Every finding on record at Rolling Green Village

Based on review of the facility policy, record review, and interviews, the facility failed to report their five-day follow-up to the State Agency (SA) within five (5) days. Findings include: Review of the facility's policy titled, Investigating Injuries and Reporting Injuries, with a revision date of December 2016 revealed, A facility shall submit a written report of its investigation of every serious accident and incident to the Department within five (5) days of the serious accident or incident. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: Thoroughly investigate the alleged violation; Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and Take appropriate corrective action, as a result of investigation findings. Upon arrival at the facility on 04/10/24, the Assistant Director of Nursing (ADON) presented an investigative file with a report dated 11/30/23, which indicated the date the facility notified the SA. Review of the facility's investigation showed the facility did complete their 24-hour initial report. However, there was no five (5) day report completed. During an interview on 04/10/24 at approximately 3 PM with the ADON and Administrator, it was stated that they only complete a 24-hour report. During their 24-hour report, they convene their Interdisciplinary Team and send all relative information and complete the total investigation then send it under the 24- hour report. If any additional information is found later, they do send that relative information to the SA. However, they did not complete the five (5) day report. The Administrator stated she did not know she needed to complete a five day.

Amended 04/05/23 Based on interview, observations, and record reviews, the facility failed to assess 4 of 6 residents for side rails safety/entrapment hazards, obtain consent, or assess for less restrictive alternatives to side rails. Resident (R)4, who lacked side rail assessments or consent, was found dead on 02/13/2023 at approximately 7:45 AM. His body was found on the ground beside his bed while his head was between the mattress and 1/4 side rails. R3, R5, and R6 also lacked side rail documentation despite observed use of side rails. This was confirmed by interview with the Director of Nursing (DON). On 02/16/2023 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/16/2023 at 4:05 PM the Administrator and the Director of Nursing (DON) were notified that the failure to assess R4 for side rails constituted immediate jeopardy at F700. The facility presented an acceptable plan of removal of the immediate jeopardy on 02/16/2023 at 4:58 PM. The survey team validated that the immediate jeopardy was removed on 02/17/2023 at 2 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F700 at a lower scope and severity of E (pattern with potential for minimal harm) following removal of the IJ. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F700, constituting substandard quality of care. Findings include: Cross refer - F689 Review of the facility's policy titled, Bed Safety - Use of Side Rails revealed If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, paroxysmal atrial fibrillation, severe vascular dementia, cognitive communication deficit, muscle weakness, and lack of coordination. Review of R4's chart revealed no documentation of side rail assessments, including risk of entanglement or assessment for alternatives to side rails or bed rails consent. The resident's baseline care plan dated 11/09/2021, indicated he used 1/4 side rails for mobility and bed parameters. Interview with the DON on 02/16/2023 at approximately 12:14 PM confirmed there were no side rail assessments for R4 in his chart other than what was written in his 11/09/2021 baseline care plan. There were no orders or care planned interventions regarding the use of side rails. There was no consent obtained to use side rails from the resident's representative. Observation of R6, a sampled resident, on 02/16/2023 at approximately 3:37 PM revealed the resident had quarter side rails up in bed. R3 was observed multiple times with side rails. Review of chart revealed the facility failed to document side rail usage in orders or care plans. R5 was observed multiple times with side rails. Review of chart revealed the facility failed to document side rail usage in orders or care plans. Interview with the Assistant Director of Nursing (ADON) on 02/16/2023 at approximately 3:45 PM revealed the right side rail will come down soon. The side rail assessment and consent were submitted just that day at 1:42 PM. Interview with the DON and Administrator on 02/17/2023 at approximately 12:10 PM revealed the facility did not assess residents for side rails safety / consents prior to the incident on 02/13/2023 involving R4. The facility's removal plan included: Dimensions of all resident mattresses and beds with bed rails were obtained. Mattresses were replaced as necessary. Side rail assessments and consents were completed for all current residents within the nursing care facility. Side rails were installed only for residents determined to need side rails. All other side rails were removed from resident beds in the nursing care facility. Education of nursing staff on Health Center Bed Safety - Use of Side Rails policy to include: documenting why a resident requires side rails, whether the resident is capable of using side rails safely, and whether other alternatives to side rails might provide the same benefits to mobility and reduction in fall risks. On a monthly basis, Maintenance technician and/or Designee will inspect all current beds that utilize side rails using an observational audit tool. Immediate corrections will be made by maintenance technician and/or Designee when necessary. New installations of side rails will only be completed by facility maintenance technicians. All new nursing staff members will be educated on the Health Center Bed Rail and Accidents and Incidents - Investigating and Report Policies during new nursing staff orientation. Corrective actions will be monitored using an observational audit tool performed monthly. The corrective actions will be tracked and trended and followed through the monthly Quality Assurance and Performance Improvement (QAPI) meeting with oversight of the Administrator until 100% completion is sustained and maintained.

Based on review of the facility policy, record review, interviews, and photographic evidence, the facility failed to protect Resident (R)4 from accidents/accident hazards resulting in death. R4 was found dead on 02/13/23 at approximately 7:45 AM. Staff discovered him with his body on the floor and his head against the window-facing side rail. R4's head was caught in the side, while the side rail was pushed up against the resident's neck. On 02/16/23 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/16/23 at 4:05 PM, the Administrator and the Director of Nursing (DON) were notified that the death of R4 constituted immediate jeopardy (IJ) at F689. The facility presented an acceptable plan of removal of the immediate jeopardy on 02/17/23 at 10:20 AM. The survey team validated that the immediate jeopardy was removed on 02/17/23 at 2 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F689 at a lower scope and severity of D (isolated with potential for more than minimal harm) following removal of the IJ. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Cross refer - F700 R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, paroxysmal atrial fibrillation, severe vascular dementia, cognitive communication deficit, muscle weakness, and lack of coordination. Review of Licensed Practical Nurse (LPN)1's written statement revealed she was called to the floor by the medication nurse. She observed the resident on the floor by the window side. His head was on the quarter rail and the bed was in its lowest position. The resident was warm to palpation, but no pulse or respirations were noted. Review of Certified Nursing Aide (CNA)1's written statement revealed she went into the room at 7:45 AM on 02/13/23. She found R4 sitting on the floor with his neck stuck between the bed and bedrails. She notified the nurse. Interview with LPN1 on 02/16/23 at approximately 12:42 PM confirmed her statement. She confirmed on 02/13/23 at approximately 7:45 AM, LPN1 found R4 in his bedroom. His body laid on the floor, and his head rested against the side rail. Review of photographic evidence taken of R4, as he was discovered, revealed the resident was on the floor with his head between the side rails and mattress. An interview with the Forensic Pathologist on 02/16/23 at approximately 12:36 PM, revealed the preliminary findings for R4's cause of death was positional asphyxia/accident. The resident was discovered with his neck/head between the side rails and mattress. Review of CNA2's statement revealed she remembered giving the resident a bath and shave that morning. He was fine when she left the building, at approximately 6:15 AM on 02/13/23. During an interview with CNA2 on 02/16/23 at approximately 1:35 PM, she confirmed she last saw the resident at around 6:15 AM on 02/13/23. He was lying comfortably in bed when she left him. The facility's removal plan included: Dimensions of all resident mattresses and beds with bed rails were obtained. Mattresses were replaced as necessary. Side rail assessments and consents were completed for all current residents within the nursing care facility. Side rails were installed only for residents determined to need side rails. All other side rails were removed from resident beds in the nursing care facility. Education of nursing staff on Health Center Bed Safety - Use of Side Rails policy to include: documenting why a resident requires side rails, whether the resident is capable of using side rails safely, and whether other alternatives to side rails might provide the same benefits to mobility and reduction in fall risks. Education of nursing staff on facility policy for Accidents and Incidents - Investigating and Reporting. On a monthly basis, Maintenance technician and/or Designee will inspect all current beds that utilize side rails using an observational audit tool. Immediate corrections will be made by maintenance technician and/or Designee when necessary. New installations of side rails will only be completed by facility maintenance technicians. All new nursing staff members will be educated on the Health Center Bed Rail and Accidents and Incidents - Investigating and Report Policies during new nursing staff orientation. Corrective actions will be monitored using an observational audit tool performed monthly. The corrective actions will be tracked and trended and followed through the monthly Quality Assurance and Performance Improvement (QAPI) meeting with oversight of the Administrator until 100% completion is sustained and maintained.

Based on interviews, record review, and review of facility policy, the facility failed to investigate and respond to resident grievances for 2 of 9 grievances reviewed for grievance resolution. The facility further failed to respond to concerns brought up during resident council meetings from January 2022 through July 2022. Specifically, the facility failed to resolve/respond to grievances/concerns related to lengthy call light response times, communication difficulties, wheelchair needs, activities of daily living (ADLs), noise levels, staff communication, staff being on their phones during ADL care, and unprofessional behavior. Findings include: Review of the facility policy titled Grievances/Complaints, Filing revised April 2017 revealed, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is Admissions Coordinator [AC] . Once grievance is obtained, Grievance officer will present to the unit supervisor to be completed for that portion (action taken) .The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years . Review of Resident Council Meeting Minutes for the months of January 2022 through July 2022 revealed multiple nursing department complaints including lengthy call light response times, communication difficulties, wheelchair needs, ADLs, noise levels, staff communication, and staff being on their phones during ADL care. Review of the documentation provided by the facility and sent out by Activities Lead [AL] revealed emails were sent to the Director of Nursing [DON] and Assistant Director of Nursing [ADON] regarding grievances/concerns voiced by multiple residents during monthly resident council meetings. Grievance notifications were sent on 01/28/22, 02/23/22, 03/30/22, 04/27/22, 06/02/22, and 06/28/22. An email sent on 01/28/22 stated Attached you will find the residents' identified concerns for the month of January .does not like it that it sometimes takes over an hour for his call light to be answered .some nursing staff .gets frustrated when trying to communicate with him, due to him being hard of hearing .would like a better wheelchair .in the evening it takes staff longer to answer her call light .some of the staff does not know how to properly make his bed .evening shift can sometimes be a little loud outside of his door. Department response was blank, was not signed off by the department head, not dated, and not returned to AL by 02/22/22 as requested. An email sent on 02/23/22 stated Attached you will find the residents' identified concerns for the month of February .still has issues with certain staff members who cannot put the catheter bag on correctly .feels like most days she is left in the bed too long .it takes 2nd shift a long time to answer call lights .would like for the water to already be warm when he is taken to the shower .would like nursing staff to tell him what activities are going on for the day . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 03/29/22 as requested. An email sent on 03/30/22 revealed Attached you will find the residents' identified concerns for the month of March .it takes the nursing staff a long time to come to her room when she needs help .continues to have issues with CNAs [Certified Nursing Assistants] not being able to properly place his catheter bag on his wheelchair without it dragging the ground .shower rooms tend to be very disheveled . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 04/26/22 as requested. An email sent on 04/27/22 stated Attached you will find the residents' identified concerns for the month of April .says he pushes his call light and ends up yelling for help because no one will answer his light in the evenings . waits a long time for help to come . still commenting that most of the CNAs cannot hang the catheter bag correctly .would prefer for staff to not be on their phone when they are in his room . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 05/31/22 as requested. An email sent on 06/01/22 stated Attached you will find the residents' identified concerns for the month of May .mentioned again that the evening shift does not answer her call light in a timely manner .it takes evening shift awhile to answer his call light .mentioned again that his catheter bag does not get hung correctly on his wheelchair . Department response was blank, was not signed off by department head, not dated, and not returned to AL by 06/28/22 as requested. An email sent on 06/28/22 stated Attached you will find the residents' identified concerns for the month of June .CNAs are sometimes slow at coming to help. When asked what time of day he was referring to, he said, 'it varies'. Department response was blank, was not signed off by department head, not dated, and not returned to AL by 07/26/22 as requested. Review of grievance logs from July 2021 through July 2022 revealed there were nine grievances reported. Grievance dated 01/19/22 regarding unprofessional behavior was not responded to or investigated. Grievance dated 02/23/22 regarding lack of nursing assistance during toileting was not responded to or investigated. In an interview with the Admissions Coordinator (AC) on 07/08/22 at 10:50 AM, revealed she was the grievance officer and was responsible for following up on grievances. Facility protocol included the AL sends out emails to all departments regarding any grievances and complaints made during the resident council meetings or individual complaints made by the resident/responsible party. If the department was able to resolve the complaint/grievance the day of the reported grievance, then the facility did not report as a grievance. AC confirmed that grievance filed 01/19/22 related to quality of care for the nursing department resulted in her speaking with the ADON with no resolution received. AC confirmed that grievance filed on 02/23/22 related to quality of care for the nursing department resulted in her speaking with the ADON with no resolution received. In an interview with the Social Work Assistant (SWA) on 07/08/22 at 11:43 AM, revealed she frequently holds the resident council meetings on the last Tuesday of the month. SWA confirmed that complaints/concerns are then forwarded to the AL who then enters the information into the system and sends out emails to the appropriate department leads who are expected to respond in a timely manner to the grievances/concerns. In an interview with the ADON on 07/08/22 at 12:22 PM, revealed she had spoken with one of the residents regarding generalized concerns, but she had not read or reviewed the emails from the AL regarding resident council grievances/concerns dated January through June 2022. The ADON further stated that the AL brought it to her attention on 07/08/22 that resident council grievances/concerns had not been responded to by the nursing department and returned to the AL. During an interview with the AL on 07/0822 at 1:28 PM stated she was responsible for typing up the resident council minutes and then sending an email to the appropriate departments with specific grievances/concerns. The emails include a summary of concerns voiced during the resident council meeting, a form to fill out including the department's response, signature of department head, date completed, and date to return the form back to her. The AL confirmed that she had not received any resolutions to nursing department complaints/concerns in the past six months reviewed with this surveyor. During an interview with the Director of Nursing (DON) on 07/08/22 at 6:08 PM stated she was aware of one resident that recently complained of call light times. Staff were educated a few weeks ago and she was not aware of a trend regarding complaints/concerns. The DON stated she did not consistently run reports for call light response times, but her expectation was for staff to answer the lights within 10 to 20 minutes. In an interview with the Administrator on 07/08/22 at 6:27 PM, revealed he was aware of extended call light response times for certain residents and the expectation would be to answer the call lights in a timely manner and let the resident know if there would be a delay in assisting them. The Administrator confirmed that the AL sends out emails to the department leads with notification of grievance/concerns, the department is expected to investigate and then notify the grievance officer with resolution. The expectation was also for the department head to return the form back to the AL with resolution. The Administrator was not aware that multiple grievances were not followed up on or investigated.

Based on interview, record review, and review of facility policy, the facility failed to ensure the resident, his or her family, and/or the resident representative (RR) was provided information related to the benefits and risks to the residents for prescribed [CONDITION(S)] medications. The facility further failed to obtain consents for the [CONDITION(S)] medications by the resident, or family, and/or the RR. This affected 3 of 5 residents (Resident (R) 21, R31, and R32) reviewed for unnecessary medications. Findings include: Review of the facility's policy titled, Lifestyle Support/Behavior Management Policy and Procedure, reviewed 06/21 indicated, If the resident is receiving a [CONDITION(S)] medication, the community will obtain consent for the medication. 1. Review of R21's Resident Face Sheet located in the Electronic Medical Record (EMR) under the Resident and Face Sheet tab, revealed an admitted [DATE] and included diagnoses of [CONDITION(S)] (altered brain function) and major depressive disorder. Review of R21's quarterly Minimum Data Set (MDS), located in the EMR under the MDS 3.0 Assessments tab, with an Assessment Reference Date (ARD) of 05/20/22 revealed a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R21's Orders located in the EMR under the Orders tab, revealed the resident was prescribed [MEDICATION(S)] (antidepressant). Review of R21's EMR revealed no evidence the resident nor the RR had been notified of the potential risks and benefits of receiving the prescribed medication, nor had the RR been given the opportunity to consent or refuse the drugs' use. 2. Review of R31's Resident Face Sheet located in the EMR under the Resident and Face Sheet tab, revealed an admitted [DATE] and included diagnoses of [CONDITION(S)], dementia without behavioral disturbance, and hallucinations. Review of R31's quarterly MDS, located in the EMR under the MDS 3.0 Assessments tab, with an ARD of 06/09/22 revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R31's Orders, located in the EMR under the Orders tab, revealed the resident was prescribed [MEDICATION(S)] (antipsychotic) and [MEDICATION(S)] (antianxiety). Review of R31's EMR revealed no evidence the resident nor the RR had been notified of the potential risks and benefits of receiving the prescribed medication, nor had the RR been given the opportunity to consent or refuse the drugs' use. 3. Review of R32's Resident Face Sheet located in the EMR under the Resident and Face Sheet tab, revealed an admitted [DATE] and included diagnoses of [CONDITION(S)], Alzheimer's disease, dementia with behavioral disturbance, and anxiety disorder. Review of R32's quarterly MDS located in the EMR under the MDS 3.0 Assessments tab, with an ARD of 05/28/22 revealed a BIMS score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Review of R32's Orders, located in the EMR under the Orders tab, revealed the resident was prescribed [MEDICATION(S)] (antipsychotic). Review of R32's EMR revealed no evidence the resident nor the RR had been notified of the potential risks and benefits of receiving the prescribed medication, nor had the RR been given the opportunity to consent or refuse the medication's use. In an interview on 07/08/22 at 9:30 AM, the Assistant Director of Nursing (ADON) stated all residents that receive [CONDITION(S)] medications should have informed consents in the medical record. The ADON stated she could not locate the consents for R21, R31, and R32 but would reach out to the Director of Nursing (DON). In a follow-up interview on 07/08/22 10:40 AM, the ADON stated she spoke with the DON and the DON noticed the consents were not in the medical records during a chart audit. In an interview on 07/08/22 at 10:47 AM, the DON stated she completed a chart audit in April of all residents that receive [CONDITION(S)] medications. The DON stated the audit uncovered residents did not have informed consents in their medical records. The DON stated she gave the task to the Admissions Coordinator (AC) to complete. In an interview on 07/08/22 at 11:27 AM, the AC stated she was not responsible for adding the informed consents to the chart. The AC stated it was discussed for her to ensure informed consents were completed upon admission. The AC confirmed the facility did not obtain consents notifying R21, R31, and R32 nor their representatives of the risks/benefits of the use of [CONDITION(S)] medications.

Based on record review and interview the facility failed to complete accurate Minimum Data Set (MDS) assessments for Residents #50 and #49, 1 of 1 sampled residents reviewed for Death and 1 of 1 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED].#50 was admitted to Hospice on [DATE]. Record review of the Minimum Data Set (MDS) assessment from [DATE], on [DATE] at 2:45 PM, revealed the resident died in the facility on [DATE]. Record review of the Minimum Data Set (MDS) assessment from [DATE], on [DATE] at 2:45 PM, revealed Section O of the MDS did not indicate the resident was receiving Hospice services. No other MDS assessments indicated the resident was receiving Hospice services. During an interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:37 AM, LPN #1 was asked if a Significant Change MDS assessment had been completed after the resident was admitted to Hospice. LPN #1 stated a Significant Change assessment was not required because the resident was on Hospice when the [DATE] assessment was completed. LPN #1 was asked if the [DATE] assessment indicated the resident was receiving Hospice services. LPN #1 confirmed Section O of the [DATE] assessment did not indicate the resident was receiving Hospice services. LPN #1 stated Section O was not accurate and should have been checked to indicate the resident was receiving Hospice services. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for Resident #49 reviewed on [DATE] indicates Resident was discharged for hospitalization . Record Review on [DATE] at 2:15 PM indicates The Occupational Therapist Discharge Summary, Physical Therapist Discharge Summary and Face Sheet show Resident #49 was discharged to home with home health. [DATE] at 2:30 PM Interview with Licensed Practical Nurse (LPN) #1, who stated Resident was discharged on [DATE] to the hospital. LPN #1 checked her/his information and reported at 2:45 PM on [DATE] that s/he made an error in the scroll down on the box on the MDS form. LPN #1 stated the Resident was released on [DATE] to home with home health care. Review of the MDS dated [DATE], on [DATE], 2:45 PM, revealed Section A of the MDS was checked for hospitalization .

Based on record review, interview and review of facility policy, the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to properly care for Resident #103, 1 of 2 sampled residents reviewed with a Urinary Catheter. The resident's baseline care plan did not indicate the resident had a Urinary Catheter. The findings included: The facility admitted Resident #103, on 12/3/20, with [DIAGNOSES REDACTED]. Record review of the hospital discharge summary and facility admission assessment, on 12/8/20 at 3:15 PM, revealed the resident was admitted to the facility with a urinary catheter in place. Record review of the baseline care plan, on 12/9/20 at 9:06 AM, revealed the resident was not care planned for having a urinary catheter and no interventions were implemented for the care of the urinary catheter. During an interview with the Director of Nursing (DON), on 12/9/20 at 9:15 AM, the DON confirmed the baseline care plan did not address the presence or care of the resident's urinary catheter. During an interview with Resident #103, on 12/9/20 at 9:40 AM, the resident was asked if staff were cleaning his urinary catheter daily. Resident #103 stated s/he thought so and didn't have any concerns with the care of the urinary catheter. Review of the facility's Care Plans - Baseline policy revealed A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation for one (1) resident who made an allegation of sexual abuse (Resident #1). The findings included: Review of the facility's undated Abuse Policy: documented the following: Protection Abuse Policy .The progress notes, concerning all residents involved, should include: 6. What was done to prevent further harm to resident or others. Documentation will continue over 72 hours. An acute care plan will be developed that identifies methods for prevention of further occurrence .In House Investigation .Steps taken to protect the alleged victim from further abuse, particularly when an alleged perpetrator has not been identified. Actions taken as a result of the investigation, to include corrective action taken .Abuse Prevention Program, Community Procedures VI. 4. Investigation procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents .7. Final Abuse Investigation Report .The final investigation report shall contain the following .Facts determined during the process of the investigation, review of medical record and interview of witnesses . Conclusion of the investigation based on known facts .Attach a summary of all interviews conducted .VIII. External Reporting of Potential Abuse. 1 .Steps the community has taken to protect the resident. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating moderate cognitive impairment. The MDS recorded the resident had minimal hearing difficulty, clear speech, made herself understood, and understood others with clear comprehension. The MDS recorded the resident had no signs or symptoms of [MEDICAL CONDITIONS], hallucinations or delusions, and had rejected care one (1) to three (3) days during the assessment period of seven (7) days. The MDS further recorded the resident required extensive assistance of one (1) staff for toileting and personal hygiene, and the resident had occasional urinary incontinence. The resident was documented as receiving antidepressants seven (7) days during the assessment period. Review of Resident #1's care plan dated 6/26/19 for occasional urinary incontinence directed staff: Check for incontinence; change if wet/soiled. Clean skin with mild soap and water, apply moisture barrier, keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bed quickly, remind to empty bladder before meals, at bedtime, and before activities. Review of the Clinical Notes from 6/30/19 through 8/1/19 written by Nursing and Social Services (SS) recorded several instances of behaviors by the resident including confusion, disorientation, refusals of care, accusations toward staff, and hallucinations. Dates for the behavior notes in the record were 6/30/19, 7/1/19, 7/6/19, 7/8/19, 7/9/19 (two notes), 7/16/19, and 7/24/19. Staff did not document any additional behaviors in the medical record. On 7/24/19, the Social Worker (SW) documented, SW place (sic) in psychiatrist book to be seen for increase (sic) hallucinations. Review of the Psychiatrist and Psychiatric Nurse Practitioner (NP) notes from 7/10/19 through 8/20/19 recorded the resident was frustrated, irritable, disoriented at times, had cognitive impairment, and expressed having hallucinations. The Psychiatric notes were dated 7/10/19, 7/16/19, 7/23/19, 7/31/19, 8/7/19, and 8/20/19. Review of the initial abuse allegation report dated 8/1/19 revealed the resident's family member reported to the Executive Director that the resident told her on a couple of occasions a staff member came to her room at night and put their finger in her vagina. The facility documented, Investigation initiate (sic). No staff member identified at this time, however the Charge Nurse for 2nd shift and 3rd shift aware and will monitor staff and resident interactions during the investigation and will notify ED/DON (Executive Director/Director of Nursing) of any questionable interactions. Review of the final abuse investigation report dated 8/6/19 recorded, no witnesses, no description of perpetrator, no date given, happened during the night, and list of 3rd shift employees. Interventions by facility to prevent future Injury/Alleged Abuse: Res (resident) to be 'checked' for incont (incontinence) last on 2nd shift, only visual checks when asleep and 1st check on 1st shift. Limit waking up the res (resident) to provide care as long as res (resident) remain (sic) safe and clean. The abuse investigation did not contain any witness statements or written statements by staff, and the facility did not interview any other residents to determine the potential scope of the alleged sexual abuse. The abuse investigation did not consider an increase in the resident's negative behaviors and hallucinations as a potential expression of actual sexual abuse. During interview on 11/14/19 at 10:20 AM, the DON presented a narrative she wrote on 11/14/19 of what transpired on the night shift, the day the allegation was made, 8/1/19. This narrative was not part of the actual sexual abuse investigation. The DON stated Licensed Practical Nurse (LPN) #A was the night time supervisor and the DON asked her to interview the three (3) Certified Nursing Assistants (CNAs) who worked the night shift on 8/1/19. The DON stated that the LPN reported the CNAs were, Turning on the lights, pulling back the covers, doing visual checks of the resident's brief, and it was apparent how the resident could have felt concerned about it; they were waking her up to check her, and she is a very sound sleeper. The DON continued, We did not do any other resident interviews on the unit. We thought it was an isolated event. We did not hear anything from other residents about night time staffing or care concerns, but no we didn't directly ask them (the residents). We did not get individual statements from staff. Statements weren't put on paper, but they occurred on the 3rd shift, with the 3 CNAs, the communication was done, and put in a summary, not individually. The residents on that unit, care issues/concerns are discussed at each care plan meeting. The Social Worker (SW) asks how the care is and how the staff is treating them. We ask the families and the resident. During interview on 11/14/19 at 2:38 PM, LPN #A stated she received an email from the DON who asked LPN #A to do a body audit on the resident and talk to the CNAs on 3rd shift. Then she reported back to the DON. LPN #A stated she asked the CNAs how they toilet and check the resident's brief. LPN #A further stated she did not get any written statements from the three (3) CNAs, she met with them and they talked about care, and she did not interview any other residents. LPN #A determined the resident was a heavy sleeper and misunderstood the staff was providing incontinent care, not sexually abusing her. After discussing it with the DON, they decided to change the way the staff checked and changed the resident, to the last check on the evening shift and the first check on the day shift. LPN #A also stated, The whole investigation process was done in one (1) day. I really did think it was a behavior (the sexual abuse allegation) from transitioning from home to LTC (Long Term Care). The (family member) stopped coming as much so that the resident could adjust and make friends, and I think (the resident) was trying to sort of manipulate her (family member) to go back home. I didn't discount what she was saying about the abuse. The reason I say that's what her problem was (versus potentially acting out with behaviors as a result of abuse) rather than actual abuse; I could tell she missed being at home. During interview on 11/14/19 at 3:24 PM, the MDS nurse stated for an acute problem, such as abuse issues, The SW is the first go-to. They write up the initial report usually. They primarily do the interviews. They would update the care plan. During interview on 11/14/19 at 4:05 PM, SW #1 stated she was informed about Resident #1's sexual abuse allegation, and staff was going in to check if she was incontinent and they put their finger down her brief. SW #1 stated the discussion was about that the resident would be the last check on 2nd shift about 11:00 - 11:30 PM and 3rd shift would not check her, and then she would be the first person on the 1st shift to be checked. SW #1 stated staff did the investigation by interviewing the resident, but did not interview anyone else, I wrote up the initial concern form and gave it to the DON. At 4:45 PM, the SW stated she did not take any actions to protect the resident during the investigation. During interview on 11/14/19 at 4:28 PM, CNA #1 stated she worked both evening and night shifts and provided care for Resident #1 on the night shift and checked the resident every two (2) hours. CNA #1 stated. I pull the covers back to check her brief and look for the line (line on the brief turns blue when wet). I wake her up, she wakes up when you go in unless she's in a deep sleep, she doesn't sleep deeply. Nobody ever interviewed me about (the resident) for anything about sexual abuse. Nobody told me or trained me about any new care interventions or procedures since then. During a follow-up interview on 11/14/19 at 4:47 PM, the DON stated the facility did not protect the resident during the investigation because, It was a quick investigation. We had the family involvement and the staff knew exactly what could have happened. The DON stated they, Should have checked to see if it was unit wide. The DON stated the abuse policy does state the resident should be protected during the investigation, But we didn't feel that there was anyone who was harming her. The DON stated typically they do take into consideration that an increase in behaviors could be a response to sexual abuse, but in this case they didn't because, We felt we knew what happened. During interview on 11/14/19 at 5:17 PM, the Executive Director (ED) stated staff usually looks at the pieces for what is causing behaviors and talk to the physician. I feel that we did a thorough investigation, and We act on the information we think is truthful, and I think we did a thorough investigation .looking back, we should have had other things documented. It may have been a nurse's rush to judgement, but she's a good judge of what has occurred because she knows the resident.

Based on observation, interview, record review and facility policy review, the facility failed to revise the care plan for one (1) resident who alleged staff sexual abuse (Resident #1). The findings included: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016 directed, 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating moderate cognitive impairment. The MDS recorded the resident had minimal hearing difficulty, clear speech, made herself understood, and understood others with clear comprehension. The MDS recorded the resident had no signs or symptoms of [MEDICAL CONDITIONS], hallucinations or delusions, and had rejected care one (1) to three (3) days during the assessment period of seven (7) days. The MDS further recorded the resident required extensive assistance of one (1) staff for toileting and personal hygiene, and the resident had occasional urinary incontinence. The resident was assessed to receive antidepressants during the assessment period. Review of Resident #1's care plan for occasional urinary incontinence, dated 6/26/19, directed staff: Check for incontinence; change if wet/soiled. Clean skin with mild soap and water, apply moisture barrier, keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bed quickly, remind to empty bladder before meals, at bedtime and before activities. The care plan for toileting, dated 6/29/19 directed interventions including: Select clothing that is easily removed. Change incontinence pad/brief. The care plan lacked any direction to staff when to provide an incontinence brief for the resident, or in which circumstances or shifts to provide a brief. Additional review of the care plan failed to reveal any new interventions to address the resident's allegation of sexual abuse. According to the Director of Nursing (DON) on 11/14/19 at 10:20 AM, Resident #1's family member reported the sexual abuse allegation to the Executive Director during a meeting, and an abuse investigation was initiated. Review of the final abuse investigation report dated 8/6/19 recorded, Interventions by facility to prevent future Injury/Alleged Abuse: Res (resident) to be 'checked' for incont (incontinence) last on 2nd shift, only visual checks when asleep and 1st check on 1st shift. Limit waking up the res (resident) to provide care as long as res (resident) remain (sic) safe and clean. During interview on 11/14/19 at 2:38 PM, Licensed Practical Nurse (LPN) #A stated she spoke to the three (3) night shift Certified Nursing Assistants (CNAs) on the night shift as part of the sexual abuse investigation; then she reported back to the DON. LPN #A stated she asked the CNAs how they toilet and check the resident's brief. LPN #A stated she determined the resident was a heavy sleeper and misunderstood the staff was providing incontinent care, not sexually abusing her. After discussing it with the DON, they decided to change the way the staff checked and changed the resident, to the last check on the evening shift and the first check on the day shift. LPN #A stated, I did not update the care plan. The nurses on the unit don't update the care plans. The RNs (Registered Nurses) and (the DON) update the care plans. During interview on 11/14/19 at 3:24 PM, the MDS Nurse stated for an acute problem, such as abuse issues, The SW (Social Worker) is the first go-to person. They write up the initial report usually. They would update the care plan. The MDS Nurse provided a copy of the Resident Summary which was the CNA's copy of the Nursing care plan. The MDS Nurse verified the Summary did not direct the CNAs when to check and change the resident on the first, second and third shifts. During interview on 11/14/19 at 4:05 PM, SW #1 stated she was informed about Resident #1's sexual abuse allegation, and staff was going in to check if the resident was incontinent, and they put their finger down her brief. SW #1 stated the discussion was about the resident would be the last check on evening shift about 11:00 - 11:30 PM and third shift would not check her. And then the resident would be the first person on the day shift to be checked. SW #1 stated, I did not do the care plan addition, just did what I was directed to do. During interview on 11/14/19 at 4:28 PM, CNA #1 stated she worked both evening and night shifts and had provided incontinent care for Resident #1 on the night shift. CNA #1 stated. I pull the covers back to check her brief and look for the line (line on the brief turns blue when wet). I wake her up, she wakes up when you go in unless she's in a deep sleep, she doesn't sleep too deeply. CNA #1 provided the CNA care plan, titled Cart 1 Report Sheet which documented for Resident #1, Cont. (continent) b/b (bowel and bladder). CNA #1 stated the resident did wear a brief at night, but it wasn't on the Report Sheet. CNA #1 stated, Nobody told me or trained me about any new care interventions or procedures since August. During interview on 11/14/19 at 4:47 PM, the DON agreed there was no care plan to communicate to staff that the resident should be checked last on the evening shift and first on day shift, skipping night shift unless the resident was awake. The DON agreed the Cart 1 Report Sheet and the Resident Summary were for directing CNAs about care and did not include these interventions in Resident #1's directives. The DON stated, It's hard to communicate (to the staff) through our computer system. During interview on 11/14/19 at 5:17 PM, the Executive Director stated, I feel that we did a thorough investigation, but I agree there should have been a care plan addition .Agree there could have been more consistency to the policy, and looking backwards, we should have had other things documented. Cross reference F610.

Based on record review and interview, the facility failed to report abuse allegations within 2 hours for 2 of 3 residents reviewed for abuse. Residents #14 and #55 made allegations regarding misappropriation of property and physical abuse respectively, and the facility did not report them to the state agency within 2 hours of becoming aware of the allegations. The findings included: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Initial report on 4/16/19 at approximately 9:10 AM revealed the following: 1. Possible theft occurred on 9/24/18. 2. Resident #14 notified staff and Social Services of possible theft on 9/25/18. 3. Facility sent initial report on 9/27/18. During an interview with the Administrator on 4/18/19 at approximately 10:55 AM s/he confirmed the delayed reporting of possible misappropriation of property. The Administrator stated the room was searched by staff and family to rule out misplacement before being reported as theft, leading to the delayed reporting to the state agency. The facility admitted Resident #55 on 2/22/19 with [DIAGNOSES REDACTED]. Record review of the facility's Initial Report and Five-Day Follow-Up Report on 4/15/19 at 11:16 AM, revealed the facility reported a suspicion of abuse, involving Resident #55, on 3/12/19 at 12:40 PM. The initial Report and Five-Day Follow-Up Report indicated the alleged incident occurred on 3/11/19 at 4:30 PM. The Five-Day Follow-Up Report was not received from the facility until 3/22/19. During an interview with the Director of Nursing (DON) on 4/18/19 at 11:50 AM, the DON confirmed s/he witnessed the alleged violation on 3/11/19 at approximately 4:30 PM. The DON stated s/he was giving Resident #55 medication at the time. The resident's son was present and grabbed the resident's hand and was verbally inappropriate towards the resident. During an interview with the DON and the Administrator on 4/18/19 at 1:15 PM, the DON and Administrator confirmed the alleged violation was not reported within 2 hours, as required. In addition, the Five-Day Follow-Up Report was not received until 11 days after the incident. Review of the facility's Abuse Policy and Procedure revealed the policy did not reflect current regulations related to reporting allegations involving Abuse. Per the policy, alleged violations involving abuse are reported within 2 hours of the violation if there is serious bodily injury or within 24 hours of the violation if there is not serious bodily injury. The results of all investigations must be reported to the Administrator, the Executive Director, and his/her designed representative and to other officials in accordance with the state law (including to the state survey and certification agency) within 5 working days of the incident

Based on record review and interview, the facility failed to revise the Care Plans for Resident's #29 and #55, 1 of 2 sampled residents reviewed for Falls and 1 of 3 sampled residents reviewed for Abuse. Resident #29's Care Plan was not revised after a fracture. Resident #55's care plan was not revised related to visitation restrictions for a family member. The findings included: The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Record review of the facility's Five-Day Follow-Up Report on 4/15/19 at 11:16 AM, revealed an incident involving Resident #55 and a family member on 3/11/19. According to the report, during medication administration, the nurse observed the family member get angry at the resident, grab her/his hand and pull at her/his fingers. The report also revealed the family member was verbally inappropriate towards the resident. Interventions implemented after the incident included visitation with restrictions for the family member. Record review of Resident #55's Care Plan on 4/18/19 at 11:08 AM, revealed no interventions related to the 3/11/19 incident. During an interview with the Director of Nursing (DON) on 4/18/19 at 11:50 AM, the DON confirmed the events on 3/11/19 and stated the facility implemented a visitation plan for the family member after the incident. The DON explained the interventions included in the plan were limiting visitation hours from 5:00-8:00 PM during meal service and until s/he goes to bed. When visiting the resident's room, the family member was to remain visible with the door open or may visit in common areas. In addition, the family member was to step out of the room during care. When asked if these interventions had been added to the care plan, the DON stated they were not. The DON stated the plan was emailed to all of the nurses. The DON provided a copy of the email with the above interventions. The facility admitted Resident #29 on 10/5/17 with [DIAGNOSES REDACTED]. Record review of Resident #29's nursing notes on 04-16-19 at approximately 2:00PM revealed nurses note dated 02-05-19 stated, Resident observed at 3AM kneeling on floor mat in praying position with knees on floor mat; resident stated (s/he) was trying to go to church, resident with no injuries at this time, denies hitting head and denies any pain at this time, resident assisted back to bed; PERRLA (pupils equal round reactive to light); floor mat remains in place, encouraged resident to please use call light and not to get up alone; call light noted in reach by this nurse; MD notified and resident's son, notified at 0700; oncoming nurse notified of fall. Review of Resident #29's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3. Review of Resident #29's Nurses note dated 02-12-19 stated the resident had an X-Ray on her/his right knee and it came back positive for fracture to her/his Tibia. Nursing note dated 02-13-19 stated, returned from the hospital at 03:45 [DIAGNOSES REDACTED]. Record review of Resident #29's physician orders [REDACTED]. Record review of Resident #29's care plan effective 10-20-2017 to present on 04-16-19 at approximately 1:28PM revealed under Problems, has history of falling and is at risk for injury related fall with a goal of will have no injury related to falls through the next 90 days. Further review revealed the Care Plan had not been updated to reflect the fall, fracture, non-weight bearing or immobilizer. During an interview on 04-17-19 at 3:13 PM the Minimum Data Set (MDS) Coordinator RN #1 confirmed that Resident #29's Care Plan had not been updated to reflect the fall, fracture and non-weight bearing or immobilizer.

Based on observation, interview and review of the facility policy titled HIPAA Workforce Confidentiality Acknowledgment the facility failed to protect resident identifiable information on 1 of 2 units. Licensed Practical Nurse (LPN) #2 left resident records accessible to unauthorized persons. The findings included: Observation of nursing medicine cart on 4/17/19 at 11:16 AM revealed the electronic medical records on the laptop were accessible to unauthorized persons. The laptop was awake and ajar with the electronic medical records onscreen. Interview with LPN #1 on 4/17/19 at 11:19 AM confirmed the medical record laptop was ajar and awake. LPN #1 stated LPN #2, who was on break, was assigned to the cart. LPN #1 confirmed the laptop should not have been left on the medical record screen. Review of the facility policy titled HIPAA Workforce Confidentiality Acknowledgment revealed workforce is responsible for protecting the use and disclosure of all protected health information that is created, obtained, handled, learned, heard or viewed in the course of his or her work . Review of the facility employee confidentiality acknowledgement revealed Protected health information (PHI) means individually identifiable health information that is transmitted or maintained in any form. Protected health information is not available to the public. Special precautions are necessary to protect this type of information from unauthorized access, use, modification, disclosure, or destruction.

Based on interviews, record reviews and review of the facility's Baseline Care Plan policy, the facility failed to ensure that newly admitted residents and/or their responsible parties were involved in participating/development of the forty-eight (48) hour baseline care plan for 4 of 4 sampled newly admitted residents. Residents #98, #99, #100 and #106 with baseline care plans developed with no documentation to ensure the residents and/or their responsible parties were involved in the development of the baseline care plan. The findings included: The facility admitted Resident #98 on 3/14/18 with [DIAGNOSES REDACTED]. A resident interview on 4/03/18 at approximately 9:30 AM, the resident stated he/she did not remember meeting anyone within forty-eight (48) hours to develop a care plan to address his/her care plan while he/she was in the facility. A review of the paper medical record on 4/04/18 at approximately 11:02 AM revealed there was no documentation to indicate the resident and/or the responsible party was involved in the development of the baseline care plan. A review of electronic medical record on 4/04/18 at approximately 3:12 PM revealed there was no documentation to indicate the resident and/or the responsible party was involved in the development of the baseline care plan. An interview on 4/02/18 at approximately 4:02 PM with Licensed Practical Nurse (LPN)#1, revealed there was a 48 hour bedside meeting with resident and/or responsible party to discuss baseline care plan. LPN #1 stated there was no documentation to confirm the baseline care plan was addressed with the resident and/or the responsible party. The facility admitted Resident #100 on 3/20/18 with [DIAGNOSES REDACTED]. A resident interview on 4/03/18 at approximately 2:17 PM revealed the resident and/or the responsible party were not involved in the development of the baseline (48) hour care plan. The resident stated he/she did not recall having a baseline care plan meeting. A family member who was present stated he/she also did not recall being involved in the development of the baseline care plan. An interview on 4/04/18 at approximately 11:28 AM with Licensed Practical Nurse #1 revealed baseline care was done with the Minimum Data Set nurse with plans to return home. A review of the paper and electronic charting revealed there was no documentation to indicate the resident and/or responsible party was involved in the development of the baseline care plan. An interview on 4/02/18 at approximately 4:02 PM with Licensed Practical Nurse (LPN)#1, revealed there was a 48 hour bedside meeting with resident and/or responsible party to discuss baseline care plan. LPN #1 stated there was no documentation to confirm the baseline care plan was addressed with the resident and/or the responsible party. The facility admitted Resident #99 on 3/27/18 with [DIAGNOSES REDACTED]. A review of the medical record on 4/04/18 at approximately 11:16 AM revealed there was no documentation to indicate the resident and/or the responsible party was involved in the development of the base line care plan. An interview on 4/02/18 at approximately 4:02 PM with Licensed Practical Nurse (LPN)#1, revealed there was a 48 hour bedside meeting with resident and/or responsible party to discuss baseline care plan. LPN #1 stated there was no documentation to confirm the baseline care plan was addressed with the resident and/or the responsible party. The facility admitted Resident #106 on 3/17/18 with [DIAGNOSES REDACTED]. A review of the medical record revealed there was no documentation to indicate the resident and/or the responsible party was involved in the development of the forty eight (48) hour baseline care plan. An interview on 4/04//18 at approximately 11:29 with Licensed Practical Nurse (LPN) #1 reviewed the baseline care was developed but he/she had no knowledge if the resident and/or responsible party was involved in the development of the care plan. An interview on 4/02/18 at approximately 4:02 PM with Licensed Practical Nurse (LPN)#1, revealed there was a 48 hour bedside meeting with resident and/or responsible party to discuss baseline care plan. LPN #1 stated there was no documentation to confirm the baseline care plan was addressed with the resident and/or the responsible party. A review of the facility's baseline care with a revised date of (MONTH) (YEAR) revealed under #4 The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting in behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on record review and staff interview the facility failed to provide a second/consultant physician's signature for the advance directive of a resident deemed unable to exercise his/her rights and make own health care decisions for 1 of 15 sampled residents reviewed for an advance directive. The findings included: Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the comprehensive care plan, reviewed on 04/04/18 at approximately 9:00 AM, Resident #43 had multiple comorbidities and health problems, impaired communication, and established advance directives/do not resuscitate (DNR) order in place. Review of the advance directive on 04/04/18 at 09:45 AM revealed that the attending physician certified that s/he has medically examined Resident #43 and that in his/her opinion the resident is unable to exercise his/her rights and make health care decisions as a result of dementia. However, there is not a second/consultant physician's signature to concur or disagree with the attending physician recommendations. During an interview with the Director of Nursing (DON) stated that s/he was unable to produce farther information regarding resident DNR and s/h confirmed the above findings.

Based on observation, record review and staff interview the facility failed to implement care plan interventions regarding diet accommodations. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. stent placement During phase one of the survey process 0n 04/04/18 at approximately 3:15 PM, while interviewing resident #36 in his/her room in the presence of his/her daughter, the Licensed Practical Nurse (LPN) #2 came into the resident's room to administer medications. After providing medications s/he gave the resident a cup of water with a straw, the resident precedes to take medication and a few sips of water with the straw. At this point, the daughter gets up, takes the straw from the resident and tells the nurse that s/he has a physician's orders [REDACTED].#2 seems to be confused and apologetic. During an interview with daughter, right after the incident, she states that LPN #2 is not the usual nurse that takes care resident #36. She also points out that the phrase no straw is written on small white boar on the right side of the entrance of the resident's room. The daughter acknowledges that resident did well using the straw and expressed that she did not want to get the LPN in trouble. physician's orders [REDACTED]. Provide beverages in a coffee mug or small plastic tumbler. On 04/05/18 at approximately 8:30 AM review of the clinical note revealed that Resident #36 was admitted to rehab on 10/23/17 with a diet of mechanical soft and no straw. Care plan review on 04/05/18 at approximately 8:45 AM revealed that Resident #36 is at risk for altered nutrition related to variable intake of meals. According to the care plan, the goal is to maintain nutritional status without significant weight loss or gain-goal date 4/30/18. The care plan intervention includes providing diet as ordered, regular bite-sized meats and no straw. On 04/05/18 at 08:58 AM during an interview with the Director of Nursing (DON) s/he stated that LPN #2 works on an as-needed basis and that s/he should have known not to give the resident #36 a straw that s/he was probably nervous.

Based on interview and record review the facility failed to include the participation of residents, to the extent possible, in the development of the care plan for 1 of 8 residents reviewed for comprehensive care plans. Resident #45 was not invited to attend the last three care plan meetings reviewed. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #45 on 4/3/18 at approximately 9:11 AM revealed he/she did not recall attending care plan meetings nor receiving an invitation to do so. Review of care plan conference attendance sheet on 4/4/18 at approximately 2:09 PM revealed that family was invited to attend care plan meetings and had attended 2 of the previous 3 care plan meetings. The attendance sheet did not state if the resident was invited to the meeting. Interview with Registered Nurse (RN) #1 on 4/4/18 at approximately 2:46 PM revealed the resident was invited to care plan meetings and declined, but s/he stated this was not documented anywhere. RN #1 stated the resident was not his/her own Power of Attorney. Review of resident's chart on 4/5/18 at approximately 9:17 AM revealed signed his/her own Notice of Medicare Non-Coverage, requested a Do Not Resuscitate, and signed the DNR. Review of policy on 4/5/18 at approximately 9:27 AM revealed it was facility policy that Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care.

Based on observation, record review and staff interview the facility failed to execute physician's order regarding the use of straw and beverageware for one of two sampled residents reviewed for nutrition. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. stent placement During phase one of the survey process 0n 04/04/18 at approximately 3:15 PM, while interviewing resident #36 in his/her room in the present of his/her daughter, the Licensed Practical Nurse (LPN) #2 came into the resident's room to administer medications. After providing medications s/he gave the resident a cup of water with a straw, the resident precedes to take medication and a few sips of water with the straw. At this point, the daughter gets up, takes the straw from the resident and tells the nurse that s/he has a physician's order of no straw. The LPN #2 seems to be confused and apologetic. During an interview with daughter, right after the incident, she states that LPN #2 is not the usual nurse that takes care resident #36. She also points out that the phrase no straw is written on small white boar on the right side of the entrance of the resident's room. The daughter acknowledges that resident did well using the straw and expressed that she did not want to get the LPN in trouble. Physician's order review 04/04/18 at 04:53 PM revealed that on 10/26/18 the physician clarified order to include regular diet, bite-size meats, No straw. Provide beverages in a coffee mug or small plastic tumbler. On 04/05/18 at approximately 8:30 AM review of the clinical note revealed that Resident #36 was admitted to rehab on 10/23/17 with a diet of mechanical soft and no straw. Care plan review on 04/05/18 at approximately 8:45 AM revealed that Resident #36 is at risk for altered nutrition related to variable intake of meals. According to the care plan, the goal is to maintain nutritional status without significant weight loss or gain-goal date 4/30/18. The care plan intervention includes providing diet as ordered, regular bite-sized meats and no straw. On 04/05/18 at 08:58 AM during an interview with the Director of Nursing (DON) s/he stated that LPN #2 works on an as-needed basis and that s/he should have known not to give the resident #36 a straw that s/he was probably nervous.

Based on record review and interviews, the facility failed to document whether medically related social services were provided at least quarterly for 1 of 5 sampled residents reviewed for unnecessary medications which included [MEDICAL CONDITION] medications. Resident #18's medical record indicated the last noted social services note was dated 8/24/17. The findings included: The facility admitted Resident #18 on 11/15/16 with [DIAGNOSES REDACTED]. A review of the medical record on 4/04/18 at approximately 9:42 AM revealed a social services note dated 8/24/17 that indicated social services attempted to contact Resident #18's family member for care plan meeting but unable to reach the family a number provided on the face sheet. The social services note further indicated social service will speak with resident, sitter and nursing staff to see if they have a better number. There was no additional information in the paper or electronic medical record of any additional social services notes. A physician's progress report dated 12/27/17 indicated the resident was seen monthly by psychiatric services due to depression with [MEDICAL CONDITION] disorder. The physician's progress report further indicated under family history that family history was unobtainable from any source and the resident was unable to provide the information. The report indicated family was not available and prior charts did not include family history and nursing staff was unable to provide information. An interview on 4/04/18 at approximately 4:17 PM with the Director of Nursing (DON) and Social Services Director (SSD) confirmed the findings that the only documented social services note was dated 8/24/17. The SSD further reviewed the electronic medical record and stated there was no other documented notes in the computer but he/she may have a handwritten note. The SSD on 4/04/18 at approximately 4:45 PM provided a note on a white untitled sheet of paper that indicated 2/10, in room ,glasses/walker Advance Dir?, no hospital ,no children/POA and Sitter Services daily. .

Based on record review, staff interview, and policy review, the facility failed to ensure the Physician and Dietician were notified of Resident (R) 53's significant weight loss and that the Physician was notified of the increase in the size of R91's pressure ulcer. The facility census was 67 and 29 residents were included in the stage 2 survey sample. Findings include: A review of R53's electronic health record (EHR) revealed an admission date of [DATE]. A review of the Activities of Daily Living (ADL) section of the quarterly Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) revealed R53 was dependent on staff to eat and had had a significant weight loss of either 5% in the last month or 10% in the last 6 months. A review of R 53's weights recorded in the EHR revealed monthly weights on 11/24/16 of 94 pounds and 12/28/16 of 89 pounds, a >5% weight loss. R53's weight on 1/2/17 was 90 pounds and on 2/2/17 was 91 pounds. A review of the Clinical Notes - Dietary Notes in R53's EHR back to 11/8/16 did not reveal notes authored by the Registered Dietician (RD). The last Nutrition Risk Evaluation in the EHR was on 10/2/16 authored by the Certified Dietary Manager (CDM). revealed the last Registered Dietician note in the EHR was dated 10/28/14. A review of the Clinical Note - Nursing Note dated 1/3/17 in R53's EHR, written by a Licensed Practical Nurse (LPN) 1 at 7:35 a.m., noted .Residents' weight was 99lb on 1/2/17 and 98lb on 12/28/16 She is on a Regular diet, mechanical soft meats with thin liquids. On 1/5/17 at 12:20 p.m., LPN2 charted Staff noticed resident's physical condition is declining and barely weight bearing. Notified NP (Nurse Practitioner) and PT (physical therapy) eval (evaluation) and treatment order given. A note by LPN1 on 1/10/17 at 2:45 a.m. stated .Residents' weight was 99lb on 1/2/17, and 98lb on 12/28/16 She is on Regular diet, Mechanical soft meats with thin liquids. In an interview on 2/9/17 at 8:30 a.m. the CDM stated R53 had not been reviewed since the 1/1/17 MDS assessment and provided the last Registered Dietician Clinical Note - Dietary Note was dated 10/28/14. In an interview on 2/9/17 at 3:55 p.m. the Director of Nursing stated there was no documentation that the physician had been notified of R53's weight loss. When asked about the last RD note date, the DON rhetorically questioned if residents shouldn't be reviewed more often than that. A review of the facility provided policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2012, stated: Assessment and Recognition: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month - 5% weight loss is significant; great than 5% is severe . 4. The Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition . The facility provided policy Weight Assessment and Intervention, revised September 2008, stated . 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification.

Based on observation, record review, staff and family interview, the facility failed to ensure the bathing care plan for Resident (R) 91 was followed. The facility census was 67 and 29 residents were included in the stage two survey sample. Findings included: A review of R91's electronic health record (EHR) revealed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. A review of R91's medications revealed a physician's orders [REDACTED]. In an interview on 2/8/17 at 12:25 p.m. Registered Nurse (RN)3 stated R91 has anxiety and agitation with showers as she does not like to be touched. Observation of R91 on 2/6/17 at 2:19 p.m. and 3:56 p.m. revealed she was asleep in bed. Observation of R91 on 2/8/17 at 11:10 a.m. showed the resident asleep in a geriatric chair near the nurses' station. A review of R91's care plan revealed a problem of (R91) has a self-care deficit: bed mobility, dressing, feeding, toileting, transfers, locomotion on/off unit. The care plan goal was (R91) will remain clean, dry, odor free, and maintain a neat appearance daily during the next 90-day review period. The interventions to attain this goal included (R91) prefers no showers or baths and will wash at sink or have bed bath as needed. The intervention was listed as Status: Active (Current). In an interview on 2/9/17 at 3:45 p.m. R91's daughter commented that everyone stays away on the days R91 receives showers because she is so sleepy - that family only visits on non-shower days. In an interview on 2/9/17 at 6:30 p.m. the Director of Nursing stated an expectation that care planned preferences for bathing would be followed.