Every finding on record at River's Bend Retirement Community

Based on observation, interview, record review and facility policy review, the facility failed to ensure drugs and biologicals were current for use and/or labeled in accordance with currently accepted professional principles, including the expiration date when applicable, for 2 of 3 medication carts reviewed and for a total of 6 out of 13 sampled residents (Resident (R)5, R8, R17, R18, R30, and R39).The findings include: Review of the facility's policy titled, Storage of Medications Policy, undated, revealed it was the facility's policy to not use discontinued, outdated, or deteriorated drugs or biologicals and all such drugs should be returned to the dispensing pharmacy or destroyed. Further review of the policy revealed nursing staff were responsible for maintaining medication storage. Review of the facility's policy titled, Medication Administration, reviewed 12/01/2022, revealed it was the facility's policy to review the expiration date of the medication prior to giving the medication. Further review revealed staff were to dispose of any expired medications per the facility's protocol and procedure. Observation on the facility's Short-Hall of the medication cart's PRN (As Needed) drawer on 09/17/2025 at 9:11 AM, revealed the following:(1) For R8- AYR Saline Nasal Gel, 22 milliliters (mL), unopened bottle with an expiration date of 03/18/2025.(2) For R18- Loperamide (antidiarrheal medication) 2 milligram (mg) capsules with an expiration date of 09/11/2025.(3) For R5- Lactulose Liquid (used to treat constipation)10 gm/15 mL with an expiration date of 08/07/2025; and Bisacodyl EC (used to treat constipation) 5 mg tablets with an expiration date of 04/14/2025 Observation on the facility's Long-Hall of the medication cart's PRN drawer on 09/17/2025 at 9:30 AM, revealed the following:(1) For R39- Bisacodyl EC 5 mg tablets with an expiration date of 04/22/2025.(2) For R17- Bisacodyl EC 5 mg tablets with an expiration date of 04/30/2025.(3) For R30-Senexon (used to treat constipation) 8.6/50 mg tablets with expiration date of 05/19/2025. During interview with Kentucky Medication Aide (KMA) 1 on 09/17/2025 at 9:20 AM, she stated she was responsible for checking the medication carts for expired medications. She said she tried to check the medications every month. She further stated a negative outcome of administering expired medications to residents was the medication could possibly not work correctly. During interview with the Assistant Director (AD) of the facility's contract Pharmacy on 09/17/2025 at 2:53 PM, she stated the consultant pharmacists came to the facility once per month to do medication reviews and chart reviews on the residents. She said the consultant pharmacists sometimes went through the medication carts; however, not very often. The contract Pharmacy's AD stated she did not know specifically how often that was being done. She further stated when they went through the carts, they checked for expired medications, and cleaned and organized them. During interview with the Director of Nursing (DON) on 09/18/2025 at 1:41 PM, she stated her expectations of maintaining the medication carts and checking for expired medications were for whoever was using the medication cart to check the medications at least weekly. She reported a negative outcome of the carts not being checked for expired medications was that the residents could receive an expired medication. The DON stated a negative outcome of the residents receiving an expired medication was the medication would not be as strong. She further stated her expectations for the medication technicians (techs)/aides or nurse was for them to call the provider to inform them if a resident received a medication that was expired. During interview with the facility's Administrator on 09/18/2025 2:04 PM, he stated his expectation was for staff to follow the facility's policy and remove any expired medications from the medication cart. The Administrator further stated a negative outcome of a resident receiving an expired medication was the medication would not be as effective.

Based on observation, interview, and review of the facility policy, the facility failed to post staffing data as required for 3 of the 3 State Survey Agency's (SSA's) survey dates. The findings include:Review of the facility's policy titled, General Nurse Staffing, initiated 08/29/2022, revealed it was the facility's policy for staffing numbers for the facility to be posted and visible to staff and visitors daily.Observation on 09/17/2025 at 4:45 PM, of the facility's daily nurse staffing information sheet, posted on a common area corkboard, revealed it was dated 09/13/2025, and had not been updated since that date. Observation on 09/18/2025 at 12:50 PM, of the facility's daily nurse staffing information sheet, posted in the common area, revealed it was still dated 09/13/2025 and contained the same information observed on 09/17/2025, indicating it had not been updated. During interview with Registered Nurse (RN) 2 on 09/17/2025 at 4:50 PM, she stated the common area corkboard was the only known place that daily staffing would be posted. She stated the nightshift nurse was supposed to update the daily staffing sheets; however, they had contract agency staff working the past couple of nights. During interview with the Director of Nursing (DON) on 09/17/2025 at 5:15 PM, she stated the daily staffing sheets were posted on the board in the commons area by the nurse's desk. She said the midnight nurses were responsible for keeping the daily staffing updated each day. The DON further stated however, they had agency nurses working the past few nights and that was why the staffing information had not been updated since 09/13/2025. During interview with the DON on 09/18/2025 at 1:41 PM, she stated her expectations were for the daily staffing sheets to be posted daily with the correct information. She reported the importance of having daily posted staffing was for her and residents' families to know the facility's daily staffing numbers and if there was an emergency, that information would be available. She further stated she expected the dayshift staff to go over with the nightshift staff what needed to be done on that shift, including updating the staffing information. During interview with the facility's Administrator on 09/18/2025 at 2:10 PM, he stated the daily staffing sheets were to be done daily and posted so we all know who was in the building and families would also know. He further stated there had been a nightshift nurse who was responsible for doing that; however, he dropped the ball on ensuring that was done and the responsibility fell through the cracks.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for one (1) of six (6) sampled residents (Resident #25). Observations and record review revealed Resident #25 had an indwelling urinary catheter, however, there was no documented evidence a care plan had been implemented to include catheter care. The findings include: Review of the facility's policy, Care Plans, dated 09/23/2022, revealed, Plans of Care were developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident. The facility developed a comprehensive plan of care for each resident that included measurable objectives and timetables to meet a residents medical, nursing, and mental/psychosocial needs that were identified on the comprehensive assessment. Care plans were individualized and specific to the resident's care needs. When a new approach/intervention or goal was identified the care plan would be updated accordingly. Review of the facility's policy, Appropriate Use of Catheters and Feeding Tubes, dated 08/02/2015 and reviewed on 12/01/2022, revealed documentation in the medical record should reveal continual assessment for use of the catheter and the plan of care should address catheter use and strategies to prevent urinary tract infections. Record review revealed the facility admitted Resident #25 on 05/26/2023 with diagnosis which included Cerebral Infarction due to Unspecified occlusion or stenosis of unspecified cerebral artery, and Retention of urine. Review of Resident #25's Quarterly Minimum Data Set (MDS) Assessment, dated 06/30/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), which indicated the resident was interviewable. Observation of Resident #25 on 09/06/2023 at 9:17 AM revealed he/she was lying in bed asleep and his/her catheter bag was lying on the floor beside his/her bed. Review of Resident #25's records revealed a care plan had not been implemented for catheter care. In an interview with Certified Nursing Assistant (CNA) #9 on 09/06/2023 at 3:30 PM she stated she would look at the Kardex to know how to care for residents. In an interview with the Minimum Data Set (MDS) Coordinator on 09/08/2023 at 12:05 PM, she stated the purpose of a Care plan was to guide staff on the care a resident would need. She stated a baseline Care Plan should be implemented upon admission by the nurse performing the admission assessment. The MDS Coordinator stated she would then complete a Comprehensive Care Plan by day twenty-one (21) and was responsible for updating the care plan with any revisions or new interventions. She further stated changes with residents were discussed daily during the morning meetings and a Care Plan should be initiated or revised immediately when changes in the resident's care occurred. The MDS Coordinator stated if the resident had a catheter the resident's care plan should continued to state that staff should reflect that. In an interview with the Director of Nursing (DON) on 09/08/23 at 9:46 AM, she stated it was the responsibility of the MDS Coordinator to ensure care plans were updated to reflect the resident's status. The DON further stated all residents should have a care plan in place if they had a catheter. She further stated she expected the resident's care plans to be up to date and revised with any change in condition. In an interview with the Administrator on 09/08/2023 at 3:14 PM, she stated the MDS coordinator was responsible for ensuring care plans were updated and this was discussed daily during morning meetings. The Administrator stated she expected staff to follow the care plans and make revisions when changes occurred with the resident.

Based on observation, interview, record review, facility policy review and review of the facility's investigation, it was determined the facility failed to ensure one (1) of six (6) sampled residents received adequate supervision to prevent elopement from the facility. Record review revealed Resident #18 exited the facility through the front door as an employee was leaving for lunch on 07/07/2023. Resident #18 exited the facility on 07/07/2023 at approximately 1:30 PM. After the incident, the Wander Risk Assessment was completed again at which time the resident scored six to eleven (6-11) points, which indicated the resident had a moderate risk and the need for an Elopement Care Plan which was initiated with interventions put into place. The findings include: Review of the facility's policy, Missing Resident/Elopement, revised 10/12/2020, revealed residents making an adjustment to the facility, or who did not understand where they were, may be subject to leaving the facility without supervision. Unsupervised activity outside the facility could lead to serious injury of a resident due to the many hazards such as traffic, water, storms and hot/cold temperatures. Further review of the policy revealed elopements occurred when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. Record review revealed the facility admitted Resident #18 on 06/26/2023 with diagnoses which included Dementia with Mood Disturbance and Hallucinations. Review of Resident #18's Admission Minimum Data Set (MDS) Assessment, dated 07/03/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15), which indicated the resident was interviewable. Review of the admission assessment, dated 06/26/2023, revealed Resident #18 was assessed to be alow risk, zero through five (0-5) for wandering on admission. Review of the facility's investigation, dated 07/11/2023, revealed that on 07/07/2023 at 1:30 PM, Resident #18 followed the maintenance man out of the front door and sat on the front porch. The resident reported to the receptionist he/she was going to wait on the daughter's arrival. At that time, the receptionist did not realize the individual was a new resident. The Certified Nurse Aide (CNA) #4 was returning from break through the front door of the facility and asked the receptionist why Resident #18 was out on the porch. At that time the receptionist realized the individual was actually a new resident. The Restorative Aide reported to the charge nurse to call a CODE PINK and the Aide and the receptionist headed back out the front door. When they reached the porch, Resident #18 had started walking around the side of the building and was located near another facility entrance. The resident was escorted back inside the facility and was assessed by the nurse and found to have no injuries. The resident was placed on increased supervision with checks every fifteen (15) minutes for forty-eight (48) hours. The resident's daughter was notified of the incident. Staff were re-educated on Elopements and Elopement drills were initiated at random times. In an interview with Resident #18, on 08/29/2023 at 10:20 AM, he/she stated she had went outside to wait for his/her daughter and had sat on the front porch. In an interview with the Receptionist, on 08/29/2023 at 3:00 PM, she stated Resident #18 was walking up the hall to the front lobby. She had opened the front door with the button for the maintenance man when Resident #18 had told the receptionist he/she was going to wait on the porch for his/her daughter. At that time, the receptionist stated she did not realize the individual was a resident of the facility. When the Certified Nurse Aide (CNA) #4 came in the front door, she asked the receptionist why the resident was outside without supervision. The Receptionist stated it was at that time she realized the individual was a current resident. She stated staff escorted the resident back into the facility. The Receptionist stated a log book of current residents was now located at the reception area for staff. In an interview with Maintenance, on 08/29/2023 at 3:51 PM, he stated he was not aware the resident was not supposed to be outside unattended until after the incident. He stated the doors were equipped with a Wanderguard system but the facility had not used it for several years. In an interview with Certified Nurse Aide (CNA) #3, on 08/30/2023 at 10:55 AM, she stated the day of the elopement of Resident #18, she remembered seeing the resident after lunch but she was unsure what time it was. She stated later that day the resident was put on every fifteen (15) minute checks after the resident was found sitting outside unattended. In an interview with CNA #4 on 08/31/2023 at 8:45 AM, she stated when returning from break on 07/07/2023 she noticed Resident #18 sitting on the front porch of the facility in a rocking chair, unattended. She asked the resident who was with him/her and the resident told her no one. CNA #4 asked the receptionist why the resident was outside and she stated the person had told her they were waiting on their daughter. She stated she told the charge nurse and the two of them walked outside where they found the resident sitting outside of a second facility entrance. CNA #4 stated the resident was escorted back into the facility. In a interview with the Director of Nursing (DON), on 08/31/2023 at 12:32 PM, she stated she had no reason to suspect Resident #18 was at risk of leaving the facility as he/she had never attempted to leave unattended. She stated she expected residents would sign out in the log book if they were leaving the facility. In an interview with the Administrator, on 09/01/2023 at 1:54 PM, she stated Resident #18 had never expressed the desire to leave the facility. She stated staff had been inserviced on the elopement policy.

Based on observation, interview, record review, and review of facility 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 for two of six (6) sampled residents (Resident #7 and Resident #25). Observations of Resident #7 and #25, on 09/06/2023 and 09/07/2023, revealed the resident's catheter bags were not properly secured and were touching the floor. The findings include: Review of the facility's policy, Infection Prevention, dated 12/01/2022, revealed the facility's Infection Prevention and Control Program would follow national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program included a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. Review of the facility's policy, Appropriate Use of Catheters and Feeding Tubes, dated 12/01/2022, revealed that documentation in the medical record should reveal continual assessment for use of the catheter and the plan of care should address catheter use and strategies to prevent urinary tract infections. 1. Record review revealed the facility admitted Resident #25 on 05/26/2023 with diagnosis which included Cerebral Infarction due to Unspecified occlusion or stenosis of unspecified cerebral artery, Retention of urine, unspecified, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #25's Quarterly Minimum Data Set (MDS) Assessment, dated 06/30/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), which indicated the resident was interviewable. Observation of Resident #25, on 09/06/2023 at 9:17 AM, revealed he/she had an indwelling catheter and the catheter bag were lying on the floor beside his/her bed. 2. Record review revealed the facility admitted Resident #7 on 10/30/2008 with diagnoses which included Neuromuscular Dysfunction of the Bladder and the presence of a Pressure Ulcer of the Sacral Region. Observation of Resident #7, on 09/06/2023 at 9:27 AM, revealed his/her indwelling catheter drainage bag was hanging from the bedrail and touching the floor. Additional observation of Resident #7, on 09/07/2023 at 2:27 PM, revealed his/her catheter drainage bag was touching the floor. In an interview with Certified Nurse Aide (CNA) #4, on 09/08/2023 at 10:19 AM, she stated the indwelling drainage bag should be hooked on the bedframe, the tubing looped and secured to the bed linen with the blue clip. She stated the bag should not touch the floor as it was an infection control issue. In an interview with Certified Nursing Assistant (CNA) #9 on 09/06/2023 at 3:30 PM, she stated catheters should be anchored to bed/chair and off the floor to ensure proper flow of urine. In an interview with Licensed Practical Nurse (LPN) #4 on 09/08/2023 at 2:06 PM, she stated all nursing staff to include CNA's were responsible for ensuring urinary catheters were properly anchored and kept off the floor. In an interview with the Director of Nursing (DON) on 09/08/23 at 9:46 AM, she stated proper catheter care should include the catheter cord being looped and hooked onto the side of the bed, not touching the floor and with a privacy bag in place. The DON further stated the catheter bag could bust and potentially cause an infection. She stated if a resident's bed was in the low position, the catheter bag should still be off the floor and in a privacy bag. In an interview with the Administrator, on 09/08/2023 at 3:15 PM, she stated she expected staff to follow facility policies related to catheter care. 31383

Based on observation, interview, record review, facility policy review and review of the Centers for Disease Control (CDC) documentation, it was determined the facility failed to maintain its infection control and prevention program in accordance with CDC guidelines for COVID-19. CDC guidelines stated for counties with substantial or high transmission rates of COVID-19, staff were to wear eye protection when caring for patients (residents). The facility failed to ensure its staff wore the appropriate eye protection during all patient encounters as indicated in the CDC guidance. The deficient practice had the potential to affect all residents residing in the facility. The findings include: Review of the CDC publication (guidelines) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/10/2021, revealed If [CONDITION(S)]-CoV-2 infection was not suspected in a patient (resident) presenting for care (based on their symptom and exposure history), healthcare personnel (HCP) who were working in facilities located in counties which had substantial or high transmission should use Personal Protective Equipment (PPE) such as eye protection (goggles or a face shield which covered the front and sides of the face) during all patient (resident) care encounters. Review of the CDC' COVID Data Tracker, on the website, revealed the facility's county had a high community transmission rate of COVID-19 as of 12/08/2021. Review of the facility's policies and procedures regarding the COVID-19 pandemic revealed no documented evidence of the CDC's guidance related to use of face shields and/or goggles as indicated in the CDC's Interim Infection Prevention and Control Recommendations for Health. Observation on 12/06/2021 at 12:27 PM, revealed six (6) unidentified staff members assisting six (6) residents with their noon meal in the common area. Per observation, the six (6) staff members were sitting approximately one (1) to two (2) feet from the resident they were assisting, with face masks in place. However, further observation revealed none of the six (6) staff members were wearing goggles and/or a face shield during their interaction with the residents. Observation on 12/07/2021 at 8:00 AM, revealed Licensed Practical Nurse (LPN) #1 administering medications to Resident #30 and Resident #31. Continued observation revealed LPN #1 wore only a face mask, with no goggles and/or face shield in place during the medication administration. Observation on 12/07/2021 at 12:01 PM, revealed a Physical Therapy Assistant (PTA providing therapy services for Resident #134 in his/her room. Per observation, the PTA was sitting approximately four (4) feet from Resident #134 wearing a mask. Further observation revealed however, the PTA did not have goggles and or a face shield on during the interaction with the resident. Observation on 12/07/2021 at 12:29 PM, revealed five (5) staff members, Certified Nursing Assistant (CNA) #1, CNA #2, CNA #3, CNA #4, and LPN #1, assisting residents with their noon meal in the common area. Per observation, the staff members were sitting approximately one (1) to two (2) feet from the resident they were assisting. Continued observation revealed all the staff members were wearing a face mask; however, did not have goggles and/or a face shield on during their interactions with the residents. Interview, with the staff members at the time of observation, revealed they only wore regular masks, unless a COVID-19 positive resident was present in the building. Further interview revealed if a COVID-19 resident was present in the building, then they had to wear a gown, face shield or goggles, gloves, an N 95 mask (a particulate-filtering facepiece respirator), and foot covers. Observation on 12/07/2021 at 12:30 PM, revealed CNA #5 sitting in the dining room area, approximately one (1) to two (2) feet from a resident who needed cueing for eating. Per observation, CNA #5 was not wearing goggles and/or face shield during the interaction with the resident. Observation on 12/07/2021 at 12:33 PM, revealed CNA #5 pushing a resident in a wheelchair from the dining room to the resident's room. Per observation, the CNA was approximately one (1) to two (2) feet from the resident during the interaction. Continued observation revealed Registered Nurse (RN) #1 was also observed sitting approximately one (1) to two (2) feet from another resident in the dining room. Observation further revealed CNA #5 and RN #1 had no goggles and/or face shield in place while assisting the residents. Interview on 12/07/2021 at 12:34 PM, with RN #1 revealed the facility only required staff to wear a face shield or goggles if a resident had been diagnosed with COVID-19. Continued observations during the survey, from 8:00 AM through 4:00 PM, on 12/06/2021 through 12/08/2021, revealed all staff observed providing resident care were not wearing goggles and/or a face shield while in resident care areas. Interview on 12/08/2021 at 9:58 AM, with the Director of Nursing (DON) revealed all staff were to wear a face mask. The DON stated even though the facility was in a high-transmission county, staff were not required to wear goggles or a face shield at that time. Per the DON, wearing eye protection when the facility did not have a COVID-19 positive resident was not a part of the facility's policy. Further interview revealed the facility based their policies and procedures on the CDC recommendations and State Guidelines.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure to develop and implement a baseline care plan for one (1) of thirteen (13) sampled residents (Resident #135). Resident #135 was care planned to keep bed in low position; however, staff failed to return the resident's bed to the low position prior to leaving the resident to wash their hands. The findings include: Review of the facility policy titled, Baseline Care Plans, dated (MONTH) (YEAR) revealed the purpose was to develop and implement a baseline care plan for each resident that includes the instructions needed to provide an effective and person-centered care of the resident that meet professional standards of quality care needs within forty-eight hours of admission. Record review revealed the facility admitted Resident #135 on 08/23/19 with [DIAGNOSES REDACTED]. No Minimum Data Set was available due to the admitted . Review of Resident #135's Baseline Plan of Care for Falls Risk/Safety not dated revealed an intervention to keep bed in low position. However, observation on 08/27/19 at 9:33 PM, revealed Certified Nurse Aide (CNA) #1 and CNA #2 failed to lower Resident #135's bed after providing incontinent care while they went to wash their hands. Interviews on 08/27/19 at 9:50 PM with CNA #1 and CNA #2 revealed they should have followed the care plan and not have left the resident alone with the bed in high position. Interview with the Clinical Nurse Leader on 08/29/19 at 10:55 AM revealed she expected the CNA's to follow the care plan and not leave the resident with the resident's bed not in the low position, Interview with the Director of Nursing on 08/29/19 at 1:17 PM revealed she expected all staff to follow the Baseline care plans as written.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of seven (7) sampled residents' environment remained as free of accident hazards as is possible (Resident #135). Observation revealed two staff left Resident #135 in bed with bed in high position. The staff failed to ensure the bed was lowered prior to leaving the resident to wash their hands. The findings include: Review of the facility policy titled, Incidents and Accidents dated (MONTH) (YEAR) and revised 02/21/18 revealed the purpose of the policy was to ensure the resident environment remains as free of accident hazards as is possible. Interventions will be implemented immediately to reduce potential for incident/accidents. Keep bed in low position. Record review revealed the facility admitted Resident #135 on 08/23/19 with [DIAGNOSES REDACTED]. No Minimum Data Set was available due to the admitted . Review of Resident #135's Baseline Plan of Care, not dated, revealed a plan for Falls Risk/Safety with a goal for the resident to remain free of injuries and falls. Further review revealed an Intervention to keep the bed in low position. Review of the Certified Nurse Aide (CNA) Care Plan dated 08/23/19 revealed the resident was to have two assist with incontinent care and was on [MEDICAL CONDITION] precautions. Observation of incontinent care on 08/27/19 at 9:33 PM, revealed CNA #1 and CNA #2 raised the residents' bed to high position. The CNA's then proceeded to go to the residents' bathroom and wash their hands together, leaving the resident alone; and with bed in high position which placed the resident in danger of falling off the bed. After incontinent care was completed, the CNA's placed the bed back in low position. Interview on 08/27/19 at 9:50 PM with CNA#1 and CNA #2 revealed they should have never left the resident alone with the bed in high position to wash their hands. They stated one should have stayed with resident and they should have taken turns to wash hands. Interview with the Clinical Nurse Leader on 08/29/19 at 10:55 AM revealed she expected one CNA to stay at resident's bedside at all times when residents' bed was in high position. Interview with the Director of Nursing (DON) on 08/29/19 at 1:17 PM revealed she expected at least one staff to stay at the bedside if resident is in the bed and the bed is raised in high position; or if they both have to leave the bedside, to place the bed back in low position. She stated she also expected staff to follow facility policy and care plans as written.

Based on observation, interview, record review, and review of the Mosby's Textbook, it was determined the facility failed to implement a comprehensive person-centered care plan for two (2) of thirteen (13) sampled residents (Residents #18 and #36). Observations revealed the facility failed to follow interventions to provide catheter care per facility protocol which included to secure the catheter and coil and secure tubing for Resident #36 on 05/30/18; and to administer oxygen at 3 liters via nasal cannula for Resident #18 on 05/31/18. The findings include: Interview with the Director of Nursing (DON) on 06/01/18 at 11:17 AM, revealed staff follow Mosby's Textbook for catheter care and the facility does have a specific care plan policy but follows state and federal guidelines on following resident care plans. 1. Record review revealed the facility admitted Resident #18 on 02/27/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/19/18 , revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Review of Resident #18's Comprehensive Care Plan, dated 02/27/18, revealed an intervention for oxygen at 3 liters via nasal cannula to maintain oxygen saturation above 87%. However, observations on 05/30/18 at 9:35 AM, 11:16 AM and 2:04 PM, revealed Resident 18's oxygen was on 2 liters via nasal cannula. Interview with Licensed Practical Nurse (LPN) #1 on 06/01/18 at 8:48 AM, revealed Resident #18's oxygen should be on at 3 liters. She stated she was not sure how it was not on the correct settings. She stated the nurse aides can't adjust oxygen settings and If they notice something is off they will let the nurse know. She revealed the care plan should be followed as it is written. 2. Record review revealed the facility admitted Resident #36 on 02/23/18, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 05/14/18 , revealed the facility assessed Resident #18's cognition as intact, with a BIMS score of thirteen (13) which indicated the resident was interviewable. Review of Resident #36's Comprehensive Care Plan, dated 02/23/18, revealed staff are to provide catheter care per facility protocol. Review of the task titled Giving Catheter Care, from Mosby's Textbook For Nursing Assistants, Eighth Edition, not dated, revealed after providing catheter care step #24 states, Secure the catheter. Coil and secure tubing. However, observation of catheter care on 05/31/18 at 10:28 AM , revealed Certified Nurse Aide (CNA) #1 and CNA #2, failed to ensure the catheter and tubing were secured with the catheter clip to keep the catheter from pulling. Interview with CNA's #1 and #2 on 05/31/18 at 2:18 PM, revealed the catheter should have been secured using the clip to keep the catheter from pulling. The CNA's stated the care plan should be followed when providing care to residents. Interview with Registered Nurse (RN) #1 on 05/31/18 at 2:10 PM, revealed the catheter should be anchored and the clipped in place to keep it from pulling. She stated she expected the aides to follow the residents care plan when providing care. Interview with the Director of Nursing (DON) on 06/01/18 at 11:17 AM, revealed staff follow Mosbys Textbook for catheter care and she would expect the CNA's to follow the instructions and the care plans for each resident. She stated she would expect the nurses to follow the care plan and monitor the residents oxygen saturation and settings.

Based on observation, interview, record review, and Mosby's Textbook, it was determined the facility failed to ensure a resident who requires a urinary catheter, receives the appropriate treatment and services related to urinary catheter care for one (1) of thirteen (13) sampled residents (Resident #36). Observation on 05/30/18 revealed staff failed to secure Resident #36's catheter and coil and secure tubing per facility protocol. The findings include: Interview with the Director of Nursing (DON) on 06/01/18 at 11:17 AM, revealed staff follow Mosby's Textbook for catheter care. Review of the task titled Giving Catheter Care, from Mosby's Textbook For Nursing Assistants, Eighth Edition, not dated, revealed the procedure steps for catheter care. Further review of the steps revealed after providing catheter care step #24 states, Secure the catheter. Coil and secure tubing. Record review revealed the facility admitted Resident #36 on 02/23/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/14/18 , revealed the facility assessed Resident #18'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 physician's orders [REDACTED].#36 was treated for [REDACTED]. Review of Resident #36's Comprehensive Care Plan, dated 02/23/18, revealed staff are to provide catheter care per facility protocol. Observation of catheter care on 05/31/18 at 10:28 AM, revealed Certified Nurse Aide (CNA) #1 and CNA #2, failed to ensure the catheter and tubing were secured with the catheter clip to keep the catheter from pulling. Interview with CNA's #1 and #2 on 05/31/18 at 2:18 PM, revealed the catheter should have been secured using the clip to keep the catheter from pulling. The CNA's stated the care plan should be followed when providing care to residents. Interview with Registered Nurse (RN) #1 on 05/31/18 at 2:10 PM, revealed the catheter should be anchored and the clip in place to keep it from pulling. She stated she expected the aides to follow the residents care plan when providing care. Interview with Resident #36 on 06/01/18 at 9:24 AM, revealed most of the time the aides make sure the catheter was secured. Resident #36 stated the catheter is secured right now and it does make it more comfortable. Interview with the Director of Nursing (DON) on 06/01/18 at 11:17 AM, revealed staff follow Mosby's Textbook for catheter care and she would expect the CNA's to follow the instructions and the care plans for each resident. She stated she would expect the nurses to follow the care plan and monitor the residents oxygen saturation and settings.

Based on observation, interview, record review, and review of Mosby's Textbook it was determined the facility failed to provide oxygen therapy according to the physician's orders [REDACTED].#18). On 05/31/18, staff failed to ensure Resident #36 was receiving oxygen at 3 liters a minute (lpm) per the physician's orders [REDACTED]. The findings include: Interview with the Director of Nursing (DON) on 06/01/18 at 11:17 AM, revealed staff follow Mosby's Textbook for oxygen administration. Review of the facility provided procedure guide titled, Oxygen Therapy: Nasal Cannula, Oxygen Mask, T Tube or [MEDICAL CONDITION] Collar, not dated, from Mosby's Pocket Guide to Nursing Skills and Procedures, revealed oxygen therapy is the administration of of supplemental oxygen to a patient to prevent or treat [MEDICAL CONDITION]. To implement oxygen staff should .Attach oxygen delivery device such as cannula, mask, T tube, to the oxygen tubing to humidified oxygen source adjusted to prescribed flow rate, apply oxygen device, observe for proper function of oxygen delivery device, and verify setting on flowmeter and oxygen source for proper setup and prescribed flow rate. Record review revealed the facility admitted Resident #18 on 02/27/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/19/18 , revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Review of Resident #18's Comprehensive Care Plan, dated 02/27/18, revealed an intervention for oxygen at 3 liters via nasal cannula to maintain oxygen saturation above 87%. Review of the physician's orders [REDACTED]. Review of Resident #18's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to administer oxygen at 3 lpm. Further review revealed licensed staff initialed on 05/30/18 at 8:00 AM, indicating the resident's oxygen was checked and it was set on 3 lpm. Observations on 05/30/18 at 9:35 AM, 11:16 AM and 2:04 PM, revealed Resident 18's oxygen was on 2 liters via nasal cannula. Interview with Licensed Practical Nurse (LPN) #1 on 06/01/18 at 8:48 AM, revealed Resident #18's oxygen should be on at 3 liters. She stated she had noticed on Wednesday (05/30/18) his/her oxygen was set on 2 liters and it was adjusted back up to 3 liters; and she checked his/her sats at that time and it was at 92%. She stated she was not sure how it was not on the correct settings. She stated the nurse aides can't adjust oxygen settings and if they notice something is off they will let the nurse know. She further stated oxygen settings are monitored and noted on the TAR. Interview with the Director of Nursing (DON) on 06/01/18 at 11:17 AM, revealed she would expect the nurses to follow the care plan and monitor the residents oxygen saturation and settings.

Based on observation, interview, record review, and facility policy and procedure review, it was determined the facility failed to ensure the services provided or arranged by the facility, were provided in accordance with two (2) of ten (10) sampled residents' plan of care (Resident #1 and Resident #2)). Observations on 04/25/16 and 04/26/17, revealed Resident #1 was not turned and repositioned every hour and a physician ordered treatment was not provided according to his/her plan of care. In addition, Resident #2's heels were not floated while in bed, according his/her plan of care. The findings include: Review of the facility policy titled, Care Plans, dated August 2015, revealed Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical/psychosocial needs that are identified in the comprehensive assessment. It further states the Director of Nursing (DON) should oversee the committee and offer assistance in problem solving as needed. 1. Record review revealed the facility admitted Resident #1 on 10/30/08 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan for actual impairment to skin integrity related to a Stage IV wound to the coccyx, last revised 03/30/17, and the April 2017 Certified Nurse Aide (CNA) Care Plan revealed an intervention to turn and reposition Resident #1 every hour; however, observations on 04/26/17 revealed Resident #1 to be lying on his/her left side at 8:50 AM and was still lying on the left side at 10:00 AM (one {1} hour and ten (10) minutes later. Interviews on 04/25/17 with CNA #7 and CNA #8 at 11:40 AM, and CNA #9 at 2:05 PM, and interview with CNA #4 on 04/27/17 at 9:05 AM revealed they thought Resident #1 was care planned to be turned and repositioned every two (2) hours. CNA #4 stated she checks the care plan and twenty-four (24) hour report to know when to turn and reposition them. Interview with the Clinical Manager, on 04/26/17 at 2:30 PM, revealed she felt the CNA'S did not pay attention to Resident #1's care plan. She stated she expected the staff to review and follow the care plan daily and to make walking rounds with the staff going off and have the resident's care plan with them to ensure all interventions are being followed. Further review of Resident #1's Comprehensive Care Plan for actual impairment to skin integrity, last revised 03/30/17 revealed an intervention to provide skin treatment per Physician Orders. Review of Physician Treatment Orders, dated 03/17/17, revealed to flush wound with ten (10) milliliters of 1/4 strength Dakins solution, apply Hydrogel Wound Dressing and pack with two by two (2 X 2) moistened with normal saline (NS). Skin prep surrounding tissue, cover with gauze, and secure with tape. However, observation of Resident #1's treatment on 04/25/17 at 2:05 PM, revealed Licensed Practical Nurse (LPN) #1 packed the wound with Dakin's moistened gauze instead of NS moistened gauze, and failed to apply Hydrogel Wound Dressing to wound and skin prep to surrounding tissue as ordered. Interview with LPN #1 on 04/26/17 at 8:20 AM revealed she was nervous during the dressing change and forgot to use the skin prep. She stated she thought she used the Hydrogel but may not have. 2. Record review revealed the facility admitted Resident #2 on 04/11/96, with a [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 03/23/17, revealed the facility assessed Resident #2's cognition as moderately impaired with A BIMS score of eleven (11), which indicated the resident was interviewable. The MDS further revealed Resident #2 required extensive assistance with bed mobility by one (1) staff member providing weight-bearing support. Review of Resident # 2's Comprehensive Care Plan for potential impairment to skin integrity related to fragile skin and [MEDICAL CONDITION], and the April 2017 CNA Care Plan revealed an intervention to float Resident #2's heels while in bed; however, observations on 04/25/17 at 3:22 PM and on 04/26/17 at 8:15 AM and 1:15 PM, revealed Resident #2 was lying in bed without a flotation device under his/her heels. Interview with CNA #2, on 04/25/17 at 3:22 PM, and CNA #1 on 04/26/17 at 8:15 AM, revealed Resident #2's heels should be floated and off the mattress while in bed. CNA #1 stated floating the resident's heels was to prevent skin breakdown. Interview with LPN #1, on 04/26/17 at 1:15 PM, revealed Resident #2's care plan should be followed and his/her heels should be floated off the mattress while in bed. She further revealed Resident #2 to be pretty much immobile, putting Resident #2 at risk for skin breakdown. Interview with the Director of Nursing (DON), on 04/27/17 at 9:30 AM, revealed she expected all staff to know and follow the resident's care plans.

Based on observation, interview, record review, and review of the facility policy and procedure, it was determined the facility failed to ensure, based on the comprehensive assessment of a resident, a resident with pressure ulcers receives 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 ten (10) sampled residents (Resident #1). Observations on 04/25/17 and 04/26/17 revealed staff failed to provide the appropriate Physician's Ordered Treatment to Resident #1s stage IV pressure ulcer on the coccyx and failed to turn and reposition the resident every hour, to promote healing. The findings include: Review of the policy titled Quality of Care-Pressure Ulcer Classifications dated 08/2015 reveals all residents are considered at risk for the development of pressure ulcers. Pressure Ulcer Care is to include: 1. [MEDICATION NAME] agents should be used when no-viable tissue is present. 2. Cleaning agents should be used to maintain a clean wound bed. 3. Infection should be treated as necessary. 4. Products should be selected based upon wound assessment and treatment goals. 5. Evaluation of the rate of healing guides the interdisciplinary team toward alterations in care approaches. Record review revealed the facility admitted Resident #1 on 10/30/08 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/24/17, 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. Review of the Comprehensive Care Plan for impaired skin integrity, last reviewed 03/30/17, revealed interventions to provide skin treatment per Physician Order and to turn and reposition every hour. Review of the April 2017 Certified Nurse Aide (CNA) Care Plan revealed to turn every hour with the assistance of two (2). Review of Resident #1's Weekly Pressure Ulcer Progress Report dated 03/06/17, revealed the wound measured 2.0 centimeters (cm.) by 1.3 cm. by 1.2 centimeters (cm), and was beefy red in color with a moderate amount of drainage; and on O3/13/17, the wound measured 1.8 cm. by 1.5 cm. by 1.5 cm, and was beefy red with a moderate amount of drainage. Review of Physician Treatment Orders, dated 03/17/17, revealed to flush wound with ten (10) milliliters of 1/4 strength Dakins solution, apply Hydrogel Wound Dressing and pack with two by two (2 X 2) moistened with normal saline (NS). Skin prep surrounding tissue, cover with gauze, and secure with tape. Observation of Resident #1's treatment on 04/25/17 at 2:05 PM, by Licensed Practical Nurse (LPN) #1, revealed the wound was irrigated with Dakins solution, packed with Dakin's moistened gauze instead of NS moistened gauze, and covered and secured with tape. The Hydrogel Wound Dressing and skin prep to surrounding tissue were omitted. Interview with LPN #1 on 04/26/17 at 8:20 AM revealed she was nervous during the dressing change and forgot to use the skin prep. She stated she thought she used the Hydrogel but may not have and that in the future would double check to ensure all supplies were available and ready to use prior to a treatment. Observations on 04/26/17 revealed Resident #1 to be lying on his/her left side at 8:50 AM and was still lying on his/her left side at 10:00 AM. Interviews with CNA #9, on 04/26/17 at 2:10 PM, revealed she was not sure of Resident#1's turning schedule prior to yesterday. Interview with CNA #7 and CNA #8, on 04/25/17 at 11:40 AM, while assisting Resident #1 up for lunch revealed they were unsure of his/her turn schedule and were turning and repositioning Resident #1 every two (2) hours. Interview with CNA #4, on 04/27/17 at 9:05 AM, revealed she had cared for Resident #1 on Monday and had turned him/her every two (2) hours, from side to side. Interview with the Director of Nursing (DON), on 04/27/17 at 9:30 AM, revealed she expected all CNA'S to know and follow the resident's care plans. She stated she expected the licensed staff to be aware of any changes and to ensure the CNA'S are implementing the changes. She further revealed she expected all licensed staff, when doing a treatment, to first read the order then have all supplies needed for the treatment ready prior to performing the treatment and it was the Clinical Leader's responsibility to ensure this was done.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure an infection control program was maintained to prevent the development and transmission of disease and infection for one (1) of ten (10) sampled residents (Resident #4) On 04/26/17, Certified Nurse Aide (CNA) #7 failed to change her soiled gloves after providing peri-care and incontinent care for Resident #4, then proceeded to touch Resident #4, his/her personal items, and bed with the soiled gloves. The findings include: Review of the facility's policy titled, Gloves Policy Number IX-XVI, effective 08/01/17, revealed all employees shall wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin. When gloves are indicated they shall be used only once and discarded into the appropriate receptacle in the soiled utility room or other designated area. Handwashing and antisepsis was necessary when gloves are removed. Record review revealed the facility admitted Resident #4 on 10/28/15 with [DIAGNOSES REDACTED]. Observation of CNA #7 providing incontinent/peri-care for Resident #4, on 04/26/17 at 10:50 AM, revealed CNA #7 failed to change his/her soiled gloves and wash hands after providing peri-care and incontinent care for Resident #4. CNA #7 proceeded to touch Resident #4, his/her personal belongings, clothing and bedding; then repositioned the resident, before changing soiled gloves and washing hands. Interview with CNA #7, on 04/26/17 at 11:05 AM, revealed she should have changed her gloves and washed her hands after they became soiled with feces, and before touching and repositioning Resident #4. She stated not changing her gloves after providing peri-care/incontinent care and continuing to touch the resident and his/her belongings and bedding would likely spread infection and germs wherever her gloves touched. Interview with the Director of Nursing (DON), on 04/26/17 at 2:40 PM, revealed she would have expected CNA #7 to change her gloves and wash her hands after providing peri-care and incontinent care, especially once the gloves became soiled, and to not touch the resident or any of his/her belongings in order to prevent the spread of germs.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of ten (10) sampled residents (Resident #9) was free from any physical restraint that was not required to treat the resident's medical symptoms. Resident #9 was observed on 03/30/16 in a wheelchair with a self-release belt alarm in front of the resident. Resident #9 was unable to remove the self-release belt alarm on command; however, the facility failed to identify it was a restraint for this resident. The findings include: Review of the facility's policy titled Physical Restraints, dated August 2015, revealed each resident would attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Further review revealed physical restraints were defined by federal regulations as any manual method or physical device .attached or adjacent to the resident's body that the individual cannot remove easily . The policy also stated a physician order [REDACTED]. Record review revealed the facility admitted Resident #9 on 03/18/14 with diagnoses, which included Hearing Loss, Dehydration, General Weakness, [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITION]. Review of the annual Minimum Data Set (MDS) assessment, dated 02/18/16, revealed the facility assessed Resident #9's cognition as understands others and is understood; however, the Brief Interview for Mental Status (BIMS) score was left blank. Further review of the MDS revealed Resident #9 required extensive assistance of one (1) person for functional status to walk in room and in corridor and the resident did not have a restraint. Review of a physician's orders [REDACTED]. Review of the Comprehensive Device Assessment, dated 11/18/15, revealed the self-release alarming belt was written on the care plan on 12/17/15 with a notation that the Power of Attorney (POA) had requested it related to falls. The assessment read the resident was able to unfasten the belt on command. Review of the quarterly Comprehensive Device Assessment, dated 02/18/16, revealed Resident #9 was alert, agitated, attempted to get out of bed and chair unassisted, had visual and hearing impairment and Dementia. Further review of the assessment revealed the resident had a sensor pad alarm to the bed and a self-release belt alarm to the wheelchair, which the resident was able to remove consistently at will. Observation of Resident #9, on 03/30/16 at 10:15 AM, revealed Certified Nurse Aide (CNA) #5 asked the resident to remove the self-release seatbelt with alarm and after prompting the resident by placing his/her hand on the belt button and instructing the resident to press the button, the resident was able to release it. CNA #5 then requested the resident to release the alarming self-release seat belt a second time and the resident did not remove it. Further observation on 03/30/16 at 3:30 PM, revealed CNA #4 requested Resident #9 to remove the alarming seat belt and the resident did not remove it. Interview with CNA #4, on 03/30/16 at 10:10 AM, revealed a restraint was something that prevents a resident from moving when able to move or prevents them from moving. CNA #4 stated Resident #9 was unable to remove the alarming seatbelt and would request to Get this off of me; therefore, she considered it a restraint. Interview with CNA #2, on 03/30/16 at 9:25 AM, revealed Resident #9 was unable to release the alarming self-release belt and would ask staff during the day to release it for him/her. Interview with Licensed Practical Nurse (LPN) #2, on 03/30/16 at 9:30 AM and 10:16 AM, revealed a restraint was anything that confines someone to a wheelchair. LPN #2 stated she considered Resident #9's alarming self-release seat belt a restraint. She revealed Resident #9 was unable to remove the alarming self-release belt his/herself, but maybe if he/she really wanted to he/she could. Interview with the Assistant Director of Nursing (ADON), on 03/30/16 at 4:40 PM and on 03/31/16 at 1:10 PM, revealed she was responsible for assessing devices and restraints quarterly and as needed. The ADON stated she did not consider the alarming self-release seat belt a restraint at the time; therefore, she did not assess it as a restraint. Interview with the Director of Nursing (DON), on 03/30/16 at 4:10 PM, revealed Resident #9 is transient and some days she can release belt and other days she cannot. She stated Resident #9 is unable to remove the self-release belt upon command so the device should have been considered a restraint and assessed as a restraint.

Based on observation, interview, record review, and review of the facility's pest control agreement, it was determined the facility failed to maintain an effective pest control program so that the facility was free of pests. Observations of Resident #2's room (#235), on 03/30/16, revealed black ants, too numerous to count, on the windowsill, a piece of cake, and on the floor, and on 03/31/16, they were on the floor and bedside table. Certified Nurse Aide (CNA) #6 was aware of the ants but failed to report the ants to the Maintenance Supervisor or write in the Maintenance Log she identified ants were in room #235 so action could be taken. The findings include: Review of the facility Pest Control Service Agreement, dated 01/13/16, revealed pest control services would be provided to the facility for roaches, c[DIAGNOSES REDACTED], wasps, ants (other than Pharoh or Carpenter), and spiders (other than Brown Recluse or Black Widow) bi-monthly (every other month) to the interior structure (living and/or working space) and exterior structure (maximum 5 (five) feet from main structure). Record review revealed the facility admitted Resident #2 on 02/24/16 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview of Mental Status score of six (6) which indicated the resident was not interviewable. However, further review revealed the resident was able to understand others and make self-understood. Observations of Resident #2's room (#235), on 03/30/16 at 8:20 AM and 9:38 AM, revealed black ants on a windowsill and a piece of cake in the window that were too numerous to count. Further observation on 03/30/16 at 3:20 PM, revealed there were still black ants too numerous to count on the windowsill but the piece of cake was gone. Observation of Resident #2's room with the Social Worker, on 03/31/16 at 8:55 AM, revealed there were black ants too numerous to count on a piece of food in the floor under the bedside table, on the bedside table, on a napkin with a red substance on the floor, and on stool in the floor. Interview with Resident #2, on 03/31/16 at 8:55 AM, revealed he/she stated, Ants were all over my table and breakfast this morning. Interview with CNA #6, on 03/31/16 at 9:55 AM, revealed when she took Resident #2's breakfast tray into his/her room, the resident's supper tray from the night before had been left in his room and there were numerous ants in the food and on the bedside table. She stated she removed the tray, cleaned off the bedside table, and placed the resident's breakfast tray on the bedside table but did not report there were ants in the room to anyone. She revealed she did not visualize any ants on the resident's breakfast food that was left when she removed the tray but did see a few on the bedside table. Interview with Housekeeper #6, on 03/31/16 at 9:12 AM, revealed she sweeps all the rooms at 6:00 AM and then cleans the rooms daily. She stated she had noticed ants in a couple of the rooms but not room #225. She revealed she sprayed cleaner on them, wiped them up and then she told the Maintenance Director what rooms the ants were found in. Interview with Maintenance Director #7, on 03/31/16 at 9:05 AM, revealed ants in several resident rooms have been brought to his attention but he was not aware of any ants in room #225. He stated there was a maintenance log at the nurse's desk for staff to fill out if there are any issues including pests. He stated he had called the exterminator earlier in the month to exterminate a few rooms #210, #205, and #110 but not Resident #2's room. He revealed the ants were looking for food therefore, it was important to keep the facility as clean as possible. Review of a receipt from the Pest Control Company, dated 03/10/16, revealed a treatment of [REDACTED].#201, #205 and #110 as well as Terro DCO ant bait in one (1) of those room behind a refrigerator. Interview with Exterminator Technician #8, on 03/31/16 at 12:52 PM, revealed the Advion Gel was placed behind baseboards in rooms #201, 205, and 110 on 03/10/16 because the Maintenance Director had called him regarding ants. He stated Terro-DCO was placed in either room #201 or 205 behind the refrigerator. He revealed that since 03/10/16 he had not received a call from the facility of any pest issues until today. He stated the contract was to treat bi-monthly which was every other month unless he received a call. He revealed the main issue was the ants were looking for food so food items and wrappers must be discarded. Interview with Administrator, on 03/31/16 at 3:05 PM revealed she expected the facility to maintain an effective pest control program to control pests such as ants in the building. Interview with the Regional Manager for Health Care Services, on 03/31/16 at 3:25 PM, revealed the housekeeper performs a monthly deep clean on the rooms in the facility. He stated in a room with increase snacks that the housekeeper would need to increase the deep cleaning and walk through. He revealed any department head manager can verbalize to our manager in the facility those rooms and we will increase walk through with those rooms.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to notify the physician related to the need for laboratory monitoring of medications that require monitoring for five (5) of ten (10) sampled residents (Residents #1, #2, #4, #6 and #7); and, one (1) Unsampled Residents (Resident B). The facility failed to ensure the physician was notified to obtain orders for laboratory levels to monitor [MEDICATION NAME] levels ([MEDICAL CONDITION] medication), [MEDICATION NAME] levels (heart medication), and Cholesterol levels per the facility's policy to identify if there was a need to alter treatment. The findings include: Review of the facility's policy titled, "Medications Requiring Lab Monitoring", dated 06/10/00, revealed some of the medications that needed monitoring included [MEDICATION NAME], [MEDICAL CONDITION] medications, diuretics, and anticoagulants. Newly admitted residents on one of the listed medications ([MEDICATION NAME], [MEDICAL CONDITION] medications, Diuretics, and Anticoagulants) or any resident who has one of the medications newly ordered should have accompanying orders for monitoring of lab levels. If no lab orders were received with the medication order, it was the responsibility of the nurse receiving the medication order to call and request orders for laboratory monitoring from the attending physician. Further review revealed the frequency of laboratory monitoring was determined at the discretion of the attending physician and/or consulting pharmacist. 1. Record review revealed the facility admitted Resident #6 on 12/31/14 with [DIAGNOSES REDACTED]. Review of the February 2015 physician's orders [REDACTED]. Further review of the December 2014, and January 2015 physician's orders [REDACTED]. During an interview with Resident #6's Physician, on 02/05/15 at 9:32 AM, he stated, "I was not aware the resident needed a [MEDICATION NAME] level ordered, it was missed by me, and I need to get that ordered". 2. Record review revealed the facility admitted Resident #2 on 05/20/14 with [DIAGNOSES REDACTED]. Review of the February 2015 physician's orders [REDACTED]. However, further review revealed there were no orders to monitor the resident's cholesterol or [MEDICAL CONDITION] levels since admission. 3. Record review revealed the facility admitted Resident #7 on 01/26/15 with [DIAGNOSES REDACTED]. Review of the January 2015 physician's orders [REDACTED]. 4. Record review revealed the facility admitted Unsampled Resident B on 10/29/14 with [DIAGNOSES REDACTED]. Review of the February 2015 physician's orders [REDACTED]. Interview with Unsampled Resident B's Physician, on 02/05/15 at 9:45 AM, revealed she was unaware the resident's [MEDICAL CONDITION] level was not being monitored. She stated she expected the facility to notify the physician if the resident was taking [MEDICAL CONDITION] medication and the levels were not being monitored. She revealed she expected the residents' [MEDICAL CONDITION] labs to be completed annually, if stable. 5. Record review revealed the facility admitted Resident #1 on 10/30/08 with [DIAGNOSES REDACTED]. Review of the February 2015 physician's orders [REDACTED]. Review of Resident #1's laboratory profile revealed the last documented [MEDICATION NAME] level ([MEDICAL CONDITION] profile) was dated 03/26/12. Interview with Resident #1's Physician, on 02/04/15 at 3:05 PM, revealed he was unaware Resident #1 was not getting [MEDICATION NAME] levels completed. He stated he expected the resident's levels to be checked every six (6) months and if stable, annually. 6. Record review revealed the facility admitted Resident #4 on 08/27/10 with [DIAGNOSES REDACTED]. Review of the February 2015 physician's orders [REDACTED]. Review of the laboratory reports revealed there was no documented evidence a [MEDICATION NAME] level was obtained since the resident's admission. Interview with Registered Nurse (RN) #1, on 02/05/15 at 2:05 PM, revealed she completes the labs as ordered when they show up on the computer screen on the service table. She stated the ADON was responsible for ordering the laboratory tests each month. Interview with the ADON and DON, on 02/05/15 at 1:45 PM, revealed it was their responsibility to complete the administrative paperwork which included taking off the physicians orders and scheduling laboratory work. She stated if the physician did not write an order for [REDACTED]. Interview with the Medical Director, on 02/05/15 at 1:35 PM, revealed the facility should ensure an order was obtained for all required laboratory tests. He stated there was a problem which needed to be addressed related to notifying the medical provider of the need to obtain lab orders. Interview with the Director of Clinical Operations, on 02/05/15 at 12:35 PM, revealed the Administrative Nurses were responsible to ensure the physicians were notified and the laboratory work was completed as ordered by the medical provider. She stated it was the DON's responsibility to notify the medical providers of any changes in status, as well as the need for laboratory tests for the residents. Interview with the Administrator, on 02/05/15 at 12:22 PM revealed the Administrative Nurses (DON and the ADON) were responsible to enter the physician's orders [REDACTED]. He further revealed the ADON was responsible for adding the laboratory requisitions into the computer each month, and to ensure the laboratory tests were transcribed as ordered by the medical providers. Further interview, on 02/06/15 at 9:00 AM, revealed the Administrator was not aware of the policy titled "Medication Requiring Lab Monitoring" until yesterday. He further revealed he found it in a policy manual at the nurses station yesterday and there had been no training related to the lab policy.

Based on interview, record review, and review of the Kentucky Board of Nursing Scope of Practice Guidelines, it was determined the facility failed to ensure services provided or arranged by the facility were provided according to acceptable standards of clinical practice related to licensed nurses not identifying and notifying the physician of a required laboratory order to monitor medications and to obtain labs as ordered by the physician. The facility failed to ensure Physicians' Orders were obtained to ensure laboratory drug levels were obtained for five (5) of ten (10) sampled residents (Residents #1, #2, #4, #6, and #7); and, two (2) Unsampled Residents (Residents A and B). The facility failed to provide laboratory monitoring of drug levels related to [MEDICATION NAME] ([MEDICAL CONDITION] medication), [MEDICATION NAME] (heart medication); and cholesterol medications ([MEDICATION NAME]); and failed to obtain a Complete Blood Counts and Basic Metabolic Panel as ordered by the physician. The findings include: Interview with the Administrator, on 02/11/15 at 3:28 PM, revealed the facility based their standards of practice on the Kentucky Board of Nursing Scope of Practice Determination Guidelines (Revised date 01/2011). Review of the Kentucky Board of Nursing Scope of Practice Determination Guidelines, revealed the Kentucky Nursing Laws (KRS Chapter 314), defines "licensed practical nursing practice", and "registered nursing practice", and holds all nurses individually accountable and responsible for their nursing decisions and actions. Statutory Definitions and Policy included KRS 314.011 (10) defines "licensed practical nursing practice" as the performance of acts requiring knowledge and skill as are taught or acquired in approved schools for practical nursing in : a) the observing and caring for the ill, injured, or infirm under the direction of a registered nurse, a licensed physician, or dentist, the administration of medication or treatment as authorized by a physician, physician's assistant, dentist, or advanced practice registered nurse. KRS 314.011 (6) defines "registered nursing practice" as the performance of acts requiring substantial specialized knowledge, judgement and nursing skill based upon the principles of psychological, biological, physical and social sciences in the application of the nursing process in the administration of medication and treatment as prescribed by a physician, physician's assistant, dentist, or advanced practice registered nurse, observing, recording, and reporting desired effects, untoward reactions, and side effects of drug therapy. 1. Record review revealed the facility admitted Resident #6 on 12/31/14 with [DIAGNOSES REDACTED]. Review of the Physician's Orders, dated 02/2015, revealed [MEDICATION NAME] (cholesterol medication) 40 mg daily and [MEDICATION NAME] (heart medication) 0.125 mg daily. Further review revealed the documented start date for both medications was 12/31/14. However, review of Resident #6's Physician Orders, dated 02/2015, revealed there was no written order for lab work to monitor the resident's [MEDICATION NAME] (heart medication) level or cholesterol level. Interview with Assistant Director of Nursing on 02/04/15 at 2:30 PM, revealed her expectations were that if the physician wanted a specific lab test he/she would order it. She further revealed she was aware of the need to monitor the medications but thought the physician would order the test if he/she wanted it done. She further stated she was not aware the residents was not getting the [MEDICATION NAME] levels drawn. Review of the Consultant Pharmacist Medication Review, dated 01/26/15, revealed a recommendation to obtain a [MEDICATION NAME] level. However there was no documented evidence the facility followed up on the recommendation. 2. Record review revealed the facility admitted Resident #1 on 10/30/08 with [DIAGNOSES REDACTED].#1's laboratory profile revealed the last documented [MEDICATION NAME] level ([MEDICAL CONDITION] profile) was dated 03/26/12. Further review of the Physician's Orders, dated 02/2015, revealed there was no evidence of an order for [REDACTED]. Interview with Director of Nursing (DON) on 02/04/15 at 4:25 PM, revealed she was not sure how Resident #1's labs were missed. She stated the resident had changed medical providers in the past and the order for the lab could have possibly been left out during the transition of Physicians' Orders. Interview with Licensed Practical Nurse (LPN) #1, on 02/05/15 at 8:00 AM, revealed that questioning the residents' lab orders was not part of her daily routine because she did not give Resident #1's [MEDICAL CONDITION] medication. She further revealed it would not be her responsibility to look at the labs if she did not receive or review the residents' physician orders. Interview with Resident #1's Physician, on 02/04/15 at 3:05 PM, revealed he was unaware Resident #1's [MEDICATION NAME] levels were not completed. He expected the resident's levels to be checked every six (6) months and if stable, annually. He stated the Pharmacy Review would inform him when he needed to order labs. 3. Record review revealed the facility admitted Resident #2 on 05/20/14 with [DIAGNOSES REDACTED]. Review of the Medication Regimen Review, dated 05/21/14, revealed to order lab work on the resident. Review of the Medication Regimen Review, dated 11/25/14, revealed a recommendation for a [MEDICAL CONDITION] level and a lipid panel; however, there was no documented evidence the recommendation was carried out. Review of the 02/2015 Medication Administration Record [REDACTED]. 4. Record review revealed the facility admitted Resident #4 on 08/27/10 with [DIAGNOSES REDACTED]. results revealed the last CBC and BMP were completed on 06/30/14. Review of the Pharmacist Medication Review, dated 01/2015, revealed the December 2014 labs for a CBC and CMP were not in the chart. There was no documented evidence the labs had been obtained as ordered. 5. Record review revealed the facility admitted Resident #7 on 01/26/15 with [DIAGNOSES REDACTED]. Review of the Physician's Orders, dated 01/2015, revealed no documented evidence a lab was obtained to check the resident's [MEDICATION NAME] level or about the physician being informed of the need for a level. 6. Record review revealed the facility admitted Unsampled Resident A on 03/18/14 with [DIAGNOSES REDACTED]. Review of the Physician's Orders, dated 01/2015, revealed the resident received [MEDICATION NAME] ([MEDICAL CONDITION] medication) 75 mcg daily. Further record review revealed no documented evidence laboratory tests were completed or the physician was made aware that the resident's [MEDICAL CONDITION] level was not rechecked as ordered on [DATE]. Interview with the Director of Nursing (DON), on 02/06/15 at 2:00 PM, revealed there were no other [MEDICAL CONDITION] levels available for Unsampled Resident A. She stated the last documented [MEDICAL CONDITION] level for the resident was dated 09/24/14. The DON stated she was unaware the labs had not been obtained as ordered. 7. Record review revealed the facility admitted Unsampled Resident B on 10/29/14 with [DIAGNOSES REDACTED]. Further review of the Physician's Orders revealed no documented evidence a [MEDICAL CONDITION] level was ordered for the resident. Review of the monthly Consultant Pharmacist's review revealed no documented evidence of reminders that the resident needed a [MEDICAL CONDITION] level. Interview with Unsampled Resident B's Physician, on 02/05/15 at 9:05 AM, revealed she expected the facility to notify the physician if the resident took medications which required routine monitoring or if there was no physician's order. She revealed her expectations were to monitor the resident's [MEDICAL CONDITION] labs yearly if stable. She also revealed she recommended a baseline [MEDICAL CONDITION] check annually for all of her residents, even those without a diagnosis. Interview with the Assistant Director of Nursing (ADON), on 02/04/15 at 2:30 PM, revealed the facility did not have a system in place to ensure adequate monitoring of medications or to ensure laboratory drug levels were obtained as ordered by the medical provider. She revealed each resident's Medication Administration Record [REDACTED]. Lab orders were separate from the MAR indicated [REDACTED] Interview with the Director of Nursing (DON), on 02/04/15 at 4:25 PM, revealed she did not conduct internal audits of Physician's Orders related to laboratory work. She stated if the physician wanted a lab, he or she would order it. The DON stated the pharmacy audit completed monthly should have picked up on the errors. She also stated she mailed out the pharmacy audits monthly after they were completed; however, she did not have any type of internal tracking in place to follow up with the recommendations. Interview with the Pharmacy Consultant on 02/04/15 at 3:50 PM, revealed that at the point of admission the admitting nurse should at the very least review the medications and note any medication that require a lab level for monitoring and notify the medical provider at that time. Interview with Director of Clinical Operations on 02/05/15 at 9:00 AM, revealed the Administrative Nurses were responsible for transcribing the Physician's Orders upon admission to the facility and were responsible to make sure labs were done as required for specific medications. Interview with the Medical Director, on 02/05/15 at 1:35 PM, revealed the facility should ensure an order was obtained for all required lab tests. He further stated obviously there was a problem that needed to be addressed related to not following through with Physician's Orders, and notifying the medical provider about the need to obtain lab orders. Interview with the Administrator, on 02/05/15 at 12:22 PM, revealed the DON was responsible for reviewing and following up on pharmacy recommendations. He further revealed the Administrative Nurses (DON and ADON) were also responsible for entering the Physician's Orders for all new admissions and re-admissions to the facility. He stated the Administrative Nurses rely on pharmacy to do the audits and make the recommendations for medication changes and lab monitoring. He further stated his expectations were if a lab test was not completed, it should be completed as soon as it was identified and the primary physician should be notified. He also stated the facility had morning meetings with the management team to discuss new orders and resident changes in condition, but the resident's medical record was not brought to the meeting for review.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure care was provided in accordance with the plan of care for (5) of ten (10) sampled residents (Residents #1, #2, #4, #6, and #7); and, two (2) unsampled residents (Unsampled Residents A and B). The facility failed to implement the plan of care to obtain laboratory drug levels for residents who were receiving [MEDICATION NAME] ([MEDICAL CONDITION] medication), and [MEDICATION NAME] (heart medication), and cholesterol medication; and other routine lab tests (Complete Blood Counts, Basic Metabolic Panels, Lipid Profiles). Additionally, the facility failed to inform the attending physicians about the Pharmacy Medication Regimen Review recommendations related to obtaining appropriate lab orders for residents not receiving routine lab monitoring. The findings include: Review of the facility's policy titled, "Comprehensive Care Plan", (undated), revealed it is the policy of the facility to strive to ensure residents are provided with a care plan. Upon admission, initial care plans will be developed by nursing staff to strive to ensure nursing staff are aware of the support for which the resident needs to be provided. The Comprehensive Care plan will be periodically reviewed and revised by a team of qualified persons periodically. 1. Record review revealed the facility admitted Resident #6 on 12/31/14 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The documented start date for both medications was 12/31/14. Review of the resident's Plan of Care, dated 01/19/15, revealed interventions were in place to obtain and monitor lab/diagnostic work as ordered. Report results to medical provider and follow up as indicated. However, further review of the February 2015 Physician order [REDACTED]. 2. Record review revealed the facility admitted Resident #1 on 10/30/08 with [DIAGNOSES REDACTED]. Review of a February 2015 physician's orders [REDACTED]. Review of the Comprehensive Care Plan, dated 10/22/13, revealed interventions in place to administer [MEDICAL CONDITION] replacement therapy as ordered and to obtain and monitor lab/diagnostic work as ordered. Review of the February 2015 physician's orders [REDACTED].#1's lab profile revealed the last documented [MEDICATION NAME] level ([MEDICAL CONDITION] profile) was obtained on 03/26/12. Interview with Resident #1's Physician, on 02/04/16 at 3:05 PM, revealed he was unaware Resident #1 was not getting [MEDICATION NAME] levels completed. He stated he expected the resident's levels to be checked every six (6) months and if stable, annually. 3. Record review revealed the facility admitted Resident #2 on 05/20/14, with [DIAGNOSES REDACTED]. Review of the February 2015 Medication Administration Record [REDACTED]. Review of the resident's Plan of Care, dated 06/06/14, revealed interventions in place to administer [MEDICAL CONDITION] replacement as ordered and obtain and monitor lab/diagnostic work as ordered, and report results to the medical provider. However, record review revealed there were no written orders for lab work to monitor the resident's [MEDICAL CONDITION] and cholesterol levels. 4. Record review revealed the facility admitted Resident #4 on 08/27/10 with [DIAGNOSES REDACTED]. Review of the February 2015 MAR indicated [REDACTED]. Review of the physician's orders [REDACTED]. Review of the resident's Plan of Care, dated 01/23/14, revealed there were interventions in place to monitor for signs and symptoms of the disease ([MEDICAL CONDITION]), and to monitor document and report any changes in the resident and obtain labs as ordered and to report abnormal labs to the medical provider. However, record review revealed there were no written orders for lab work to monitor the resident's [MEDICAL CONDITION] levels and review of the resident's lab results revealed the last CBC and CMP was completed on 06/30/14. 5. Record review revealed the facility admitted Resident #7 on 01/26/15 with [DIAGNOSES REDACTED]. Review of the resident's January 2015 MAR indicated [REDACTED]. Review of the resident's Interim Plan of Care, dated 01/26/15, revealed interventions were in place to obtain labs as ordered; however, further review of the physician's orders [REDACTED]. 6. Record review revealed the facility admitted Unsampled Resident A on 03/18/14 with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's Comprehensive Care Plan, dated 04/02/14, revealed interventions were in place to obtain and monitor lab/diagnostic work as ordered by the medical provider. Review of lab results, dated 09/23/14, revealed the physician had documented on the report to increase the resident's [MEDICATION NAME] to 75 mcg daily and recheck the labs in three (3) months. Review of the physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 02/06/15 at 2:00 PM, revealed the last documented [MEDICAL CONDITION] level for the resident was dated 09/24/14 and there were was no other [MEDICAL CONDITION] levels available for Unsampled Resident A. The DON stated she was unaware the labs were not obtained as ordered.. 7. Record review revealed the facility admitted Unsampled Resident B on 10/29/14 with [DIAGNOSES REDACTED]. Review of the February 2015 physician's orders [REDACTED]. Review of the resident's Plan of Care, dated 11/14/14, revealed an intervention in place to monitor lab work and report abnormal labs to the medical provider; however, further review of the physician's orders [REDACTED]. Interview with the ADON, on 02/06/15 at 12:00 PM, revealed the residents' care plans were initiated upon admission by the Minimum Data Set (MDS) Coordinator after completion of the assessment. She revealed after it was completed, it was put into the point click care system. She stated the care plans were updated quarterly and as needed. She indicated she expected the staff to follow the care plan interventions as written and notify the medical provider whenever indicated. Interview with the DON, on 02/06/15 at 12:10 PM, revealed her expectation was for all staff to follow the interventions on the resident's plan of care as written. Interview with the Administrator, on 02/06/15 at 12:40 PM, revealed his expectation was that all staff should follow the resident's plan of care at all times and notify the medical provider as indicated.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure adequate monitoring of medications for five (5) of ten (10) sampled residents (Residents #1, #2, #4, #6 and #7) and two unsampled residents (Resident A and B). The facility failed to provide laboratory monitoring of drug levels related to [MEDICATION NAME] ([MEDICAL CONDITION] medication), for Residents #1, #2, and #4 and Unsampled Resident A and B; [MEDICATION NAME] (heart medication) for Resident #6, and cholesterol levels for Residents #2. The findings include: Review of the facility's policy, titled "Labs", (undated), revealed it was the facility's policy " ... to strive to ensure that labs are obtained as indicated per physician's orders." Review of the facility's policy titled, "Medications Requiring Lab Monitoring", dated 06/10/00, revealed some of the medication levels that needed monitoring were [MEDICATION NAME], [MEDICAL CONDITION] medications, diuretics, and anticoagulants. Newly admitted residents on one of the listed medications ([MEDICATION NAME], [MEDICAL CONDITION] medications, Diuretics, and Anticoagulants) or any resident who has one of the medications newly ordered should have accompanying orders for monitoring of lab levels. If no lab orders were received with the medication order, it was the responsibility of the nurse receiving the medication order to call and request orders for lab monitoring from the attending physician. Further review revealed the frequency of lab monitoring was determined at the discretion of the attending physician and/or consulting pharmacist. 1. Record review revealed the facility admitted Resident #1 on 10/30/08, with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated February 2015, revealed an order for [REDACTED]. Review of Resident #1's lab profile revealed the last documented [MEDICATION NAME] level ([MEDICAL CONDITION] profile) was obtained on 03/26/12. Review of the Consultant Pharmacist Medication Review, dated March 2012, revealed an entry indicating the resident was receiving [MEDICAL CONDITION] Levels (TSH) every three (3) months. They were documented as being completed on 09/2011, 12/2011 and 03/2012. Further review of the monthly Consultant Pharmacist Medication Review, dated 01/26/15, revealed no documented evidence the pharmacist had identified the resident had not had a [MEDICAL CONDITION] level obtained since 03/2012. Interview with the Director of Nursing (DON) on 02/04/15 at 4:25 PM, revealed she was not sure how Resident #1's labs were missed. She stated the resident had changed medical providers in the past and the order for the lab could have possibly been left out during the transition of Physicians' Orders. She revealed when a resident changes medical providers all standing orders were sent to the new physician for review and acceptance. She indicated it was the floor Charge Nurses' responsibility to make sure all Physician's Orders were carried over during the transfer. Interview with Resident #1's Primary Medical Provider, on 02/04/16 at 3:05 PM, revealed he was not aware Resident #1 was not getting [MEDICATION NAME] levels done. He stated he expected the resident's levels to be checked every six (6) months and if stable, annually. He also stated the Pharmacist would inform him when he needed to order labs. 2. Record review revealed the facility admitted Resident #2 on 05/20/14, with [DIAGNOSES REDACTED]. Review of the February 2015 Medication Administration Record [REDACTED]. Review of the February 2015 Physician's Orders, revealed there were no written orders for lab work to monitor the resident's [MEDICAL CONDITION] and cholesterol levels. Review of the Medication Regimen Review, dated 05/21/14, revealed a notation to order lab work on the resident. Review of a Medication Regimen Review, dated 11/25/14, revealed a recommendation for a [MEDICAL CONDITION] level and a lipid panel. Review of the Physician's Orders from 11/25/14 through 02/2015, revealed there was no documented evidence these recommendations had been acted upon. 3. Record review revealed the facility admitted Resident #4 on 08/27/10 with [DIAGNOSES REDACTED]. Review of the February 2015 Physician's Orders revealed the resident was receiving [MEDICATION NAME] 50 mcg daily, with a documented start date of 04/28/11; however, further review revealed there was no order for a [MEDICAL CONDITION] level. Review of the laboratory reports revealed there was no documented evidence a [MEDICATION NAME] level was obtained since admission. Review of the Consultant Pharmacist Medication Review, dated January 2015, revealed there was no documented evidence the pharmacist had identified a [MEDICAL CONDITION] level had not been obtained since admission. 4. Record review revealed the facility admitted Resident #6 on 12/31/14 with [DIAGNOSES REDACTED]. Review of the February 2015 Physician's Orders revealed the resident was taking [MEDICATION NAME] (cholesterol medication) 40 milligrams (mg) daily and [MEDICATION NAME] (heart medication) 0.125 mg daily. The documented start date for both medications was 12/31/14. Further review revealed there was no order to monitor the resident's [MEDICAL CONDITION] and [MEDICATION NAME] level. Review of the Consultant Pharmacist Medication Review, dated 01/26/15 revealed a recommendation to obtain a [MEDICATION NAME] level. However, there was no documented evidence that the facility followed up on the recommendation. Interview with Resident # 6's Primary Medical Provider, on 02/05/15 at 9:32 AM, revealed he was not aware of the pharmacy recommendation to order a [MEDICATION NAME] level for the resident. He stated "It was missed by me" and "I need to get that ordered". He revealed the pharmacy recommendations were sent to him and then he would write the orders as needed. 5. Record review revealed the facility admitted Resident #7 on 01/26/15 with [DIAGNOSES REDACTED]. Review of the January 2015 MAR indicated [REDACTED]. Further review revealed there was no order for [MEDICAL CONDITION] levels. 6. Record review revealed the facility admitted Unsampled Resident A on 03/18/14 with [DIAGNOSES REDACTED]. Review of the January 2015 Physician Orders revealed Unsampled Resident #A was receiving [MEDICATION NAME] ([MEDICAL CONDITION] medication) 75 mcg daily. Review of lab results, dated 09/23/14, revealed an order written [REDACTED]. 7. Record review revealed the facility admitted Unsampled Resident B on 10/29/14 with [DIAGNOSES REDACTED]. Review of February 2015 Physician Orders revealed an order for [REDACTED]. Review of the Pharmacist's Monthly Medication Regimen Review revealed no documented evidence the Pharmacist identified the resident had not had a cholesterol level since admission. Interview with Unsampled Resident B's Medical Provider, on 02/05/15 at 9:05 AM, revealed she expected the facility to notify her if the resident was taking medications that required routine monitoring and there was no physician's order. She stated the resident's [MEDICAL CONDITION] levels should be obtained annually, if stable. She also revealed that she recommends a baseline [MEDICAL CONDITION] check annually for all her residents even the ones without a diagnosis. Interview with the Assistant Director of Nursing (ADON), on 02/04/15 at 2:30 PM, revealed the facility did not have a system in place to ensure adequate monitoring of medications. She stated each resident's Medication Administration Records are reviewed monthly, but they do not check to make sure the labs are being completed as ordered or if the residents have the necessary labs orders. She revealed lab orders were separate from the MAR indicated [REDACTED] Interview with the Pharmacy Consultant on 02/04/15 at 3:50 PM, revealed he completes a pharmacy review monthly on all residents. He stated that after he completes the reviews he places the recommendations in the DON's mail box, unless it's something that he thinks needs immediate attention then he takes it to the Charge Nurse working that day. He revealed his expectations were that when a resident was admitted to the facility on a medication that required monitoring, the nurse needed to make the medical provider aware if there was not an order on the chart to obtain a level. He also indicated that he expected the [MEDICAL CONDITION] levels to be completed at least annually on all residents receiving medication. Interview with Director of Nursing (DON) on 02/04/15 at 4:25 PM, revealed she did not conduct internal audits of Physician's Orders related to lab work. She stated if the physician wanted a lab they would order it. The DON stated the pharmacy audit that was completed monthly should have picked up on the omission of the lab orders. She revealed she mailed out the pharmacy audits weekly after they were completed; however, she did not have any type of internal tracking in place to follow up with the recommendations. Interview with the Administrator on 02/05/15 at 12:22 PM, revealed the DON was responsible for pharmacy recommendations, that after the pharmacist completed his audits the DON receives a copy of the recommendations. He further revealed the Administrative Nurses ( DON and the ADON) were also responsible for entering the Physician's Orders for all new admissions and re-admissions to the facility. He also revealed the Administrative Nurses rely on pharmacy to do the audits and make the recommendations for medication changes and lab monitoring. He further revealed his expectations were if a lab test was not done it should be completed as soon as it was identified and the primary physician notified. He also stated the facility had morning meetings with the management team to discuss new orders and resident changes in condition but the resident's medical record was not brought to the meeting for review. Interview with Medical Director on 02/05/15 at 1:35 PM, revealed he thinks the facility should ensure an order was obtained for all lab tests that were needed. He further stated, obviously there was a problem that needed to be addressed related to not following through with Physician's Orders and notifying medical provider of the need to obtain lab orders. Interview with Director of Clinical Operations on 02/05/15 at 12:35 PM, revealed the Administrative Nurses were responsible for making sure lab work was completed as ordered by the medical provider. She further revealed the orders for lab work came from the medical provider or the pharmacy consultant. She stated after the pharmacy recommendations were completed the DON placed them in a self addressed envelop and mailed them to the attending medical providers for review.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure residents' comprehensive care plans were periodically reviewed and revised for four residents (#1, #3, #4 and #5), in the selected sample of six residents, who [MEDICAL CONDITION] hot coffee. Resident #1 received second [MEDICAL CONDITION] hot coffee, which had been re-heated in the microwave on 12/06/12, and required hospitalization on [DATE]. Resident #3, Resident #4 and Resident #5, received first [MEDICAL CONDITION] hot coffee, prepared in the kitchen and spilled by the residents. Resident #3 received first [MEDICAL CONDITION] 07/27/12 and on 08/14/12. and Resident #5 received first [MEDICAL CONDITION] 07/27/12. Resident #4 [MEDICAL CONDITION] coffee spilled during a [MEDICAL CONDITION] on 12/04/12. Further review of the care plans revealed Residents #1, #3, #4 and #5 were not care planned for assistance with hot beverages, and there was no effective revisions made to the care plans to prevent further reoccurrence of burns. Findings include: A review of the facility's undated policy and procedure, "Comprehensive Care Plans," revealed the initial care plan was to be developed by the nursing staff to ensure all nursing staff are aware of the supports the resident needs to be provided with; developed seven (7) days after completion of the comprehensive assessment and to provide a frame work for the Certified Nurse Aide (CNA) care plan. The comprehensive care plan was to be reviewed and revised, by a team of qualified persons periodically. 1. A record review revealed the facility admitted Resident #1 on 11/05/12 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment, dated 11/11/12, revealed Resident #1 required set-up and supervision with meals. The Brief Interview for Mental Status (BIMS) score was eight (8), which indicated the resident had modified independence in cognitive skills and some difficulty in his/her cognitive thinking ability in new situations. A review of the care plan revealed the resident had impaired safety awareness and the staff was to assist with or cue the resident to drink fluids. Record review revealed the resident received second degree burns, on 12/06/12, after receiving a cup of coffee which had been reheated in the microwave. Review of the resident's care plan revealed interventions added were to have a cup with a lid and not to drink coffee in bed. However, there was no assessment to indicate the assistance needed with drinking hot beverages, no intervention to address the second degree burns, treatment and dressing changes, or any changes in the care plan for pain regarding the source of the pain other than Chronic Pain and Neuralgia and alternative therapies to alleviate the pain from the burns. 2. A record review revealed the facility admitted Resident #3 on 9/12/08 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 9/27/12, revealed the resident required extensive assistance with meals. A review of the Activities of Dally Living (ADL) care plan, dated 10/10/12, revealed the resident required assistance with feeding and to have a divided dish with Dycem under the dish for meals. The resident required thickened liquids due to the [DIAGNOSES REDACTED]. A record review of the nurses notes, for July and August 2012 and the event reports, dated 07/27/12 and 08/14/12 revealed the resident had a history of [REDACTED]. The first burn occurred on 7/27/12 and the second burn occurred on 8/14/12, with [MEDICAL CONDITION] from coffee spills. A care plan intervention after the first burn, on 07/27/12, was to place a lid on the coffee cup. After the second burn, on 08/14/12, Occupational Therapy (OT) was to evaluate the resident for an assistive device, as the resident turned the sippy cup with hot coffee upside down, causing a first degree burn to the left groin area. However, there were no interventions, on the care plan, per the OT. 3. A record review revealed the facility admitted Resident #5 on 11/03/10 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 09/27/12, revealed the resident required extensive assistance with eating. A review of the ADL care plan, dated 01/12/12, for Resident #5 revealed an intervention for a magic cup daily for lunch and supper, and was to have a lid for hot beverages. Further review of the care plan, dated 12/09/12, revealed an intervention to provide assistance with meals as needed. A review of the potential for skin impairment care plan, dated 12/09/12, did not mention a burn, nor did the care plan reveal an intervention for treatment or the amount of assistance the resident required with hot beverages, only that the resident required a lid with hot beverages. 4. A record review revealed the facility admitted Resident #4 on 10/11/02 with [DIAGNOSES REDACTED]. A review of the annual MDS, dated [DATE], revealed the resident was severely cognitively impaired and totally dependent on staff for all care needs and required the limited assistance of one staff member for meals. A review of the nurses' notes, dated 12/04/12, revealed the resident was observed by staff having [MEDICAL CONDITION] activity. The resident had a "hot cup of coffee, when the [MEDICAL CONDITION] began and the coffee was spilled." The resident sustained [REDACTED]. An intervention added to the care plan, dated 12/04/12, revealed the resident was to have a "cup with a lid when given hot fluids." An interview with the Administrator, on 12/11/12 at 5:36 PM, revealed, after the incident regarding Resident #1's burn on 12/06/12, the company who furnished food supplies was contacted and the temperature setting of the coffee pot was turned down from 190 degrees F to 165 degrees F, on 12/10/12. However, the facility did not determine the root cause of the [MEDICAL CONDITION] the hot coffee and did not have the temperatures decreased from the initial burns, on 07/27/12. The facility failed to ensure all residents were assessed in order to identify the need for assistance related to to handling of hot beverages in order to revise the plans of care, in order to reflect any new interventions that might be needed in order to protect the residents.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure four residents (#1, #3, #4 and #5), in the selected sample of six residents, remained as free of accident hazards as possible and failed to assess for and ensure each resident received adequate supervision to prevent accidents from the use of hot liquids. On 12/06/12, Resident #1 received second degree burns from hot coffee that was re-heated in the microwave, which resulted in the resident experiencing pain and requiring hospitalization . The facility failed to ensure the resident was evaluated for the ability to safely and independently drink hot liquids, failed to test the temperature of the hot liquid prior to leaving it at the resident's bedside, and failed to assess the resident's ability to independently maneuver the hot cup of coffee. Resident #3, Resident #4, and Resident #5 received first degree burns from hot coffee spills which were not re-warmed in the microwave. Resident #3 and Resident #5 received first degree burns on 07/27/12. Resident #3 was burned again, on 08/14/12. Resident #4 received burns from spilled coffee during a seizure on 12/04/12. Findings include: A review of the facility's policy/procedure, "Minimum Temperatures at the Point of Service to the Resident," dated 07/30/08, revealed coffee, tea, broth or hot beverages were to be served at a temperature greater than 150 degrees F" and stated "these beverages have a fast temperature drop." 1. A record review revealed the facility admitted Resident #1 on 11/05/12 with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 11/11/12, revealed Resident #1 required set-up and supervision with meals. The Brief Interview for Mental Status (BIMS) Score was eight (8) which indicated the resident had modified independence in cognitive skills and some difficulty in his/her cognitive thinking ability in new situations. A review of the care plan, dated 11/26/12, revealed the resident had impaired safety awareness and the staff was to assist with or cue the resident to drink fluids. A review of the nurses log, dated 12/06/12 at 7:30 AM revealed the resident had burns to his/her chest, breast and abdomen. To the resident's right breast, there was an area that measured 7.5 centimeters (cm) by (X) 8.0 cm, where the skin was not intact. Blisters were present throughout the area. A review of the weekly skin assessment, dated 12/09/12, revealed the resident had three areas of concern: The right breast; with an open area, measuring 3.0 cm X 1.5 cm and an area of redness measuring 18.0 cm X 10 cm; the right upper abdomen; with an open area measuring 9.5 X 10.5 and an area of redness 30.0 cm X 6.0 cm; and the right flank area; with an open area, measuring 2.5 cm X 1.0 cm and an area of redness, measuring 17.5 X 1.0. In addition, under the comments section, the report stated there were three blisters that had not ruptured. A review of the nurse's notes/Incident notes, dated 12/06/12, revealed Resident #1 sustained burns to his/her chest, breast and abdomen due to having spilled hot coffee on self, on 12/06/12 at 7:30 AM. The note indicated the physician was notified and an order received for Silvadene Cream and Lortab was given for pain. Review of the initial Physician's phone order, dated 12/06/12, no time designated, revealed an order for [REDACTED]." A review of the physician's History and Profile, dated 12/07/12 at 3:30 PM, revealed an order was written for Silvadene to burns with four by fours (4 x 4's) and place an elastic bandage (6) inches. Change the dressing every day, gently remove the old Silvadene cream." The plan was for the physician to return to the facility, on 12/13/12, to recheck the burn during her rounds. An order was written, on 12/07/12 at 6:05 PM, for "Silvadene to be applied generously everyday to the burns and cover with non-adherent 4 x 4's, then wrap the chest with an elastic bandage or stockinette shirt every day. Gently remove the Silvadene everyday." According to the physician's physical exam, dated 12/07/12, during the office visit with Resident #1, the resident "experienced first and second degree burns to the right chest wall, above the breast, blistering is present and the blistering is off the skin above the breast. There is [DIAGNOSES REDACTED] and blistering on the breast, as well as the abdomen below the breast and no burn under the breast." The hospital admission report, dated 12/09/12, revealed the reason for the admission was due to "chest wall pain and second degree burn to the right chest wall and right upper abdominal wall". An entry in the Nurse Log Report, dated 12/06/12 at 7:30 AM revealed the "resident was lying in bed with burns to the chest, breast, and abdomen. To the right breast, there is an area that measures 7.5 by 8.0 centimeters (cm,) where the skin is not intact, at this time. Blisters are present throughout the area." An interview with Nurse Aide (NA) #3, on 12/13/12 at 10:25 AM, revealed the NA was unaware of a policy about re-heating coffee until after Resident #1 was burned. The NA stated she saw other staff warming coffee in the microwave, near the Nurses Station's Nourishment Room and was not aware of a problem with this. She stated Resident #1 requested to have the coffee warmed and the NA re-heated the coffee "about 30 seconds," in the microwave. The coffee was "steaming a little" and the NA put powdered creamer in the coffee and placed the lid back on the thermal mug. She then took the coffee back to the resident's room and placed the coffee on the resident's bed side table, that lay across the bed, as the resident was sitting at a 90 degree angle in bed, with the breakfast tray in front of him/her. The NA left the room, after telling the resident to be careful, the coffee "was hot," and went down the hall to pass other trays. She was summoned back to the room by a family member of Resident #2's (roommate of Resident #1). Resident #2's family member was calling out to say Resident #1 was "choking." Once in the room, NA #3 observed Resident #1 had spilled coffee on the hospital gown he/she was wearing and removed the gown to note the resident's reddened skin to the chest and right side. The NA and Resident #2's family member starting applying cold wash cloths, and the NA left the room to get the nurse. The NA stated she did not see the skin peeling off until the wash cloths were removed by the nurse. An interview with Resident #2's family member, on 12/12/12 at 1:30 PM, revealed the NA came into the room the morning Resident #1 was burned, and awoke the resident, sat him/her up in the bed and brought in the breakfast tray. While the NA set-up the resident's tray, Resident #1 complained the coffee was cold and the NA left the room to warm the coffee. The NA brought the coffee back and set it on the table, telling the resident "it was hot," and left the room. The family member indicated she exited the room and was not gone "two to three minutes" when she entered and saw Resident #1 was "red-faced and making gestures" with his/her mouth open and hands with fingers spread out next to his/her face. The family member "thought Resident #1 was choking, because there were no understandable words coming out of his/her mouth." The family member went out to the hallway and called NA #3 to come, that "something was wrong" with Resident #1. When they both realized the resident had spilt the coffee, they both started taking off the gown and applying cold wash cloths. The family member stated she saw blistering to the right chest and the right side was "raw." Other staff came into the room and the curtain was pulled and she could hear the resident "moaning." An interview with Registered Nurse (RN) #1, on 12/12/12 at 11:25 AM, revealed the RN was called to Resident #1's room on 12/06/12, approximately "30 seconds" after NA #3 requested her assistance, to find the resident lying in bed with redness to the right breast, sternal area and to the right side of the abdomen, "with the first layer of skin already removed" from the right breast area and described as "raw." The resident stated, "It hurts, it hurts." The RN called for the Assistant Director of Nursing (ADON) to assist her and to contact the physician, while RN #1 stayed with the resident. A Lortab was given for pain and a fan was placed at bedside, while the RN fanned the resident. The resident "acted like the pain eased up after 20 to 25 minutes." The ADON went to the pharmacy and brought back the physician ordered Silvadene cream and RN #1 applied the cream to the burns, where "small blisters" were starting to appear underneath the right breast. The RN stated there was no dressing ordered to cover the burns at that time. Prior to applying the cream, the RN notified the POA that the resident spilled coffee during breakfast and had some redness to his/her breast and abdomen. The RN was unsure if the POA was told about the rawness of the burns, but stated there were no blisters at the time of the call. An interview with the ADON on 12/06/12, at approximately 7:30 AM, revealed NA #3 requested the ADON's assistance with Resident #1, who was sitting up in bed and had spilled coffee on himself/herself. The ADON stated the resident presented with "the first layer of skin off on his/her right breast, approximately four (4) to six (6) inches in diameter, above the right nipple, and the rest of the abdomen, the right side and right flank area was a bright pink." The resident was described as "moaning and said (he/she) was in pain." The ADON stated the physician was notified and was told the resident sustained [REDACTED]. The ADON also stated first degree burns were comparable to sunburn. Second degree burns were between skin peeling and blistering and was sure the resident's burns were third degree which was conveyed to the physician. Further interview with the ADON, on 12/13/12 at 11:50 AM, revealed the physician did not order a dressing to cover the burns until after the office visit on 12/07/12. An interview with the physician, on 12/13/12 at 11:00 AM, revealed the physician stated she was not made aware of the source and the extensiveness of the burns and received information that the resident received a burn while eating breakfast. The physician stated it was not communicated to her and she was unaware of the burns severity until the resident was taken to the physician's office, per the Power of Attorney (POA's) request, on 12/07/12 at approximately 3:30 PM, when the physician realized the resident had " second degree" blisters to the right torso and abdomen. In addition, the physician stated she specifically ordered the ointment be covered with a dressing to cover the burns, in order for the wound to properly heal and "this was not done." A review of the physician's progress notes, dated 12/07/12, revealed the resident was alert and had a history of [REDACTED]. The resident was assessed as having second degree burns to the right chest wall, right breast and abdomen, a six (6) percent (%) total body surface area involved in the burns, in addition to an exacerbation of COPD. The resident was hospitalized , on 12/10/12, per the Son/Power of Attorney (POA's) insistence and treated for [REDACTED]. An interview with Certified Nurse Aide (CNA) #1, on 12/11/12 at 5:25 PM, revealed the CNA had previously warmed water in a cup for coffee singles for a resident and stated she normally microwaved the cup "about a minute, until it steamed," and stated they had to stop warming anything in the microwave, when Resident #1 was burned. An interview with the Dietary Manager, on 12/12/12 at 2:15 PM, revealed the dietary staff were "suppose to take coffee temperatures with every meal," but explained the staff were "lax" in doing this on the week of 12/06/12, as the Dietary Manager had been "out that week." An interview with the Dietician, on 12/13/12 at 4:47 PM, revealed she was unaware of a problem with hot coffee "until a couple of days ago" after Resident #1 "was already in the hospital." She was not made aware there were other residents burned with hot liquids. An interview with the Administrator, on 12/11/12 at 5:36 PM revealed after Resident #1 was burned, the company was called that furnished food supplies and the temperature setting of the coffee pot was turned down from 190 degrees F to 165 degrees F, on 12/10/12. However, the facility did not determine the root cause of the previous burns from hot coffee and did not have the temperatures decreased from the initial burns, on 07/27/12. 2. A record review revealed the facility admitted Resident #3 on 09/12/08 with [DIAGNOSES REDACTED]. An interview with Certified Nurse Aide (CNA) #1 on 12/11/12 at 5:25 PM, and a review of the event reports from July 2012 through 12/11/12, revealed the resident had a history of [REDACTED]. A review of the quarterly MDS assessment, dated 09/27/12, revealed the resident required extensive assistance with meals. A review of the ADL care plan, dated 10/10/12, revealed the resident required assistance with feeding and to have a divided dish with Dycem under the dish for meals. An intervention from the "At Risk for Skin Breakdown care plan, dated 07/27/12, was for the resident to have a cup with a lid. An intervention from the Event Report, dated 07/27/12 was to "assure assistance with coffee." The care plan for nutrition, dated 07/14/11, revealed the resident required thickened liquids due to the [DIAGNOSES REDACTED]. A review of the Nurses Log Report, dated 07/27/12, revealed "the resident has what appears to be a first degree burn with minimal redness on her left lower arm." There was no mention of pain and the resident has no recollection. An interview with Resident #3, on 12/12/12 at 8:50 AM, revealed he/she recalled getting burned; however, he/she did not remember the details of how it happened. An interview with CNA #2, on 12/12/12 at 8:50 AM, revealed she recalled seeing the burn on the resident's left forearm while she gave the resident a shower. The CNA recalled the burn as being red, but not blistered. She was told by the Charge Nurse on duty that the resident had spilled hot coffee on himself/herself. An interview with the Dietary Manager, on 12/12/12 at 2:25 PM, revealed the resident was in activities drinking thickened hot coffee when the burn occurred. The Dietary Manager continued to explain the nectar thickened coffee should sit a little longer than usual and be stirred well, to cool off, before being served to any resident. 3. A record review revealed the facility admitted Resident #5 on 11/03/10 with [DIAGNOSES REDACTED]. Review of the record revealed the resident had experienced a first-degree burn, on 07/27/12 to his/her left upper arm with minimal redness, related to a coffee spill, while in activities. A review of the quarterly MDS assessment, dated 09/27/12, revealed the resident required extensive assistance with eating. A review of the ADL care plan for Resident #5, dated 12/09/12, revealed an intervention of providing assistance with meals as needed. An intervention for a magic cup daily for lunch and supper and lid for hot beverages was added to the care plan, on 01/12/12. However, the potential for skin impairment care plan, dated 12/09/12, did not mention the burn, nor did the care plan reveal intervention for treatment or the amount of assistance the resident required with hot beverages. An observation of Resident #5, on 12/13/12 at 5:15 PM, in the dining room during the evening meal, revealed he/she was eating independently after the meal tray was set up. The tray had milk and juice on it, but there were no hot beverages noted. An interview with the resident was attempted on 12/12/012 at 5:15 PM, the resident was unable to state her name and appeared to be confused. 4. A record review revealed the facility admitted Resident #4 on 10/11/02 with [DIAGNOSES REDACTED]. A review of the annual MDS, dated [DATE], revealed the resident was severely cognitively impaired and totally dependent on staff for all care needs and required the limited assistance of one staff member for meals. A review of the nursing notes, dated 12/04/12, revealed the resident was observed by staff having seizure activity on 12/04/12. Further review of the nurses notes revealed, the resident had a "hot cup of coffee, when the seizure began and the coffee was spilled." The resident sustained [REDACTED]. A review of the physician's orders [REDACTED]." An interview with the Administrator, on 12/12/12 at 11:12 AM, revealed the causative factor for the resident's burns was the resident's seizure activity. Further interview with the Administrator on 12/11/12 at 5:36 PM revealed the facility currently did not assess the residents for the safe use of hot beverages.

Based on observation, interview, review of the facility's policy/procedure, it was determined the facility failed to be 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. The Administrator failed to ensure the facility had assessed the causative factors [MEDICAL CONDITION] by four residents (#1, #3, #4 and #5), in the selected sample of six residents, who [MEDICAL CONDITION] a hot beverage. The Administrator failed to take action and have methods put into place to decrease the temperature of the hot beverages, and assess residents for the safe use of hot beverages, prior to other residents being affected. Findings include: A review of the facility's policy/procedure, "Minimum Temperatures at the Point of Service to the Resident," dated 07/30/08, revealed coffee, tea, broth or hot beverages were to be served at a temperature greater than 150 degrees F" and stated "these beverages have a fast temperature drop." Record review and interview revealed Residents #3 and #5 [MEDICAL CONDITION] 07/27/12 from hot coffee. There was no documented evidence the residents were assessed for the safe use of hot beverages and Resident #3 was burned again on 08/14/12. Resident #4 sustained a burn on 12/04/12 from a hot coffee spill which occurred during a [MEDICAL CONDITION]. On 12/06/12, Resident #1 sustained second [MEDICAL CONDITION] a coffee spill from coffee which was reheated in the microwave. An interview with the Administrator, on 12/11/12 at 5:35 PM and on 12/12/12 at 11:05 AM, revealed the initial action to the residents' [MEDICAL CONDITION] to "assure assistance with coffee" and provide a lid for the coffee cup. The Administrator revealed an investigation of Resident #1's second degree burns, caused by spilled coffee that was re-heated in the microwave, had not been completed. Per interview, the Administrative Action was to review reports made by the Incident Review Committee (IRC) and to speak with the Nurse Aide (NA) about not heating coffee in the microwave. The intervention proposed for Resident #1 was to ensure the resident did not drink coffee in bed. Further interview with the Administrator revealed the Dietary Manager confirmed temperatures were appropriate when coffee left the kitchen, and the policy in place revealed the temperatures for hot coffee had to be "greater than 150 degrees Fahrenheit (F). Per interview, the food supplier was not called to the facility, until 12/10/12. At that time, the temperature of the coffee pot was decreased from 195 degrees F to 160 degrees F. However, no further action was taken to ensure the safety of residents with hot beverages. An interview with the Dietician, on 12/13/12 at 4:47 PM, revealed she was unaware of the residents [MEDICAL CONDITION] hot beverages "until a couple of days ago," when the Dietary Manager called and stated Resident #1 was in the hospital related to a burn. The Dietician was unaware of three other residents who [MEDICAL CONDITION] had not attended a QA Meeting regarding this issue, stating she was only contracted to visit the facility two times a month. An interview with the Medical Director on 12/13/12 at 1:40 PM, revealed he was made aware of [MEDICAL CONDITION]"two minutes ago," per a phone call and did not recall ever being contacted or made aware of the burns, or about having a discussion regarding these issues during the QA meetings. The Medical Director stated he would have expected the facility to contact him.

Based on interview, review of event reports, and review of the facility's policy/procedure, it was determined the facility failed to identify issues, develop, and implement appropriate plans of action to correct identified quality deficiencies, related [MEDICAL CONDITION] from hot beverages. Resident #3, Resident #4 and Resident #5 received first [MEDICAL CONDITION] hot coffee spills that were not re-heated in the microwave. Resident #3 and Resident #5 received first [MEDICAL CONDITION] 07/27/12. Resident #3 was burned again on 08/14/12. Resident #4 [MEDICAL CONDITION] coffee spilled during a [MEDICAL CONDITION], on 12/04/12. Resident #1 was burned from coffee re-heated in the microwave, on 12/06/12, and received second [MEDICAL CONDITION] required hospitalization . Findings include: A review of the undated facility's policy and procedure, "Continuous Quality Improvement Program," revealed it was the policy of the organization to collect data about all aspects of care and services through the use of quality indicator tools to monitor and assess regularly to determine whether desired outcomes have been reached. In addition, information obtained from other sources assists in identifying areas that may need to be improved upon. Sources may include satisfaction surveys, regulatory surveys, consultant reports, internal audits, or resident council concerns. The focus of the program was to strive to continually improve the delivery of care and services to residents, involve various departments and address key facility practices. The committee was composed of the Administrator, Director for Nursing (DON) consolation of the Medical Director or designee and various department representatives. The committee meets at least quarterly, reviews and analyses quality control data and if a problem or a potential problem, a plan of correction may be implemented. A review of the Event Reports for Residents #1, #3, #4, and #5 revealed various causative factors for the burns, including [MEDICAL CONDITION] activity, spilling coffee on himself/herself, turning sippy cups upside down and the resident requesting the coffee be warmed. However, the reports failed to determine the root cause of the burns. Interventions were providing lids for cups and assuring assistance with coffee and ensuring residents were not drinking coffee in bed. The facility did not ensure the temperature of the coffee was decreased, until 12/10/12, and did not provide evidence the Medical Director and the Dietician were involved in the QA process or that effective solutions were put into place, monitored, and re-evaluated to ensure a re-occurrence [MEDICAL CONDITION] not take place. An interview with the Dietician, on 12/13/12 at 4:47 PM, revealed she was unaware of the residents [MEDICAL CONDITION] hot beverages "until a couple of days ago". Per interview, she did not attend a QA Meeting regarding this issue, stating she was only contracted to visit the facility two times a month. An interview with the Dietary Manager (DM) on 12/12/12 at 2:08 PM, revealed there was no policy on taking temperatures for hot liquids, except the one stating it had to be over 150 degrees F. This policy on hot liquids had been in effect "every since I came to work here in October 2011." The DM stated the policy was not changed and the temperatures dropped on the coffee pot until 12/10/12. When asked if the QA team discussed the hot liquids with the Dietary staff, the DM stated "they were told not to fill the cups too full, they would be way too heavy and to put a cube of ice in all cups and to use a cup with a lid on a couple of residents." An interview with the Medical Director on 12/13/12 at 1:40 PM, revealed he was made aware of [MEDICAL CONDITION]"two minutes ago," per a phone call and did not recall ever being contacted or made aware of the burns, or about having a discussion regarding these issues during the QA meetings. The last QA meeting occurred two months ago "and nothing was said about any burns. He also stated he would have expected the facility to have contacted him, regarding these issues. An interview with the Administrator on 12/11/12 at 5:36 PM revealed she was in the process of finding an assessment form to utilize for resident's regarding hot beverages. Per interview, there was no policy to state coffee was not to be re-warmed in the microwave, only a policy that the delivery temperature of the coffee was to be over 150 degrees Fahrenheit F. The Administrator stated the last QA meeting was held 12/10/12; however,[MEDICAL CONDITION] not discussed.

Based on interview, record review, review of the facility's policies and procedures, and the Final Investigative Report, it was determined the facility failed to ensure one resident (#1) was free from neglect, in the selected sample of four residents. On 03/04/12 at 3:30 PM, Resident #1 sustained a fall from the wheelchair. The resident was found in front of the nurse's station with his/her pants down and urine on the floor. Certified Nurse Aide (CNA) #5 started her shift at 6:00 AM, with CNA #3 starting her shift at approximately 9:30 AM. Both CNAs were responsible for the resident's care, on 03/04/12, but failed to ensure the resident was changed or toileted the entire shift prior to the fall. Additionally, it was determined the resident's sensor pad alarm was not turned on or functioning at the time of the fall. The resident sustained [REDACTED]. Findings include: A review of the facility's "Resident Abuse and Neglect" policy, undated, revealed neglect was defined "as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." A record review revealed the facility admitted Resident #1 on 11/03/10 with [DIAGNOSES REDACTED]. A review of the Comprehensive Device Assessment, dated 10/21/11, and the Resident Care Guide, undated, revealed the resident had a sensor alarm pad and a self release belt to the wheelchair for safety. A review of the Comprehensive Care Plan, dated 01/12/12, revealed the resident should be toileted every two hours and as needed. A review of the Fall Assessment Screening Tool, dated 01/12/12, revealed the facility identified the resident as a high risk for falls. A review of the Final Investigative Report, dated 03/08/12, revealed CNA #3 and CNA #5 did not toilet Resident #1, on 03/04/12, from 6:00 AM to approximately 4:00 PM. The report revealed Resident #1 was found in the floor with his/her pants pulled down and urine on the floor. The resident's sensor pad alarm was turned off and was not sounding prior to the fall. The resident sustained [REDACTED]. CNA #3 and CNA #5 were suspended on 03/05/12 and terminated on 03/08/12 for neglect. An interview with Registered Nurse (RN) #1, on 03/23/12 at 1:25 PM, revealed she was the nurse who worked on 03/04/12. She revealed she did not witness Resident #1's fall; however, she examined the resident afterwards. She revealed the resident was lying on his/her right side with his/her pants pulled slightly down, and there was urine on the floor. She further revealed CNA #5 admitted she had not toileted the resident the entire shift. An interview with Certified Medication Tech (CMT) #1, on 03/23/12 at 10:30 AM, revealed she was passing medications when Resident #1 fell , on 03/04/12. She revealed CNA #3 and CNA #5 verified they had not provided care for the resident all day, as the resident was already up in the wheelchair when their shift began. She revealed CNA #3 and CNA #5 stated that the resident was "next on their list," but the resident fell before care was provided. An interview with CNA #3, on 03/23/12 at 10:40 AM, revealed she started her shift, on 03/04/12 at 9:30 AM. She stated that Resident #1 was already up in the wheelchair, so she "assumed" the resident had already been provided care. She revealed the resident was supposed to be toileted every two hours, but it had been a "hectic" day. An attempted interview with CNA #5, on 03/23/12 at 10:20 AM, 12:50 PM, and 3:00 PM, was unsuccessful; however, a review of the Final Investigative Report, dated 03/08/12, revealed CNA #5 admitted the resident was not toileted prior to 4:00 PM, as she had "forgotten." An interview with the DON, on 03/23/12 at 3:25 PM, revealed she conducted an interview with CNA #5, on 03/05/12. CNA #5 admitted she did not provide care for Resident #1 on 03/04/12, prior to the fall. She revealed CNA #5 stated she "was busy." She expected CNA #3 and CNA #5 to follow the resident's care guide, providing incontinent care/toileting every two hours and as needed. An interview with the Risk Manager, on 03/23/12 at 5:15 PM, revealed she witnessed the interview with the Director of Nursing (DON) and CNA #5, on 03/05/12. She revealed CNA #5 admitted she did not toilet the resident her entire shift on 03/04/12. Additionally, the resident's sensor pad alarm on the wheelchair was not turned on prior to the fall. A review of the "Personal Safety Alarms" policy, undated, revealed "personal safety alarms would be checked at least every two hours for proper functioning by direct care staff. Alarms should be checked for proper placement, to ensure they are functioning or in good working order. Ongoing surveillance of proper device use would be done during routine care and compliance rounds." A review of the "Alarms Monitoring" policy, undated, revealed "the Certified Medication Aide was to access each resident alarm at the beginning of the shift by sounding the alarm and ensuring it functioned correctly." An interview with Registered Nurse (RN) #1, on 03/23/12 at 1:25 PM, revealed the resident was sitting at the nurse's desk prior to the fall, and she noticed the self-release belt attached to the resident; however, she did not ensure the resident's sensor alarm was turned on and functioning. She revealed the Certified Medication Tech (CMT) was responsible for ensuring the alarm was turned on and functioning. An interview with Certified Medication Tech (CMT) #1, on 03/23/12 at 10:30 AM, revealed she worked on 03/04/12 from 6:00 AM to 6:00 PM. She revealed it was the responsibility of "all staff" to ensure alarms were on and functioning. She revealed she checked to ensure the self-release belt was attached to the resident, but could not recall if the sensor alarm was turned on and functioning. An interview with CNA #3, on 03/23/12 at 10:40 AM, revealed she started the shift on 03/04/12 at 9:30 AM. She revealed she did not ensure the resident's sensor alarm was on and functioning prior to the fall. She further revealed the resident was ambulated by restorative prior to the fall and it should have been checked at that time. An interview with Certified Nurse Aide (CNA) #1, on 03/23/12 at 9:35 AM, revealed she provided level 2 restorative care for Resident #1 on 03/04/12. She revealed she ambulated the resident between 10:00 AM and 11:00 AM. She revealed when she stood the resident up, the alarm did not sound. After ambulating the resident, she ensured the self-release belt was attached, but did not turn on the resident's sensor pad alarm. An attempted interview with CNA #5, on 03/23/12 at 10:20 AM, 12:50 AM, and 3:00 PM, was unsuccessful; however, a review of the Final Investigative Report, dated 03/08/12, revealed she did not ensure the resident's alarm was turned on and functioning prior to the fall. Interview with the Director of Nursing (DON), on 03/23/12 at 3:25 PM and at 5:20 PM, revealed she expected the staff to ensure the residents' alarms were placed, according to the resident care guide.

Based on interview, review of the facility's policy/procedures, and the Final Investigative Report, it was determined the facility failed to ensure written policies and procedures were implemented that prohibit neglect for one resident (#1) in the selected sample of four residents. Certified Nurse Aide (CNA) #3 and CNA #5 failed to toilet Resident #1, on 03/04/12, from 6:00 AM to approximately 4:00 PM. Resident #1 was found in the floor, at 3:30 PM, with his/her pants pulled down and urine on the floor. The resident's sensor pad alarm was not turned on prior to the fall. The resident sustained [REDACTED]. (Refer to F224) CNA #3 and CNA #5 were not removed from resident care, on 03/04/12, and were allowed to work a partial shift, on 03/05/12, before suspension was initiated. Findings include: A review of the facility's policy/procedure, "Resident Abuse and Neglect," undated, revealed" the resident's safety and protection would be assured. If an incident involved an employee, the employee would immediately be placed on suspension until the investigation was completed." A review of CNA #3's timesheet, dated 03/04/12, revealed she worked from 9:24 AM to 6:30 PM, and on 03/05/12, she worked from 5:57 AM to 12:28 PM. An interview with CNA #3, on 03/23/12 at 10:40 AM, revealed she did not provide incontinent care/toileting for Resident #1, on 03/04/12, prior to the resident's fall at 3:30 PM. Sh revealed she did not ensure the resident's sensor alarm pad was turned on and functioning. She was issued a written disciplinary action after the events by Certified Medication Tech (CMT) #1, but she was allowed to continue with resident care for the remainder of the shift. She revealed she was supposed to report to the Director of Nursing (DON) at 11:00 AM, on 03/05/12; however, she was not aware she could not complete her shift as scheduled, on 03/05/12. A review of CNA #5's timesheet, dated 03/04/12, revealed she worked from 5:58 AM to 6:28 PM, and on 03/05/12, she worked from 6:01 AM to 12:40 PM. An attempted interview with CNA #5, on 03/23/12 at 10:20 AM, 12:50 PM, and 3:00 PM, was unsuccessful; however, an interview with Registered Nurse (RN) #1, on 03/23/12 at 2:35 PM, revealed CNA #5 completed her shift on 03/04/12, and worked 03/05/12, until she was suspended by the DON. An interview with CMT #1, on 03/23/12 at 10:30 AM and at 2:30 PM, revealed CNA #3 and CNA #5 reported to her that they had not toileted Resident #1 prior to the fall, on 03/04/12 at 3:30 PM. She reported the allegation of neglect to RN #1 immediately. She revealed the DON instructed her to inservice CNA #3 and CNA #5 about neglect. They received disciplinary action at that time; however, the DON did not instruct her to send the two staff members home. She revealed she would remove a staff member from resident care if there was an allegation of physical or verbal abuse; however, she was "not sure" about a neglect allegation. An interview with RN #1, on 03/23/12 at 1:25 PM, revealed she first reported the resident's fall (with no alarm sounding) to the Assistant Director of Nursing (ADON), as she was on call. It was later in the shift when it was discovered the resident had not been checked for incontinence/toileting the entire shift. She revealed the ADON was notified immediately after the allegation of neglect. CMT #1 was instructed by the DON to inservice CNA #3 and CNA #5, and issue disciplinary action. She revealed the CNAs were not removed from resident care, as she was not instructed to remove them. She revealed she did not know what the policy stated. She stated "I didn't even think about removing them." An interview with the ADON, on 03/23/12 at 3:10 PM, revealed she was made aware of the allegation of neglect, as she was on call for the facility, on 03/04/12. She revealed she made the Administrator aware and the Administrator took over the investigation. An interview with the DON, on 03/23/12 at 3:25 PM, revealed she instructed CMT #1, on 03/04/12, to inservice CNA #3 and CNA #5 related to "alarms" and "providing care to their residents." She revealed CMT #1 was to issue written disciplinary action at that time. CNA #3 and CNA #5 were supposed to meet in her office the next morning at specific scheduled times. She revealed they were not supposed to provide resident care, on 03/05/12. She stated that she was not aware they worked the floor prior to meeting with her. An interview with the Administrator, on 03/23/12 at 4:00 PM, revealed she did not speak with CNA #3 and CNA #5 specifically, but gave direction to the ADON and DON. She revealed CNA #3 and CNA #5 were suppose to report to the DON's office at specific times, on 03/05/12. They were not suppose to provide resident care, as an investigation would be conducted for possible neglect. She was not aware CNA #3 and CNA #5 worked the floor, on 03/05/12; however, she did recall CNA #3 had "scrubs" on during the interview process. A review of the Final Investigative Report, dated 03/08/12, revealed CNA #3 and #5 were terminated as of 03/08/12 for neglect.

Based on interview, record review, review of the facility's policy/procedure, and the Final Investigative Report, it was determined the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care for one resident (#1), in the selected sample of four residents. The Comprehensive Care Plan indicated Resident #1 should be toileted every two hours and as needed. Certified Nurse Aide (CNA) #3 and CNA #5 did not follow the Comprehensive Care Guide related to toileting, as the resident was not toileted on 03/04/12, from 6:00 AM to 4:00 PM. The Resident Care Guide indicated Resident #1 required a sensor pad alarm to the wheelchair for safety. Resident #1 fell from the wheelchair, on 03/04/12. The resident was found with his/her pants pulled down and urine on the floor. CNA #1, CNA #3, and CNA #5 failed to ensure the resident's sensor pad alarm was turned on and functioning, according to the Resident Care Guide. Resident #1 sustained a intertrochanteric right femoral neck (right hip) fracture as a result from the fall. Findings include: A review of the facility's "Comprehensive Care Plan" policy/procedure, undated, revealed "the CNA care plan would be provided to strive to ensure that nursing staff were aware of supports that were to be provided for the resident." A record review revealed the facility admitted Resident #1 on 11/03/10 with [DIAGNOSES REDACTED]. The MDS revealed the resident was incontinent of bowel and bladder. A review of the Comprehensive Care Plan, dated 01/12/12, revealed the resident should be toileted every two hours and as needed. A review of the Resident Care Guide, undated, revealed the resident should have a sensor pad alarm to the wheelchair for safety. A review of the Final Investigative Report, dated 03/08/12, revealed Resident #1 fell from the wheelchair, on 03/04/12 at 3:30 PM, with his/her pants pulled down and urine on the floor. The resident's sensor alarm pad was turned off and not sounding at the time of the fall. The resident sustained [REDACTED]. An interview with CNA #1, on 03/23/12 at 9:35 AM, revealed she ambulated the resident between 10:00 AM and 11:00 AM, on 03/04/12. She revealed the sensor alarm pad was not sounding when the resident stood up, and she did not turn it on after assisting the resident back into the wheelchair. An interview with CNA #3, on 03/23/12 at 10:40 AM, revealed she clocked in at 9:30 AM, on 03/04/12, and did not toilet Resident #1 her entire shift. She revealed the resident should have been toileted every two hours and as needed. She also revealed she did not ensure the resident's sensor alarm pad was turned on and functioning. Attempted interview with CNA #5, on 03/23/12 at 10:20 AM, 12:50 PM, and 3:00 PM, was unsuccessful; however, a review of the Final Investigative Report revealed she did not toilet the resident from 6:00 AM to 4:00 PM, on 03/04/12. The report also revealed she did not ensure the resident's alarm sensor pad was on and functioning. An interview with the Director of Nursing (DON), on 03/23/12 at 5:20 PM, revealed she expected the staff to follow the care plan for each resident.

Based on interview, record review, review of the facility's policy and procedures, and the Final Investigative Report, it was determined the facility failed to ensure each resident received adequate supervision and assistance device to prevent accidents for one resident (#1), in the selected sample of four residents. On 03/04/12 at 3:30 PM, Resident #1 fell from the wheelchair. It was determined the resident's sensor pad alarm was not turned on and functioning at the time of the fall. The resident sustained [REDACTED]. Findings include: A review of the facility's "Personal Safety Alarms" policy, undated, revealed "personal safety alarms would be checked at least every two hours for proper functioning by direct care staff. Alarms should be checked for proper placement, to ensure they are functioning or in good working order. Ongoing surveillance of proper device use would be done during routine care and compliance rounds. " A review of the facility's "Alarms Monitoring" policy, undated, revealed "the Certified Medication Aide would access each resident alarm at the beginning of the shift by sounding the alarm and ensuring it functioned correctly." A record review revealed the facility admitted Resident #1 on 11/03/10 with [DIAGNOSES REDACTED]. A review of the Comprehensive Device Assessment, dated 10/21/11, and the Resident Care Guide, undated, revealed the resident had a sensor alarm pad and a self-release belt to the wheelchair for safety. A review of the Fall Assessment Screening Tool, dated 01/12/12, revealed the facility identified the resident as a high risk for falls. A review of the Final Investigative Report, dated 03/08/12, revealed Resident #1 was found in the floor with his/her pants pulled down and urine on the floor. The resident's sensor pad alarm was turned off and not sounding prior to the fall. The resident sustained [REDACTED]. An interview with Registered Nurse (RN) #1, on 03/23/12 at 1:25 PM, revealed she was the nurse who worked on 03/04/12. She revealed she did not witness Resident #1's fall; however, she examined the resident afterwards. She revealed the resident's sensor pad alarm was not turned on at the time of the fall. She further revealed the resident was sitting near the nurse's desk that day, and she noticed the self- release belt was attached to the resident; however, she did not ensure the resident's sensor alarm was turned on and functioning. She revealed the Certified Medication Tech (CMT) was responsible for ensuring the alarm was turned on and functioning. An interview with Certified Medication Tech (CMT) #1, on 03/23/12 at 10:30 AM, revealed she worked on 03/04/12 from 6:00 AM to 6:00 PM. She revealed it was the responsibility of "all staff" to ensure alarms were on and functioning. She revealed she checked to ensure the self-release belt was attached to the resident, but could not recall if the sensor alarm was turned on and functioning. An interview with CNA #3, on 03/23/12 at 10:40 AM, revealed she started the shift on 03/04/12 at 9:30 AM. She revealed she did not ensure the resident's sensor alarm was on and functioning prior to the fall. She further revealed the Restorative CNA ambulated the resident earlier in the shift, and she should have ensured the sensor pad alarm was turned on at that time. An interview with CNA #1, on 03/23/12 at 9:35 AM, revealed she provided Level 2 Restorative for Resident #1 on 03/04/12. She revealed she ambulated the resident between 10:00 AM and 11:00 AM. She revealed when she assisted the resident to stand up, the alarm did not sound. After ambulating the resident, she ensured the self-release belt was attached, but she did not turn on the resident's sensor pad alarm. An attempted interview with CNA #5, on 03/23/12 at 10:20 AM, 12:50 AM, and 3:00 PM, was unsuccessful; however, a review of the Final Investigative Report, dated 03/08/12, revealed she did not ensure the resident's alarm was turned on and functioning prior to the fall. Interview with the Director of Nursing (DON), on 03/23/12 at 3:25 PM and 5:20 PM, revealed she expected the staff to ensure the residents' alarms were placed, according to the resident care guide.