTs), who were in the building for another resident, to assist him to get the resident out of the chair as he/she was dead weight, and unable to assist with standing or pivoting. CNA #1 stated the resident's spouse was visiting and stated he/she had never seen the resident like this. CNA #1 stated vital signs were taken and were within the resident's normal range and he informed LPN #2 of his (CNA #1) and the spouse's concerns and was assured it was due to the PRN medications. Interview with Resident #1's spouse, on 05/12/15 at 9:50 AM and on 05/17/15 at 5:11 PM, revealed the spouse had visited the resident on 03/13/15 after supper and the resident did not eat his/her supper. Resident #1's spouse stated the resident looked drugged out or over-medicated. The Spouse stated he/she stayed until about 9:00 PM and the resident looked like (he/she) was gone. The Spouse stated the resident had never had this type of reaction to the medication before and stated he/she never usually slept more than two (2) or three (3) hours at a time, because he/she was in so much pain all the time, from a spinal fracture in December 2014. Further interview with the resident's Spouse revealed he/she told two (2) or three (3) staff members he/she was concerned. He/She stated he/she felt they should have gotten (the resident) out then. He/She also stated he requested vital signs be taken and was told they were fine and the resident was just resting from the PRN medication. Interview with LPN #1, on 05/15/15 at 9:55 AM; and, on 05/18/15 at 3:38 PM, revealed she had worked the 6:00 AM - 6:00 PM shift on 03/13/15 when the resident had repetitive complaints and was needy and demanding. LPN #1 stated both the resident and the spouse requested the resident have something for pain and anxiety. The LPN stated she had given the resident [MEDICATION NAME] 5/325 milligrams (mg) and [MEDICATION NAME] 0.5 mg, as a PRN, on 03/13/15, at approximately 2:30 PM, for the resident's complaints of nervousness and chronic pain. She stated this was the first time she had administered these medications to the resident. The LPN stated no one made her aware that Resident #1 had a change in condition and the resident was OK when she left at 6:00 PM so she had no need to call the physician. However, review of the Nursing Notes and review of the March 2015 Electronic Medication Administration Record [REDACTED]. Interview with LPN #2, on 05/15/15 at 11:10 AM; and, on 05/16/15 at 3:28 PM, revealed the LPN worked the 6:00 PM - 6:00 AM shift, on 03/13/15. She stated the resident was sleeping as she made rounds at the start of her shift. LPN #2 stated the resident's spouse was visiting at the bedside and the resident never fully awakened, throughout the night, yet pulled his/her arm away when vital signs and accu-checks (for blood sugar testing) were administered. The LPN stated no one made her aware of any change in the resident's condition. LPN #2 stated the resident was resting well from receiving the PRN medications and she felt there was no change in condition to warrant calling the physician. However, review of the Nurse's Notes revealed no documented evidence LPN #2 assessed the resident to determine if there was a need to notify the physician. Review of a Nurse's Note documented by Registered Nurse (RN) #1, dated 03/14/15 at 8:47 AM, revealed Resident has been very unresponsive, I believe this to be because (he/she) had received pain medication prior to my shift, according to report, (he/she) does not react particularly well and has sluggish pupil [MEDICATION NAME]. There was no documented evidence the physician was notified of the resident's condition. The next entry, made by RN #1, on 03/14/15 at 11:36 AM, revealed the resident was unresponsive to two (2) sternal rubs and sent to the emergency room (ER) at 11:34 AM. Interview with RN #1, on 05/15/15 at 8:25 PM and 10:40 AM; and, on 05/17/15 at 4:09 PM, revealed he worked the 6:00 AM - 6:00 PM shift on 03/14/15 and Resident #1 was mostly unresponsive when he started his shift at 6:00 AM and remained that way, until sent to the ER at 11:34 AM. He stated the resident's vital signs were stable and the Pulse Oximeter (used to measure the oxygen saturation of the blood) was 96 percent and the heart rate was 109. RN #1 stated he felt he had a window of time to work in and he felt the PRN medications were still hanging around. The RN stated he did an assessment of the resident at 8:47 AM and there was no facial drooping, yet the resident was unable to follow commands to stick out his/her tongue or grip his (RN #1) hands, to test for grip strength. He stated he had to hold (the resident's) eyes open to assess the pupils, which were noted to have been sluggish. The RN stated he was aware of the need to call the physician of any changes of condition. RN #1 stated he had graduated from RN school five (5) months ago and felt the need to get a second opinion on the resident's condition from another nurse working at the time. He stated RN #2 came to assess the resident at approximately 11:00 AM and administered two (2) sternal rubs on the resident and the process was begun to get the resident to the ER. The resident's spouse and physician were called and the resident left the facility at 11:34 AM. The RN stated looking back, I probably should have sent (him/her) out earlier. Interview with RN #2, on 05/14/15 at 9:15 AM, revealed she was not the resident's assigned nurse on 03/14/15 but was working another area, at approximately 11:00 AM, when she was asked to come and take a look at the resident. The RN stated the resident was not responsive to sternal rubs. She assisted the staff to get the resident to the ER, as the resident was a Full Code. Review of the Hospital Physician Consultation Reports, dated 03/14/15, revealed the Attending Physician's clinical impression was a non-traumatic [MEDICAL CONDITION] involving a distal branch of the posterior cerebral artery. TPA was not administered because the time the resident was last known well, was greater than three (3) hours prior to arrival. The resident had suffered an Acute [MEDICAL CONDITION] ([MEDICAL CONDITION]-stroke); was admitted to the Intensive Care Unit; was unresponsive, non-communicative, and required a Gastric Feeding Tube (GT), due to the inability to sustain nutrition. Interview with the Assistant Director of Nursing (ADON), on 05/18/15 at 6:00 PM, revealed her expectation was for staff to call the physician with any change of condition. Interview with the Director of Nursing (DON), on 05/18/15 at 5:30 PM, revealed she felt if the LPN had entered the PRN medications into the EMAR, there would have been an automatic pop up to remind the nurse that a follow-up assessment was due, regarding the effectiveness or possible side-effects of the PRN medications. However, this was not done. Further interview revealed there was no documented evidence the resident was assessed after the PRN medications were given. She stated the physician should have been notified as soon as a change of condition was noted. Interview with the Administrator, on 05/18/15 at 5:05 PM, revealed the Administrator had been made aware of the resident having been administered the PRNs, although she was unsure when. However, she stated the staff should have called the physician when they first noticed the change in condition. During an interview with Resident #1's attending physician, on 05/15/15 at 12:16 PM, he stated You have to look back to the last time the resident was normal before an acute intervention (as TPA) could have been administered effectively and this has to be within the three (3) hour window of time, from the last resident's normal. He revealed the administration of the [MEDICATION NAME] and [MEDICATION NAME] would not have caused the stroke. He stated the resident having been drowsy, early on after the administration of the medications, would not have been unusual. However, the physician stated if the resident's condition had drastically changed, he would have expected the licensed staff to have made him aware of the change of condition. ** The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides at the facility. 2. On 05/18/15, assessments were conducted for eighty-one (81) of eighty-one (81) current residents, to determine if there were any medical needs requiring physician notification that the physician was not already aware of. This assessment included vital signs, respiratory assessment, bowel sounds, and changes in level of consciousness. There were no identified residents with a change in condition that the physician was not aware of, or that required further physician notification. 3. The DON and ADON conducted an audit of all current residents, on 05/18/15, to identify any resident who had received an as needed (PRN) pain medication, in the past twenty four hours and to ensure that a follow up to the effectiveness or adverse side effects of the PRN pain medication was completed. There were no noted adverse side effects of any PRN pain and all had effect relief of pain and there were no identified residents with a change in condition that the physician was not aware of or requiring further physician notification. 4. On 05/18/15 through 05/19/15 the DON, ADON, Unit Managers and the MDS Coordinator reviewed all current residents' plans of care to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. On 05/18/15, the Regional Quality Manager re-educated the DON, ADON, Unit Managers for all three units (Units One (1), Two (2) and Three (3) and the MDS Coordinator on Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS (Centers for Medicare and Medicare Services), to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. 6. On 05/18/15, all license staff was re-educated by the DON, ADON and Unit Managers Physician Notification for a significant change in condition, based on the INTERACT program, developed under funding from CMS, to prevent unnecessary acute care transfers, to provide guidance to nurses on when to notify the physician and care paths for certain common symptoms to help guide assessment and assist in completing a through assessment. Training also included conducting an assessment based on resident condition, follow up assessments as well as physician notification for a significant change condition, as well as utilizing the 911 system in an emergent situation. In addition, they were educated on the requirement to follow the plan of care, and if the plan of care cannot be followed and an alternative is not within their scope of practice that the physician must be notified. Competency tests were administered, to validate understanding and all received 100% accuracy. No licensed staff will work after 05/20/15 without having completed this re-education and competency test. All newly employed licensed nurses will receive this education prior to taking sole charge of a unit. On 05/18/15 and ongoing all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. In addition, re-education was provided related to reporting a change in condition to the Charge Nurse. If there are further concerns, the CNAs were then to report to the other nurse and up the chain of command. A competency test was administered to validate understanding with a minimum score of 100% accuracy and all CNAs passed with 100 % accuracy. No staff will work at the facility, after 05/20/15, without having this training and competency test with a minimum score of 100% accuracy, any staff not receiving 100% accuracy will be immediately re-educated and will not work until competency test is 100% accurate. 7. Beginning 05/18/15, the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents' conditions each shift, to determine if licensed staff were notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. This will continue on each shift including weekends until the Immediate Jeopardy is lifted, then five (5) times per week for twelve (12) weeks thereafter. 8. The DON, ADON or Unit Manager will review five (5) residents' plans of care per week for twelve (12) weeks to evaluate if interventions are in place and being followed. The results of these audits will be reviewed with the Quality Assurance and Improvement Committee weekly until substantial compliance then monthly thereafter. 9. The DON, ADON, or Unit Managers, or the MDS Coordinator audited all narcotic records daily, to identify any PRN pain medication given and compare to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented, weekly including weekends, until the Immediate Jeopardy was lifted then five (5) times a week for twelve (12) weeks thereafter. 10. An Ad Hock Quality Assurance and Performance Improvement (QAPI) Committee was convened to review the facility investigation and concerns. An allegation of compliance was developed and reviewed with the Medical Director, who attended via phone. The results of all audits will be reviewed with the Quality Assurance and Improvement Committee weekly, until substantial compliance has been achieved, then monthly thereafter. The QAPI committee will meet weekly or anytime concerns are identified until substantial compliance, then monthly thereafter. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. The resident no longer resides at the facility. 2. Review of the 100% (81 of 81) resident assessments, dated 05/18/15, revealed the residents were assessed to determine if there were any medical needs to warrant physician notification with no concerns identified. Chart reviews were completed on Residents #4, #5 and #6 with no identified areas of concern. 3. Review of the DON and ADON conducted audits of all current residents, dated 05/18/15 to identify any resident that required a PRN medication and to ensure a follow-up assessment, monitoring for any side effect or reactions and to evaluate the effectiveness of the PRN, revealed they were completed without concerns. 4. Review of the audits dated 05/18/15 through 05/19/15 completed by the DON, ADON, Unit Managers and MDS Coordinator revealed all current residents' plans of care were reviewed to determine if all interventions were being followed and any identified interventions not in place were immediately put into place. 5. Materials and sign-in sheets, dated 05/18/15,were reviewed regarding in-services held by the Regional Quality Manager, for the Nursing Administration Staff and re-training on the EMAR system, documentation of PRN medications, physician notification, care planning and the INTERACT process were reviewed. Review of the Competency testing revealed staff had a 100% pass rate with no concerns noted. Interview with the DON, on 05/28/15 at 10:45 AM, revealed she and the Administrative Nurses had all had the re-education completed by the Regional Quality Manager related to assessments, implementing the care plan, change of condition, documentation of PRN medications, and physician notification and the INTERACT process. 6. Materials and sign-in sheets, dated 05/18/15-05/20/15, revealed the DON, ADON and Unit Managers re-educated all licensed staff on the same requirements with a competency test with a minimum score of 100% accuracy required. Staff interviews conducted on 05/28/15 with LPN #4 at 8:35 AM; LPN #5 at 8:51 AM; RN #2 at 10:12 AM; LPN #6 at 10:25 AM revealed the training had been completed and all the licensed staff had passed the test. On 05/18/15 through 05/20/15 all CNAs were re-educated with competency test by the DON, ADON, and the Unit Managers or MDS Coordinator, related to following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse and notify the nurse of a change in condition and going up the chain of command. There were competency tests with a minimum score of 100% accuracy. Staff interviews on 05/28/15 with CNA #4 at 9:17 AM; CNA #5 at 9:25 AM; CNA #6 at 10:35 AM; and CNA #7 at 10:38 AM revealed the staff verified their training had been done and they had been tested regarding the care plans and notification of a change in condition. 7. Reviews of the every shift audits, dated 05/18/15 to 05/20/15, revealed the DON, ADON, MDS Coordinator or the Unit Managers, reviewed with facility licensed nursing staff, all current residents conditions each shift, to determine if licensed staff was notifying the physician of significant changes in condition and follow up assessments were occurring based on clinical condition. Interview with the DON, on 05/28/15 at 10:45 AM, revealed audits for residents' change of condition, notification of physician, and follow-up assessments were done on each shift until the AoC was accepted, and were now being done five times a week for twelve weeks. She stated the results of these audits will be reviewed in the QA Meetings. 8. Review of audits conducted by the DON, ADON or Unit Manager revealed five (5) residents' plans of care were reviewed to evaluate if interventions were in place and being followed. 9. Review of daily audits conducted by the DON, ADON, Unit Managers, or the MDS Coordinator revealed all narcotic records were audited daily, to identify any PRN pain medication administered and compared to EMAR records, to validate that follow up to effectiveness and adverse side effects of PRN pain medications was documented. 10. A review of the QA meetings, dated 05/20/15, 05/21/15 and 05/22/15, revealed the agenda regarded concerns with the allegation deficiencies as well as the annual survey deficiencies, complaint, and facility self-reported complaints. The meeting was attended by the Administrator, DON, Activities Director, MDS Coordinator, Business Office Manager, Dietary Services Manager, Medical Records, Housekeeping and Maintenance and the Marketing Manager. Interview with the Medical Clinical Officer (MCO) revealed the Medical Director attended the 05/18/15 meeting, by phone and was kept abreast of any concerns and the meetings were to continue weekly, then monthly until resolved.

Based on interview and record review, it was determined the facility failed to review and revise a plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed as requiring extensive assistance of two (2) or more staff for bed mobility and toileting; however, the Plan of Care revealed the resident was incontinent of bowel and bladder and required one person and extensive assistance with toileting. Additionally, the resident was assessed as having limitation in range of motion (ROM) of the upper and lower extremity on one side and incontinent of urine and bowel. On 02/22/14, Resident #1 sustained a fall from the bed during incontinent care, which resulted in an injury. At approximately 6:15 AM, Certified Nurse Aide (CNA) #1 was providing perineal care for Resident #1, and as she turned the resident, he/she slid off the bed into the floor on his/her backside. About 8:40 AM, Resident #1 was sent to the hospital emergency room , where x-rays revealed he/she had a fractured right femur. The findings include: Record review revealed the facility admitted Resident #1 on 07/01/12 with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] NOS, Muscle Weakness, and Peripheral Disease. Review of the facility's Minimum Data Set (MDS) assessment, dated 02/20/14, revealed the facility assessed Resident #1's cognition as cognitively intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), and, as requiring the extensive assistance of two (2) or more staff for bed mobility and toileting. The resident was also assessed as having limitation in range of motion (ROM) of the upper and lower extremity on one side and was incontinent of urine and bowel. Review of the seven (7) day Activities of Daily Living (ADL) Coding Summary, dated 02/14/14 - 02/20/14, revealed under physical functioning and structural problems, Resident #1 required the assistance of two (2) persons with bed mobility eleven (11) times out of twenty (20), with extensive assist. In addition, Resident #1 required the assistance of two (2) persons with toileting twelve (12) of nineteen (19) times, with extensive assist. Review of Resident #1's Fall Risk Assessment, dated 02/20/14, revealed a score of thirteen (13), which indicated the resident was a high risk for falls. Review of the Comprehensive Care Plan for Self Care Deficit, dated 02/18/14, revealed an intervention for the assistance of two (2) staff for toileting and bed mobility. However, review of the Certified Nurse Aide Care Plan (Activities of Daily Living (ADL) Plan of Care) revealed, for toileting and incontinent of bladder, dated 01/28/14 -03/06/14, the level of support needed for toileting and incontinent of bladder was one (1) person, and there was no intervention that addressed how much assistance was needed for bed mobility. Review of the facility's Incident Report, dated 02/22/14 at 6:29 AM, revealed Certified Nurse Aide (CNA) #1 called out for help. Licensed Practical Nurse (LPN) #1 entered Resident #1's room and noted Resident #1 was sitting on the floor on his/her bottom. LPN #1 assessed Resident #1 with no complaints of pain and no signs or symptoms of hitting his/her head. Resident #1 was not able to communicate what had happened. No injuries were noted. Three (3) CNAs assisted Resident #1 back to bed with a mechanical lift. Review of the facility's Investigation revealed, on 02/24/14, it was reported Resident #1 was admitted to the hospital after a fall at the facility. CNA #1 reported, at approximately 6:15 AM, while she was providing perineal-care for Resident #1, the resident slid off the side of the bed. Resident #1 was assessed by the Charge Nurse and no pain was noted. Resident #1 was then sent to the hospital emergency room where x-rays were negative for fractures. Resident #1 was admitted to the hospital for an irregular heart rate and later that day the facility received a phone call from the Social Worker at the hospital stating Resident #1 had sustained a right femur fracture from the fall. Four (4) attempts to reach CNA #1 per phone on 03/19/14 and 03/20/14 were unsuccessful and the CNA no longer worked at facility. However, review of a written statement, dated 02/24/14, provided by CNA #1, revealed she had provided care for Resident #1 on 02/21/14, on the 10:30 PM to 6:30 AM shift. She stated she had made rounds and provided care for Resident #1 throughout the night without any problems. On the final round at approximately 6:15 AM - 6:30 AM, she went in the room to provide care for Resident #1. When she turned Resident #1 toward the window, Resident #1 started to slide off the bed. She attempted to catch Resident #1 but could not stop Resident #1 from continuing to slide off the bed. She braced Resident #1's shoulder to the bed to help ease the resident to the floor. She assisted the resident into a sitting position beside the bed and called for assistance. She stated Resident #1 did not appear to be in any pain. LPN #1 came to the room, assessed Resident #1, then Resident #1 was lifted off the floor with a mechanical lift with the assistance of three (3) CNAs and placed back into bed. Interview with LPN #1, on 03/19/14 at 9:10 AM and 2:48 PM, revealed she was assigned to Resident #1 when he/she fell . She stated she was at the nurse's station when CNA #1 called her to Resident #1's room. She revealed Resident #1 was on the floor behind the bed. She stated CNA #1 did not offer an explanation of how the fall occurred and she assumed CNA #1 found Resident #1 on the floor. LPN #1 stated she asked CNA #1 what happened and CNA #1 did not say anything. The LPN stated CNA #1 then asked for assistance to get Resident #1 up from the floor. She assessed him/her first, asked for assistance from other staff and used the lift to place Resident #1 back in bed. LPN #1 stated there were no obvious injuries. She stated Resident #1 appeared to be irritated by the look on his/her face; however, when the nurse moved his/her right leg, he/she did not seem to be hurt or in any pain. She notified the resident's sister, told her he/she had fallen and did not appear to be injured. The sister stated she would be at the facility later to check on Resident #1. The LPN stated there was no indication the resident needed to be sent out to the hospital. LPN #1 notified the Director of Nursing (DON) about the incident and wrote a statement about what happened. LPN #1 stated she gave report to the oncoming shift just after it happened. She stated she filled out the incident report, but did not recall when she spoke to the DON. LPN #1 stated she thought she told the DON that she did not know how Resident #1 fell out of bed. She stated she was sure Resident #1 was assistance of two because the resident did not help at all. Interview with CNA #2, on 03/19/14 at 10:00 AM, revealed she always requested another staff for assistance when giving Resident #1 a bath, changing him/her, or providing incontinent care. The CNA stated the resident was top heavy and only had one leg. Interview with CNA #4, on 03/19/14 at 10:10 AM, revealed she was trained for two (2) people to bathe Resident #1 because he/she was top heavy. The CNA stated staff would assist him/her to roll and turn on his/her side and always used two (2) staff. She also stated she would use two (2) staff for perineal-care. Interview with CNA #5, on 03/19/14 at 1:00 PM, revealed she had taken care of Resident #1 only once, but used two (2) assist for perineal care. Interview with LPN #3, on 03/20/14 at 8:25 AM, revealed nurses update care plans if there had been a change or residents had gone to the hospital and come back with something new. She stated she did not recall being there when Resident #1 came back from the hospital, on 02/13/14. She stated she went through the care plan a day or so after he/she came back and had put the date he/she came back on the care plan. She stated she did not change the resident's care plan from one assist to two assist for toileting. She stated she did not recall if it had been changed when she reviewed it. Interview with the Minimum Data Set (MDS) Registered Nurse (RN) #1, on 03/19/14 at 3:20 PM, and on 03/20/14 at 12:30 PM, revealed she assessed residents for functional ability, looked at reports, checked the Accu-Nurse and the seven (7) day ADL tracking. She stated Resident #1 needed quite a bit of assistance. The MDS RN stated they looked at the whole seven (7) days and determined how much assistance was needed. She further stated they do all the Comprehensive Care Plans, and update once a quarter or with any significant change. The nurses update in between these times. She stated the dates on top of the care plans revealed when they were updated. Resident #1's care plan indicated it was updated on 02/18/14. She stated there was no way to know when toileting was changed from one assist to two assist. She stated Resident #1 was assessed as an assist of two (2) for toileting one or more times and Resident #1's care plan would need to indicate the resident needed two (2) assist. She stated the CNA ADL Plan of Care was updated on the Accu-Nurse. The MDS nurse updated it or the nurses on the floor could update it. On all the MDS assessments, the annual and two (2) quarterly, Resident #1 was two assist for toileting. MDS RN #1 stated she did the assessment on 11/20/13 and would have changed Resident #1 to two (2) assist, and she could have updated and changed Resident #1 to two (2) assist for toileting. She stated it only takes one time for two (2) people to move Resident #1 in bed to code him/her assist of two on the MDS. Interview with MDS RN #2, on 03/19/14 at 3:45 PM, revealed information pulls from Accu-nurse ADLs what CNAs put in the Accu-nurse, look at therapy notes and assess residents. The Quarterly assessment reference date was 02/20/14, and we looked back seven (7) days for ADLs. She stated they do CNA care plans on quarterly updates. Resident #1 was coded a three (3) but that did not always match the care plan, because it only takes one time of two people or more needed to code a three (3). She stated Care Plans were reviewed weekly by the team which consists of the DON, Dietary, Social Services, and Nursing. Further interview revealed they compared the care plans to the Accu-nurse. She stated they were told from the Regional Office to update the CNA Care Plan with our quarterlies, annuals, and change of status during care plan reviews to ensure the CNA Care Plan and the Comprehensive Care Plans matched. Interview with the DON, on 03/20/14 at 9:10 AM and 11:00 AM, revealed the facility does not have a care plan policy and does not follow any standard of practice regarding care plans. She stated she does not know who changed Resident #1's care plan. She stated LPN #3 told her she updated the care plan but did not change Resident #1 from one assist to two assist because he/she was only one assist and would not have changed it on the ADL care plan. The DON stated MDS is always going to code the higher level and is not a reflection of the resident's current status. MDS are done quarterly and there was no significant change during the seven (7) day look back. Accu-nurse care plan reflects what the clinical team deems as the most appropriate care. We have consistent CNAs that work the same wing and if there is a CNA that prefers two assist when turning or doing ADL care with the residents, then he or she would use two people. This does not mean the resident requires two people, the CNA may feel more comfortable with using two people. She stated she would not expect, if a nurse or MDS changed the care plan, to update the CNA ADL care plan unless the clinical team discusses it and it was deemed necessary. Interview with the Administrator, on 03/20/14 at 11:05 AM, revealed Resident #1's ADL care plan is assist of one for dressing and hygiene. Resident #1 uses briefs and his/her bladder/bowel is one person support and would be one person to clean him/her up. She stated perineal-care would be part of hygiene and she would expect the CNA to follow the ADL care plan. She stated she would expect someone to change the ADL care plan to two assist for toileting if they changed the comprehensive care plan and then stated she was not saying that. She stated toileting is being assisted to the commode, incontinent care is assist of one on the ADL care plan, and it does not specify on the comprehensive care plan. It is two totally different things. Incontinent care was being performed and she is not knowledgeable of Resident #1 ever being assisted to the commode.

Based on interview, record review, and review of the facility's Fall Assessment/Intervention Process Policy, it was determined the facility failed to ensure adequate supervision to prevent accidents was provided for one (1) of three (3) sampled residents (Resident #1). Resident #1 sustained a fall from the bed during incontinent care on 02/22/14 which resulted in an injury. Certified Nurse Aide (CNA) #1 was providing perineal care for Resident #1, on 02/24/14, at 6:15 AM, with him/her facing toward her. As she turned the resident to the other side, the resident slid off the bed into the floor on his/her backside. About 8:40 AM, Resident #1 was sent to the hospital emergency room , at the Power of Attorney's (POA) request, where x-rays taken which revealed the resident had a right femur fracture. The findings include: Review of the facility's "Fall Assessment/Intervention Process", last revised 09/13, revealed all residents on admission, re-admission, and at least quarterly would be assessed for fall risk and appropriate interventions initiated immediately to reduce the risk of injuries with falls. The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. The clinical Quality Assurance (QA) team along with the Interdisciplinary Team (IDT) may form a sub-committee to review and implement additional interventions for target residents who are high risk for falls. The fall risk assessment is also to be completed quarterly and annually by the Minimum Data Set (MDS) Manager or designee to compliment the MDS schedule and allow for resident review whether a fall has occurred or not. The Accu-Nurse-Care Plans are updated frequently for point of care needs of the resident to ensure safety and accurate care was being delivered. Record review revealed the facility admitted Resident #1 on 07/01/12 with [DIAGNOSES REDACTED]., Renal Failure NOS, Muscle Weakness, and Peripheral Disease. Review of the facility's MDS assessment, dated 02/20/14, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) and requiring extensive assistance of two (2) or more staff for bed mobility and toileting. The resident was also assessed as having limitation in range of motion (ROM) of the upper and lower extremity on one side and was incontinent of urine and bowel. Review of the seven (7) day Activities of Daily Living (ADL) Coding Summary, dated 02/14/14 - 02/20/14, revealed under physical functioning and structural problems, Resident #1 required the extensive assistance of two (2) persons. In addition, Resident #1 required the extensive assistance of two (2) persons with toileting. Review of Resident #1's Fall Risk Assessment, dated 02/20/14, revealed a score of thirteen (13), which indicated Resident #1 was a high risk for falls. Review of the Comprehensive Care Plan for Self Care Deficit, dated 02/18/14, revealed an intervention for the assistance of two (2) staff for toileting and bed mobility; however, review of the Certified Nurse Aide (CNA) Care Plan (ADL Plan of Care) revealed for toileting and incontinent of bladder, dated 01/28/14 - 03/06/14, the level of support needed for toileting and incontinent of bladder was one person. There was no intervention that addressed how much assistance was needed for bed mobility. Review of the facility's Incident Report, dated 02/22/14 at 6:29 AM, revealed CNA #1 called out for help. Licensed Practical Nurse (LPN) #1 entered Resident #1's room and noted Resident #1 was sitting on the floor on his/her bottom. LPN #1 assessed Resident #1 with no complaints of pain and no signs or symptoms of hitting his/her head, no injuries were noted. Resident #1 was assisted back to bed by three (3) CNAs, with a mechanical lift. Review of the facility's Investigation revealed, on 02/24/14, it was reported Resident #1 was admitted to the hospital after a fall at the facility. CNA #1 reported, at approximately 6:15 AM, that while she was providing perineal-care for Resident #1, the resident slid off the side of the bed. Resident #1 was assessed by the Charge Nurse and no pain was noted. Resident #1 was then sent to the hospital emergency room where it was noted x-rays taken were negative for fractures. Resident #1 was admitted to the hospital for an irregular heart rate and later that day the facility received a phone call from the Social Worker at the hospital stating Resident #1 had sustained a right femur fracture from the fall. Follow up to the investigation revealed CNA #1 was providing perineal-care for Resident #1 between 5:30 AM and 6:00 AM. She stated she had cleaned Resident #1 with him/her facing toward her and as she turned him/her to the other side, he/she slid in the floor on his/her backside. CNA #1 attempted to guide him/her and brace his/her shoulder against the bed as she was unable to stop the fall. CNA #1 called for assistance from other CNAs on the wing and LPN #1 to assess Resident #1. CNA #1 stated Resident #1 did not appear to be in any pain. LPN #1 assessed Resident #1 and then the resident was assisted back into bed using a lift. Resident #1 gave no indication he/she was in pain. LPN #1 stated she was called into the room by CNA #1 and observed Resident #1 sitting in the floor between the bed and window when called into the room. After assessing Resident #1 who did not appear to be in pain, LPN #1 instructed the CNAs to assist Resident #1 to bed with the lift. LPN notified the Power of Attorney (POA). LPN #2 stated she was made aware of the fall during report from LPN #1. About 8:40 AM, the POA came to the facility and requested that Resident #1 be sent out. Resident #1 was sent by ambulance service to the hospital emergency room where it was noted the x-rays taken were negative for fractures. The facility was made aware later that Resident #1 had sustained a femur fracture. Review of the Accu-Nurse CNA documentation revealed no evidence of documentation related to Resident #1's fall. Review of a written statement, dated 02/24/14, provided by CNA #1 revealed she had provided care for Resident #1 on 02/21/14, on the 10:30 PM to 6:30 AM shift. On the final round, at approximately 6:15 AM - 6:30 AM, she went in to provide care for Resident #1, and when she turned Resident #1 toward the window, he/she started to slide off the bed. She attempted to catch Resident #1 but could not stop Resident #1 from continuing to slide off the bed. She assisted Resident #1 into a sitting position beside the bed and called for assistance. She stated Resident #1 did not appear to be in any pain. LPN #1 assessed the resident then Resident #1 was lifted off the floor with a mechanical lift with the assist of three (3) CNAs and placed back into bed. Interview with CNA #2, on 03/19/14 at 10:00 AM, revealed she always requested another staff for assistance when giving Resident #1 a bath, changing him/her, and providing incontinent care. The CNA stated the resident was top heavy and only had one leg. Interview with CNA #4, on 03/19/14 at 10:10 AM, revealed she was trained for two people to bathe Resident #1 because he/she was top heavy. The CNA stated staff would assist him/her to roll and turn on his/her sides. She stated she would use two (2) staff for perineal-care. The CNA stated she came in on the morning of the fall and received report from CNA #1 who stated Resident #1 had fallen out of bed but she was not told how it happened. CNA #4 stated Resident #1 had a knot on his/her head and an abrasion on his/her right leg. She revealed Resident #1 complained of pain in his/her back when she laid him/her back in the bed. CNA #4 stated she was feeding Resident #1 when his/her sister came in and told LPN #2 she wanted him/her sent out to be on the safe side. Interview with LPN #1, on 03/19/14 at 9:10 AM and 2:48 PM, revealed she was assigned to Resident #1 when he/she fell . She stated she was at the nurse's station when CNA #1 called her to Resident #1's room. She revealed Resident #1 was on the floor behind the bed. She stated CNA #1 did not offer her an explanation of how the fall occurred and she assumed CNA #1 had found Resident #1 on the floor. The LPN revealed CNA #1 asked for assistance to get Resident #1 up from the floor. LPN #1 assessed him/her first, asked for assistance from other staff and used the lift to place Resident #1 back in bed. LPN #1 stated there were no injuries that she could tell. She stated Resident #1 had an irritated look on his/her face but did not act like he/she was hurt or in any pain. She stated she moved his/her right leg and the resident did not appear to be in pain. She notified his/her sister, told her the resident had fallen and there appeared to be no injuries. The Sister stated she would be in later to check on Resident #1. The LPN revealed there was no indication the resident needed to be sent out. She stated she spoke with the Director of Nursing (DON) about the incident and she wrote a statement about what had happened. LPN #1 stated she gave report to LPN #2 when she came in just after it happened. She stated she filled out the incident report and she did not recall when she spoke to the DON. LPN #1 stated she told the DON she did not know how Resident #1 fell out of bed. LPN #1 stated she was pretty sure Resident #1 was two (2) assist because the resident did not help at all. Interview with LPN #2, on 03/19/14 at 10:20 AM, revealed she received report from LPN #1 who told her Resident #1 had fallen while reaching for drinks on the floor, but found out later he/she fell during care. She stated Resident #1's sister came in and asked if Resident #1 could be sent out to have x-rays. She stated Resident #1's sister called her back and said the hospital was keeping Resident #1 to watch him/her and that he/she had no fractures. LPN #2 stated she later found out he/she had a fracture. She stated two (2) people should provide care for Resident #1 and she believed he/she was care planned for two (2) persons to care for him/her. She stated Resident #1 could be rolled over, but two people did his/her care sometimes. Review of the emergency room x-rays of the right tibia and fibula, Computer Tomography (CT) Scan of the cervical spine, CT Scan of the head, and CT Scan of the lower lumbar spine, dated 02/22/14, revealed no fractures and no acute abnormality. However, review of Resident #1's CT of the abdomen and pelvis, dated 02/23/14 at 7:00 PM, revealed "Impression: there is a new fracture involving the proximal right femur. There is a subcapital right femoral neck fracture which is comminuted. There is also a intertrochanteric comminuted fracture. Overall, there is no significant displacement". Review of the Orthopedic Physician Consultation Report, dated 02/22/14, revealed Resident #1 had a stroke in the past that left him/her paretic on the right upper and lower extremities. Resident #1 does not ambulate and is unable to transfer. He stated he was consulted regarding management of the right hip fracture. Extremities: right lower extremity exam, Resident #1's hip lies in a position of external rotation and in a frogleg position. Resident has pain with attempt of movement of right lower extremity. Diagnostic data: CT scan as well as x-rays show a severely comminuted intertrochanteric hip fracture which extends into the femoral neck region. CT scan verify's the displacement and comminution which is present. Plan: Discussion with the sister regarding treatment and recommendations. Told her given Resident #1's current functional status that a non-operative course would be in Resident #1's best interest. Believe Resident #1 to be a severe risk for postoperative complications if surgery performed. Interview with the DON, on 03/19/14 at 11:00 AM and 5:00 PM, revealed she had received a call from the Unit Manager on 02/22/14 (who was on call) stating they were sending Resident #1 to the hospital. She stated she asked her why and was told Resident #1 had a fall and his/her sister insisted he/she be sent out for x-rays. She stated the Unit Manager told her Resident #1 fell out of the bed and that she had heard a couple different things. Resident #1 slid out of bed while trying to reach for drinks, and the CNA was giving care and he/she slid off the bed. The DON stated during her investigation she was told both things and that she spoke with the sister who said when she was called, she was told he/she was reaching for something and slid off the bed. The DON stated when she spoke to CNA #1, she told her she was giving perineal-care and Resident #1 slid off the side of the bed and the CNA tried to break his/her fall. CNA #1 told her she turned Resident #1 toward her and he/she started to slide and she tried to break his/her fall. The DON stated Resident #1 was one assist for changes and incontinent care. Interview with the MDS Registered Nurse (RN) #1, on 03/19/14 at 3:20 PM, and on 03/20/14 at 12:30 PM, revealed she assessed residents for functional ability, looked at reports, checked the Accu-nurse, the seven (7) day ADL tracking and assessed the residents. She stated Resident #1 needed quite a bit of assistance. The MDS RN stated they looked at the whole seven (7) days and determined how much assistance was needed. She stated the MDS Nurses completed all the comprehensive care plans, and update them once a quarter or with any significant change. The staff update them between their update. RN #1 further stated Resident #1's care plan indicated it was updated 02/18/14. She stated there was no way to know when toileting was changed from one assist to two (2) assist. She stated Resident #1 was assessed as a assist of two (2) for toileting one or more times and Resident #1's care plan would need to indicate the resident needed two assist. She stated the CNA ADL plan of care was updated on Accu-nurse. She stated the MDS nurses updated it or the nurses on the floor could update it. On all the MDS assessments, the annual and two (2) quarterly, Resident #1 was a two person assist for toileting. MDS RN #1 stated she did the assessment on 11/20/13 and maybe she changed Resident #1 to two person assist. She stated they looked at the MDS as a starting point, the Care Assessment Areas (CAAs), interview staff on what care they were providing and how much the resident could do for themselves. She stated they coded Resident #1 two assist because that's what the ADLs reflected. She stated they do observe care being done; however, she had not observed Resident #1's incontinent care/perineal-care. Interview with MDS RN #2, on 03/19/14 at 3:45 PM, revealed information comes from the Accu-nurse ADLs, what CNAs put in, therapy notes and resident assessments. She stated they do CNA care plans on quarterly updates. Resident #1 was coded a three (3) but that did not always match the care plan. She stated Care Plans were reviewed weekly by the team which consists of the DON, Dietary, Social Services, and Nursing. She stated they compare the care plans to the Accu-nurse. She further stated they were told by the Regional Office to update the CNA Care Plans with our quarterlies, annuals and change of status during care plan reviews to ensure that the CNA care plan and the care plan matched. Interview with LPN #3, on 03/20/14 at 8:25 AM, revealed nurses updated the care plan if there has been a change or residents were readmitted with something new. She stated she went through the care plan a day or so after he/she came back and had put the date he/she came back on the care plan. She stated she did not change the resident from one assist to two assist for toileting. She stated she does not recall if it had been changed when she reviewed it. Interview with Resident #1's sister, on 03/20/14 at 8:55 AM, revealed there was normally two people caring for Resident #1. She stated the resident was sent to the hospital and that's when they found out he/she had the fracture. She stated they could not do surgery on his/her right leg because of his/her heart. Interview with the DON, on 03/20/14 9:10 AM and 11:00 AM, revealed the facility did not have a care plan policy and did not follow any standard of practice regarding care plans. She stated she did not know who changed Resident #1's care plan. She stated LPN #3 told her she updated the care plan but did not change Resident #1 from one assist to two assist because he/she was only a one person assist and would not have changed it on the ADL care plan. The DON stated MDS was always going to code the higher level and that was not a reflection of the resident's current status. She stated the Accu-nurse care plan reflected what the clinical team deemed as the most appropriate care. She stated she would not expect if a nurse or MDS changed the care plan to update the CNA ADL care plan unless the clinical team discussed it and they deemed it necessary. Interview with the Administrator, on 03/20/14 at 11:05 AM, revealed Resident #1 stayed in the bed most of the time. She stated if you ever use two people in the assessment period or anytime, you want to count the highest number. Sometimes a person may only need one person and sometimes they may need two.

Based on interview, record review, allegation of compliance and the facility file review, it was determined that Immediate Jeopardy identified during the abbreviated survey (09/26/11) had been removed related to neglect; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC) as related to neglect. The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 09/27/11, revealed that the facility conducted assessments for all current residents, on 09/23/11, and found no resident had a change in condition, requiring immediate intervention. On 09/26/11, the Director of Nursing, Regional Director of Clinical Operations and the Unit Managers reviewed the previous 30 days of nurses' notes for all current residents to identify accidents/incidents and/or allegations of abuse or neglect to ensure investigations were completed and incidents were reported. Review of facility provided inservices, revealed all staff was re-educated related to abuse and neglect, on 09/23/11, 09/26/11, 09/29/11 and 10/02/11, with emphasis placed on not leaving a resident unattended who had an emergent change in condition; reporting immediately a resident's complaint/request for assistance and ensuring immediate response and assessment by nursing staff, for residents experiencing a change in condition. Interviews were conducted on 10/10/11, with the Administrator, the Director of Nursing, (DON), the Regional Director of Clinical Operations (RDCO), six Certified Nurse Aides (CNA)s, three Licensed Practical Nurses (LPN)s, four Registered Nurses (RN)s, a Registered Dietician, one Housekeeper, and one Physical Therapy staff member. The nursing staff interviewed represented all three shifts. All interviews revealed staff had received re-education related to facility policies and procedures and demonstrated a working knowledge of their personal responsibilities. Review of the facility file revealed that the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 9/26/11. Furthermore, interviews conducted with the Administrator, the DON and the RDCO, on 10/10/11 at 3:30 PM, revealed quality assurance activities had been initiated, however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures related to abuse and neglect, after provision of staff re-education.

Based on observation, interview, and record review it was determined the facility failed to provide services for three residents (#1, #2 and #4), in the selected sample of four (4), in accordance with each resident's written plan of care. Resident #2 was care planned for a "Respiratory" problem with interventions which included to monitor for cyanosis, shortness of breath (SOB), and change in level of consciousness. On [DATE] at 3:00 PM, Resident #2 experienced breathing difficulty and informed the Certified Nurse Aides (CNA #1 and CNA #2). Per CNA interview, two Licensed Practical Nurses (LPN #1 and LPN #2) were informed four times of Resident #2 breathing difficulty and the resident's request to see a nurse. When LPN #1 and LPN #2 went to the resident's room, Resident #2's oxygen (O2) saturation level was assessed to be 80 percent (%). The resident's O2 was increased to 5 liters per minute (LPM) and both nurses left the resident's room leaving Resident #2 unattended. When LPN #2 returned to Resident #2's room, the resident was observed to be lying on the floor in a pool of blood. Resident #2 was transferred to a local hospital on [DATE], at approximately 3:48 PM, forty-eight (48) minutes after Resident #2's first complaint of breathing difficulty. Resident #2 expired at the hospital on [DATE] related to respiratory/[MEDICAL CONDITION]. (Refer to F309) Resident #1 was care planned to have an alarm while in the bed, and on [DATE] the resident got up from his/her bed unassisted and fell to the floor. Resident #1 sustained a [MEDICAL CONDITION]. Resident #4 was care planned to have an alarm on his/her wheelchair. On [DATE] and [DATE], Resident #4 was observed to be sitting in his/her wheelchair and the wires to the sensor pad were not connected to the alarm box. (Refer to F323) This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on [DATE] and is on-going. The findings include: The Director of Nursing (DON) revealed she could not provide a policy/procedure related to following the care plan. 1. A record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #2 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of "14." The resident required supervision of one (1) staff for bed mobility, transfers, and locomotion on and off the unit. At intervals, the resident used a rolling walker and wheelchair for ambulation in the facility. A review of the physician's orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s. Staff interviews revealed Resident #2 wore O2 per nasal cannula continuously. A review of the comprehensive care plan, "Respiratory," dated [DATE], revealed the resident had his/her O2 level checked each shift and prn. The staff was to administer O2 as ordered, change tubing/devices per protocol, vital signs as ordered and prn, report adventitious breath sounds, monitor for cyanosis, shortness of breath (SOB), change in level of consciousness, and updated the physician and family prn. A review of the nurses' notes, dated [DATE] at 3:30 PM, revealed the CNA reported to two (2) nurses the resident was having trouble breathing. LPN #2 documented the nurse went to the room and found the resident sitting on the side of bed with labored breathing. His/her O2 level was checked and it was 80 percent (%) and the O2 rate was increased to five (5) liters per minute (LPM). Resident #2's O2 level came up to 86%. The resident was instructed to lie down, but he/she refused. The resident yelled out his/her back was hurting. LPN #2 stepped out of the room, leaving Resident #2 unattended, to get help and call 911. She returned to the room and found the resident lying on the floor on his/her left side. Further review of Resident #2's medical record revealed no order for O2 to be administered at 5 LPM, and no evidence the resident's physician was notified of the resident's condition. In addition, there was no evidence the resident had been assessed related to complaints of breathing difficulty except for checking the resident's O2 level. An interview with LPN #2, on [DATE] at 2:37 PM and on [DATE] at 4:00 PM, revealed she was one of the nurses, who was informed by a CNA, about Resident #2's breathing problem. She informed the CNA to wait a minute and she would come down to the room to check the resident. LPN #2 revealed she went to the resident's room and observed the resident experiencing shortness of breath. She checked the O2 level and it was low (80% per documentation in the nurses' notes). LPN #1, who was also present in the room, increased the O2 rate to five (5) LPM, then left the room to call Emergency Medical Services (EMS or 911). LPN #2 stated she went to the door, then to the hall and called for help. When she turned around, Resident #2 was on the floor lying on his/her right side. She could not explain how the resident ended up lying on the floor. LPN #2 revealed she was trained not to leave a resident who experienced respiratory distress and she acknowledged Resident #2 experienced respiratory distress at that time. She stated time had lapsed from the time LPN #1 called EMS, and she wanted to get the resident some assistance. An interview with LPN #1, on [DATE] at 10:05 AM, revealed she was the other nurse with LPN #2 when the CNA told them about Resident #2's breathing difficulty. She stated when she arrived to Resident #2's room, the resident was lying flat in the bed and was experiencing shallow breathing. LPN #1 revealed she increased the resident's O2 rate from two (2) LPM to five (5) LPM. She reported she called EMS. LPN #1 stated LPN #2 came to the nurses' station, then called EMS a second time. She stated when she returned to Resident #2's room, the Acting DON was in the floor with the resident. An interview with the former Acting DON, on [DATE] at 5:34 PM and on [DATE] at 6:20 PM, revealed she became aware of Resident #2's breathing difficulties when she heard the CNA yell that the resident was lying on the floor. She went to the room and observed Resident #2 lying on the floor, with "blue discoloration" and a puddle of blood was underneath his/her head. She stated the two nurses (LPN #1 and LPN #2) were at the nurses' desk when she went to the resident's room. She stated the nurses were expected to assess and monitor a resident when they received a complaint from the resident. 2. A record review revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the significant change MDS, dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of "3." The resident required extensive assistance of one staff for transfers, bed mobility, and locomotion on and off the unit. A review of the comprehensive care plan, dated [DATE], revealed the resident was identified as a falls risk related to poor weight bearing, advanced age, [MEDICAL CONDITION] infarct, unsteady, bowel/bladder incontinence, Dementia and History of [MEDICAL CONDITIONS], hearing impairment and [MEDICAL CONDITION]. The resident had interventions in place since [DATE] for a chair alarm and a bed alarm. A review of the nurses' notes, dated [DATE] at 6:45 AM, revealed the resident was found on the floor in his/her room. It was not documented in the nurses' notes if the resident's alarm sounded when the resident was found on the floor. An interview with CNA #1, on [DATE] at 8:45 AM, revealed the morning of [DATE] around 6:35 AM, she noticed Resident #1 was on the floor. She revealed there was no sound coming from the resident and there was no alarm sounding. An interview with LPN #3, on [DATE] at 10:30 AM, revealed she was the Charge Nurse on [DATE]. When CNA #1 yelled about Resident #1 lying on the floor, she and LPN #4 went to the resident's room and observed him/her lying on the floor on his/her back with his/her knees bent. LPN #3 stated the resident had an alarm on his/her bed and she thought the alarm sounded. An interview with LPN #4, on [DATE] at 5:40 PM, revealed he heard a day shift CNA yell that the resident was on the floor. LPN #4 stated he and LPN #3 went to the resident's room and observed Resident #1 lying on the floor. He stated the resident had the alarm on his/her bed removed a while ago, and no alarm was sounding when they went in the room. He could not say how long the alarm on the resident's bed was not utilized. An interview with CNA #4, on [DATE] at 5:41 PM, revealed she worked on [DATE]. She stated the resident had an alarm on the bed and on the wheelchair. She stated when she arrived to the resident's room, LPN #3, LPN #4 and CNA #1 were in the room and she did not hear an alarm sound. LPN #4 put the resident back in the bed and CNA #4 reported she did not see an alarm on Resident #1's bed. 3. A record review revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated ,[DATE]//11, revealed the resident was moderately cognitively impaired with a BIMS score of "9." Resident #4 required extensive assistance to total dependence of one (1) to two (2) staff for activities of daily living. The resident had no falls prior to the assessment. A review of the comprehensive care plan, dated [DATE], revealed Resident #4 was at risk for falls related to pain, stiffness, weakness, cardiovascular diagnosis, Dementia and [MEDICAL CONDITION]. There were interventions in place since [DATE] which included a bed alarm and a wheelchair alarm. An observation, on [DATE] at 1:10 PM, revealed Resident #4 was sitting in the wheelchair in his/her bedroom, awake and alert. The resident had a sensor pad alarm beneath the cushion to the wheelchair and the wire from the sensor pad hung down beneath the seat of the wheelchair. There was no box connected to the wire. At 4:00 PM, Resident #4 was sitting in his/her wheelchair across from the nurses' desk. The resident did not have an alarm box to the sensor pad alarm on the wheelchair. An observation on [DATE] at 8:20 AM, the resident was supine in bed with his/her eyes closed. An alarm was observed to be on the bed and the resident's wheelchair was in the room, without an alarm box connected to the wire. At 1:00 PM, the resident was observed in his/her wheelchair across from the nurses' desk, awake and alert. The resident had the sensor pad in the wheelchair; however, there was no alarm box connected to the wire which hung down beneath the wheelchair. Further observations on [DATE] at 3:00 PM, revealed the resident was in his/her wheelchair at the nurses' desk. The resident had the sensor pad in his/her wheelchair; however, there was not an alarm box connected to the wire which hung down beneath the seat of the wheelchair. An interview with CNA #8, on [DATE] at 10:35 AM, revealed the resident utilized a pillow between his/her legs, foot board and had a low bed. She stated the resident did not have an alarm on his/her wheelchair. She revealed the resident was able to let staff know if he/she wanted to stay in his/her room or come out into the hall. She stated she followed the CNA assignment sheet for the care of the residents she was assigned and looked at it throughout the day. Upon review of the CNA assignment sheet, CNA #8 observed the resident was supposed to have an alarm on the wheelchair and on his/her bed. CNA #8 stated she was not aware of the alarm on the resident's wheelchair. An interview with CNA #7, on [DATE] at 1:53 PM, revealed she provided care to the resident on [DATE] and [DATE]. The resident had an alarm on his/her bed and wheelchair. She stated Resident #4 had a sensor pad beneath the cushion of his/her wheelchair. She revealed the resident had the alarm on the wheelchair when he/she was up; however, she provided no explanation as to why the box was not connected to the alarm on the wheelchair, on [DATE] and [DATE]. She stated if the resident did not have a box for the alarm to the chair, then she went to the DON to get an alarm box. She revealed, at times, she removed the alarm box from the bed and attached it to the alarm on the wheelchair. An interview with the DON, on [DATE] at 2:36 PM and on [DATE] at 12:38 PM, revealed she questioned LPN #3 if the alarm was on and sounding when Resident #1 was found on the floor. The DON stated she was informed the alarm sounded when the resident fell . She stated the resident had an alarm on his/her bed and on the grab bars on the bed. She revealed it was everybody's responsibility in the facility to ensure the residents have his/her alarms in place. The alarms were checked every shift for placement and functioning. She stated the staff monitored the alarms everyday and reported to her if an alarm was not on a resident or in need of batteries. She reported she had not devised a form to track information related to the residents with alarms, but she received a couple of reports from the previous week related to alarms not being on a resident. She was unaware Resident #4 did not have an alarm on his/her wheelchair. The facility failed to ensure interventions were implemented related to Resident #2's "Respiratory" plan of care when the resident complained of breathing difficulties. The nurses failed to monitor the resident while he/she experienced breathing difficulties and there was no evidence the resident's physician was contacted regarding the resident's condition. Per interview, the facility was unaware if other residents had been affected by this deficient practice, and the facility had taken no action to prevent recurrence.

Based on interviews, record review, allegation of compliance, and facility file review, it was determined that Immediate Jeopardy identified during the abbreviated survey (09/26/11) had been removed related to the failure to provide resident care in accordance with the individualized care plan; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring audits results, and development and implementation of the Plan of Correction (POC) to ensure care was provided in accordance with care plans. The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 09/27/11, revealed that the facility conducted assessments for all current residents and reviewed all current residents' medical records to identify any issues related to provision of care. Record review revealed the facility provided inservices for all staff, on 09/23/11, 09/26/11, 09/29/11 and 10/02/11, which included the requirement to provide care based on the resident's individual care plan. Emphasis was placed on the need to respond immediately when a resident voiced a need for assistance and the need for the staff member to remain with the resident who had an emergent change in condition. Interviews were conducted on 10/10/11, with the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Operations (RDCO), six Certified Nurse Aides (CNA)s, three Licensed Practical Nurses (LPN)s, four Registered Nurses (RN)s, a Registered Dietician, one Housekeeper, and one Physical Therapy staff member. The nursing staff interviewed represented all three shifts. All interviews revealed staff had received re-education related to providing care in accordance with the individualized care plan and each staff member demonstrated a working knowledge of their personal responsibilities, should a resident exhibit a change in condition and a need for immediate assistance. Review of the facility file revealed that the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 9/26/11. Furthermore, interviews conducted with the Administrator, the DON and the RDCO, on 10/10/11 at 3:30 PM, revealed quality assurance activities had been initiated; however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures, after provision of staff re-education.

Based on interview and record review it was determined the facility failed to ensure one resident (#2), in the selected sample of four (4), was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility failed to ensure Resident #2 was assessed and monitored after he/she experienced breathing difficulties. On [DATE] at approximately 3:00 PM, Resident #2 experienced breathing difficulty and informed the Certified Nurse Aides (CNA #1 and CNA #2). Per CNA interview, two Licensed Practical Nurses (LPN #1 and LPN #2) were informed four times of Resident #2's breathing difficulty and the resident's request to see a nurse. When LPN #1 and LPN #2 went to the resident's room, Resident #2's oxygen (O2) saturation level was assessed to be 80 percent (%). The resident's O2 was increased to 5 liters per minute (LPM) and both nurses left the resident's room leaving Resident #2 unattended. Resident #2 fell from his/her bed and was found lying on the floor in a pool of blood. Resident #2 was transferred to a local hospital on [DATE], at approximately 3:48 PM, forty-eight (48) minutes after Resident #2's first complaint of breathing difficulty. Resident #2 expired at the hospital on [DATE] related to respiratory/[MEDICAL CONDITION]. (Refer to F224 and F282) This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on [DATE] and is on-going. The findings include: A record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #2 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of "14." The resident required supervision of one staff for bed mobility, transfers, and locomotion on and off the unit. At intervals, the resident used a rolling walker and wheelchair for ambulation in the facility. A review of the physician's orders dated [DATE] through [DATE] revealed an order for [REDACTED]. Review of the comprehensive care plan entitled "Respiratory", dated [DATE], revealed the resident had his/her O2 level checked each shift and as needed (prn). The staff were to administer O2 as ordered, change tubing/devices per protocol, vitals signs as ordered and prn, report adventitious breath sounds, monitor for cyanosis, shortness of breath (SOB), change in level of consciousness, and updated the physician and family as needed. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s with the O2 in use. A review of the nurses' notes, dated [DATE] at 3:30 PM, revealed a CNA reported to two (2) nurses the resident was having difficulty breathing. The nurses went to the room and found the resident sitting on the side of the bed with labored breathing. The O2 saturation level was checked and 80%. The nurse raised the O2 rate from 2 liters per minute to 5 liters per minute. The resident's O2 saturation level was rechecked and it 86%. The nurses encouraged the resident to lie back in the bed, but he/she refused. The resident hollered out in pain that his/her lower back was hurting. The resident sat back up on the side of the bed and the nurse left the room to get help and call 911. The nurse returned to find the resident lying in the floor on his/her left side. Further review of the resident's medical record revealed [REDACTED]. to administer 5 liters of O2. In addition, there was no evidence nursing staff assessed the resident's condition at the time Resident #2 was discovered on the floor exhibiting breathing difficulties. A review of the ambulance run sheet, dated [DATE] at 3:48 PM, revealed EMS personnel checked the resident and he/she was unresponsive on the floor with agonal breathing (associated with the dying process), and his/her skin was cyanotic (discoloration of the skin caused by a lack of O2). An interview with the Emergency Medical Services (EMS) personnel, on [DATE] at 11:45 AM, revealed, on [DATE] at 3:40 PM and 3:45 PM, calls were received from the facility. An interview with CNA #1, on [DATE] at 9:50 AM, revealed she stayed over, on [DATE], to work second shift, which began at 2:30 PM, and to help provide care for the residents on Wing II. Per interview, she reported the resident's difficulty breathing to LPN #1 and LPN #2, returned to the resident's room, and waited with the resident for approximately 10 minutes. CNA #1 revealed neither nurse responded after she made the nurses (LPN #1 and LPN #2) aware of the resident's difficulty breathing. She stated CNA #2 also went to the nurses' desk and reported Resident #2's breathing problems to LPN #1 and LPN #2. An interview with CNA #2, on [DATE] at 2:08 PM, revealed on [DATE], as she began her rounds between 2:30 PM and 3:00 PM, Resident #2 requested to lie down, and wanted the CNA to inform the nurse that he/she was having difficulty breathing and did not feel well. The CNA informed LPN #1 and LPN #2, who were counting controlled narcotics, about the resident's request. CNA #2 stated Resident #2 put his/her call light on two times, complaining of breathing difficulty and requesting the nurse. Per CNA #2, she informed nurses after each request and was told by the nurses that they were on their way to check on the resident. An interview with LPN #2, on [DATE] at 2:37 PM and on [DATE] at 4:00 PM, revealed she was the second shift nurse on Wing II, on [DATE]. She stated she was getting shift report, when a CNA came to her and told her about Resident #2 having difficulty breathing. LPN #2 told the CNA #2 to "wait a minute, I will be right there." LPN #2 stated she thought the resident had surgery the day before and she instructed LPN #1 to grab the blood pressure cuff and the oximeter. She stated they (LPN #1 and LPN #2) went to the resident's room and observed that the resident was experiencing shortness of breath. They checked his/her O2 saturation and recalled it was low (80% per documentation in the record). She stated they transferred the resident to the bed but could not get the bed to raise any higher, so LPN #1 left the room to call maintenance and 911. LPN #2 stated she went to the door and then to the hall and yelled for help. LPN #2 turned around and observed Resident #2 lying on the floor on his/her right side. She could not provide an explanation as to how the resident ended up lying on the floor. LPN #2 revealed she did the best thing for the resident at that time, and stated "what stuck out was he/she turned blue so fast." She revealed she was trained not to leave a resident who experienced respiratory distress and she acknowledged Resident #2 experienced respiratory distress during that time. She stated "time lapsed from whenever the first nurse called the ambulance, and I was concerned about getting Resident #2 some assistance. That is the reason why I went to the hall and called for the nurse." An interview with LPN #1, on [DATE] at 10:05 AM, revealed she, along with LPN #2, was informed of Resident #2's difficulty breathing by CNA #2. She was getting shift report at the time and told LPN #2 to grab a stethoscope. She could not recall the time Upon arrival to the resident's room, he/she was lying flat on the bed, had his/her O2 in place, and was experiencing shallow, labored breathing at that time. She increased the resident's O2 to 5 LPM; however, she and LPN #2 were unable to get the head of the bed to raise. She stated she came out of the room and paged maintenance, then she called 911. LPN #1 remained at the nursing station to complete paperwork for the resident's transfer to the hospital. She stated the maintenance staff sat the resident up on the side of his/her bed and LPN #2 left the room. She stated "we waited for the ambulance to get here and it was taking so long, I know over five (5) minutes, seven (7) minutes I don't know the exact time". By the time she returned to Resident #2's room, the Acting Director of Nursing (DON) was in the room attending to the resident, who was lying on the floor. An interview with the former Acting DON, on [DATE] at 3:12 PM, on [DATE] at 5:34 PM, and on [DATE] at 6:20 PM, revealed CNA #2 stuck her head out of the resident's door and stated Resident #2 was lying on the floor. She stated she took off to the resident's room but could not recall the time; however, it was at the time of shift change, from first to second shift. When she entered the room, she observed CNA #2 in the doorway and Resident #2 lying on the floor, with a blue discoloration and a puddle of blood was under his/her head. She went over and checked on the resident, and she was aware the resident was a Do Not Resuscitate (DNR). The blood was coming from the resident's head but she could not determine the location. She raised the resident's head and placed a towel beneath it, brought in by CNA #1. The Acting DON continued to care for the resident and she asked CNA #1 and CNA #2 what happened. She was informed by the CNAs the resident had trouble breathing, so the aides had laid him/her down and told LPN #1 and LPN #2. The CNAs told her a few minutes had passed since they informed the nurses. The Acting DON revealed LPN #1 and LPN #2 were getting shift report at the desk at the time she went to Resident #2's room, and LPN #1 and LPN #2 came to the room afterwards. The DON did not know the amount of time that had lapsed when the two nurses were notified by the CNAs, regarding the resident's condition. Additionally, she stated when the nurses were made aware of a resident's concern/complaint/request, they should have gone immediately to the resident to do an assessment (listen to lung sounds, check vital signs, put O2 on and check O2 level). She was unaware if the resident was checked by the nurses prior to being found on the floor. Interviews with LPN #1 and LPN #2 revealed they went to check on the resident immediately after being made aware of the resident's breathing trouble. However, interview with CNA #1 and CNA #2 revealed the nurses had been informed four (4) times, with the first time being at approximately 3:00 PM. Record review revealed the nurses' note was timed at 3:30 PM; however, the ambulance run sheet revealed an arrival time at the resident's bedside of 3:48 PM. In addition, record review revealed no evidence the nurse completed an assessment of the resident's condition. The facility failed to provide necessary and timely care and services to a resident with complaints of breathing difficulties. The nurses failed to assess and monitor the resident while he/she experienced breathing difficulties. Per interview, the facility was unaware if other residents had been affected by this deficient practice, and the facility had taken no action to prevent recurrence.

Based on interviews, record review, allegation of compliance, and the facility file, it was determined that Immediate Jeopardy identified during the abbreviated survey (09/26/11) had been removed related to failure to provide appropriate care and services for a resident exhibiting a change in condition; however, non-compliance continued to exist at a S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC) as related to provision of care. The findings include: Review of the acceptable Allegation of Compliance (AOC), received on 09/27/11, revealed that the facility conducted assessments for all current residents, on 09/23/11, and found no resident had a change in condition, requiring immediate intervention. On 09/26/11, the Director of Nursing, Regional Director of Clinical Operations and the Unit Managers reviewed the medical records for all current residents to identify any issues with provision of care. Record review revealed the facility provided inservices for all staff, on 09/23/11, 09/26/11, 09/29/11 and 10/02/11, which emphasized the need to respond immediately when a resident voiced a need for assistance and the need for the staff member to remain with the resident who had an emergent change in condition. The inservices included the immediate response by the nurse with provision of assessments and appropriate intervention to address changes in condition. Interviews were conducted on 10/10/11, with the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Operations (RDCO), six Certified Nurse Aides (CNA)s, three Licensed Practical Nurses (LPN)s, four Registered Nurses (RN)s, a Registered Dietician, one Housekeeper, and one Physical Therapy staff member. The nursing staff interviewed represented all three shifts. All interviews revealed staff had received re-education related to immediate response to a resident's voiced need for assistance or an observed change in condition, nursing assessment and appropriate intervention. The staff interviews revealed understanding of the facility's policies and procedures and knowledge of their personal responsibilities, should a resident exhibit a change in condition and a need for immediate assistance. Review of the facility file revealed that the facility had not submitted their plan of correction for the identified deficiencies from the abbreviated survey of 9/26/11. Furthermore, interviews conducted with the Administrator, the DON and the RDCO, on 10/10/11 at 3:30 PM, revealed quality assurance activities had been initiated, however, the facility needed to continue quality assurance activities to ensure compliance with established policies and procedures, after provision of staff re-education.

Based on interview, record review, and review of facility policy and procedures, it was determined the facility failed to ensure one resident (#2), in the selected sample of four (4), was free from neglect. On [DATE] at approximately 3:00 PM, Resident #2 experienced breathing difficulty and informed the Certified Nurse Aides (CNA #1 and CNA #2). Per CNA interview, two Licensed Practical Nurses (LPN #1 and LPN #2) were informed four times of Resident #2 breathing difficulty and the resident's request to see a nurse. When LPN #1 and LPN #2 went to the resident's room, Resident #2's oxygen (O2) saturation level was assessed to be 80 percent (%). The resident's O2 was increased to 5 liters per minute (LPM) and both nurses left the resident's room leaving Resident #2 unattended. When LPN #2 returned to Resident #2's room, the resident was observed to be lying on the floor in a pool of blood. Resident #2 was transferred to a local hospital on [DATE], at approximately 3:48 PM, forty-eight (48) minutes after Resident #2's first complaint of breathing difficulty. Resident #2 expired at the hospital on [DATE] related to respiratory/[MEDICAL CONDITION]. The facility failed to promptly respond, assess and monitor Resident #2's complaint of breathing difficulty. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on [DATE] and is on-going. The findings include: A review of the facility's policy and procedures "Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property," dated ,[DATE] and revised ,[DATE], revealed the facility had designed and implemented processes, which strived to ensure the prevention and reporting of resident abuse and neglect. The policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Per policy, this presumed that instances of abuse/neglect of all residents, even those in a coma, caused physical harm, pain, or mental anguish. A record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was coded as a Do Not Resuscitate (DNR) meaning if found without a pulse or not breathing do not initiate measure to revive. A review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #2 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of "14." The resident required supervision of one (1) staff for bed mobility, transfers, and locomotion on and off the unit. At intervals, the resident used a rolling walker and wheelchair for ambulation in the facility. A review of the nurses' notes, dated [DATE] at 3:30 PM, revealed a CNA reported to two (2) nurses the resident was having difficulty breathing. The nurses went to the room and found the resident sitting on the side of the bed with labored breathing. The O2 saturation level was checked and at 80%. The nurse raised the O2 rate from 2 liters per minute to 5 liters per minute. The resident's O2 saturation level was rechecked and it was 86%. Per record review, the nurses encouraged the resident to lie back in the bed, but he/she refused. The resident hollered out in pain that his/her lower back was hurting. The resident sat up on the side of the bed and the nurse left the room to get help and call 911. The nurse returned to find the resident lying on the floor on his/her left side. Further review of Resident #2's medical record revealed no physician's order for 5 liters of oxygen to be administered and no evidence the resident's physician was notified. In addition, there was no evidence an assessment of the resident's status was completed. An interview with CNA #1, on [DATE] at 9:50 AM, revealed she stayed over, on [DATE], to work second shift, which began at 2:30 PM, and to help provide care for the residents on Wing II. Per interview, she was the first CNA to report to the nurses about Resident #2's difficulty breathing. After she reported the resident's difficulty breathing, she returned to the resident's room and waited with the resident for approximately 10 minutes. CNA #1 revealed neither nurse responded after she made the nurses (LPN #1 and LPN #2) aware of the resident's complaint and request. She stated CNA #2 also went to the nurses' desk and reported Resident #2's breathing problems to LPN #1 and LPN #2. The CNAs transferred Resident #2 from the wheelchair to his/her bed, covered him/her up, and a nurse still had not come to the room. CNA #1 and CNA #2 left Resident #2's room to provide care for other residents on the unit. CNA #1 revealed when she came out of the last resident's room, the ambulance service staff was coming down the hall. She returned to Resident #2's room and observed the Acting Director of Nursing (DON) on the floor, leaning over Resident #2, asking the resident if he/she hurt anywhere or if he/she could hear her. She stated LPN #1 and LPN #2 were in the room at that time; however, they were standing off to the side while the Acting DON attended to the resident. An interview with CNA #2, on [DATE] at 2:08 PM, revealed on [DATE], as she began her rounds between 2:30 PM and 3:00 PM, Resident #2 requested to lie down, and wanted the CNA to inform the nurse that he/she was having difficulty breathing and did not feel well. The CNA informed LPN #1 and LPN #2, who were counting controlled narcotics, about the resident's request. CNA #2 stated she went down the hall to provide other residents care, and as she was going down the hall, Resident #2 put his/her call light on. CNA #2 responded to the call light, raised the resident's head of bed, and informed the nurses of the resident's complaint and his/her request for a nurse. She stated Resident #2 put his/her call light on again, and stated the resident wanted to sit on the side of the bed, so she assisted him/her to sit up. She stated she informed the nurses a third time of the resident's complaint and request. CNA #2 stated she was told by the nurses that they were on their way to check on the resident, so she continued her rounds. She stated, at the completion of her rounds, she came out of a resident's room and observed Resident #2 on a stretcher leaving the facility. An interview with LPN #2, on [DATE] at 2:37 PM and on [DATE] at 4:00 PM, revealed she was the nurse on Wing II on [DATE]. She stated she was getting shift report, when a CNA came to her and told her Resident #2 having difficulty breathing. LPN #2 told the CNA to "wait a minute, I will be right there." She recalled the resident had his/her scheduled eye surgery prior to the day of the incident. She stated they (LPN #1 and LPN #2) went to the resident's room and observed that the resident was experiencing shortness of breath. They checked his/her O2 saturation and it was low (80 % per documentation in the record). She stated they transferred the resident to the bed and LPN #1 left the room to call 911. However, interview with CNA #1 revealed the CNAs had transferred the resident to the bed before they had left the resident's room. Further interview with LPN #2 revealed the resident screamed as they attempted to get him/her to lean back on the bed and the resident sat back up on the side of the bed. She went to get some help. She went to the door and then to the hall and yelled for help. LPN #2 turned around and observed Resident #2 on the floor on his/her right side (nurses' notes stated left side and LPN #2 stated she incorrectly document which side). She could not provide an explanation as to how the resident ended up lying on the floor. An interview with LPN #1, on [DATE] at 10:05 AM, revealed she, along with LPN #2, was informed of Resident #2's difficulty breathing. She was getting shift report at the time and told LPN #2 to grab a stethoscope. Upon arrival to the resident's room, he/she was lying flat in the bed. Resident #2 was experiencing shallow breathing at that time. The resident screamed, as if in pain, and they were unable to get the head of the bed to raise. She stated she came out of the room and paged maintenance. She paged maintenance overhead then called 911. She stated the maintenance staff sat the resident up on the side of his/her bed and LPN #2 left the room. LPN #1 could not recall who informed her they had assisted the resident to sit up on the side of the bed. By the time she returned to Resident #2's room, the Acting DON was in the room attending to the resident, who was lying on the floor. An interview with the former Maintenance Supervisor, on [DATE] at 1:54 PM, revealed he did not assist the resident to sit up on the side of his/her bed, on [DATE]. He stated when he entered the resident's room, the nurses were in the hall and the resident was lying in his/her bed. He was informed by the nurses the head of the bed would not raise any higher. He stated he checked the plug but could not determine if it was bad so he left the room. He could not recall who was in the room. He went to the maintenance room and searched for about five (5) minutes for a plug for the bed, then returned to the floor. He was told the resident expired. A review of the ambulance run sheet, dated [DATE] at 3:48 PM, revealed EMS personnel checked the resident and he/she was unresponsive on the floor with agonal breathing (associated with the dying process), and his/her skin was cyanotic (discoloration of the skin caused by a lack of O2). An interview with the EMS personnel, on [DATE] at 11:45 AM, revealed on [DATE] at 3:40 PM and 3:45 PM, calls were received from the facility. An interview with the former Acting DON, on [DATE] at 3:12 PM and on [DATE] at 5:34 PM, revealed she did not think the incident was neglectful. Per interview, she first knew of Resident #2's breathing trouble when she overheard CNA #2 state the resident was on the floor. The former Acting DON immediately went to Resident #2's room and observed him/her lying on the floor. She stated LPN #1 and LPN #2 were still at the nurse's station when she went to the resident's room. The resident was blue and a puddle of blood was underneath his/her head. She started checking the resident and asked the aides what was going on with the resident. The aides (CNA#1 & CNA #2) told her they had reported to the nurses (LPN #1 & LPN #2) the resident's request to see a nurse because he/she was having trouble breathing. The former Acting DON stated LPN #1 and LPN #2 informed her, after the aide (CNA #2) had reported the resident's breathing difficulty, that they were "getting ready" to go to the room and check on the resident. The former Acting DON stated the nurses were expected to assess the resident or the situation once they were made aware of a resident's complaint and she was unaware the two nurses had failed to assess the resident. Interviews with LPN #1 and LPN #2 revealed they went to check on the resident immediately after being made aware of the resident's breathing trouble. However, interview with the Acting DON revealed she observed the two nurses at the nursing station, when Resident #2 was found on the floor. In addition, interview with CNA #1 and CNA #2 revealed the nurses had been informed four (4) times, with the first time being at approximately 3:00 PM. Record review revealed the nurses' note was timed at 3:30 PM; however, the ambulance run sheet revealed an arrival time at the resident's bedside of 3:48 PM. The facility failed to assess, monitor, and respond timely to a resident with complaints of breathing difficulties. Per interview, this incident was not investigated and the facility was unaware if other residents had been affected by this deficient practice.

Based on interview, review of facility policy/procedure, manufacturer instructions, and record review, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as possible and failed to ensure adequate supervision was provided to prevent accidents for three residents (#1, #3 and #4), in the selected sample of four (4). The facility utilized full body mechanical lifts for resident transfers. On [DATE], Resident #3 sustained a fractured left and right femur (thigh bone), during an assisted transfer using the full body mechanical lift. The facility failed to assess the resident for the safe use of the mechanical lift or determine the risk and benefits for the resident. Resident #1 was care planned to have a bed alarm and a wheelchair alarm in place. On [DATE] at 7:00 AM, Resident #1 was found lying in the floor by staff, with no alarms sounding. Resident #4 was care planned to have an alarm on his/her wheelchair. Observations, on [DATE] and [DATE], revealed no wheelchair alarm was present. The findings include: A review of the facility's policy/procedure, "Accidents and Incidents: Report, Investigation, Follow-up and Final Disposition" dated ,[DATE] and revised ,[DATE], revealed "a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not because of overwhelming external force. Supervision/adequate supervision refers to an intervention and means of mitigation the risk of an accident. Centers are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident's environment. Supervision may vary resident to resident and time to time for the same resident. The use of tools or items such as personal alarms can help monitor a resident's activities but does not eliminate the need for staff vigilance and are not to be utilized in lieu of supervision. Lack of adequate supervision to prevent accidents occurs when the center has failed to: accurately assess a resident and/or the resident environment to determine whether supervision to avoid an accident or injury was necessary; provide supervision of the resident and/or resident's environment as determined. Proper action following a fall includes: ascertaining if there were injuries and providing treatment as necessary; determining what may have caused or contributed to the fall; addressing the contributing factors of the fall; revising the resident's plan of care and/or center practices to reduce the likelihood of another fall. Report all accidents/incidents to the Administrator. Notify the Administrator immediately, if a medical device is to have caused or contributed to an injury." 1. A review of the facility's policy/procedure, "Minimal Lift Programs" dated ,[DATE], revealed "lifting devices are utilized according to plans of care based on individual resident assessment or when a resident is on the floor and cannot get up independently. Use an assessment and communication system to identify resident lifting, transferring, and repositioning needs to appropriate care personnel." A record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Comprehensive Admission Data Collection and Assessment, dated [DATE], revealed the resident was alert and oriented to person, place and time. The facility assessed the resident as totally dependent for transfers; however, the assessment did not indicate the amount of support required. Further record review revealed no evidence an assessment for the use of a mechanical lift was completed to determine the risk and benefits. A review of the Accident/Incident Report, dated [DATE] at 9:00 AM, revealed "the resident was up in the lift, in the lift pad. The lift hook slipped, causing the resident to fall out of the sling to the floor and onto his/her right side. The resident complained of pain. The mechanical lift was used to return the resident back to his/her bed. The ambulance was called to transport the resident to the hospital." A review of the ambulance record, dated [DATE], revealed a call was received from the facility at 9:25 AM. The ambulance arrived to the facility at 9:33 AM and the resident was lying in the bed. The staff stated the resident fell from a lift and landed on his/her right side. The resident did not complain of pain in his/her right side, but had a deformity in the left femur and complained of pain in the left hip. The staff placed the resident in the bed after the fall. The ambulance left the facility at 9:51 AM. An interview with Resident #3, on [DATE] at 1:05 PM, revealed he/she had a fall from the mechanical lift on [DATE]. He/she stated the fall happened early in the morning, but the resident could not recall the exact time. The staff assisted him/her up after the fall. Resident #3 reported he/she broke both of his/her legs and his/her hip. There were two female staff members in there at the time. "One female staff guided my feet as the other staff operated the controller to raise me from the bed. The staff started pulling me back, then I fell suddenly, hitting the floor. The staff transferred me a day or two prior to the incident and did well. The staff did not say anything at the time of the incident. Afterwards, one of the staff left the room and returned with six more people." Resident #3 stated the facility staff did not touch him/her, and he/she remained on the floor until Emergency Medical Service (EMS) personnel arrived and transported him/her to an acute care hospital. An interview with Certified Nurse Aide (CNA) #6, on [DATE] at 8:48 AM and on [DATE] at 4:15 PM, revealed she was operating the lift when the resident fell , but could not recall the time. Per interview, the only way to transfer Resident #3 was with a mechanical lift, and physical therapy approved the use of the lift for the resident. She was getting the resident up from his/her bed, put the lift pad under him/her and hooked Resident #3 to the mechanical lift. Licensed Practical Nurse (LPN) #1 assisted her and guided his/her legs as she pulled him/her back with the mechanical lift. She opened the legs of the mechanical lift and the resident fell to the floor. The mechanical lift was shaky and it bounced around on the uneven surfaces. The lift pad which was used was based on the size the resident needed. The lift pad was hooked on three sides and the bottom left loop came unattached. The other lifts had a latch on the hooks to secure the loops of the pad, but the lift used for Resident #3 did not have the secure latches on it. The lift pads have multiple colored loops on it and she was trained to use "green" at the top and "black" at the bottom to assist a resident to sit in a wheelchair. She visually checked to ensure the loops were secured on the hooks when the resident was lifted from the bed. Additionally, she reported, during orientation, she was with another CNA and was trained how to use the lift. She stated the first in-service she attended on mechanical lifts was after Resident #3's fall. An interview with LPN #1, on [DATE] at 9:35 AM, revealed she was the nurse on duty on Wing II, on [DATE]. She was administering medications to the resident in the "A" bed, when CNA #6 asked her to help transfer Resident #3. She advised the CNA to get the resident on the lift pad of the mechanical lift. She assisted to guide the resident's legs off the bed. She walked with the resident as CNA #6 scooted the lift backwards. Suddenly the resident fell to the floor and she heard a "thump." Resident #3 was asked if he/she was in pain and Resident #3 stated "no." LPN #1 examined the resident while he/she was lying on the floor and there appeared to be nothing abnormal. The resident was returned to his/her bed with the assistance of another mechanical lift and three staff. LPN #1 stated she and CNA #6 thought the lift strap broke, but it was intact when she looked at it. CNA #6 questioned the nurse if the resident always had a knot in his/her leg. She explained the knot was there as far as she knew, but she would have another nurse examine the resident. The Director of Nursing (DON) came to the room and examined the resident's leg. She stated she was advised to send the resident for an evaluation at the local hospital. She stated she notified the ambulance. She could not recall the time the incident occurred or the time the ambulance arrived to the facility. An interview with CNA #1, on [DATE] at 9:00 AM, revealed she was not assigned to care for the resident on [DATE]. She stated another CNA (#6) was assigned to the resident's care that day, but LPN #1 requested CNA #1's assistance. She entered the resident's room and observed him/her lying on the floor. The resident's head was toward the door and his/her legs were toward the window. The lift pad was still hooked to the mechanical lift and the bottom lower left loop on the mechanical lift was not hooked. She was told by LPN #1, there was a "pop" with the lift and he/she slid from the lift pad and hit the floor. Resident #3 complained of left leg and right shoulder pain. She assisted LPN #1 and CNA #6 to put the resident back on the lift pad and moved him/her back to the bed. An interview with the Maintenance Supervisor, on [DATE] at 10:10 AM, revealed he checked the lifts every morning when he came on duty, but the weekend supervisor checked the lifts on Saturday and Sunday. He made sure the brakes were operative, the legs swung in and out properly, the emergency shut off worked, and all the hooks and metal rings were in accordance with the Original Equipment Manufacturer (OEM). Additionally, he completed a visual check of the bolts on the mechanical lift. He did not service the lifts and did not know how often an outside contractor came to check them. An interview with the former Staff Development Coordinator (SDC), on [DATE] at 2:45 PM and on [DATE] at 11:12 PM, revealed she provided training upon hire, and newly hired employees had to complete a return demonstration with the lift. During this training, she stressed and made sure the hires understood that two people were required to operate the lift. She stated the mechanical lift used, on [DATE], was smaller and had three small hooks beneath it and the CNA said she hooked the resident to these small hooks beneath it. The SDC questioned CNA #6 as to why she used the smaller hooks and explained it would be safer to use the bigger loops. She stated the staff was not told or trained to use the smaller hooks beneath it. The staff was told after the sling was hooked up, to raise the lift and visualize that the sling hooks were secured. The legs of the mechanical lift were always supposed to be open to help balance the lift. She was unsure if one of the loops of the sling slipped off the hook when the resident was turned. Per interview, the staff involved in the incident did a re-enactment that evening and training was immediately provided for the CNAs and nurses that night. All staff were re-trained on the proper use of the lift. An interview with the Administrator, on [DATE] at 9:10 AM and 3:30 PM, revealed assessments for the mechanical lifts were completed in Daily Clinical Review (DCR) meeting and therapy was a part of the team. The mechanical lift was taken out of service immediately. The lift was in her office, then moved to the facility storage area. A representative from the manufacturer came and "checked out" the lift. They received written approval from the manufacturer the lift was safe to use. The maintenance supervisor inspected the lift following the incident and found no problems. Additionally, the Regional Director of Clinical Services (RDCS) checked the lift and no problems were found. There were no identified problems with the lift or the sling. They could not actually determine what happened, but one of the straps slipped off. Per interview, the manufacturer did not service the lifts on a routine basis and would only come when there was a problem. An interview with the DON, on [DATE] at 2:14 PM, revealed with new admissions, nursing and therapy communicate with each other regarding the residents' abilities to transfer. The therapy department screened the residents, then the resident was discussed in the DCR meeting. She stated therapy completed the assessments for the use of mechanical lifts with the residents, and the residents were also discussed in the Interdisciplinary Team (IDT) meeting. The IDT discussed everything from the resident's discharge summary, therapy notes from the hospital, and the report nursing received. All of those things are taken into consideration. During the IDT meeting, the resident's needs were discussed and a care plan was generated. She stated the risk and benefits of using the mechanical lift were identified for the residents. The information was documented in the DCR note and also documented on the care plan and the CNA assignment sheet. When a mechanical lift was deemed to be used for a resident, the nurse communicated this information on the 24 hour report. CNAs reported to each other and then reported to the nurse. If a problem was noted by the CNA, then the CNAs were to let the nurse know. Additionally, when oriented and in-serviced, she was instructed to use the "blue loops" at the top of the pad and "green loops" at the bottom. . The DON reviewed Resident #3's record and stated, based on the evaluation, Resident #3 required total assistance, which meant the resident required the use of a mechanical lift. An interview with the Regional Director of Rehab Services, on [DATE] at 1:45 PM, revealed when they had an admission, therapy received a request for a screen/evaluation. They determine from the evaluation the type of assistance the resident required for transfers. Therapy assesses the resident more for transfer techniques. The resident would be discussed in the DCR and therapy would inform them if they recommended a lift. A discussion with the team would take place to see if all were in agreement with the recommendations. She stated the nursing department would take over once an agreement was reached related to the use of the lift. She stated therapy does not provide any instruction on which loops to be used on lifting a resident. She stated "we get a referral, screen and evaluate the resident and determine if a lift needed to be used or therapy needed to work with the resident to improve their transfer abilities. The CNAs are trained from a nursing standpoint on which loops of the lift are to be used with each resident." A review of the care and maintenance for the resident lift revealed a six (6) month check and lubrication should ensure the continued safety and reliability. The facility provided no evidence of the mechanical lifts being serviced. An interview with a former sales representative for the lift manufacturer, on [DATE] at 10:25 AM, revealed he came to the facility in [DATE], after the resident sustained [REDACTED]. He checked the moving parts of the mechanical lift. Additionally, he tested the lift involved in the incident and it worked properly. He had not been to the facility to check the mechanical lifts, but recommended the lifts be looked at annually. An interview with the RDCS, on [DATE] at 9:14 PM, revealed she received a call following the incident on [DATE]. She came to the facility that afternoon, had the staff involved come back to the facility and demonstrate how they hooked up the resident. She observed the re-enactment and everything appeared to be fine. The loop of the sling was not in disrepair and it just slipped off the hook. The sling and the lift were looked at, and found nothing wrong with it. The staff demonstrated appropriate technique during the re-enactment. She reported all of the lifts in the facility were from one manufacturer and the slings were interchangeable on all of the models. The lifts pads were the same and the loops were color coded related to the size of the resident. The staff also have a mesh lift pad used in the showers. The lift and sling were immediately taken out of service after the incident and began competencies with the staff. 2. A record review revealed Resident #1 was admitted to the facility, [DATE], with [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired with a BIMS score of "3." The resident required extensive assistance of one staff for transfers, bed mobility, locomotion on and off the unit. A review of the comprehensive care plan, dated [DATE], revealed the resident was identified as a falls risk related to poor weight bearing, advanced age, myocardial infarct, unsteady gait, bowel/bladder incontinence, Dementia, History of Cerebral Vascular Accident (CVA), hearing impairment and Osteoporosis. The resident had interventions in place since [DATE] for a chair alarm and a bed alarm. A review of the Accident/Incident Report, dated [DATE], revealed the resident was found on the floor, with a complaint of left hip pain, at approximately 7:00 AM. Documentation revealed the fall was unwitnessed. A review of the facility's final investigation, dated [DATE], revealed the resident was found lying on the floor beside his/her bed at 6:45 AM. The resident was placed back into bed, with no complaint of pain voiced at that time. It was noted the resident's alarms were on and functioning. At 7:45 AM, it was reported that the resident complained of left hip pain. After an assessment by the nurse, a physician's orders [REDACTED]. The results of the x-ray revealed a fractured left hip. The family did not want the resident to be sent out to the hospital. At 4:30 PM, it was reported that the resident was deceased , with the family at the bedside. A review of the nurses' notes, dated [DATE] at 6:45 AM, revealed the resident was found on the floor in his/her room. The nurses' notes did not mention if the resident's alarm sounded when the resident was found on the floor. An interview with CNA #1, on [DATE] at 8:45 AM, revealed she took another resident to restorative dining on the morning of [DATE], around 6:35 AM, and noticed Resident #1 was lying on the floor. She revealed there was no sound coming from the resident and there was no alarm sounding. She did not know if an alarm was on the resident after he/she was returned to the bed. She stated the resident was care planned for an alarm to the bed and the wheelchair. An interview with LPN #3, on [DATE] at 10:30 AM, revealed she was the Charge Nurse on [DATE]. She stated she received report from LPN #4 when CNA #1 called about Resident #1 being on the floor. LPN #3 and LPN #4 went to the resident's room and observed him/her lying on the floor on his/her back with his/her knees bent. LPN #4 examined the resident and he/she voiced no complaints of pain. LPN #4 picked the resident up and placed him/her back in the bed. LPN #3 stated the resident had an alarm on his/her bed and she thought the alarm sounded. An interview with CNA #4, on [DATE] at 5:41 PM, revealed she worked on [DATE]. She stated the resident should have an alarm on the bed and the wheelchair. She stated when she arrived to the resident's room, LPN #3, LPN #4 and CNA #1 were in the room and she did not hear an alarm sound. LPN #4 put the resident back in the bed and she reported she did not see an alarm on Resident #1's bed. An interview with LPN #4, on [DATE] at 5:40 PM, revealed he finished giving report to the LPN #3, and heard a day shift CNA yell that the resident was on the floor. LPN #4 stated he and LPN #3 went to the resident's room and observed Resident #1 lying on the floor. He stated they examined Resident #1 completely, then he picked the resident up and placed the resident back in the bed. He stated the resident had the alarm on his/her bed removed a while ago, and no alarm sounded when they entered the room. He could not say how long the alarm on the resident's bed was not utilized. 3. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated ,[DATE]//11, revealed the facility assessed the resident as moderately cognitively impaired with a BIMS score of "9." Resident #4 required extensive assistance to total dependence with one to two staff assistance for activities of daily living. The resident had no falls prior to the assessment. A review of the comprehensive care plan, dated [DATE] revealed Resident #4 was at risk for falls related to pain, stiffness, weakness, cardiovascular diagnosis, Dementia, and CVA. The resident had interventions in place since [DATE] for a bed alarm and a wheelchair alarm. Observation, on [DATE] at 1:10 PM, revealed the resident was sitting in the wheelchair in the bedroom awake and alert. The resident had a sensor pad alarm beneath the cushion on his/her wheelchair and the wire from the sensor pad hung down below the wheelchair. There was no alarm box connected to the wire. At 4:00 PM, Resident #4 was sitting in his/her wheelchair across from the nurses' desk. The resident did not have an alarm box (for the sensor pad alarm) on the wheelchair. On [DATE] at 8:20 AM, the resident was resting quietly with his/her eyes closed in the bed. An alarm was observed on the bed and the resident's wheelchair was in the room without an alarm box connected to the wire. At 1:00 PM, the resident was observed in his/her wheelchair across from the nurse's desk, awake and alert. The resident had the sensor pad in place; however, there was no alarm box connected to the wire hanging down beneath the seat of the wheelchair. At 3:00 PM, the resident was in his/her wheelchair at the nurses' desk. The resident had the sensor pad on his/her wheelchair; however, there was not an alarm box connected to the wire which hung down beneath the seat of the wheelchair. An interview with CNA #7, on [DATE] at 10:35 AM, revealed the resident did not have an alarm on his/her wheelchair. She stated she followed the CNA assignment sheet for the care of the residents she was assigned to, and looked at it throughout the day. CNA #7 stated she was not aware the resident was supposed to have an alarm on his/her wheelchair. An interview with CNA #6, on [DATE] at 1:53 PM, revealed she provided care for the resident on [DATE] and [DATE]. The resident had an alarm on his/her bed and wheelchair. She stated Resident #4 had a sensor pad beneath the cushion of his/her wheelchair. She revealed the resident had the alarm on the wheelchair when he/she was in the wheelchair; however, she provided no explanation as to why the box was not connected to the alarm on the wheelchair, on [DATE] and [DATE]. She stated if the resident did not have a box for the wheelchair alarm, then she went to the DON for an alarm box. She revealed, at times, she removed the alarm box from the bed and attached it to the alarm on the wheelchair. An interview with the DON, on [DATE] at 2:36 PM and on [DATE] at 12:38 PM, revealed she questioned LPN #3 if the alarm was in place, and sounded when Resident #1 was found on the floor. The DON stated she was informed the alarm sounded when the resident fell . She stated the resident had an alarm on his/her bed and grab bars. She revealed it was the nursing staff's responsibility to ensure the residents had his/her alarms in place. The alarms were checked by the licensed staff or CNAs every shift for placement and functioning. She stated the staff monitored the alarms each day and reported back to her if an alarm was not on a resident or was in need of batteries. She reported she had not devised a form to document information for tracking residents with alarms, but she received a couple of reports from the previous week related to alarms not being on a resident. She was unaware Resident #4 did not have an alarm on his/her wheelchair.

Based on interview, review of facility policy/procedure, manufacturer instructions, and record review, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as possible and failed to ensure adequate supervision was provided to prevent accidents for three residents (#1, #3 and #4), in the selected sample of four (4). The facility utilized full body mechanical lifts for resident transfers. On [DATE], Resident #3 sustained a fractured left and right femur (thigh bone), during an assisted transfer using the full body mechanical lift. The facility failed to assess the resident for the safe use of the mechanical lift or determine the risk and benefits for the resident. Resident #1 was care planned to have a bed alarm and a wheelchair alarm in place. On [DATE] at 7:00 AM, Resident #1 was found lying in the floor by staff, with no alarms sounding. Resident #4 was care planned to have an alarm on his/her wheelchair. Observations, on [DATE] and [DATE], revealed no wheelchair alarm was present. The findings include: A review of the facility's policy/procedure, "Accidents and Incidents: Report, Investigation, Follow-up and Final Disposition" dated ,[DATE] and revised ,[DATE], revealed "a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not because of overwhelming external force. Supervision/adequate supervision refers to an intervention and means of mitigation the risk of an accident. Centers are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident's environment. Supervision may vary resident to resident and time to time for the same resident. The use of tools or items such as personal alarms can help monitor a resident's activities but does not eliminate the need for staff vigilance and are not to be utilized in lieu of supervision. Lack of adequate supervision to prevent accidents occurs when the center has failed to: accurately assess a resident and/or the resident environment to determine whether supervision to avoid an accident or injury was necessary; provide supervision of the resident and/or resident's environment as determined. Proper action following a fall includes: ascertaining if there were injuries and providing treatment as necessary; determining what may have caused or contributed to the fall; addressing the contributing factors of the fall; revising the resident's plan of care and/or center practices to reduce the likelihood of another fall. Report all accidents/incidents to the Administrator. Notify the Administrator immediately, if a medical device is to have caused or contributed to an injury." 1. A review of the facility's policy/procedure, "Minimal Lift Programs" dated ,[DATE], revealed "lifting devices are utilized according to plans of care based on individual resident assessment or when a resident is on the floor and cannot get up independently. Use an assessment and communication system to identify resident lifting, transferring, and repositioning needs to appropriate care personnel." A record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Comprehensive Admission Data Collection and Assessment, dated [DATE], revealed the resident was alert and oriented to person, place and time. The facility assessed the resident as totally dependent for transfers; however, the assessment did not indicate the amount of support required. Further record review revealed no evidence an assessment for the use of a mechanical lift was completed to determine the risk and benefits. A review of the Accident/Incident Report, dated [DATE] at 9:00 AM, revealed "the resident was up in the lift, in the lift pad. The lift hook slipped, causing the resident to fall out of the sling to the floor and onto his/her right side. The resident complained of pain. The mechanical lift was used to return the resident back to his/her bed. The ambulance was called to transport the resident to the hospital." A review of the ambulance record, dated [DATE], revealed a call was received from the facility at 9:25 AM. The ambulance arrived to the facility at 9:33 AM and the resident was lying in the bed. The staff stated the resident fell from a lift and landed on his/her right side. The resident did not complain of pain in his/her right side, but had a deformity in the left femur and complained of pain in the left hip. The staff placed the resident in the bed after the fall. The ambulance left the facility at 9:51 AM. An interview with Resident #3, on [DATE] at 1:05 PM, revealed he/she had a fall from the mechanical lift on [DATE]. He/she stated the fall happened early in the morning, but the resident could not recall the exact time. The staff assisted him/her up after the fall. Resident #3 reported he/she broke both of his/her legs and his/her hip. There were two female staff members in there at the time. "One female staff guided my feet as the other staff operated the controller to raise me from the bed. The staff started pulling me back, then I fell suddenly, hitting the floor. The staff transferred me a day or two prior to the incident and did well. The staff did not say anything at the time of the incident. Afterwards, one of the staff left the room and returned with six more people." Resident #3 stated the facility staff did not touch him/her, and he/she remained on the floor until Emergency Medical Service (EMS) personnel arrived and transported him/her to an acute care hospital. An interview with Certified Nurse Aide (CNA) #6, on [DATE] at 8:48 AM and on [DATE] at 4:15 PM, revealed she was operating the lift when the resident fell , but could not recall the time. Per interview, the only way to transfer Resident #3 was with a mechanical lift, and physical therapy approved the use of the lift for the resident. She was getting the resident up from his/her bed, put the lift pad under him/her and hooked Resident #3 to the mechanical lift. Licensed Practical Nurse (LPN) #1 assisted her and guided his/her legs as she pulled him/her back with the mechanical lift. She opened the legs of the mechanical lift and the resident fell to the floor. The mechanical lift was shaky and it bounced around on the uneven surfaces. The lift pad which was used was based on the size the resident needed. The lift pad was hooked on three sides and the bottom left loop came unattached. The other lifts had a latch on the hooks to secure the loops of the pad, but the lift used for Resident #3 did not have the secure latches on it. The lift pads have multiple colored loops on it and she was trained to use "green" at the top and "black" at the bottom to assist a resident to sit in a wheelchair. She visually checked to ensure the loops were secured on the hooks when the resident was lifted from the bed. Additionally, she reported, during orientation, she was with another CNA and was trained how to use the lift. She stated the first in-service she attended on mechanical lifts was after Resident #3's fall. An interview with LPN #1, on [DATE] at 9:35 AM, revealed she was the nurse on duty on Wing II, on [DATE]. She was administering medications to the resident in the "A" bed, when CNA #6 asked her to help transfer Resident #3. She advised the CNA to get the resident on the lift pad of the mechanical lift. She assisted to guide the resident's legs off the bed. She walked with the resident as CNA #6 scooted the lift backwards. Suddenly the resident fell to the floor and she heard a "thump." Resident #3 was asked if he/she was in pain and Resident #3 stated "no." LPN #1 examined the resident while he/she was lying on the floor and there appeared to be nothing abnormal. The resident was returned to his/her bed with the assistance of another mechanical lift and three staff. LPN #1 stated she and CNA #6 thought the lift strap broke, but it was intact when she looked at it. CNA #6 questioned the nurse if the resident always had a knot in his/her leg. She explained the knot was there as far as she knew, but she would have another nurse examine the resident. The Director of Nursing (DON) came to the room and examined the resident's leg. She stated she was advised to send the resident for an evaluation at the local hospital. She stated she notified the ambulance. She could not recall the time the incident occurred or the time the ambulance arrived to the facility. An interview with CNA #1, on [DATE] at 9:00 AM, revealed she was not assigned to care for the resident on [DATE]. She stated another CNA (#6) was assigned to the resident's care that day, but LPN #1 requested CNA #1's assistance. She entered the resident's room and observed him/her lying on the floor. The resident's head was toward the door and his/her legs were toward the window. The lift pad was still hooked to the mechanical lift and the bottom lower left loop on the mechanical lift was not hooked. She was told by LPN #1, there was a "pop" with the lift and he/she slid from the lift pad and hit the floor. Resident #3 complained of left leg and right shoulder pain. She assisted LPN #1 and CNA #6 to put the resident back on the lift pad and moved him/her back to the bed. An interview with the Maintenance Supervisor, on [DATE] at 10:10 AM, revealed he checked the lifts every morning when he came on duty, but the weekend supervisor checked the lifts on Saturday and Sunday. He made sure the brakes were operative, the legs swung in and out properly, the emergency shut off worked, and all the hooks and metal rings were in accordance with the Original Equipment Manufacturer (OEM). Additionally, he completed a visual check of the bolts on the mechanical lift. He did not service the lifts and did not know how often an outside contractor came to check them. An interview with the former Staff Development Coordinator (SDC), on [DATE] at 2:45 PM and on [DATE] at 11:12 PM, revealed she provided training upon hire, and newly hired employees had to complete a return demonstration with the lift. During this training, she stressed and made sure the hires understood that two people were required to operate the lift. She stated the mechanical lift used, on [DATE], was smaller and had three small hooks beneath it and the CNA said she hooked the resident to these small hooks beneath it. The SDC questioned CNA #6 as to why she used the smaller hooks and explained it would be safer to use the bigger loops. She stated the staff was not told or trained to use the smaller hooks beneath it. The staff was told after the sling was hooked up, to raise the lift and visualize that the sling hooks were secured. The legs of the mechanical lift were always supposed to be open to help balance the lift. She was unsure if one of the loops of the sling slipped off the hook when the resident was turned. Per interview, the staff involved in the incident did a re-enactment that evening and training was immediately provided for the CNAs and nurses that night. All staff were re-trained on the proper use of the lift. An interview with the Administrator, on [DATE] at 9:10 AM and 3:30 PM, revealed assessments for the mechanical lifts were completed in Daily Clinical Review (DCR) meeting and therapy was a part of the team. The mechanical lift was taken out of service immediately. The lift was in her office, then moved to the facility storage area. A representative from the manufacturer came and "checked out" the lift. They received written approval from the manufacturer the lift was safe to use. The maintenance supervisor inspected the lift following the incident and found no problems. Additionally, the Regional Director of Clinical Services (RDCS) checked the lift and no problems were found. There were no identified problems with the lift or the sling. They could not actually determine what happened, but one of the straps slipped off. Per interview, the manufacturer did not service the lifts on a routine basis and would only come when there was a problem. An interview with the DON, on [DATE] at 2:14 PM, revealed with new admissions, nursing and therapy communicate with each other regarding the residents' abilities to transfer. The therapy department screened the residents, then the resident was discussed in the DCR meeting. She stated therapy completed the assessments for the use of mechanical lifts with the residents, and the residents were also discussed in the Interdisciplinary Team (IDT) meeting. The IDT discussed everything from the resident's discharge summary, therapy notes from the hospital, and the report nursing received. All of those things are taken into consideration. During the IDT meeting, the resident's needs were discussed and a care plan was generated. She stated the risk and benefits of using the mechanical lift were identified for the residents. The information was documented in the DCR note and also documented on the care plan and the CNA assignment sheet. When a mechanical lift was deemed to be used for a resident, the nurse communicated this information on the 24 hour report. CNAs reported to each other and then reported to the nurse. If a problem was noted by the CNA, then the CNAs were to let the nurse know. Additionally, when oriented and in-serviced, she was instructed to use the "blue loops" at the top of the pad and "green loops" at the bottom. . The DON reviewed Resident #3's record and stated, based on the evaluation, Resident #3 required total assistance, which meant the resident required the use of a mechanical lift. An interview with the Regional Director of Rehab Services, on [DATE] at 1:45 PM, revealed when they had an admission, therapy received a request for a screen/evaluation. They determine from the evaluation the type of assistance the resident required for transfers. Therapy assesses the resident more for transfer techniques. The resident would be discussed in the DCR and therapy would inform them if they recommended a lift. A discussion with the team would take place to see if all were in agreement with the recommendations. She stated the nursing department would take over once an agreement was reached related to the use of the lift. She stated therapy does not provide any instruction on which loops to be used on lifting a resident. She stated "we get a referral, screen and evaluate the resident and determine if a lift needed to be used or therapy needed to work with the resident to improve their transfer abilities. The CNAs are trained from a nursing standpoint on which loops of the lift are to be used with each resident." A review of the care and maintenance for the resident lift revealed a six (6) month check and lubrication should ensure the continued safety and reliability. The facility provided no evidence of the mechanical lifts being serviced. An interview with a former sales representative for the lift manufacturer, on [DATE] at 10:25 AM, revealed he came to the facility in [DATE], after the resident sustained [REDACTED]. He checked the moving parts of the mechanical lift. Additionally, he tested the lift involved in the incident and it worked properly. He had not been to the facility to check the mechanical lifts, but recommended the lifts be looked at annually. An interview with the RDCS, on [DATE] at 9:14 PM, revealed she received a call following the incident on [DATE]. She came to the facility that afternoon, had the staff involved come back to the facility and demonstrate how they hooked up the resident. She observed the re-enactment and everything appeared to be fine. The loop of the sling was not in disrepair and it just slipped off the hook. The sling and the lift were looked at, and found nothing wrong with it. The staff demonstrated appropriate technique during the re-enactment. She reported all of the lifts in the facility were from one manufacturer and the slings were interchangeable on all of the models. The lifts pads were the same and the loops were color coded related to the size of the resident. The staff also have a mesh lift pad used in the showers. The lift and sling were immediately taken out of service after the incident and began competencies with the staff. 2. A record review revealed Resident #1 was admitted to the facility, [DATE], with [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as severely cognitively impaired with a BIMS score of "3." The resident required extensive assistance of one staff for transfers, bed mobility, locomotion on and off the unit. A review of the comprehensive care plan, dated [DATE], revealed the resident was identified as a falls risk related to poor weight bearing, advanced age, myocardial infarct, unsteady gait, bowel/bladder incontinence, Dementia, History of Cerebral Vascular Accident (CVA), hearing impairment and Osteoporosis. The resident had interventions in place since [DATE] for a chair alarm and a bed alarm. A review of the Accident/Incident Report, dated [DATE], revealed the resident was found on the floor, with a complaint of left hip pain, at approximately 7:00 AM. Documentation revealed the fall was unwitnessed. A review of the facility's final investigation, dated [DATE], revealed the resident was found lying on the floor beside his/her bed at 6:45 AM. The resident was placed back into bed, with no complaint of pain voiced at that time. It was noted the resident's alarms were on and functioning. At 7:45 AM, it was reported that the resident complained of left hip pain. After an assessment by the nurse, a physician's orders [REDACTED]. The results of the x-ray revealed a fractured left hip. The family did not want the resident to be sent out to the hospital. At 4:30 PM, it was reported that the resident was deceased , with the family at the bedside. A review of the nurses' notes, dated [DATE] at 6:45 AM, revealed the resident was found on the floor in his/her room. The nurses' notes did not mention if the resident's alarm sounded when the resident was found on the floor. An interview with CNA #1, on [DATE] at 8:45 AM, revealed she took another resident to restorative dining on the morning of [DATE], around 6:35 AM, and noticed Resident #1 was lying on the floor. She revealed there was no sound coming from the resident and there was no alarm sounding. She did not know if an alarm was on the resident after he/she was returned to the bed. She stated the resident was care planned for an alarm to the bed and the wheelchair. An interview with LPN #3, on [DATE] at 10:30 AM, revealed she was the Charge Nurse on [DATE]. She stated she received report from LPN #4 when CNA #1 called about Resident #1 being on the floor. LPN #3 and LPN #4 went to the resident's room and observed him/her lying on the floor on his/her back with his/her knees bent. LPN #4 examined the resident and he/she voiced no complaints of pain. LPN #4 picked the resident up and placed him/her back in the bed. LPN #3 stated the resident had an alarm on his/her bed and she thought the alarm sounded. An interview with CNA #4, on [DATE] at 5:41 PM, revealed she worked on [DATE]. She stated the resident should have an alarm on the bed and the wheelchair. She stated when she arrived to the resident's room, LPN #3, LPN #4 and CNA #1 were in the room and she did not hear an alarm sound. LPN #4 put the resident back in the bed and she reported she did not see an alarm on Resident #1's bed. An interview with LPN #4, on [DATE] at 5:40 PM, revealed he finished giving report to the LPN #3, and heard a day shift CNA yell that the resident was on the floor. LPN #4 stated he and LPN #3 went to the resident's room and observed Resident #1 lying on the floor. He stated they examined Resident #1 completely, then he picked the resident up and placed the resident back in the bed. He stated the resident had the alarm on his/her bed removed a while ago, and no alarm sounded when they entered the room. He could not say how long the alarm on the resident's bed was not utilized. 3. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated ,[DATE]//11, revealed the facility assessed the resident as moderately cognitively impaired with a BIMS score of "9." Resident #4 required extensive assistance to total dependence with one to two staff assistance for activities of daily living. The resident had no falls prior to the assessment. A review of the comprehensive care plan, dated [DATE] revealed Resident #4 was at risk for falls related to pain, stiffness, weakness, cardiovascular diagnosis, Dementia, and CVA. The resident had interventions in place since [DATE] for a bed alarm and a wheelchair alarm. Observation, on [DATE] at 1:10 PM, revealed the resident was sitting in the wheelchair in the bedroom awake and alert. The resident had a sensor pad alarm beneath the cushion on his/her wheelchair and the wire from the sensor pad hung down below the wheelchair. There was no alarm box connected to the wire. At 4:00 PM, Resident #4 was sitting in his/her wheelchair across from the nurses' desk. The resident did not have an alarm box (for the sensor pad alarm) on the wheelchair. On [DATE] at 8:20 AM, the resident was resting quietly with his/her eyes closed in the bed. An alarm was observed on the bed and the resident's wheelchair was in the room without an alarm box connected to the wire. At 1:00 PM, the resident was observed in his/her wheelchair across from the nurse's desk, awake and alert. The resident had the sensor pad in place; however, there was no alarm box connected to the wire hanging down beneath the seat of the wheelchair. At 3:00 PM, the resident was in his/her wheelchair at the nurses' desk. The resident had the sensor pad on his/her wheelchair; however, there was not an alarm box connected to the wire which hung down beneath the seat of the wheelchair. An interview with CNA #7, on [DATE] at 10:35 AM, revealed the resident did not have an alarm on his/her wheelchair. She stated she followed the CNA assignment sheet for the care of the residents she was assigned to, and looked at it throughout the day. CNA #7 stated she was not aware the resident was supposed to have an alarm on his/her wheelchair. An interview with CNA #6, on [DATE] at 1:53 PM, revealed she provided care for the resident on [DATE] and [DATE]. The resident had an alarm on his/her bed and wheelchair. She stated Resident #4 had a sensor pad beneath the cushion of his/her wheelchair. She revealed the resident had the alarm on the wheelchair when he/she was in the wheelchair; however, she provided no explanation as to why the box was not connected to the alarm on the wheelchair, on [DATE] and [DATE]. She stated if the resident did not have a box for the wheelchair alarm, then she went to the DON for an alarm box. She revealed, at times, she removed the alarm box from the bed and attached it to the alarm on the wheelchair. An interview with the DON, on [DATE] at 2:36 PM and on [DATE] at 12:38 PM, revealed she questioned LPN #3 if the alarm was in place, and sounded when Resident #1 was found on the floor. The DON stated she was informed the alarm sounded when the resident fell . She stated the resident had an alarm on his/her bed and grab bars. She revealed it was the nursing staff's responsibility to ensure the residents had his/her alarms in place. The alarms were checked by the licensed staff or CNAs every shift for placement and functioning. She stated the staff monitored the alarms each day and reported back to her if an alarm was not on a resident or was in need of batteries. She reported she had not devised a form to document information for tracking residents with alarms, but she received a couple of reports from the previous week related to alarms not being on a resident. She was unaware Resident #4 did not have an alarm on his/her wheelchair.