Every finding on record at Seneca Place

Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care for 1 of 5 residents (Resident (R) 3) reviewed for activities of daily living (ADL) care. Specifically, the facility failed to regularly trim or clean Resident #3's fingernails. Review of facility policy, Activities of Daily Living (ADLs), dated 01/02/2024, indicated, 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of facility policy, Interdisciplinary Team (IDT) Risk Review Meeting, dated 01/02/2024, indicated, 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Review of facility admission Record revealed the facility admitted Resident #3 on 06/22/2023 with diagnoses including cerebrovascular disease affecting the left non-dominant side, cerebral infarction (ischemic stroke), and cerebral palsy. Other diagnoses included type 2 diabetes mellitus, vascular dementia, generalized muscle weakness, and contractures of the left elbow, right hand, and left hand. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2025, revealed the facility assessed Resident #3 with a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident did not reject evaluation or care, such as ADL assistance, that was necessary to achieve their goals for health and well-being. The MDS further indicated Resident #3 had functional limitations in range of motion with impairment of both upper extremities and was dependent on staff to maintain personal hygiene. Review of Resident #3's Care Plan Report included a focus area, initiated 06/22/2023, that indicated the resident needed ADL assistance related to cerebrovascular accident with left hemiplegia (paralysis) and cerebral palsy. Interventions directed staff to check the resident's nail length, and trim and clean them on bath day and as necessary (initiated 06/23/2023). An observation and interview, on 07/02/2025 at 9:10 AM, revealed Resident #3 had long, dirty fingernails that extended approximately one centimeter beyond their fingertips. There was a brownish-gray substance noted under the resident's fingernails. During interview Resident #3 stated they wanted their fingernails trimmed, but only the nurses could do that. An observation on 07/02/2025 at 11:16 AM revealed Resident #3's fingernails remained long and dirty and still extended at least one centimeter beyond their fingertips. There was blackish-grey and brown material underneath the resident's fingernails, and some of their left-hand fingernails had jagged edges. During an interview on 07/02/2025 at 1:18 PM, Registered Nurse (RN) #1 stated only nurses or a podiatrist could cut Resident #3's fingernails because the resident was diabetic. RN #1 stated that he did not remember the last time he cut the resident's nails. During an interview on 07/02/2025 at 1:28 PM, RN #2 stated only the podiatrist could cut Resident #3's fingernails, and the podiatrist only came to the facility once a month. During an interview on 07/02/2025 at 1:39 PM, Licensed Practical Nurse (LPN) #3 stated nurse aides were expected to perform ADL care for residents, including clipping fingernails. She stated if a resident was diabetic, only nurses clipped that resident's fingernails. LPN #3 stated it was not necessary for a podiatrist to provide fingernail care because they provided only toenail care. During an interview on 07/03/2025 at 2:00 PM, LPN #3 confirmed that, when she observed Resident #3's fingernails the prior day, they were long and needed to be trimmed. She acknowledged the resident did not refuse care when she offered to cut their nails. During an interview on 07/03/2025 at 12:10 PM, the Executive Director stated nail care was to be completed as needed for residents. During an interview on 07/04/2025 at 10:06 AM, the Director of Nursing (DON) stated residents' nail care should be done with every shower and between showers as needed. The DON said if a resident had diabetes, nurses could still do diabetic fingernail care. She stated nurses did not give showers, but they had the shower schedule, and nurse aides turned in shower sheets to the nurses after completing residents' showers. The DON stated if a resident was diabetic the nurse would know that a shower had been performed, and the nurse should check the resident's nails at that time. The DON stated it was not an expectation that nurse aides had to remind nurses to perform nail care for diabetic residents.

Based on interview, record review, and review of facility documents and policy, the facility failed to resolve a grievance related to a missing item in a timely manner for 1 of 3 residents (Resident (R) 83) reviewed for personal property. The findings included: Review of facility policy, Grievances, effective 10/01/2024, revealed 3. Definitions ‘Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The policy specified, G. In accordance with the resident's/patient's right to obtain a written decision regarding the grievance, the Grievance Official will issue a written decision on the grievance to the resident/patient or representative at the conclusion of the investigation. The written decision will include at a minimum the date received, steps taken to investigate, summary of findings, statement of confirmation or non-confirmation, corrective actions, and the date of decision. Review of facility admission Record revealed the facility admitted Resident #83 on 09/23/2024. According to the admission Record, the resident had a medical history that included a diagnosis of moderate, recurrent, major depressive disorder. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2025, revealed Resident #83 had adequate hearing, clear speech, was able to express their ideas and wants, and had clear comprehension. The MDS revealed the facility assessed Resident #83 with a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Review of Resident #83's Care Plan Report included a focus area, initiated on 12/20/2024, that indicated the resident exhibited signs of cognitive impairment related to their BIMS score. Interventions directed staff to encourage and support the resident's family to bring in familiar items that the resident recognized to promote security in the environment (initiated 12/20/2024). Review of facility form, Inventory of Resident's Belongings, dated 09/24/2024, revealed Resident #83's list of personal belongings included a cell phone. Review of facility document, Report of Concern, dated 10/18/2024, revealed Family Member (FM) #6 filed a grievance regarding Resident #83's missing cell phone. A Report of Concern section titled, Follow Up/Resolution, indicated, Corrective Action Taken: Conduct facility search. Family refused to have phone replaced. The report indicated the grievance was confirmed and status of Resolved/Satisfied. The Report of Concern revealed the complainant was notified on 10/18/2024, but there was no signature for the complainant or the resident to validate notification. The report was signed off on 10/19/2024 by responsible staff, namely the Social Services Director (SSD). During a telephone interview on 07/02/2025 at 1:59 PM, FM #6 stated Resident #83 had a cell phone on admission to the facility, but it disappeared. FM #6 stated they purchased another cell phone for Resident #83, which cost $800.00, and that one also went missing. FM #6 stated $345.00 was still owed on the resident's first phone, so the family provided Resident #83 with another family member's old phone. FM #6 confirmed they spoke with the SSD regarding the missing cell phone but stated the SSD did nothing and acted like she did not care. During an interview on 07/03/2025 at 11:07 AM, the SSD stated she recalled Resident #83 reported a missing cell phone charger the prior year, and it was immediately replaced. The SSD stated she was not aware of a missing cell phone. During a follow up telephone interview on 07/03/2025 at 11:36 AM, the facility's documentation of satisfactory grievance resolution was discussed with FM #6. FM #6 repeated that they told the facility about the missing phone and nothing was done about it. FM #6 denied they had any conversations with the facility regarding a resolution of the grievance and stated they would never have refused an offer to replace the cell phone. During a follow up interview on 07/04/2025 at 10:43 AM, the SSD recalled she spoke with Resident #83's family member regarding the missing cell phone, but the family member refused the facility's offer to replace the cell phone. During an interview on 07/04/2025 at 10:45 AM, the Director of Nursing (DON) stated she was aware Resident #83's phone was missing, noting it was discussed by the team. The DON stated her expectation was that the facility's policy would be followed, and there should be documentation such as a signature from the resident's family member to acknowledge or approve the facility's grievance resolution. During an interview on 07/04/2025 at 11:10 AM, the Executive Director (ED) stated that all grievances should be filed, reviewed, and followed up with a resolution. The ED confirmed the person who filed a grievance should sign off as acknowledgement or agreement regarding the resolution.

Based on observation, interview, record review, review of facility signage, and review of facility policy, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident (R) 8) investigated for enhanced barrier precautions. The findings include: Review of the facility policy, Enhanced Barrier Precautions not dated, revealed the facility was to implement enhanced barrier precautions to prevent the transmission of multidrug resistant organisms. Further review revealed all staff were to comply with designated precautions, including wearing personal protective equipment (PPE) while dressing a resident or while changing resident linens. Continued review revealed residents with chronic wounds, such as pressure ulcers, were to be placed in enhanced barrier precautions. Review of the facility signage, Enhanced Barrier Precautions, not dated, posted outside R8's room revealed staff were to don PPE, including gown and gloves, before performing high-contact resident care activities, including changing resident linens and assisting the resident with getting dressed. Review of R8's Admission Record revealed the facility admitted the resident on 12/03/2022 with diagnoses including Parkinson's disease, protein calorie malnutrition, and adult failure to thrive. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/2024, revealed the facility was unable to conduct a Brief Interview for Mental Status (BIMS), as the resident never or rarely made herself understood. Further review revealed the staff assessed R8's cognitive skills as moderately impaired, with short and long-term memory problems noted. Continued review revealed the facility assessed R8 as having a Stage 4 pressure ulcer that was not present on admission. Review of R8's Care Plan, dated 07/26/2024 revealed the facility included enhanced barrier precautions as an intervention for the focus area for impaired skin integrity and stage 4 pressure wound on the resident's sacrum. Observation on 01/14/2025 at 3:06 PM revealed State Registered Nurse Aide (SRNA)1 failed to don a gown when she repositioned R8. Further observation revealed SRNA1 continued to provide high-contact care, including changing R8's clothes and linens, while SRNA1 was not wearing a gown. In an interview on 01/14/2025 at 3:11 PM, SRNA1 stated she should have worn a gown while providing care for R8, but she forgot to check the sign posted outside R8's door. In an interview on 01/16/2025 at 3:02 PM, the Assistant Director of Nursing (ADON) stated her expectations for staff caring for a resident in enhanced barrier precautions (EBP) were for the staff members to follow the signage posted outside the resident's room and don a gown and gloves when performing high-contact care. In an interview on 01/17/2025 at 10:02 AM, the Director of Nursing (DON) stated her expectations were for staff to wear a gown and gloves when providing direct patient care for residents with wounds. She further stated this was important to protect residents and staff from the spread of pathogens. In an interview on 01/17/2025 at 11:11 AM, the Administrator stated her expectations were for staff to follow the facility policy on enhanced barrier precautions. She further stated staff were to wear PPE, including gowns and gloves with high-contact care, such as changing linens.

Based on observation, interview, record review, and facility policy review, 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 (2) of twenty-three (23) sampled residents (Residents #22 and #69). Observation revealed Enhanced Barrier Precautions (EBP) signage outside Resident #22's room with guidance for staff; however, a Registered Nurse (RN) was observed to enter the resident's room without donning the appropriate Personal Protective Equipment (PPE) and provide wound care for him/her. Additionally, observation revealed no PPE located outside the resident's door as per the facility's policy. Observation revealed Resident #69 was on Enhanced Barrier Precautions (EBP) related to having an indwelling medical device (gastrostomy tube). However, on 02/07/2024, a facility staff member was observed providing personal hygiene care for Resident #69 without her Personal Protective Equipment fully donned, which allowed the staff member's clothing to come into contact with Resident #69's bed linens. The findings include: Review of the facility policy titled, Enhanced Barrier Precautions, dated 2023, revealed the policy was to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). Per review, Enhanced barrier precautions refer to the use of gown and gloves, or Personal Protective Equipment (PPE) for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Continued policy review revealed when EBP were implemented, gowns and gloves were to be available immediately outside of the resident's room. Additionally, further review revealed high-contact resident care activities included wound care of any skin opening requiring a dressing, providing hygiene, changing briefs, or assisting with toileting. 1. Review of Resident #22's Electronic Health Record (EHR) revealed the facility admitted the resident, initially on 07/07/2023, with last readmitted on 11/30/2023. Continued review of the EHR revealed the facility admitted Resident #22 with diagnoses which included: Osteomyelitis, right ankle, and foot; Cerebral Infarction due to Embolism; Diabetes Mellitus due to underlying condition with foot ulcer; and Cellulitis of right lower limb. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #22 dated 12/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), which indicated he/she had severe cognitive impairment and was not interviewable. Observation on 02/03/2024 at 9:30 PM, revealed signage outside Resident #22's room noting the resident was on Enhanced Barrier Precautions (EBP) due to wounds, with guidance for staff. Continued observation revealed Registered Nurse (RN) #2 was in Resident #22's room, with the door slightly ajar which allowed observation of RN #2 performing wound care for Resident #22's feet. Observation revealed however, RN #2 did not don a gown as required for EBP. Observation of B Hall, where Resident #22 resided, on 02/04/2024 and on 02/08/2024, at various times revealed no visual evidence of personal protective equipment (PPE) located outside of Resident #22's door. In addition, observation further revealed only one (1) bin had been placed in the B hallway. In interview with RN #2, on 02/03/2024 at 9:30 PM, he stated he was a new RN since 10/2023. He stated he had provided wound care for Resident #22 and had forgotten to wear a gown as required. RN #2 stated there could be potential for harm for Resident #22 if staff were not following the requirements for someone on EBP. Additionally, he stated possible outcomes from not following the EBP requirements could include the spread of germs to others or cause infections, or cause residents to get sick. 2. Review of the Admission Record, printed 02/09/2024, for Resident #69 revealed the facility admitted the resident on 03/09/2021, with diagnoses that included gastrostomy tube (indwelling medical device); Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side; contracture of muscle of the right hand; and generalized muscle weakness. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #69 to have impairment on one (1) side of of his/her upper extremity causing functional limitation in range of motion of shoulder, elbow, wrist, and hand. Further MDS review revealed the facility assessed Resident #69 as dependent on facility staff for personal hygiene. Review of Resident #69's Comprehensive Care Plan, revealed the facility care planned the resident as at risk for falls related to balance problems related to cardiovascular accident (CVA) with right Hemiplegia. Further review of the CCP revealed an intervention the facility initiated on 05/05/2023, for staff to assist Resident #22 with his/her toileting/incontinence care. Observation on 02/03/2024 at 8:33 PM, revealed EBP signage on the door of Resident #69's room. Continued observation revealed the resident was lying on his/her bed, with a tubefeeding pump and tubing connected to a bottle of tubefeeding and to the resident via his/her gastrostomy tube (g-tube). Further observation revealed the tubefeeding pump was running, Observation on 02/07/2024 at 10:09 AM, revealed State Registered Nurse Aide (SRNA) #12 donned PPE which included a gown and gloves in preparation to enter Resident #69's room to provide personal hygiene care for the resident. Continued observation revealed SRNA #12 knocked on the door and entered the resident's room. The State Survey Agency (SSA) Surveyor then, with permission from SRNA #12, also entered Resident #69's room. Further observation revealed SRNA #12's PPE gown was not tied in the back and her gown fell down over her shoulder in front exposing the right side of the SRNA's uniform top and pants. In addition, observation further revealed SRNA #12's uniform clothing touched Resident #69's bed while she was giving Resident #69 a bed bath. Observation further revealed SRNA #12's right side of her uniform top and pants continued to come into contact with the right side of Resident #69's bedsheets. During an interview, on 02/07/2024 at 10:36 AM, SRNA #12 stated her gown should have been tied in back; however, she stated she had trouble reaching around behind her and that's why she had not tied the gown. SRNA #12 stated when using the green PPE gowns she had to tie it in back first and then put the gown over her head. Observation, on 02/07/2024 at 10:51 AM, revealed SRNA #1 exited a resident's room, walked down hallway past three (3) other residents' rooms to reach the bin containing PPE. Continued observation revealed SRNA #1 retrieved PPE from the bin, and returned to the resident's room where she had been providing care, which required her to walk back down the hallway and past the three (3) other residents' rooms. During an interview, on 02/07/2024 at 10:56 AM, SRNA #1 stated walking past three (3) residents' rooms twice to get the required PPE made her feel like it was a whole lot of extra work. In an interview with the DON, on 02/09/2024 at 7:00 PM, she stated her expectation was for nurses and SRNA's providing resident care to follow the facility's guidance and wear gloves and gowns when residents were on EBP. Additionally, she stated if nursing staff were not following the facility's guidance provided for EBP, residents could experience potential harm through staff carrying germs or other bacteria from other residents' rooms. In an interview with the Administrator, on 02/09/2024 at 8:15 PM, she stated her expectations were for nursing staff to follow physicians' orders and the facility's EBP guidelines when completing care for residents. She further stated EBP guidelines were provided for protection of staff as well as the safety of all residents. 47567

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicated otherwise for one (1) of twenty-three (23) sampled residents, (Resident #22) who had exceeded a twelve (12) percent weight loss in sixty-seven (67) days. The findings include: Review of the facility policy titled, Nutritional Management, dated 2023, revealed the facility was to provide care and services to each resident to ensure the residents maintained acceptable parameters of nutritional status in the context of his or her overall condition. Continued review revealed a systematic approach was used to optimize each resident's nutritional status. Further review revealed optimizing the residents' nutritional status included: identifying and assessing each resident's nutritional status and risk factors; evaluating and analyzing the assessment information; developing and consistently implementing pertinent approaches; and monitoring the effectiveness of interventions and revising them as necessary. Review of Resident #22's Electronic Health Record (EHR) revealed the facility admitted the resident, initially on 07/07/2023, with a last readmitted [DATE], with diagnoses of: acute Osteomyelitis, right ankle and foot; Diabetes Mellitus; foot ulcer; Cellulitis of right lower limb; and Cerebral Infarction due to Embolism of left middle cerebral artery. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #22, dated 12/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15) which indicated he/she was severely cognitively impaired and not interviewable. Review of the facility's weights and vitals summary for Resident #22, dated 12/03/2023, revealed the resident weighed 191.5 pounds (lbs) and on 02/08/2024, the resident was noted to weigh 168 lbs. (Which was calculated as a -12.27 percent weight loss). Review of the facility's documented nutrition intake for Resident #22, for the time period of 12/01/2024 through 02/06/2024, revealed the percentages of the resident's meals noted as eaten per occurrence: was 0-25% for eight (8) meals; 26-50% for twenty (20) meals; 51-75% for thirty-five (35) meal times; 76-100% occurred for one hundred and twenty (120) meals. In addition, review of the nutrition intake documented for Resident #22 revealed the resident noted to have refused meals two (2) times, and not applicable documented for three (3) meal times. Review of Resident #22's physician's orders initiated on 12/08/2023, with a start date of 12/08/2023, revealed orders for a Consistent Carbohydrate Diet (CCD) and 2 Gram sodium (salt) diet with Dysphagia pureed texture, regular (None/Thin) consistency, for his/her diet. Continued review revealed the orders included for Resident #22 to have double portions. Per review of the physician's orders, Resident #22 had orders initiated on 12/14/2023 with start date of 12/15/2023 for multi-vitamin/minerals supplement, one (1) tablet to be administered by mouth one (1)time a day. Further review revealed physician's orders dated 12/15/2023, with a start date on 12/16/2023, for Glucerna supplements twice a day at 240 cc. Continued review of Resident #22's physician's orders revealed an order dated 01/18/2024 with start date of 01/18/2024, for Mirtazapine (an antidepressant medication with a side effect of weight gain) oral tablet 7.5 mg, one (1) tablet by mouth at bedtime for weight. Review of Resident #22's comprehensive care plan revealed the facility care planned the resident for potential/actual weight loss with interventions. Continued review revealed Resident #22's care plan was updated to reflect the physician's orders for the dates of 12/08/2023, 12/14/2023, 12/15/2023, and 12/18/2023. Observation of Resident #22 on 02/04/2024 at 12:45 PM, revealed State Registered Nurse Aide (SRNA) #4 was talking to and feeding the resident. Continued observation revealed SRNA #4 continually asked Resident #22 if he/she was still hungry or was finished eating. Further observation revealed Resident #22 was drowsy and did not continue to eat. In an interview with SRNA #4, on 02/08/2024 at 1:30 PM, she stated Resident #22 needed feeding assistance, and she had to report the resident's food intake at every meal, and document the results in the Kardex (SRNA care plan). She stated when Resident #22 did not want anything to eat she reported that to the nurse. SRNA #4 stated whenever Resident #22 did not want to eat what was provided she offered the resident something else to eat. She stated Resident #22 loved to eat breakfast, sometimes skipped lunch; however, usually ate his/her dinner meal. SRNA #4 stated when she assisted Resident #22 with eating, the resident was able to express when he/she was full. She further stated Resident #22 was a weekly weight and resident's weights were conducted by two (2) SRNAs with the use of the mechanical lift. Observation of Resident #22, on 02/08/2024 at 1:45 PM, revealed SRNA #4 and SRNA #10 were operating the mechanical lift to obtain the resident's current weight. Continued observation revealed revealed SRNA #10 removed the resident's boots to obtain an accurate weight. Per observation, the first attempted weight was 168 lbs and SRNA #4 questioned Resident #22's weight loss from Tuesday to Thursday, so she performed second weight which was 168.1. Further observation revealed the SRNAs obtained a third weight for Resident #22 which was 167.1 lbs. In addition, SRNA #4 noted Resident #22's weight on 02/06/2024, had been 173 lbs per the SRNA's list of weekly weights. Review of Resident #22's EHR revealed the facility's Interdisciplinary Team (IDT) risk review dated 01/24/2024, noted the resident's orders for 7.5 mg Mirtazapine, and 240 ml Glucerna twice daily were in place, and the resident's intake averaged 50%. Continued review revealed Resident #22's double meal portions for his/her meal intakes appeared to usually be 51-100%. Per review, Resident #22 was to continue on the facility's Nutrition at Risk (NAR) program due to his/her previous weight loss with no recommendations; however,consultations with the Registered Dietician (RD) as necessary (PRN) was noted. Additionally, review of the IDT risk review, revealed the IDT members in attendance for the review were the RD and Assistant Director of Nursing (ADON). Additional review of Resident #22's EHR revealed a progress note dated 01/24/2024, revealed the resident was discussed in the weekly NAR meeting and had experienced a one (1) pound weight loss. Further review of the progress note revealed no new RD recommendations were noted at that time; however, staff were to continue to assist Resident #22 with his/her meals. Observation of Resident #22 on 02/09/2024 at 1:21 PM, revealed SRNA #14 assisted the resident with eating his/her lunch meal, of pureed sweet potatoes, pureed meat with gravy, ice cream, and tea. Continued observation revealed SRNA #14 sat with Resident #22, feeding him/her the food, and asking between each bite if he/she was ready for more or was he/she still hungry. Further observation revealed Resident #22 ate all items on the plate and drank all of the tea and some water. In an interview with the Nurse Practitioner (NP) on 02/09/2024 at 6:15 PM, she stated the RD monitored residents' weight loss and added them to the IDT risk review list. She stated she did not recall if she had been notified of Resident 22's weight loss, but stated either the DON or RD made her aware when recommendations were made. She stated when she received the recommendations as orders she signed off on the orders. The NP further stated the RD sometimes recommended an appetite stimulant such as Mirtazapine that helped increase the resident's appetite. In an interview with DON, on 02/09/2024 at 7:00 PM, she stated Resident #22 was in the facility's NAR program. She stated the SRNAs were asked about residents' meal intakes and the RD tracked the residents' weights. The DON stated the SRNAs were to report any concerns with residents who had not eaten or consumed very little of their meals. She stated if Resident #22 had orders to receive a Glucerna supplement she expected staff to follow the physicians orders. The DON stated when Resident #22 received the Glucerna as per the physician's orders, that information was to be tracked in the resident's EHR on the date he/she received the supplement. She stated Resident #22 had a State Guardian who had been made aware of the weight concerns regarding the resident, and the interventions being implemented. The DON further stated the State Guardian was trying to initiate palliative care for Resident #22 because of his/her decreasing weight loss, severity of his/her wounds, and decreased mental status. In an interview with the Administrator, on 02/09/2024 at 8:15 PM, she stated the IDT met to discuss the residents on the NAR list. She stated they looked at residents' weights, and obtained the residents' weight for four (4) weeks, or longer if needed. The Administrator stated the IDT tried to determine what could be done to help a resident to gain weight, which could include protein supplements, vitamins, and/or increased food intake. She stated the Dietician helped tremendously by making recommendations such as when it would be appropriate to consider gastrostomy tube (g-tube) placement. The Administrator stated there was ongoing discussion with Resident #22's State Guardian, state nurses and doctors with the IDT team to determine if palliative care was the best option due to the resident's co-morbidities and wounds. She stated oversight to ensure interventions were put into place and carried out had been completed by conducting rounds. The Administrator further stated depending on what the concern was related to and what interventions had been implemented, administrative staff could better ensure those interventions were in place, and the processes were being followed by all staff.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for one (1) of twenty-three (23) sampled residents (Resident #79). Resident #79 had outpatient surgery on 01/22/2024, to change his/her gastrostomy tube (g-tube) to a jejunostomy tube. However, upon return to the facility after the outpatient surgery, the facility failed to revise Resident #79's care plan to reflect the changes in his/her feeding tube. The findings include: Review of the facility policy titled, Care Plan Revisions Upon Status Change undated, revealed the purpose of the policy was to provide a consistent process for reviewing and revising the care plan for residents experiencing a status change. Further review revealed the Minimum Data Set (MDS) Coordinator and the Interdisciplinary Team (IDT) were to discuss the resident's condition and collaborate on intervention options. In addition, the care plan was to be updated with new or modified interventions. Review of the Admission record for Resident #79 revealed the facility admitted the resident on 05/24/2023, with diagnoses that included Dysphagia (inability to swallow) following a Cerebrovascular Accident, Gastrostomy tube placement, Acute Respiratory Failure with Hypoxia, and aspiration. Review of Resident #79's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of (00) which indicated severe cognitive impairment. Review of Resident #79's medical record revealed since his/her original admission on 03/22/2023, the resident experienced three (3) hospitalization s. Per review, those hospitalization s were: on 06/23/2023 for aspiration pneumonia; on 08/24/2023 after sustaining a fall; and on 11/30/2023 for aspiration Pneumonia. Continued record review revealed on 01/22/2024, Resident #79 had an outpatient procedure performed to replace his/her g-tube (a feeding tube in the stomach) for a jejunostomy tube (a feeding tube inserted into the small intestine). Review of Resident #79's Care Plan revealed no documented evidence the facility revised the care plan regarding the resident's g-tube being changed to a jejunostomy tube on 01/22/2024. Review of Resident #79's Care Plan revealed a focus initiated on 03/22/2023, for the resident as at risk for complications due to his/her Dysphagia diagnosis and being on tube feeding, and being NPO (nothing by mouth). Per review of the focus related to the resident's risk for complications, revealed the goal was for the resident to remain free of complications related to tube feeding. Continued review revealed the focus was revised on 07/05/2023, to include Resident #79's being on bolus g-tube feedings which had been started on 06/27/2023. Further review revealed the care plan interventions included: checking for tube placement and gastric contents/residual volume per the facility's protocol; recording and documenting abnormal findings and notifying the physician; elevating the head of his/her bed during and for thirty (30) minutes after administering his/her tube feeding; providing local care to the g-tube site as ordered; and observing for signs or symptoms of infection. Review of Resident #79's Physician Orders dated 01/22/2024, revealed the current orders for the resident's Jejunostomy tube (enteral) feeding order. Continued review revealed Resident #79 was to receive Two Cal 2.0 (a nutritionally complete, high-calorie formula) at thirty (30) milliliters (mls) per hour continuously tor a total volume of 720 mls over twenty-four (24) hours. During an interview on 02/09/2024 at 7:30 PM, the Resident Assessment Instrument (RAI) Coordinator stated the facility had recently hired two (2) new MDS who were in training at that time. She stated the purpose of residents' Care Plans was to guide staff in caring for the resident and his/her needs. The RAI Coordinator stated the admitting nurse was responsible for initiating a new resident's baseline care plan. She stated the baseline care plan was to be generated within the first forty-eight (48) hours of the new resident's admission. The RAI Coordinator stated if revisions were required with order changes, functional changes, or any other change the Unit Managers (UM), Floor Nurses, Executive Director (ED) and/or Director of Nursing (DON) could update the resident's Care Plan. She stated although it was usually the Unit Manager or the Assistant Director of Nursing (ADON) who revised residents' Care Plans. The RAI Coordinator stated the expectations were for residents' Care Plans to be revised as quickly as possible; however, she stated a resident's care plan did not direct his/her care it was only a guide. She further stated staff should always look at the resident's Kardex and orders, and any communicate any changes during the shift change report. In addition, the RAI Coordinator stated if a resident's Care Plan was not revised with necessary interventions incidents could occur. She further stated that the care plan should have been revised and updated with the changes for Resident #79 in order to provide appropriate treatment. During an interview with the Executive Director (ED) on 02/09/2024 at 7:50 PM, she stated her expectation was for care plans to be revised as soon as possible when necessary, to ensure appropriate care was provided to meet the residents' needs. The ED further stated that Resident #79's care plan should have been updated as soon as possible with the changes in the resident's status. During an interview with the DON on 02/09/2024 at 9:15 PM, she stated her expectation was care plans to be updated/revised as soon as possible when necessary to direct the care being provided to meet the residents' needs. She stated revisions to care plans were completed during the facility's morning meetings after reviewing residents' order changes. The DON stated oversight was provided by checking charts for necessary revisions/updates to residents' care plans by the Interdisciplinary Team (IDT) members during their meetings. She further stated the IDT members included herself, the ED, ADON, the Registered Dietician (RD), Unit Managers (UM), MDS staff, and therapy department staff. The DON further stated Resident #79's care plan should have been updated with changes immediately following the resident's change in status.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for one (1) of twenty-three (23) sampled residents, Resident #69. The facility initiated a care plan intervention to keep a touch call light within Resident #69's reach; however, observation revealed the resident had a push-button call light. The findings include: Review of the policy titled, Comprehensive Care Plans, undated, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident which was consistent with resident rights. Continued review revealed residents' comprehensive person-centered care plans that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the resident's comprehensive assessment. Further review revealed the comprehensive care plan was to describe, at a minimum, the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the policy titled, Call Lights: Accessibility and Timely Response, undated, revealed the policy's purpose was to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Per review, each resident was to be evaluated for his/her unique needs and preferences to determine any special accommodations that might be needed in order for the resident to utilize the call system. Continued review revealed special accommodations were to be identified on the resident's person-centered plan of care and provided accordingly. (Examples included: touchpads, larger buttons, bright colors, etc.) Further interview revealed staff were to ensure the call light was within reach of the resident and secured, as needed. Review of the Admission Record, for Resident #69, printed 02/09/2024, revealed the facility admitted the resident on 03/09/2021, with diagnoses that included Hemiplegia (paralysis of one [1] side of the body) and Hemiparesis (partial weakness of one [1] side of the body) following a cerebral infarction affecting right dominant side, contracture of muscle in the right hand, and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/17/2023, revealed the facility assessed Resident #69 to have no score on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was rarely/never understood. Additionally, the facility assessed Resident #69 to have impairment on one (1) side of his/her body with functional limitation in range of motion of the upper extremity (shoulder, elbow, wrist, hand). Review of Resident #69's Comprehensive Care Plan revealed the facility care planned the resident as at risk for falls related to balance problems due to the cardiovascular accident (CVA) which resulted in right Hemiplegia. Further review revealed an intervention the facility initiated on 03/24/2021, for Resident #69 to have a touch call light (a sensitive touchpad which gave residents with limited movement the ability to summon help). Observation, on 02/07/2024 at 3:20 PM, revealed Resident #69 had a regular push-button type of call light which Licensed Practical Nurse (LPN) #1 handed to the resident and asked him/her to push to alert staff. Continued observation revealed Resident #69 wrapped his/her left fingers, thumb, and palm around the shaft of the push button call light device and squeezed with his/her left hand. However, further observation revealed Resident #69 did not touch or push the red button on the end of the call light device, therefore the resident's call light did not activate. During an interview, on 2/07/2024 at 3:24 PM, LPN #1 stated if Resident #69 was moaning he knew the resident needed something. LPN #1 then stated Resident #69 needed a touchpad call light, which came from the maintenance department. He stated he would tell maintenance to put in an order for a touchpad call light for Resident #69. During an interview, on 02/09/2024 at 7:36 PM, the Regional Resident Assessment Instrument (RAI) Coordinator stated lots of work went into residents' care plans. Per the Regional RAI Coordinator, the care plan was to provide guidance for staff regarding the care needs and problems of the resident. The Regional RAI Coordinator further stated a possible outcome for a resident whose care plan was not implemented would be for the resident to have an unmet need. During an interview, on 02/07/2024 at 3:42 PM, the Maintenance Manager (MM) stated if someone needed a call light staff could tell us, and maintenance would get one (1) immediately. The MM searched the facility's electronic maintenance system records and stated no work order had been placed in the electronic maintenance system for Resident #69 to receive a touchpad call light. The MM stated no one had notified the maintenance department of Resident #69's need for a touchpad call light. During further interview the MM stated the maintenance department did not make the call on who gets a touchpad call light, nursing or management must tell us to supply a resident with a call light. The MM further stated, I did have one touchpad in stock, and just handed it out for Resident #69's use. In addition, the MM stated more touchpads were on order. During an interview, on 02/09/2024 at 6:21 PM, the DON stated it was the facility's expectation all call lights to be within a resident's reach. The DON stated for residents who had weaknesses and were not able to push the regular call light button, a touchpad type call light could be utilized which the resident could tap on to alert staff. She stated Resident #69 should have had a touchpad type call light. The DON stated if a touchpad type call light was on a resident's care plan, then a touchpad call light should be in that resident's room. Further interview revealed the DON stated she was not aware Resident #69 had a push-button type call light earlier that week, instead of the touchpad type call light noted on the resident's care plan. In addition, the DON stated Resident #69 was at risk for everything. During an interview, on 02/09/2024 at 7:59 PM, the Administrator stated residents' care plans provided a care path for the residents' needs. The State Survey Agency (SSA) Surveyor asked the Administrator what could happen if there was an intervention for a touchpad call light on a resident's care plan, but the resident did not have the touchpad call light. The Administrator stated it depended on the situation, but the resident might not have been able to call out for help.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for two (2) of twenty-three (23) sampled residents, Resident #69 and Resident #78. The facility initiated a plan of care to keep a touch call light within Resident #69's reach, however observation revealed Resident #69 had a push-button call light. The facility initiated a plan of care to keep Resident #78's call light within reach; however, observation revealed the resident's call light was lying on his/her bedside table. The findings include: Review of the policy titled Call Lights: Accessibility and Timely Response, undated, revealed the policy's purpose was to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing location to allow residents to call for assistance. Per policy review, each resident was evaluated for unique needs and preferences to determine any special accommodations that might be needed in order for the resident to utilize the call system. Continued review revealed special accommodations were to be identified on the resident's person-centered plan of care and provided accordingly. (Examples of special accommodations included touch pads, larger buttons, bright colors, etc.) Further review revealed staff were to ensure the resident's call light was within reach and secured, as needed. Review further revealed the call system was to be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Review of the Admission Record, for Resident #69, printed 02/09/2024, revealed the facility admitted the resident on 03/09/2021, with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting his/her right dominant side; contracture of muscle, right hand; and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #69 to have no score on the Brief Interview for Mental Status (BIMS), indicating he/she was rarely/never understood. Continued review revealed the facility also assessed Resident #69 to have impairment on one (1) side of his/her upper extremity with functional limitation in range of motion of the shoulder, elbow, wrist, and hand. Review of Resident #69's Comprehensive Care Plan, revealed the facility care planned the resident as at risk for falls related to balance problems due to cardiovascular accident (CVA) with right hemiplegia. Further review revealed interventions included a touch call light for Resident #69 initiated on 03/24/2021. Observation, on 02/07/2024 at 3:20 PM, revealed no visual evidence Resident #69 had a touch call light as care planned, he/she had a regular push-button type of call light. The State Survey Agency (SSA) Surveyor and Licensed Practical Nurse (LPN) #1 entered Resident #69's room, and the LPN handed the push-button type of call light to Resident #69 in his/her left hand. Continued observation revealed LPN #1 asked Resident #69 to push the call light; however, the resident wrapped his/her left fingers, thumb, and palm around the shaft of the call light device and squeezed the device with his/her left hand. Further observation revealed Resident #69 did not push the red button on the top of the call light device, and therefore the resident's call light did not activate. During an interview, on 2/07/2024 at 3:24 PM, LPN #1 stated he knew Resident #69 needed something if he/she was moaning. The LPN stated Resident #69 needed to have a touch-pad call light, which came from the facility's maintenance department. He further stated he would tell maintenance to put in an order for a touch-pad call light for Resident #69. During an interview, on 02/07/2024 at 3:42 PM the Maintenance Manager (MM) stated if someone needed a call light they could tell us, and we would get one (1) immediately. The MM searched the facility's electronic maintenance system records, and stated no one had told the maintenance department Resident #69 needed a touch-pad call light, and there was no work order for the resident to receive a touch pad call light. During further interview the MM stated the maintenance department did not make the call on who gets one (touch pad call light), nursing or management must tell us to supply a resident with a call light. The MM further stated he had just handed the last one out (touch pad call light). During an interview, on 02/09/2024 at 6:21 PM, the DON stated if a touch-pad type call light was on a resident's care plan, then a touch-pad call light should be in the resident's room. Per interview, the DON stated she had not been aware of Resident #69 having a push-button type call light, instead of a touch-pad type call as noted on his/her care plan. She further stated Resident #69 was at risk for everything, During an interview, on 02/09/2024 at 7:59 PM, the Administrator stated the care plan provided a care path for the residents. When asked what could happen if there was a touch-pad call light on a resident's care plan and the resident did not have access to a touch-pad call light, the Administrator stated it depended on the situation, but the resident might have been not able to call out for help. 2. Review of Resident #78's Admission Record, printed 02/09/2024, revealed the facility admitted the resident on 02/28/2023, with diagnoses which included: muscle weakness (generalized); type two (2) diabetes mellitus with hyperglycemia; and radiculopathy (pinching of the nerves at the root) of the lumbar region. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #78 to have a BIMS score of thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Additional review revealed the facility also assessed Resident #78 to have impairment on both sides of upper body, with functional limitation in range of motion the shoulder, elbow, wrist, and hand. Review of Resident #78's Comprehensive Care Plan, revealed the facility care planned the resident as at risk for falls related to decreased vision, medications in use, and fear of falling. Further review revealed the interventions included educating Resident #78 to ask for assistance and use hi/his/her call light before trying to transfer himself/herself, initiated on 05/15/2023. Observation, on 02/07/2024 at 10:58 AM, revealed Resident #78's call light was lying on his/her bedside table. During an interview, on 02/07/2024 at 10:59 AM, Resident #78 said his/her television in his/her room did not work, and the SSA Surveyor the television remote and asked him/her to push his/her television remote, which did not work. The SSA Surveyor then asked Resident #78 to push his/her call light to let staff know about the television not working, and he/she stated it's just so hard to reach. Observation at the time of interview, revealed the SSA Surveyor entered the hallway and saw the Director of Nursing (DON) and asked her to come into Resident #78's room and look at something. Further observation revealed State Registered Nurse Aide #12 was nearby and also entered the resident's room. In addition, observation further revealed as SRNA #12 approached Resident #78's bedside table, she moved the resident's call light from the bedside table and clipped it to the resident's bedsheets. During an interview, on 02/07/2024 at 11:10 AM, the DON stated housekeeping staff had just moved Resident #78's call light onto the bedside table while they were cleaning the resident's room. During an interview, on 02/07/2024 at 11:30 AM, Housekeeper #1 stated, using a language translator application on his phone, that he had been trained not to touch residents' call lights and to call the nurse about call lights issues. Housekeeper #1 and the SSA Surveyor walked to Resident #78's room and observed the resident's call light. Housekeeper #1 then stated he had not cleaned Resident #78's room yet. During an interview, on 02/09/2024 at 4:45 PM, the Housekeeping Manager stated the facility's housekeeping staff were trained to not move residents' call lights. Per interview, the Housekeeping Manager stated if housekeeping staff saw a resident's call light lying on the floor, they were to notify nursing staff. During an interview, on 02/09/2024 at 3:40 PM, SRNA #3 stated if a call light was not within reach of the resident, he/she might roll out of bed and hurt himself/herself. During an interview, on 02/01/2024 at 4:24 PM, Registered Nurse #1 stated the SRNA's and Nurses rounded on residents to make sure their call lights were within reach. The SSA Surveyor asked RN #1 if there was a potential that a resident could fall, or have other potential outcomes, if his/her call light was not within reach; however, the RN did not answer the question. During an interview, on 02/09/2024 at 7:36 PM, the Regional Resident Assessment Instrument (RAI) Coordinator stated lots of work went into developing the care plans, which were to provide guidance for residents' care needs and any problems the resident had. The Regional RAI Coordinator stated if a resident's care plan indicated the call light was to be kept within the resident's reach, the expectation was for the call light to be kept within the resident's reach. The Regional RAI Coordinator further stated an outcome for a resident whose care plan was not implemented would be the resident experiencing an unmet need. During an interview, on 02/07/2024 at 3:42 PM, when asked how something broken in a resident's room was fixed, the Maintenance Assistant stated either the nurse, the aide or the unit manager could put an order in the electronic maintenance system. He further stated if he was just walking through the building he would just go in there (meaning a resident's room that needed maintenance service) and do it for them (fix the problem the resident had). During an interview, on 02/09/2024 at 6:21 PM, the DON stated it was the expectation call lights be within each resident's reach. The DON stated for residents who had weaknesses and were not able to push the call light button, they could benefit from touch-pad type call light which they just had to tap on. The DON stated the facility needed to have residents' call lights close to them and within reach.

The facility failed to ensure all drugs and biologicals were labeled and stored in accordance with professional standards to include labels, the date opened and the securement of medication carts for two (2) of four (4) medication carts observed out of the facility's total of eight (8) medication carts. Observation of one (1) medication cart revealed it was left unlocked and unattended while the Registered Nurse (RN) passed medications to residents in their rooms. In addition, opened, undated medications were observed stored in medication carts. The findings include: Review of the facility policy titled, Storage of Medications revised 08/2020, revealed medications and biologicals were to be stored safely, securely, and properly, following the manufacturer's recommendations or recommendations of the supplier. Per policy review, the medication supply was to be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Continued review revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) were permitted to access medications. In addition, policy review further revealed medication rooms, carts, and medication supplies were to be locked when they were not attended by persons with authorized access. Observation on 02/03/2024 at 7:35 PM, of the medication cart on E Hall revealed it was left in the hallway with no attending staff. Observation at 7:37 PM, RN #9 came out of a resident's room and returned to the medication cart. Continued observation at 7:44 PM, revealed RN #9 went to another resident's room and leaving the medication cart unlocked and unattended. Further observation of the medication cart, from 7:44 PM through 7:49 PM, revealed the medication cart continued to sit in the hallway on the E Hall unlocked while RN passed medications to residents in their rooms. Additional observation revealed at 7:49 PM, RN #9 returned to the medication cart and locked it. During an interview on 02/09/2023 at 7:51 PM, with RN #9 he stated he was not supposed to leave the medication cart unlocked at anytime that he was not present at the cart. He further stated any resident or others could take medications from the cart. Observation on 02/09/2024 at 4:12 PM, revealed the facility had medication carts located on halls A, B, C (two [2]carts), D, E, F, G, for a total of eight (8) medication carts containing insulin vials and pens. Observation of a medication cart on the C-Hall revealed two (2) vials of insulin without an opened date. Continued observation of the C-Hall medication cart revealed one (1) insulin pen not labeled with opened date. Further observation revealed a container of Nitroglycerin 0.4 milligram (mg) for sublingual use, which had no opened date. In addition, Active Liquid Protein multidose bottle, Levetiracetam liquid multidose bottle, Milk of Magnesium liquid multidose bottle, Amantadine liquid multidose bottle, and Polyethylene Glycol multidose bottle which were all opened, and not expired; however had no opened dates noted. ) During an interview with RN #7 on 02/09/2024 at 4:30 PM, she stated they were supposed to put an open date on each medication once it was opened for multidose medications. RN#7 stated persons passing medications were to appropriately discard any medications left when a resident was discharged . The RN further stated insulin pens and bottles were to be refrigerated until opened; however, once opened the insulin pens were to be dated and could remain on the medication cart for twenty-eight (28) days before being discarding. Observation on 02/09/2024 at 4:45 PM, of the E-Hall medication cart revealed two (2) inhalers not labeled with an opened date. Further observation of the E-Hall medication cart revealed a Liquid Protein multidose bottle and Chlorhexidine liquid multidose vial opened with no opened date noted. In interview with RN #1 on 02/09/2024 at 4:50 PM, he stated medications should always be labeled with an opened date and any expired medications were to be discarded per the facility's protocol. RN#1 further stated the medication cart should always remain locked when unattended or not in use. During an interview on 02/09/2024 at 7:50 PM, with the Executive Director (ED) she stated her expectations were for staff administering medications to ensure all medications were secured as per policy. She stated she expected those staff were also to ensure medications were labeled, stored, and disposed of properly as per policy. The ED further stated oversight was provided by administrative and nursing managers through walking rounds performed daily. During an interview on 02/09/2024 at 9:15 PM, with the Director of Nursing (DON) revealed her expectations were for the medication carts to always be locked when not attended by staff. The DON stated she expected an opened date to be noted on medications as soon as they were opened to ensure resident safety. The DON further stated she would re-educate staff immediately. She stated she would ensure ongoing education was provided regarding administering medications, and on ensuring medications were secured and labeled properly, and reprimand staff as needed for not following the facility's policy.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, as based on the comprehensive assessment of the resident, the comprehensive person-centered care plan, and the resident's choices for one (1) of twenty-three (23) sampled residents (Resident #22). Review of Resident #22's Physician's Orders dated 01/20/2024 and the resident's Treatment Administration Record (TAR) dated 02/2024, revealed wound care orders for his/her wound on the right foot anterior first digit to be provided daily at bedtime. However, observation on 02/08/2024, revealed a gauze with tape noting the date of 02/03/2024, and the bottom of the gauze dressing on Resident #22's left foot was reddish-brown in color and was soiled with what resembled blood seeping through the gauze. The findings include: Review of the facility policy titled, Wound Treatment Management, undated, revealed the policy was to promote wound healing of various types of wounds and provide evidence-based treatments in accordance with current standards of practice and physician orders. Further review revealed wound treatments were to be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Review of Resident #22's Electronic Health Record (EHR) revealed the facility admitted Resident #22, initially on 07/07/2023, with last readmitted on 11/30/2023, with diagnoses which included Cerebral Infarction due to Embolism of left middle cerebral artery, Diabetes Mellitus due to underlying condition with foot ulcer, Cellulitis of right lower limb, and other acute Osteomyelitis, right ankle, and foot. Review of Resident #22's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15) indicating he/she was severely cognitively impaired and not interviewable. Review of Resident #22's physician order dated 01/20/2024, revealed an ongoing order to cleanse the wound to the resident's right anterior foot, first digit with wound cleanser, apply betadine (topical antiseptic used for infection protection) to the base of the wound, secure with an abdominal (ABD) pad and wrap with rolled gauze at bedtime and change as necessary (PRN). Review of Resident #22's Treatment Administration Record (TAR) dated 02/2024 revealed the resident's wound care was to be provided daily by nursing staff. Further review of the TAR revealed RN #2 had signed off Resident #22's wound care as having been completed on 02/03/2024 through 02/07/2024. Observation of Registered Nurse (RN) #2, on 02/03/2024 at 9:30 PM, revealed Resident #22's door was slightly ajar and RN #2 was observed performing wound care for Resident #22's feet, and dated the dressing. Additional observation of Resident #22, on 02/08/2024 at 1:45 PM, revealed State Registered Nurse Aide (SRNA) #4 and SRNA #10 were obtaining Resident #22's current weight via a Hoyer lift. Per observation, while Resident #22's protective boots were off, the State Survey Agency (SSA) Surveyor observed the tape holding the gauze on both the resident's right and left foot was dated 02/03/2024, and was initialed by RN #2. Further observation revealed the gauze on the bottom of Resident #22's left foot was reddish-brown in color and was soiled with what resembled blood seeping through the gauze. In an interview with RN #2, on 02/08/2024 at 3:34 PM, he stated he had made a mistake and marked the wrong date on the tape holding Resident #22's dressing in place. RN #2 stated he dated the dressing 02/03/2024, which was a mistake. He stated he was aware of who Resident #22 was and he stated he had provided wound care daily every night he had worked, 02/03/2024 through 02/07/2024. RN #2 stated he did the treatment for both the resident's feet; however, had just kept repeating the first date he had written on the tape he originally placed on it, which was 02/03/2024. In an interview with SRNA #4, on 02/08/2024 at 3:50 PM, she stated RN #5 and RN #1 completed Resident #22's wound care, after the observation by the State Survey Agency (SSA) Surveyor of the incorrect date noted on the dressing. She stated she was aware the nurses were to date the wound care treatment dressings; however, did not recall the past date on the tape holding the gauze covering Resident #22's feet. In an interview with the Nurse Practitioner (NP), on 02/09/2024 at 6:15 PM, she stated she was in the facility everyday; however, was not involved with the daily wound care for residents. She stated she only became involved if a resident's wound had become infected. Per the NP, Health Partners wound care usually handled everything else related to wounds. She stated her expectations for the facility's nursing staff was for would care to be provided as ordered. Additionally, she stated the Wound Care Practitioner checked on resident's wounds weekly. In an interview with the DON, on 02/09/2024 at 7:00 PM, she stated when a nurse provided wound care they were required to date the dressing, and sign off on the wound care on the resident's TAR. The DON stated nurses were to also enter any observed changes to the wound and document those changes in the resident's EHR. She stated if the date on a dressing was incorrect that would be a concern for residents with wounds. The DON stated providing proper wound care was a priority. Per the DON, if the nurse had not completed the wound care or noted the incorrect date of completion, the nurse was to be written up, reeducated, and made aware of the risk of not completing proper wound care as ordered. She stated the residents had the potential for harm as their wound could worsen, which could potentially be dangerous for the resident's health. The DON further stated her expectation for nursing staff providing wound care was for them to follow the provided guidance and physician's orders. In an interview with the Administrator, on 02/09/2024 at 8:15 PM, she stated expectations were for nursing staff to follow physician's orders when completing a resident's wound care. She stated she did not believe there was potential for harm to other residents; however, if the wound splashed onto the nurse there could be possible harm for the staff member. The Administrator stated it was her expectation for nursing staff to date wound care dressing changes to ensure other staff were aware of when the wound care had been completed and to prevent any further deterioration of the wound.

Based on observation, interview, personnel file review and review of the facility's policy, it was determined the facility failed to complete annual performance reviews at least once every twelve (12) months for four (4) of five (5) sampled Certified Nurse Assistants (CNA) (CNAs #12, #18, #20, and #29); and, failed to provide regular in-service education based on the outcome of performance reviews for four (4) of five (5) sampled CNAs (CNAs #12, #18, #20, and #29). The findings include: Review of the facility's policy, In-Service Training Program, Nurse Aide dated 2001, revised October 2017 revealed the facility completed a performance review of nurse aides at least every twelve (12) months. In-service training was based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Annual in-services ensured the continuing competence of nurse aides; was no less than twelve (12) hours per employment year; addressed areas of weakness as determined by nurse aide performance reviews; addressed the special needs of the residents, as determined by facility staff. In-services included training that addressed the care of residents with cognitive impairment; and included training in dementia management and abuse prevention. Additionally, all training classes attended by the employee were entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor, records shall be filed in the employee's personnel file or shall be maintained by the department supervisor. Review of the facility's personnel files revealed CNA #12's date of hire (DOH) was 03/25/2020, CNA #18's DOH was 09/25/2019, CNA #20's DOH was 09/11/2018 and CNA #29's DOH was 11/14/2017. When annual performance reviews for these four (4) SRNA's for the past twelve (12) months was requested from the facility, no annual performance reviews were presented to the State Survey Agency (SSA). Further review of the facility's personnel files for CNAs #12, #18, #20 and #29, revealed these four (4) CNAs, during the past year, had not completed a total of twelve (12) hours of in-service training as required by the facility's policy. Interview with CNA #12, on 07/06/2021 at 3:40 PM, revealed he had received email reminders to complete his annual in-service training. CNA #12 stated the training was important for him to keep his skills current and his mind sharp. Interview with CNA #13, on 07/06/2021 at 3:30 PM, revealed he had problems logging into the annual in-service training system. CNA #13 stated he couldn't login. Interview with CNA #29, on 07/06/2021 at 4:00 PM revealed she received a new login last week so she could login to the facility's training system and complete her twelve (12) hours of annual in-service training as required and per the facility's policy. She stated she was expected to have to complete twelve (12) hours of annual in-service training each year. CNA #29 stated training was important so she could stay updated on the facility's policies, infection control and dementia training. Interview with the Staff Development Coordinator (SDC), on 07/07/2021 at 2:39 PM, revealed she joined the facility within the past two (2) weeks. The SDC stated she recently audited the CNA personnel files for evidence of twelve (12) hours of annual in-service training and discovered CNA training was missing. Telephone interview with the Former Assistant Director of Nursing and Infection Control Nurse, on 07/07/2021 at 11:20 AM, revealed she was employed by the facility from October through December 2020. She stated she voiced her concerns about insufficient training for newly hired CNAs to the facility's administration and was told not to worry about it and that administration was working on CNA training. On 07/07/2021 at 9:14 AM, attempts to reach the former Human Resources Director were unsuccessful. Telephone interview with the Regional Human Resources Director, on 07/07/2021 at 12:54 PM, revealed she ensured all CNAs were trained by referring them to the online training system. She stated her role related to annual CNA performance reviews was support to the Human Resources Manager and the SDC in each facility in her region. She also stated she . was the reminder for in-services. Continued interview revealed that she was confident that CNA training would be back on track within the next thirty (30) days. She stated the facility's current Human Resources Manager began her employment at the facility on Tuesday 07/06/2021. Interview with the Director of Nursing Services (DNS), on 07/07/2021 at 2:39 PM, revealed she joined the facility within the past two (2) months and for some reason some staff did not do all the annual in-service online training. She stated she did not know if CNAs met the criteria for twelve (12) hours. The DNS stated she had not done any performance reviews since she began working at the facility. Telephone interview with the former Executive Director (ED), on 07/07/2021 at 3:10 PM revealed she had not identified any CNA training needs during her employment at the facility. She stated that it was important for CNAs to have training so they had the tools and resources to care for residents and so there are no adverse reactions. Interview with the Interim ED, on 07/07/2021 at 3:14 PM, revealed part of the CNA training was that she made observations and and was constantly doing some type of education based on what her observations. She stated she monitored to ensure annual in-service training was completed by asking the SDC for the training progress report. Further interview revealed the ED knew there was an issue with the CNAs' annual twelve (12) hours in-service training, but not with the performance reviews. She stated the Assistant Director of Nursing (ADON) and the DNS were responsible for the annual performance reviews of CNAs, and to ensure the reviews were completed annually according to each CNA's anniversary date. The ED stated the person designated to track the performance review completion would be the Human Resources Director.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to provide respiratory care, including [CONDITION(S)] care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for one (1) of nine (9) sampled residents (Resident #79). Resident #79 was transferred to an acute care for [CONDITION(S)] ([CONDITION(S)]) replacement due to his/her [CONDITION(S)] became dislodged for an unknown period of time during day shift (7:00 AM - 7:00 PM). Night shift staff (7:00 PM - 7:00 AM) were unable to replace the [CONDITION(S)] using the obturator (device used to reinsert the [CONDITION(S)]) due to narrowing of the stoma. The findings include: Review of the facility's policy, Accidents and Incidents-Investigating and Reporting, revised July 2017, revealed all accidents and incidents involving residents were investigated and reported to the administrator. Continued review revealed the facility was in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. Additionally, the Safety Committee reviewed any incident/accident reports for trends related to accidents or safety hazards in the facility and to analyze any individual resident vulnerabilities. The facility failed to provide an incident report regarding Resident #79's [CONDITION(S)] being dislodged on 03/28/2021. Review of the facility's policy, [CONDITION(S)] Care, revised August 2013, revealed the purpose of the procedure was to guide [CONDITION(S)] care and the cleaning of reusable [CONDITION(S)] cannulas. Review of the Admission Record, revealed the facility readmitted Resident #79 on 03/09/2021, after an acute care facility stay. Further review revealed Resident #79's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Minimum Data Set (MDS), dated [DATE], revealed Resident #79 was not assessed for cognitive status or behaviors. Continued review revealed Resident #79 was totally dependence with one (1) person assist for all Activities of Daily Living (ADL) and had a feeding tube in place at the time of the assessment. Further review revealed Resident #79 received oxygen therapy, [CONDITION(S)] care and suctioning. Review of the Comprehensive Care Plan (CCP), dated 02/26/2021, revealed Resident #79 had a [CONDITION(S)] and was at risk for complications related to impaired breathing mechanics. Interventions for this focus included: document abnormal findings and notify the MD; ensure [CONDITION(S)] ties were secure at all times; observe for signs and symptoms of infection; observe for symptoms of respiratory distress; apply oxygen therapy as ordered; provide good oral care daily; reassure resident to decrease anxiety; suction with [CONDITION(S)] care and, as needed; and, [CONDITION(S)] care as ordered. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #79's history of respiratory failure. Review of the Medication Administration Record (MAR), dated March 2021, revealed on 03/28/2021 at 8:00 AM, Licensed Practical Nurse (LPN) #3 assessed Resident #79 to have clear breath sounds, heart rate of 88, respirations of 18 and oxygen saturation of ninety-four percent (94%) via [CONDITION(S)] collar. Review of the Treatment Administration Record (TAR), dated March 2021, revealed on 03/28/2021 at 9:00 AM [CONDITION(S)] ties were changed, at 7:00 AM and sometime in the PM (unable to determine time) [CONDITION(S)] suctioning was completed along with [CONDITION(S)] care, and at 8:00 AM verification was made of the emergency [CONDITION(S)] at bedside. All documentation was completed by LPN #3. Additional review of the MAR and TAR revealed no further documentation regarding Resident #79's [CONDITION(S)] status during the day. Review of the Progress Notes, dated 03/28/2021 at 7:31 PM, revealed at 7:05 PM the night shift nurse (Licensed Practical Nurse, LPN #15) rounded on Resident #79 to find him/her without his/her [CONDITION(S)] in place. Further review revealed, [CONDITION(S)] site appeared to be closing and the emergency replacement was not able to occur. Continued review of the Progress Note revealed the night shift nurse called Emergency Medical Services (EMS), the Nurse Practitioner (NP). The resident's family was notified that Resident #79 was being sent out for [CONDITION(S)] replacement. Additional review of the Progress Notes revealed no further documentation regarding Resident #79's [CONDITION(S)] status during the course of the day prior to being transferred to an acute care facility. Review of the Electronic Health Record (EHR) revealed Resident #79 did not return to the facility after being transferred to acute care facility on 03/28/2021. Interview with CNA (certified nurse assistant) #12, on 07/01/2021 at 3:15 PM, revealed he was the aide on duty the night of 03/28/2021 when it was discovered Resident #79's [CONDITION(S)] was dislodged. He stated he recalled having to reposition the resident more frequently due to him/her squirming around. CNA #12 stated he could not recall the last time he laid eyes on Resident #79 on 03/28/2021, but he did recall LPN #15 stating that the resident's [CONDITION(S)] was out. Review of the Documentation Survey Report V2, dated March 2021, revealed no documented evidence Certified Nurses Assistant (CNA) #12 assisted Resident #79 with bed mobility, dressing, locomotion on/off the unit, personal hygiene, toilet use, and/or transfers during the 3:00 PM - 11:00 PM shift on 03/28/2021. Interview with CNA #27, on 07/01/2021 at 10:39 AM, revealed she recalled caring for Resident #79 and the resident was able to move around in the bed, but he/she could not follow commands. Continued interview revealed she was aware she had to monitor Resident #79 more frequently due to him/her moving around the bed a lot. She stated at times, she would enter the resident's room to find his/her legs over the side of the bed or the pillows were on the floor or in the resident's face. Further interview revealed she believed Resident #79 had the potential to be able to pull out his/her [CONDITION(S)] although it would not be on purpose, it would be due to his/her constant moving around. Interview with CNA #33, on 07/01/2021 at 2:15 PM, revealed she cared for Resident #79 during night shift. She stated the resident was very mobile in the bed. CNA #33 stated she had to constantly reposition the resident. Continued interview revealed on her rounds she would find Resident #79's legs over the rails and at times the resident would be almost out of bed. However, she stated she did monitor the resident more frequently. She continued that she did not recall ever noticing Resident #79 appearing to pull at his/her [CONDITION(S)]. CNA #33 stated she did have to keep her eyes on (him/her) often. Interview with LPN #1, on 07/01/2021 at 2:30 PM, revealed she recalled caring for Resident #79. LPN #1 stated Resident #33 was a mover. LPN #1 stated the resident would frequently be laying sideways and sometimes his/her oxygen would be off. The LPN stated Resident #79 was a resident that had to be checked on every thirty (30) minutes because he/she was everywhere. Interview with LPN #3, on 07/01/2021 at 3:31 PM, revealed she was not the nurse on duty when Resident #79 was transferred to acute care facility. LPN #3 stated she could not recall the resident nor, could she recall anything about a [CONDITION(S)] being dislodged. Review of the facility's schedule for 03/28/2021 revealed LPN #3 was assigned to Resident #79 during the day shift (7:00 AM- 7:00 PM). Interview with LPN #15, on 07/06/2021 at 1:23 PM, revealed she was the night shift nurse that discovered Resident #79's [CONDITION(S)] was dislodged. LPN #15 stated she did not receive any significant report from LPN #3 regarding Resident #79. She stated when she went in to the resident's room at 7:05 PM she was disturbed at how she found the resident-sideways in the bed and his/her [CONDITION(S)] was out, laying in the bed with him/her. LPN #15 stated she was unsure about how long Resident #79's [CONDITION(S)] was out. She stated she had to go find help to reposition him/her to try to attempt to reinsert his/her [CONDITION(S)]. LPN #15 stated, Surprisingly the resident did not seem to be in distress and appeared to be laying comfortably. She revealed it was typical behavior for Resident #79 to scoot down in the bed and to kick his/her legs over the sides causing staff to have to monitor him/her more frequently. Further interview revealed she did not obtain the resident's vital signs because she was more concerned about reinserting his/her [CONDITION(S)]. Continued interview revealed the stoma appeared to be very small and when she was unable to advance the obturator, she called 911. She stated she asked CNA #12 about the last he had seen Resident #79 and he stated he/she was fine, but he could not remember a specific time. Additionally, LPN #15 revealed after the transfer there was no additional follow up or subsequent education from management. Interview with the Respiratory Therapist (RT), on 07/06/2021 at 2:00 PM, revealed she worked in the facility as needed and she rounded on all the [CONDITION(S)] residents. The RT stated she completed [CONDITION(S)] care and suctioning and assessed the stoma. She continued if she identified any concerns she would notified the nurse or if she noticed a significant change, she notified the physician herself. Additionally, she stated that she recalled Resident #79. She stated sometimes she would have to reposition him/her due to not being able to adequately see his/her [CONDITION(S)]. Continued interview revealed Resident #79 did move a lot but, she never saw him/her reach for his/her [CONDITION(S)] or collar. Additionally she stated that stomas close at different rates, depending on the resident. The RT stated it could take a few hours to a few days. Interview with the Medical Director (MD), on 07/06/2021 at 11:28 AM, revealed he cared for Resident #79 in the facility and as inpatient at two (2) acute care facilities, and was well versed with him/her. Continued interview revealed when Resident #79 arrived to the Emergency Department (ED), his/her stoma was not completely closed but had narrowed enough to not be able to reinsert the [CONDITION(S)]. The Medical Director stated that Resident #79 was not in distress while in the ED without his/her [CONDITION(S)] present. Continued interview revealed the ED staff placed a non-rebreather mask with fifteen (15) liters (L) of oxygen on Resident #79 as a precaution, but the resident was quickly weaned down to 2 L nasal cannula. Further interview revealed he was aware that Resident #79 had a lot of un-purposeful movement and the number one cause for a [CONDITION(S)] to become dislodged was coughing, but with Resident #79, there was no way of knowing what exactly happened. Interview with the Director of Nursing Services (DNS), on 07/07/2021 at 10:50 AM, revealed she was hired on 05/04/2021 and was not in the facility when this incident occurred. She stated staff supervised the residents the best of their ability and if there was an identified concern the nurse would tell the Unit Manager or the Assistant Director of Nursing Services (ADNS) if an additional intervention was needed. The DNS stated it was the facility's duty to ensure adequate staffing ratios and provide any special education to staff if needed. She stated the facility identified any potential safety concerns by performing rounds on the residents. The DNS stated since she had taken over the DNS position, her telephone number was posted at the nurses' stations so staff would have the availability to contact her if they have identified concerns regarding resident monitoring. Interview with the Interim Executive Director, on 07/07/2021 at 3:13 PM, revealed to ensure adequate supervision staff made rounds, along with talking to families and residents to identify potential concerns. She stated she expected her staff to do what was needed to care for the residents.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to revise a Comprehensive Care Plan (CCP) for one (1) of nine (9) sampled residents (Resident #79). Per staff interviews, Resident #79 required increased monitoring by staff due to his/her increased movement when in bed. Resident #79's [CONDITION(S)] ([CONDITION(S)]) became dislodged for an unknown period of time and staff were unable to reinsert his/her [CONDITION(S)]. The facility transferred Resident #79 to an acute care facility for [CONDITION(S)] replacement. The facility failed to revise the careplan for increased monitoring realted to Resident #79's constant movement. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. Continued review revealed the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Further review revealed the care planning process included an assessment of the resident's strengths and needs. Review revealed the CCP described services to be furnished to attain or maintain the resident's highest well-being, incorporated identified problem areas, incorporated risk factors associated with identified problems, and aided in preventing or reducing decline in the resident's functional status and/or functional goals. Further review of the facility's policy revealed no information regarding care plan revisions and updates. Review of the Admission Record, revealed the facility readmitted Resident #79 on 03/09/2021 after an acute care facility stay. Resident #79's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Minimum Data Set (MDS), dated [DATE], revealed Resident #79 was not assessed for cognitive status or behaviors. Continued review revealed the facility assessed Resident #79 to be totally dependence with one (1) person assist for all Activities of Daily Living (ADL) and he/she had a feeding tube in place at the time of assessment. Further review revealed he/she was receiving oxygen therapy, [CONDITION(S)] care and suctioning. Review of the Comprehensive Care Plan (CCP), dated 02/26/2021, revealed Resident #79 had a [CONDITION(S)] and was at risk for complications related to impaired breathing mechanics. Interventions for this focus included: document abnormal findings and notify the MD; ensure [CONDITION(S)] ties were secure at all times; observe for signs and symptoms of infection; observe for symptoms of respiratory distress; apply oxygen therapy as ordered; provide good oral care daily; reassure resident to decrease anxiety; suction with [CONDITION(S)] care and as needed; and, [CONDITION(S)] care as ordered. Further review of the CCP revealed there was no intervention regarding monitoring the resident's [CONDITION(S)] status for dislodgement or frequency of monitoring, although staff were aware that Resident #79 required more frequent monitoring. Interview with Certified Nursing Assistant (CNA) #12, on 07/01/2021 at 3:15 PM, revealed he recalled having to reposition and monitor Resident #79 more frequently due to him/her squirming around. He continued that the resident's increased monitoring would not be something that needed to be care planned. Further interview revealed the care plan informed him how to care for the residents and was accessible to the CNAs. Interview with CNA #27, on 07/01/2021 at 10:39 AM, revealed the care plan was a plan of care that told staff what the resident's needs were. Continued interview revealed she was aware she had to monitor Resident #79 more frequently due to him/her moving around the bed a lot and at times she would enter the resident's room to find his/her legs over the side of the bed or pillows on the floor or in the resident's face. Continued interview revealed CNA #27 believed increased monitoring should not have been on the care plan because it was a point of care, meaning everyone knew to go in there and check on him/her more often. Interview with Licensed Practical Nurse (LPN) #1, on 07/01/2021 at 2:30 PM, revealed she recalled caring for Resident #79 and stated he/she was a mover. She stated the resident would frequently be laying sideways and sometimes his/her oxygen would be off. LPN #1 stated Resident #79 was a resident that required checking on every thirty (30) minutes because he/she was everywhere. Further interview revealed she believed increased monitoring was not something that needed to be care planned. She stated it was like a standard of care, just like every two (2) hour rounding, it doesn't have to be care planned, it's just something everyone knows. Additionally, she stated the care plan was a guide on how to provide care to each resident. Interview with the Minimum Data Set (MDS) Nurse, on 07/06/2021 at 11:23 AM, revealed the care plan was a person-centered guide on how the facility met the resident's needs and any nurse could update the care plan. Continued interview revealed she was responsible primarily during the morning meetings. She stated care plans were revised when there was a change such as, a new order, a fall, or a significant change. Additional interview revealed she would not comment if increased monitoring for Resident #79 would be something that needed to be included in the care plan. Interview with the Medical Director, on 07/06/2021 at 11:05 AM, revealed Resident #79 was well known to him and he did not expect staff in the facility to monitor him/her more frequently due to his/her constant movement and airway status. Interview with the Director of Nursing Services (DNS), on 07/07/2021 at 10:50 AM, revealed staff used the care plan to ensure they provided appropriate care to the residents. Continued interview revealed she did not recall if she had ever care planned increased monitoring in the past. The DNS stated increased monitoring for Resident #79 could have changed at different times, from shift to shift and she stated she did not think increased monitoring for Resident #79 would be appropriate to be included in the care plan. Interview with the Interim Executive Director, on 07/07/2021 at 3:13 PM, revealed the care plan provided general guidance for staff on how to provide care to the residents. Continued interview revealed she would not expect the increased monitoring staff were doing for Resident #79 to be care planned due to that frequency of monitoring could fluctuate shift to shift and day to day. She revealed the increased monitoring would ideally be communicated in report from shift to shift.

Based on observation, interview, record review and review of the facility policy related to Quality Assurance Performance Improvement (QAPI) and review of the Executive Director's Job description, it was determined the facility failed to ensure the Governing Body who was responsible for the establishment and implementation of policies managed the operation of the facility. Interviews revealed not all listed participants were aware of their GB role and/or responsibility. The facility's GB failed to hold responsible the Executive Director (ED) in regards to the establishment and implementation of policies/procedures to ensure the provision of quality care and services. Interviews revealed the ED did not report QAPI/GB findings to the Owner/CEO and the Owner/CEO did not attend QAPI/GB meetings, nor was not listed on the GB committee. The facility failed to be governed in a manner to ensure residents were free from accidents and hazards, provided nutrition/hydration to prevent weight loss or dehydration, weights were monitored, care plan interventions implemented, along with ensuring employees providing care with a provisional license had supervision. In addition, the facility failed to ensure medications were available and administered as ordered. (Refer to F656, F689, F692, F693, F726, F755, F835, F837, and F865). The facility's failure to provide an effective Governing Body to ensure oversite which included the establishment and implementation of policies for the effective management and operation of the facility has caused or is likely to cause serious injury, harm, impairment or death to residents. Total census 90. An abbreviated survey was initiated 03/03/2021 to investigate KY , KY , KY , KY , KY , KY , KY , KY , KY , KY , and KY . Immediate jeopardy was identified on 03/07/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of J; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of L. Substandard quality of care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the immediate jeopardies on 03/07/2021. The abbreviated survey transitioned to a standard health recertification survey on 03/09/2021. Additional complaints were investigated, including KY , KY , KY , and KY . Immediate Jeopardy was identified on 03/21/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of J and F693 Tube Feeding Management/Restore Eating Skills at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of K; 42 CFR 483.70 Administration, F835 Administration at a S/S of L; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities at a S/S of L. Substandard Quality of Care was identified at 42 CFR 483.25, F692 Nutrition/Hydration Status Maintenance, and F693 Tube Feeding Management/Restore Eating Skills. The facility was notified of these immediate jeopardies on 03/21/2021. After supervisory review immediate jeopardy was identified on 03/24/2021 and determined to exist on 07/09/2020 in the area of 42 CFR 483.70 Administration, F837 Governing Body at a S/S of L. Additional deficiencies were cited in the areas of 42 CFR 483.10 Resident Rights, F550 Resident Rights/Exercise of Rights at a S/S of D, F553 Right to Participate in Planning Care at a S/S of D, F558 Reasonable Accommodations of Needs/Preferences at a S/S of E, F583 Personal Privacy/Confidentiality of Records at a S/S of D, and F584 Safe/Clean/comfortable/Homelike Environment at a S/S of F; 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F606 Not Employ/Engage Staff with Adverse Actions at a S/S of F, and F609 Reporting of Alleged Violations at a S/S of D; 42 CFR 483.20 Resident Assessments, F641 Accuracy of Assessments at a S/S of E; 42 Comprehensive Resident Centered Care Plans, F657 Care Plan Timing and Revision at a S/S of D; 42 CFR 483.24 Quality of Life, F677 ADL Care Provided for Dependent Residents at a S/S of D; 42 CFR 483.35 Nursing Services, F725 Sufficient Nursing Staff at a S/S of E; 42 CFR 483.45 Pharmacy Services, F759 Free of Medication Error Rates of 5% or More at a S/S of F and F761 Label/Store Drugs & Biologicals at a S/S F; 42 CFR 483.60 Food and Nutrition Services, F812 Food Procurement, Store/Prepare/Serve - Sanitary at S/S of F; and 42 CFR 483.80 Infection Control, F880 Infection Prevention and Control at a S/S of F. Additional substandard quality of care was identified at 42 CFR 483.10 Resident Rights, F584 Safe/Clean/Comfortable/Homelike Environment; 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F606 Not Employ/Engage Staff with Adverse Events; and F759 42 CFR 483.45 Pharmacy Services. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified, on 03/07/2021, and was determined to exist on 12/17/2020, in the areas of 42 CFR 483.25 Quality of Care (F689 at S/S of J); and, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 at S/S of K). The facility provided an acceptable credible Allegation of Compliance (AoC) on 03/30/2021, alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 03/30/2021, as alleged, prior to exit on 04/03/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility untitled policy statement, undated, revealed the facility process for QAPI included a GB. The GB included the Vice President of Operations (VPO), the Regional Director of Operations (RDO), Medical Director (MD), Executive Director (ED), and Director of Nursing Services (DNS). The GB responsibilities included the identification and prioritization of problems based on data performance, incorporation of resident and team member input, to ensure corrective action addressed gaps in the system and evaluated for effectiveness, set clear expectations for safety, quality, rights, choices and respect. In addition the GB ensured to have adequate resources to conduct QAPI efforts. Review of the DNS and ED job description revealed the responsibilities did not include GB participation. Record review of contract titled Health Care Services Agreement (Medical Director Services), undated, revealed the agreement included services with a company owned and operated by an Advanced Practice Nurse Practitioner. Review revealed the contractor responsibility included the MD agreed to serve as part of the facility Governing Body (GB). However, the facility did not list the MD of the contracted company as part of the GB. Review of contract titled Health Care Services Agreement (Medical Director Services), undated, revealed the agreement included services with a company owned and operated by an Advanced Practice Nurse Practitioner. Review revealed the contractor responsibility included the MD agreed to serve as part of the facility Governing Body (GB). However, the facility did not list the MD of the contracted company as part of the GB. Interview with the DNS, on 03/21/2021 at 12:58 PM, revealed the facility did not approach him about being on a board of a GB for the facility. He revealed he did not know anything about inclusion of a GB role with the DNS title. Further interview with the DNS, on 04/02/2021 at 12:11 PM, revealed the ED notified him he was part of the GB because he was part of the QAPI. The DNS revealed the ED revealed the GB helped identify issues and improved the care of the residents through the QAPI process. However, he revealed participation on the GB was not part of his signed contract. Interview with the Executive Director (ED), on 04/03/2021 at 2:00 PM, revealed the RDO was her direct supervisor. She revealed she did not report to anyone above her who had ownership of the facility. She revealed the facility was not a part of a corporation but rather a facility under its own ownership. She revealed the RDO and VPO were employees of a consultation agency, she reported to them, and they participated as members of the GB. She revealed the GB met during the QAPI meeting because the GB consisted of the same members and discussed the same topics. Furthermore, she revealed the first standalone GB meeting since 08/2019 occurred on 03/25/2021 for the Immediate Jeopardy. She revealed the CEO and Board of Directors did not participate with QAPI/GB meetings and did not attend on 03/25/2021. She further revealed the medical directors held contracts with the facility. She revealed the facility did not govern itself even though members listed as on the GB, included facility management,such as the Medical Directors, the VPO, and RDO who were contracted consultants. The ED further revealed the QAPI members were the same as the listed GB members. The ED revealed she did not refer to reference material for Federal and State Regulations during the QAPI/GB meetings to review and ensure the regulations were followed. She revealed facility did not identify issues with the areas of notification of jeopardy. The ED revealed she knew she and the facility had areas to improve. Review of the blank facility QAPI Agenda/Minutes tool, dated 2017, revealed four (4) pages. Review revealed the facility GB notes, updates, discussion were identified on the 4 pages provided. The facility did not have the title Governing Body on the tool or an area to address any discussion in reference to the GB. In addition, the RDO and VPO were not listed on the tool for signature. Interview with the Pulmonary Medical Director (PMD),03/20/2021 at 9:30 AM, revealed he did not govern any part of the facility, did not do politics for the facility, and did not know what the surveyor was talking about regarding the topic of a GB of the facility. The PMD revealed he did not participate with the development of the facility assessment. The PMD revealed his responsibility included provision of care for the resident's with respiratory care needs. In addition, he attended or the facility updated him on the QAPI meeting and he provided over site for the care provided to the residents. Interview with the MD, on 03/20/2021 at 12:01 AM, revealed he was not a part of the GB of the facility. He revealed he only conducted the medical portion of care. He revealed he attended QAPI by phone or in person. However, the ED never vocally or in writing identified the QAPI meetings as a dual meeting for GB during the attended meetings. He revealed he had not discussed with anyone, including the CFO/COO about participation in a GB. Interview with the RDO, 04/02/2021 at 11:16 AM, revealed she did not work for the facility but consulted with the facility for a consultation agency. She revealed the facility held QAPI/GB at the same time because the agenda and members were the same. She revealed she attended the facility QAPI/GB meeting either in person or by phone. She revealed she and the VPO were members of the GB committee. She revealed she reviewed with the facility the discussed topic, which may require an improvement plan and made recommendations to the facility. She revealed she reported recommendations, follow-up, and resolutions of the facility consultation for concerns to the VPO. She revealed she did not have a set schedule to meet with the facility before surveys but had been in the building at least weekly. She revealed she reviewed the completed audits of the facility's improvement plans to ensure resolution by discussion and observations. She revealed she consulted with the facility to ensure resident care followed the regulations required by the state and federal guidelines; and the facility held the responsibility to act on the recommendations, to ensure the facility met the care and service needs for the residents. However, she revealed the consultation company and the facility did not identify issues prior to survey which the survey identified. Interview with the VPO, on 04/03/2021 at 9:11 AM, revealed she did not work for the facility but consulted with the facility for her consultation agency. She revealed the facility held QAPI/GB meetings together because the content covered, and members were the same. She revealed she and the RDO identified facility issues, cause, and resolution under the responsibilities as part of their duties under the services provided by the agency. The facility QAPI team included the ED, DNS, MD, and the clinical supervisors for the facility. She revealed the RDO attended the QAPI/GB meetings and the RDO reported to her and she reviewed weekly reports submitted by the ED. However, on 03/25/2021, she revealed the facility conducted the first GB meeting with all the members present. She revealed the COO/CEOs or Board of Directors did not meet as part of the GB. She further revealed the facility was a stand-alone facility that was responsible for the care and services for the residents under a Limited Liability Company (LLC), which featured both partnerships and a traditional corporation. The VPO revealed the facility did not report to her or the RDO the identified survey concerns related to jeopardy or the other identified care areas. In addition the VPO revealed the consultation members did not identify issues in the areas with jeopardy. The facility alleged it implemented the following actions to remove immediacy: 1. The facility held a QAPI meeting on, 03/24/2021, to discuss F656, F689, F726, F692, F693, F755, F835, and F865, to discuss abatement and interventions. The ED, DNS Regional Nurse Consultant, RDO, and Medical Director met on 03/24/2021 and 03/25/2021 to discuss Governing Body. 2. Review of the 01/2021, 02/2021, and 03/2021 QAPI meeting notes were reviewed by the ED for trends and used the fishbone diagram for root cause on 03/24/2021. On 03/25/2021, the ED shared the notes with the QAPI team ad hoc. 3. On 03/24/2021, the RDO educated the QAPI committee on the QA process and audit calendar. The RDO and VPO met and provided education to the ED, DNE, and Medical Directors for Governing Body (GB) duties, on 03/25/2021. The fish bone diagram tool would be utilized for root cause analysis. 4. The facility QAPI committee would meet twice weekly until abatement. Then the QAPI committee would be held bi-weekly for three months, then monthly. In addition, a regional QAPI meeting would be held weekly for four weeks with the regional team in attendance and then monthly. The Regional team included the RDO and VPO. 5. The Governing Body meeting would occur quarterly for the year and then reevaluate. The SSA validated the facility implemented the following actions: 1. Interview with the ED, on 04/03/2021 at 2:00 PM, revealed the facility held a meeting on 03/24/2021 and on 03/25/2021 for a Governing Body meeting. The meetings were held to discuss the abatement the areas of jeopardy. She revealed she reviewed three months of QAPI notes, plans, and shared with the GB and QAPI committee. She revealed a fishbone diagram was used to determine root causes for each area. She revealed the received education for the QA process and the audit calendar, as well of the responsibility of the Governing Body. 2. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed he attended meetings on 03/24/2021 and 03/25/2021 for QAPI and GB. He revealed the RDO educated on the duties of the members of the Governing Body, QA process, root cause analysis, the QAPI calendar, and the use of the fishbone diagram for root cause. He revealed the GB would meet quarterly as a separate entity for a year. 3. Interview with the Medical Director, on 04/02/2021 at 11:16 PM, revealed the GB met on 03/24/2021 and on 03/25/2021 with attendance on the phone and then in person. He revealed the ED reviewed the responsibilities of the GB with policy, procedure, and the QAPI process to ensure in the future the facility resident's received the care by the policies of the facility. He revealed the ED, DNS, RDO, and VPO discussed what the GB meetings would be in the future with quarterly meetings. He further revealed QAPI meetings were increased to twice a month for three months until the GB and QAPI committee concluded the facility could continue the achieved care without continued audits. 4. Interview with the RDO, on 04/03/2021 at 9:11 AM, revealed the GB meet on 3/24/2021 and 03/25/2021 with the QAPI meeting to discuss the immediacy notification. She revealed the ED reviewed past QAPI with the committee's and past Process Improvement Plans (PIP). She revealed the committee' were educated on the QAPI process and calendar for review of systems in the facility. She revealed she consulted with the ED for success of abatement. She further revealed the facility would increase QAPI meetings to twice a month for three months and then return to the monthly schedule. She revealed the GB committee would meet every three months. Furthermore, she revealed the facility used the fishbone diagram for root cause analysis for all notified immediate jeopardizes in order to formulate the plan for abatement. 5. Interview with the VPO, on 04/02/2021 at 11:25 AM, revealed she attended all meetings in the facility during the abatement formulation process and to provide over site consultation for success. She revealed the RDO provided education to the facility administration for GB and QAPI duties and expectations. She revealed the facility increased QAPI meetings and set a quarterly meeting for the GB. She revealed the RDO would be in all QAPI/GB meetings which would be reported to her and she would review reports submitted by the ED to ensure the facility met compliance. Furthermore, all reports would be sent to the Corporate Compliance Officer for further review of all audits and report after her review.

Based on interview, record review and review of the facility's policy it was determined the facility failed to have an effective system to maintain a Quality Assurance Performance Improvement (QAPI) program which developed and implemented plans of action to correct system failures in a manner to maintain compliance. The facility failed to ensure residents were free from accidents/hazards, and provided nutrition and hydration. In addition, the facility failed to ensure residents were monitored for weight loss and their care plans implemented. Further it was determine nursing applicants employed by the facility were not provided supervision and or had licensed nurse immediately available to assist with provision of resident care. Additionally, the facility failed to ensure infection control practices cited from the 11/16/2020 survey were monitored to identify infection control risks and resulted in F880 as a repeat deficiency. (Refer to F656, F689, F692, F693, F726, F755, F835, F837, F865, and F880). The facility's failure to provide an effective QAPI program that identified, developed and implemented plans of action to correct quality deficiencies has caused or is likely to cause serious injury, harm, impairment or death to residents. An abbreviated survey was initiated 03/03/2021 to investigate KY , KY , KY , KY , KY , KY , KY , KY , KY , KY , and KY . Immediate jeopardy was identified on 03/07/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of J; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of L. Substandard quality of care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the immediate jeopardy on 03/07/2021. The abbreviated survey transitioned to a standard health recertification survey on 03/09/2021. Additional complaints were investigated, including KY , KY , KY , and KY . Immediate Jeopardy was identified on 03/21/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of J and F693 Tube Feeding Management/Restore Eating Skills at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of K; 42 CFR 483.70 Administration, F835 Administration at a S/S of L, ; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities at a S/S of L. Substandard Quality of Care was identified at 42 CFR 483.25, F692 Nutrition/Hydration Status Maintenance, and F693 Tube Feeding Management/Restore Eating Skills. The facility was notified of these immediate jeopardy on 03/21/2021. After supervisory review immediate jeopardy was identified on 03/24/2021 and determined to exist on 07/09/2020 in the area of 42 CFR 483.70 Administration, F837 Governing Body at a S/S of L. Additional deficiencies were cited in the areas of 42 CFR 483.10 Resident Rights, F550 Resident Rights/Exercise of Rights at a S/S of D, F553 Right to Participate in Planning Care at a S/S of D, F558 Reasonable Accommodations of Needs/Preferences at a S/S of E, F583 Personal Privacy/Confidentiality of Records at a S/S of D, and F584 Safe/Clean/comfortable/Homelike Environment at a S/S of F; 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F606 Not Employ/Engage Staff with Adverse Actions at a S/S of F, and F609 Reporting of Alleged Violations at a S/S of D; 42 CFR 483.20 Resident Assessments, F641 Accuracy of Assessments at a S/S of E; 42 Comprehensive Resident Centered Care Plans, F657 Care Plan Timing and Revision at a S/S of D; 42 CFR 483.24 Quality of Life, F677 ADL Care Provided for Dependent Residents at a S/S of D; 42 CFR 483.35 Nursing Services, F725 Sufficient Nursing Staff at a S/S of E; 42 CFR 483.45 Pharmacy Services, F759 Free of Medication Error Rates of 5% or More at a S/S of F and F761 Label/Store Drugs & Biologicals at a S/S F; 42 CFR 483.60 Food and Nutrition Services, F812 Food Procurement, Store/Prepare/Serve - Sanitary at S/S of F; and 42 CFR 483.80 Infection Control, F880 Infection Prevention and Control at a S/S of F. Additional substandard quality of care was identified at 42 CFR 483.10 Resident Rights, F584 Safe/Clean/Comfortable/Homelike Environment; 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F606 Not Employ/Engage Staff with Adverse Events; and F759 42 CFR 483.45 Pharmacy Services. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified, on 03/07/2021, and was determined to exist on 12/17/2020, in the areas of 42 CFR 483.25 Quality of Care (F689 at S/S of J); and, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 at S/S of K). The facility provided an acceptable Credible Allegation of Compliance (AoC) on 03/30/2021, alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 03/30/2021, as alleged, prior to exit on 04/03/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The facility provided an acceptable credible Allegation of Compliance (AoC) on 03/30/2021, alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 03/30//2021, as alleged, prior to exit on 04/03/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility untitled policy statement, undated, revealed the facility process for QAPI included to monitor, evaluate, and follow-up to continue improvement in the facility. The QAPI consisted of a systematic comprehensive, data-driven approach for performance improvement. The committee identified opportunity for improvement, addressed system break down or process, developed, implemented, and monitored the effectiveness of the interventions at each monthly meeting. The Executive Director (ED) served as the QAPI chair person. Department heads completed the Quality Assessment Tool (QAT). The QAPI team would incorporate direct care staff, department team members, or family as needed. Department directors who identified an area or process to improve conducted a root cause analysis, developed and initiate an action plan, and guided systematic change for the area which needed improvement. Discussion of the facility QAPI initiatives occurred with resident council, family meetings, and orientation with staff as needed. A Pharmacy consultant should attend QAPI as able. Completed QA tools were shown to surveyors as requested. However, all other documents (completed tools, tracking forms) were internal documents and did not need to be shared. One of the tracking forms included the Resident Council minutes and these concerns were added to QAPI. In addition, the facility QAPI was an improvement process for performance base on data which would fix and resolve an issue rather than a continued Band-Aid or provide a quick fix. In addition, the QAPI policy included Governing Body (GB) to which the GB responsibilities included to develop and implement the facility QAPI program. Interview with the Director of Nursing Service (DNS), on 03/2/2021 at 12:58 PM, revealed he had only attended one QAPI since becoming DNS. He stated the facility did identify issues with medication availability through resident complaints. He stated the facility just initiated an automatic refill process for all resident medications except scheduled medications. He stated the facility initiated this because residents complained they did not receive ordered medication because they were unavailable so they took the reorder process to an automatic reorder. He stated the facility had many areas to improve for resident care, and the processes to ensure care and services were provided. He stated his expectation would be for the facility to provide the best care and services for the residents; because the residents in the facility required assistance or else they would not be in the facility. He stated going forward the facility clinical care would improve with the DNS input and over site of clinical care, which would include the QAPI process to look at all services after completion of survey requirements. Interview with the Executive Director (ED), on 04/03/2021 at 2:00 PM, revealed the facility gathered information through audits, chart review, review of new admissions, quality tools filled out by the department heads, trends, discussions with staff, observations, and complaints from residents or family. She stated as the head of QAPI she directed and guided the facility for good service and care for the residents. She stated the facility could not provide or allow the survey team to review audit tools gathered for QAPI determination because they were part of the QAPI process. She stated the facility did not have floor staff on the QAPI committee. The ED stated the QAPI committee included members of the clinical management team who completed monthly audits from the QAPI audit form. The ED stated the tool included staff interviews and this met the requirement to have front line staff involved with QAPI. She stated she had the responsibility to ensure the QAPI process identified areas for improvement. She stated the consultants ensured identified concerned were followed through with the QAPI process and the concern was resolved or improved. The ED stated the committee removed concerns from the QAPI ongoing audits by observations, interviews, record review, reports, and resident satisfaction. In addition, she stated the facility identified process issues with the reorder of resident medications through resident complaints. The ED stated the facility recently initiated automatic refills for all routine medications. She stated the facility identified scheduled medication refills as well. However, she stated the facility needed to work with the providers for a better process. She further stated the facility QAPI committee and GB members did not identify or come to her with identified issues for citations identified on survey. Further interview, on 03/21/2021 at 2:26 PM, with the ED revealed she was responsible to ensure the facility followed KBN requirements for the RNAs and LPNA. She stated she, the DNS at the time, and Human Resources (HR) made the decision to hire RNAs and LPNAs. The Executive Director revealed the Quality Assurance (QA) committee did not discuss use of the RNAs or LPN in the facility. She further revealed she did not inform or seek approval from higher up in the corporation. Interview with the Pulmonary Medical Director (PMD), 03/20/2021 at 9:30 AM, revealed he attended QAPI or the facility kept him up to date with QAPI results and plans. He stated he brought concerns to the ED for resident care needs to QAPI. He stated he saw residents twice a week to ensure their needs were met and that any QAPI identified concerns had improved. He further stated his practitioners had not identified nor had he identified concerns to bring and discuss in the QAPI meetings for the areas of the notified jeopardy's. Interview with the Medical Director (MD), on 03/20/2021 at 12:01 AM, revealed he attended QAPI by phone or in person. He stated the facility had marked improvement from a year prior. He stated he brought concerns to the ED, which were discussed in QAPI. He stated the facility, nor he, had identified issues identified on survey. He stated the facility had consultants in the building to help identify issues and concerns. He stated the consultant reviewed and made suggestions for improvement for care, services, and physical needs of the building. He stated when he came to the facility a year ago the whole facility smelled of urine. He stated he immediately brought this the ED and QAPI was started with good resolution. He stated he did not except anything but high quality of care for the residents under his and the facility care. However, he further stated the facility had a long way to go with improvements. Interview with the Regional Director of Operations (RDO), 04/02/2021 at 11:16 AM, revealed she provided consultation services to the facility. She stated she attended or was involved with QAPI/GB over site. She stated she made suggestions for care, services, and improvement for the facility with identified issues. She stated identified issues were brought to QAPI, with the identification of a root cause and used the fishbone diagram. She stated she reviewed the facility QAPI, audit tools, monthly reports, spoke with staff, residents and department heads to help identify issues for improvement. However, her time in the building was dictated by the needs in the facility. In addition, she continued constant contact with the ED, when she was not physical in the building. The RDO stated the QAPI/GB identified agency staff, who did not have a commitment to residents, as a factor for the identified issues through the QAPI process. She stated the goal of the facility included not to use agency staff, hire for the Staff Development position, and bring the level of care identified by survey into compliance working with the ED. Interview with the Vice President of Operations (VPO), on 04/03/2021 at 9:11 AM, revealed she provided consultation to the ED for over site with the facility. She stated she could not be in the facility weekly for observations and review of services. However, the RDO gave frequent reports verbally and written, which she reviewed because the RDO could spend more time for the needs of the facility. She stated the RDO role included to help resolve issues identified through QAPI. She stated the ED was ultimately responsible to ensure the compliance in the facility through QAPI. However, she stated the RDO nor the ED had identified systemic process issues which needed to be brought to QAPI. She stated the identified care issues with notification of immediate jeopardy determined a need to review of the ability of the ED to effectively oversee the care and services for the residents in the facility with a total census capability of one hundred and seven (107). Review of the facility Plan of Correction from the State Survey Agency (SSA) Covid-19 Focused Infection Control Survey, dated 11/16/2020 through 11/17/2020, revealed F880 was cited as a scope and severity of a D. The Plan of Corrective, revealed the Director of Nursing Services (DNS) and other members of the clinical team would round the facility five (5) days a week for three (3) weeks to ensure staff appropriately used PPE and infection control procedures were followed on each unit. Results were forwarded to the QAPI committee for review. However, observation, on 03/04/2021 at 8:41 AM, of the F hall revealed a yellow zone sign on F6's door, with listed PPE required included a gown with each encounter. Certified Nurse Aide (CNA) #8 entered the room without putting on a gown. Observation of CNA #5, on 03/09/2021 at 12:50 PM, on the G Hall (the yellow zone) revealed the CNA did not don (put on) gloves before entering seven (7) isolation rooms during lunch tray delivery. Observation, on 03/09/2021 at 8:42 AM, revealed a yellow zone sign on Resident #24's door, with PPE required included a gown. CNA #20 entered the resident's room with towels, without putting on a gown. The aide exited the room at 8:51 AM with a trash bag of items and placed the bag in a hallway closet Observation of RN #10, on 03/11/2021 at 4:10 AM, revealed the RN sitting at nurse's station without a mask or eye protection. On 03/03/2021 at 3:04 PM, observation of the F Hall revealed Registered Nurse (RN) #12 entered Resident #24's room, without putting on a gown. The RN left the room still wearing gloves. On 03/19/2021 at 10:08 AM, interview with the DNS revealed he provided on the spot education to staff when he identified infection control risks. He stated he rounded the facility and did not identify any systemic concerns which needed to be addressed in QAPI. Interview with the Executive Director (ED), on 04/02/2021 at 2:31 PM, revealed QAPI committee identified infection control issues in November 2020 and conducted frequent audits. She stated infection control issues were isolated instances to particular team members. She revealed QAPI audits monitored use of personal protective equipment (PPE) and hand hygiene. She stated she was unsure of the current frequency of QAPI audits for infection control and no other concerns were identified which needed to be addressed with QAPI to resume the Improvement Plan or generate a new Performance Improvement Plan. The facility alleged it implemented the following actions to remove immediacy: 1. The facility held a QAPI meeting on, 03/24/2021 and continued the meeting on 03/25/2021 to review, identify, and plan on what the facility needed to do to remove the immediate jeopardy for F656, F689, F726, F692, F693, F755, F835, and F865. Attendee's included the ED, Regional Nurse Consultant (RCC), Medical Directors, DNS, and the RDO. 2. The ED reviewed the 01/2021, 02/2021, and 03/2021 QAPI meeting notes for trends and shared with the committee. The ED and committee used the fishbone diagram for root cause identification. The ad hoc QAPI meeting on 03/24/2021 and on 03/25/2021 discussed all relevant factors and findings related to the jeopardy's. 3. On 03/24/2021 the RDO educated the QAPI committee on the QA process and audit calendar. The committee members included the ED, DNE, Assistant DNE, Activity Director (AD) , Housekeeping Manager (HM), Admissions, Maintenance Director, and Medical Records (MR). 4. On 03/25/2021, the RDO and VPO provided education to the ED, DNS, and Medical Directors for the Quality Assurance Analysis (QAA) process for the QAPI process, participation, and the need to identify root causes of identified concerns. The facility would utilize the fish bone diagram tool for root cause analysis, which followed federal guidelines and the audit. The QAPI committee would follow the QAPI calendar for auditing systems in the facility. 5. The facility QAPI committee would meet twice weekly until abatement. Then the QAPI committee would be held weekly for four weeks, then bi-monthly for three months, then monthly. In addition, a regional team person would attend weekly QAPI meetings until abatement was achieved and then monthly. 6. The ED would forward all QAPI meeting minutes to the VPO, Regional VPO, DNS, and MD for review. The facility would forward all audit results and results from the QAPI calendar to the Corporate Compliance Officer (CCO) for review. The SSA validated the facility implemented the following actions: 1. Interview with the QAPI committee members, on 04/03/2021 at 8:33 AM, revealed the members in attendance included the AD, HM, Admissions Director, Maintenance Director, and Medical Records (MR). The committee staff stated to have received education from the RDO for the QAPI process, expectations, and the QAPI calendar. The committee members stated the jeopardy's were reviewed and then they were dismissed because they were not clinical staff. 2. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed he attended meetings on 03/24/2021 and 03/25/2021 for QAPI. He stated the RDO and VPO educated the committee on duties, QAA process, root cause analysis, reviewed the QAPI calendar and reasons to follow the calendar. He stated the facility used of the fishbone diagram to identify root cause. He stated the facility started audits for the identified jeopardy's 3. Interview with the ED, on 04/03/2021 at 2:00 PM, revealed the facility held an ad hoc QAPI meeting on 03/24/2021 and on 03/25/2021 with all the QAPI committee members. The meetings were held to discuss the abatement for the areas of jeopardy. She stated she reviewed three months of QAPI notes, plans, and shared with the GB and QAPI committee to identify trends. She stated the facility used the fishbone diagram to determine a root causes for every area. She stated the RDO and VPO provided education for the QAA process and the QAPI audit calendar. She stated all audits will be forwarded to the RDO, VPO, and CCO for review during and after abatement. She further stated the facility held twice a week meetings until notified of abatement. Then the committee would meet weekly and then bimonthly for three months. She stated the facility would return to monthly when all area's continued to show compliance. She stated the RDO or VPO would attend QAPI monthly. 4. Interview with the Medical Director, on 04/02/2021 at 11:16 PM, revealed the QAPI committee met on 03/24/2021 and on 03/25/2021. He stated he attended on the phone and then in person. He stated the RDO and VPO educated the team on the QAPI process and discussed to ensure the QAPI calendar was followed. He stated the ED and RDO reviewed the root cause found for the notified jeopardy's. and the clinical team completed what audits were to be completed and by whom. 5. Interview with the RDO, on 04/03/2021 at 9:11 AM, revealed the full QAPI committee met on 3/24/2021 and she provided education for the QAA and QAPI process with emphasis on the QAPI calendar. She stated on 03/25/2021 the RDO and VPO discussed the clinical portion for abatement for the jeopardy notification. She stated the facility increased the QAPI meetings to twice a week until abatement, weekly for four weeks and then twice a month for three months with the return to a monthly schedule. She stated she would attend the QAPI meetings monthly and report to the VPO. 6. Interview with the VPO, on 04/02/2021 at 11:25 AM, revealed she attended all QAPI meetings in the facility during the abatement process. She stated she educated the ED, DNS, and ADNS on the QAPI process and expectations. She stated the RDO would attend monthly QAPI meetings and report back to her. She stated the CCO would receive all audits and QAPI minutes to review for compliance.

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure those with a provisional license were provided with direct supervision while providing resident care. The facility failed to ensure, per the Kentucky Board of Nursing regulatory requirements, that six (6) Registered Nurse Applicants (RNA) were provided direct supervision by a Registered Nurse (RN) during the provision of resident care. In addition, the facility failed to ensure one (1) Licensed Practical Nurse Applicant (LPNA) was provided direct supervision by a RN or Licensed Practical Nurse (LPN) during the provision of resident care, and licensed staff were at all times physically present in the facility and immediately available to applicants while the applicants held a provisional license. The facility utilized the RNAs and LPNAs independently, on six (6) out of seven (7) halls (A/B, C/D, and E/F), across all three (3) shifts, and across all seven (7) days of the week, for a total sample of sixty-nine (69) residents. In addition, the facility did not obtain or track competencies prior to independent work. The facility's failure to have sufficient licensed staff to monitor/supervise unlicensed staff (RNAs and LPNA) that provided nursing services to assure resident safety has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy was identified on 03/07/2021 and determined to exist on 12/17/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of K; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of L. Substandard quality of care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the immediate jeopardies on 03/07/2021. Immediate Jeopardy was identified on 03/21/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of J and F693 Tube Feeding Management/Restore Eating Skills at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of K; 42 CFR 483.70 Administration, F835 Administration at a S/S of L; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F865 QAPI Program/Plan, disclosure/Good Faith Attempt at a S/S of L. Substandard Quality of Care was identified at 42 CFR 483.25, F692 Nutrition/Hydration Status Maintenance and F693 Tube Feeding Managment/Restore Eating Skills. The facility was notified of these immediate jeopardies on 03/21/2021. After supervisory review immediate jeopardy was identified on 03/24/2021 and determined to exist on 07/09/2020 in the area of 42 CFR 483.70 Administration, F837 Governing Body at a S/S of L. The facility provided an acceptable credible Allegation of Compliance (AoC) on 03/30/2021, alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 03/30/2021, as alleged, prior to exit on 04/03/2021, with remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of E; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of D; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of F; 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of D and F693 Tube Feeding Management/Restore Eating Skills at a S/S of D; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of E; 42 CFR 483.70 Administration, F835 Administration at a S/S of F; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F865 QAPI Program/Plan, disclosure/Good Faith Attempt at a S/S of F, and, 42 CFR 483.70 Administration, F837 Governing Body at a S/S of F, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: 1. Review of the Kentucky Board of Nursing (KBN) website https://kbn.ky.gov/ revealed a Provisional License (PL) was invalidated upon unsuccessful completion of the NCLEX (the national exam to license nurses in the United States). Practice on a PL required direct supervision and required the nurse responsible for the applicant should at all times be physically present in the facility and immediately available to the applicant during work hours while the applicant held a PL. An RNA required direct supervision by a Registered Nurse (RN) or Advanced Practice Registered Nurse (APRN) and an LPNA required direct supervision by an LPN, RN, or APRN. Additionally, practice under a PL required use of the title RN Applicant (RNA) or LPN Applicant (LPNA). The PL required practice under direct supervision until full licensure was issued. Review of the facility policy Credentialing of Nursing Service Personnel, revised May 2019, revealed nursing personnel who require a license to perform resident care or treatment without direction or supervision must present verification of such license prior to or upon employment. Nursing personnel who require a license were not permitted to perform direct resident care services until a licensing check was completed. The Director of Nursing Services (DNS) or designee would contact the appropriate state licensing board to obtain verification/computer printout of the license. Inquiries concerning credentialing were referred to the Executive Director or DNS. Review of RNA #1, #2, #3, #4, #5, ad #6 Personnel Files, revealed each RNA held a provisional license (PL) with the KBN. Review of the KBN Online Validation Results for each RNA, revealed the individual must practice under the direct supervision of an Advanced Nurse Practitioner (APRN) or a RN. Review of RNA #1's Personnel File, revealed the facility hired the RNA on 10/01/2020. The KBN Online Validation Result, revealed the RNA held a PL with an expiration date of 08/05/2021. The signed Job Description by the RNA was for an RN. Review of RNA #2's Personnel File, revealed the facility hired the RNA on 10/01/2020. The KBN Online Validation Result, revealed the RNA held a PL with an expiration date of 03/24/2021. The signed Job Description by the RNA was for an RN. Review of RNA #3's Personnel File, revealed the facility hired RNA #3, on 07/09/2020. The KBN Online Validation Result revealed the RNA held a PL with an expiration date of 06/29/2021. The signed Job Description by the RNA and the Executive Director, dated 07/10/2020, was for an RN. Review of RNA #4's Personnel File, revealed the facility hired RNA #4, on 09/24/2020. The KBN Online Validation Result revealed the RNA held a PL with an expiration date of 08/31/2021. The Job Description signed by the RNA and the Executive Director, on 09/24/2020, was for an RN. Review of RNA #5 and RNA #6 Personnel Files, revealed the facility hired both RNAs on 10/06/2020. RNA #5 had a signed job description for an RN. The facility was unable to provide a signed job description for RNA #6. Review of the personnel file for LPNA #1, revealed the LPNA began employment at the facility on 01/19/2021. Review of the KBN Online Validation Results for licensure verification, dated 01/05/2021, revealed the LPNA held a PL with an expiration date of 05/29/2021. The results also revealed the individual must practice under the direct supervision of an Advanced Nurse Practitioner (APRN), a Registered Nurse (RN), or Licensed Practical Nurse (LPN). Review of the signed Job Description by the LPNA, revealed she signed the job description for an LPN, on 01/19/2021. On 03/12/2021 at 9:14 AM, interview with the HR Manager revealed she was re-hired on 12/22/2020. She stated the RNAs had already been working the floor when she started. She stated she did not hire any RNAs, however she did hire the LPNA. She revealed the Scheduler and Executive Director informed her the RNAs worked in the facility. She stated the Scheduler was responsible for who the RNAs and LPNA oriented with, and those nurses were responsible to supervise the PL nurse. The HR Manager stated the RNAs and LPNAs orient on the floor for two (2) weeks, or longer if needed. She revealed she checked in with LPNA #1 once a week to see if she had any concerns, and her floor orientation lasted three (3) weeks. She stated she provided LPNA #1 a skills checklist, however she had not followed up and had not gotten it back from LPNA #1. She revealed she was unable to find any skills checklists for any of the RNAs hired before she started. The HR Manager further revealed after they completed floor orientation, the RNAs and LPNA were scheduled on a cart on the floor. She revealed she would check with the nurse orienting the applicants to see how they were doing, however there was no documentation of this. The HR Manager stated the facility did not have a Staff Development Coordinator (SDC); however, the ADNS performed some of the SDC duties, as well as the DNS. She revealed the A in RNA and LPNA referred to a Nurse Applicant, who had completed education but must be supervised. She stated supervision did not mean with someone the entire time, but paired up with to double check the RNAs and LPNA work for accuracy for the entire shift. She stated if the nurse went to lunch, another nurse would need to take over or they would take lunch at the same time. The HR Manager stated there was no official training program to train an orientee and training was based on the new employee's experience. Additionally, she stated there was no official evaluation after floor orientation. She revealed the ADNS and DNS were responsible to know the KBN requirements for the RNAs and LPNAs and they had a corporate support staff as well. She revealed she checked the RNAs and LPNA licensure in January 2021 as the RNAs and LPNAs have different expiration dates than the RNs and LPNs. She stated the RNAs and LPNA were listed in the computer as RN and LPN as the system did not have a code for RNA or LPNA. She stated if the nurse applicant's documented in the chart, it could appear as if they were an RN or LPN. Interview with the Scheduler, on 03/10/2021 at 11:38 AM, revealed the RNAs and LPNA were provisional nurses and thought they had forty-five (45) days to take the NCLEX licensure exam. He stated the RNAs and LPNA were trained three (3) to four (4) weeks. The Scheduler revealed the RNAs trained with an RN, and the LPNA trained with an LPN or RN. He stated the facility had not used RNAs or LPNAs before the pandemic. He stated the ADNS was responsible to check and document the RNAs and LPNA skills in orientation. He further stated once the nurse applicants felt comfortable, they were assigned to work independently by themselves. The Scheduler revealed if the RNAs or LPNA had questions they could go to another nurse or the ADNS. He stated he was informed the RNAs and LPNA did not require one to one (1:1) supervision, only that an RN was in the building. He revealed an RN scheduled on the COVID unit did not meet the requirement as that nurse was not available to help the RNA or LPNA. He further revealed he scheduled an RNA on the COVID unit, who could call the ADNS to come in if needed. The Scheduler revealed the ADNS was not in the building at night, and would therefore not meet the KBN requirement for direct supervision. Review of the Nursing Daily Schedule, dated 12/17/2020 and 12/18/2020, revealed an RNA was scheduled as the only nurse on the COVID unit from 7:00 PM to 7:00 AM. Review of the facility Nursing Daily Schedules, dated 03/01/2021 through 03/07/2021, revealed the facility scheduled LPNA #1 and RNA #1 through RNA #6, as the only nurses on their hall for six (6) out of seven (7) halls (A/B, C/D, and E/F), across all three (3) shifts, and across all seven (7) days of the week. The schedule, dated 03/03/2021, revealed between 11:00 PM and 7:00 AM, RNA #3 worked the E/F Unit and the only other scheduled RN worked the COVID unit. Continued review of the schedule, dated 03/06/2021, revealed between 7:00 PM and 11:00 PM the facility scheduled a RNA on the C/D unit and the only other RN in the building scheduled on the COVID unit. Review of the facility Nursing Daily Schedule, dated 03/03/2021, revealed Registered Nurse Applicant (RNA) #3 was scheduled as the only nurse on the E/F Unit (covering both E and F Halls) from 11:00 PM to 7:00 AM. Review of the COVID unit schedule, dated 03/03/2021, revealed RN #10 was scheduled as the only nurse on the COVID unit. RN #10 was the only RN scheduled in the building from 11:00 PM to 7:00 AM. Interview with the Scheduler, on 03/10/2021 at 11:38 AM, revealed an RN scheduled on the COVID unit was not available to assist the scheduled RNA on another unit. He stated he was informed an RN had to be in the building, but did not need to provide one to one (1:1) supervision. The Scheduler revealed an RN scheduled on the COVID unit did not meet the requirement to be available to help the RNA as the RN could not leave the COVID unit to another part of the building. Interview with LPNA #1, on 03/04/2021 at 6:10 AM, revealed she had been employed by the facility for three (3) months and referred to herself as a LPN. She stated she was assigned to the A/B Hall with twenty (20) residents. She also stated she oriented LPN #6 to work the floor for a total of two (2) shifts. Review of the facility Nursing Daily Schedule, dated 03/04/2021, revealed RNA #1 was scheduled as the only nurse on the E Hall from 07:00 AM to 3:00 PM. Review of the Nursing Daily Schedule, dated 03/05/2021, revealed RNA #1 was scheduled as the only nurse on the E Hall from 7:00 AM to 3:00 PM, and RNA #2 was scheduled as the only nurse on the F Hall from 7:00 AM to 3:00 PM. Observation of RNA #1, on 03/06/2021 at 11:45 AM, revealed he worked independently and flushed a resident's G-tube, which did not have a gauze dressing present around the tube and crust-like drainage was noted. RNA #1 stated he would clean the site later. Interview with RNA #1, on 03/04/2021 at 7:24 AM, revealed he identified himself as a RN. He stated he was the only nurse on the E Hall at the time. Further interview with RNA #1, on 03/05/2021 at 2:04 PM, revealed he identified himself as an RN and was hired as a nurse. He stated he worked for the facility about six (6) months. He revealed he did not know what the A in RNA meant. The RNA stated he was an RN for six (6) months and had not yet scheduled the exam for licensure. RNA #1 further stated he planned to take the exam in June or July 2021. He stated he worked as the only nurse on the floor on the E Hall. The RNA revealed he oriented on the floor with another nurse about two (2) weeks and then worked as the only nurse after those two (2) weeks of orientation. He stated he ensured residents were safe, administered medications, even via resident G-tubes. He stated he administered insulin and continuous feeding for residents with a g-tube. Provided residents oxygen therapy and assessed vital signs and oxygen saturation. RNA #1 stated he conducted new admissions assessments for resident newly admitted from the hospital or another facility. He notified physician or NP of change in condition, and performed skin assessments and wound care. He further stated if he had concerns or questions he would go to the supervisor or the Administrator (who was not a nurse). Observation of RNA #2, on 03/06/2021 at 11:20 AM, revealed she checked a resident's blood sugar in room D3 and administered insulin via insulin pen into the left upper arm, with no concerns noted. Additional observation of RNA #2, on 03/06/2021 at 1:20 PM, revealed he worked independently and administered insulin via syringe in room E7 a resident's right lower abdomen and administered an oral medication with no concerns noted. Interview on 03/05/2021 at 10:21 AM, with RNA #2, revealed she identified herself as a RN and the facility hired her as a nurse about five (5) to six (6) months ago. She stated she did not know what the A in RNA stood for. She revealed she provided care to residents can we say unsupervised here?? such as blood pressure checks, obtaining blood sugar, medication administration, and completing pain assessments and assessments for medication effectiveness. She also stated she provided Gastrostomy Tube (g-tube) care, including check patency and placement. She stated she administered medications through the g-tube also. RNA #2 revealed she conducted lung assessments, assessed oxygen saturation and respiration rate. The RNA further revealed she conducted neurological checks, wound assessments and wound care. She stated she conducted skilled nursing assessments, documented skilled nurse's notes, completed skin assessments, and monitored intake and output. She revealed when the facility hired her as a nurse, she oriented with another nurse on the floor for two (2) weeks. She further revealed after the two (2) weeks of floor orientation with another nurse she began working alone. RNA #2 stated if she had questions regarding what to do for a resident she did not know who she would go to for help and would just ask the first nurse she saw. Interview on 03/04/2021 at 6:14 AM, with Registered Nurse Applicant (RNA) #3, revealed he was the only nurse on the E/F Unit after 11:00 PM. The RNA identified himself as an RN. He stated the night House Supervisor (an LPN) was available if he needed assistance. Interview on the E/F Unit with the House Supervisor, on 03/04/2021 at 6:14 AM, revealed she was an LPN and it was her first night back working for the facility. She stated she could help RNA #3 if needed. On 03/04/2021 at 2:25 PM, interview with RN #8, revealed she worked on 12/17/2020 and she was the only nurse on the F Hall, and RNA #4 was the only nurse on the E Hall. The RN stated RNA #4 worked independently. On 03/05/2021 at 10:55 AM, interview with RNA #4, revealed she identified herself as an RNA and still needed to take the exam for licensure. She stated she had not yet scheduled the test. The RNA stated she began employment at the facility as a nurse in October 2020. She revealed when Resident #248 eloped, on 12/17/2020, she was the only nurse assigned to the E Hall and the other nurse, RN #8, worked the F Hall. She stated there was usually only one (1) nurse assigned the E Hall from 3:00 PM until 11:00 PM. She revealed she completed all nursing activities on her shift including: medication administration and documentation on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she checked vital signs, completed assessments, made skilled notes, and obtained new physician or NP orders. She stated she provided test results to the physician and NP, observed resident intake of meals, checked blood sugar and gave insulin. In addition, she assessed and cared for g-tubes and removed Foley catheters. She revealed when she began employment with the facility, she oriented on the floor with another nurse for two (2) weeks and the other nurse said her orientation was up. She revealed if she needed assistance she could ask a more experienced nurse. RNA #4 stated the nurse scheduled on the F Hall recently, was an LPN. Interview with LPN #6, on 03/11/2021 at 4:12 AM, revealed she was employed with the facility for five (5) shifts. She further stated two (2) of her three (3) orientation shifts were provided by LPNA #1. LPN #6 revealed LPNA #1 showed her, during her orientation, the process of [CONDITION(S)] care as she was unfamiliar with the task. Interview on 03/12/2021 at 8:47 AM, with the Assistant Director of Nursing Services (ADNS), revealed she worked for the facility for four (4) weeks. She stated she was the only ADNS at the time. She stated the facility did not have an Staff Development Coordinator at the time and was unaware who was performing those duties. She revealed she was still learning her role and was unaware of the process for using RNAs and LPNAs. She stated the A stood for Applicant and the RNAs and LPNA had a PL. The ADNS stated she had not worked with the RNAs and LPNA and was unsure what they could or could not do in their roles. She revealed she was ADNS for the entire building, however she supervised the E/F Unit and was unaware who supervised the A/B, C/D, or G Units. She stated the RNAs had not come to her with questions, concerns, or need of assistance as they would go to the DNS. She revealed she was not asked, and did not keep documentation, on the nurse applicants and had not been presented with any documentation. She further revealed no one had asked her how the RNAs progressed and was unaware who was responsible to follow up with the RNAs and LPNA. The ADNS stated she did not know if they worked independently as a nurse on the floor, or under supervision. Continued interview with the ADNS, on 03/15/2021 at 11:15 AM, revealed she was unaware if anyone was assigned to supervise the RNAs or LPNA on 03/07/2021 or 03/08/2021. She stated the DNS would have that information. She stated no one discussed with her the RNAs or LPNA could work independently. The ADNS revealed she did not observe the RNAs or LPNA administer medications, perform breathing or wound treatments, care of IVs, or g-tubes. Interview, on 03/06/2021 at 4:15 PM, with the Director of Nursing Services (DNS), revealed he began employment with the facility on 02/01/21, and was out sick the last two (2) weeks of February. He stated an RNA and LPNA was a provisional license (PL) and the individual had finished nursing school but had not taken the NCLEX licensure exam. Additionally, the DNS stated if the PL nurse was unsuccessful in the exam, the applicant's PL was voided. He revealed he did not know what the A in RNA meant. The DNS stated Human Resources (HR) was responsible to check nurse licensure through the KBN website for the nurse applicants. He further revealed he was unsure how the RNAs and LPNA were trained before he began employment at the facility. He revealed once the RNAs and LPNA were checked off, and they and their preceptor felt comfortable, the RNAs and LPNA would be scheduled by themselves. The DNS revealed the facility had complex residents who required care of g-tubes, [CONDITION(S)]. He stated the KBN requirement of direct supervision for RNAs and LPNAs was a loose term and an active RN or House Supervisor could be utilized to oversee the RNA or LPNA. He stated direct supervision did not mean walk side by side but to review and audit the RNA's and LPNA's work, identify weakness in charting, and immediately address issues with the RNA or LPNA. He revealed if the RNAs and LPNA needed assistance or had questions, they could go to their immediate supervisor. He revealed he was unaware the reason the LPN Night Supervisor supervised RNA #3, on 03/03/21. The DNS stated the RNAs and LPNA could do anything an RN or LPN could do, even with a PL, including: any type of assessment, g-tubes, [CONDITION(S)] care, medication administration, injections, and admissions. The DNS stated the facility utilized a lot of RNAs on the E/F Unit. He stated he did not like using RNAs and LPNAs and would rather have a licensed nurse. Continued interview, on 03/15/2021 at 3:10 PM, with the DNS revealed, on 12/17/2020 and 12/18/2020 from 7:00 PM to 7:00 AM, it appeared an RNA was scheduled alone on the COVID unit. He stated there was an RN scheduled in the facility from 11:00 PM to 7:00 AM; however, the DNS was unaware if the RN provided assistance to the RNA. He stated he was unsure who was responsible to ensure KBN requirements were met when the RNAs were hired before he began employment. He revealed he had faith those before him did their due diligence and operated within the KBN regulations. He stated to work independently meant work free of direct supervision. He revealed the facility had complex acuity of residents and the RNAs and LPNA may not perform nursing duties per standard. Additionally, the DNS revealed he was unaware the LPNA trained an LPN. He further revealed it was not okay for a PL nurse to train another nurse. He stated a nurse should be trained by an equal or greater than nurse, and not a nurse lesser than their license. He stated an LPN should not train a RN as their scopes of practice were different. He revealed he was unsure what the KBN requirement for RNA and LPNA titles were, compared to RN and LPN, and did not want to speculate those differences as related to documentation in the computer reflected as RN and LPN. Interview with the Administrator, dated 03/06/2021 at 5:44 PM, revealed the RNA and LPNA was a provisional licensed nurse. She stated the RNAs and LPNA attended one (1) to two (2) days of classroom orientation, then oriented on the floor for three (3) to four (4) weeks. She stated she was unsure what was involved in the floor orientation or what the RNAs and LPNA could or could not do. She revealed she expected the RNAs and LPNA fulfilled the position of the nurse on duty. The Administrator stated the KBN requirement of direct supervision by an RN meant any of the RNs in the facility were readily accessible, including the managers such as the Assistant DNS (ADNS), the DNS, and the House Supervisor. She stated the House Supervisor was an LPN and not able to supervise and RNA. Additionally, she revealed the LPNA should not have oriented LPN #6 to the floor as she did not expect unlicensed staff to orient licensed staff. She stated she could not speculate on a potential outcome for utilizing unlicensed staff to orient an LPN. Continued interview, on 03/16/2021 at 2:26 PM, with the Administrator, revealed RNA and LPNA direct supervision meant an RN in the building. She stated immediately available meant the nurse be accessible and included the leadership team. The Administrator stated her expectation was the RNAs and LPNA would reach out to an RN, if they needed supplies or had questions. She further stated if an RN needed to go to the COVID unit to assist an RNA, the RN would then need to leave the facility, as he/she could not return to their unit from the COVID unit. The Administrator, revealed she was responsible for knowledge of the KBN requirements. She further revealed the first RNA began 07/09/2020. Additionally, the Administrator revealed the RNAs and LPNA documenting as RN or LPN did not meet the KBN requirement of use of the title RNA or LPNA. 2. Review of the facility policy, Orientation Program for Newly Hired Employees, Transfers, Volunteers, revised January 2008, revealed an orientation program should be conducted for all newly hired employees. In addition, to the general orientation, each department would orientate newly hired employee to the department's policies and procedures. The orientation program was an in-depth review of the facility's policies and procedures. A checklist was used to record materials reviewed with each employee. A written record would be maintained for each employee's individual orientation program. The orientation records should include the date reviewed, employee's initials, subject matter reviewed, and other information deemed necessary or appropriate. Orientation records should be filed in the employee's personnel file upon completion of the orientation program. Completed copies of the Employee Orientation Checklist were filed in the employee's personnel file. Review of a blank facility Registered Nurse RN Orientation/Competency Checklist and Licensed Practical Nurse LPN Ortientation /Competency Checklist revealed a list of competencies and skills, a column to document the date, and a column to document employee initials. Review of six (6) of six (6) RNA and one (1) of one (1) LPNA employee files, revealed there were no floor orientation/skills checklists in the personnel files. This surveyor requested copies of Job decriptions, however, the facility was unable to provide Job Descriptions for the role of an RNA or LPNA (instead of RN or LPN) or Orientation/Competency Checklists for the role of an RNA or LPNA. On 03/10/2021 at 9:55 AM, interview with RN #6, revealed he began employment with the facility in September 2020 and was his first job as a nurse. He stated he oriented three (3) to four (4) weeks and had a form to document which he kept. Interview, on 03/10/2021 at 10:01 AM, with RN #11, revealed he worked for the facility about six (6) months. He stated he oriented on the floor for about two (2) weeks with a different person every two (2) days. He revealed he also trained new nurses, however could not recall any documentation of the training. He stated the new nurses oriented to the floor for two (2) weeks, however, training could extend another seven (7) days if needed. RN #11 revealed the DNS and SDC asked him if he thought the nurses were ready to work independently. He stated he was not trained how to precept new nurses and he was not instructed to continue to follow up or supervise the new nurses after they completed floor orientation. The nurse revealed after the new nurses completed floor orientation they were scheduled to work by themselves. He stated the PL meant they graduated nursing school but had not taken the licensure exam. Interview with LPN #2, on 03/10/2021 at 10:22 AM, revealed he worked for the facility about fourteen (14) months. He stated he last oriented incoming nurses, including RNAs and LPNAs, to the floor in 2020. The LPN revealed orientation included medication administration, and what they involved with new nurses just out of school, how to complete an admission, document in the computer, and assessments. He stated the facility did not train him how to orient new staff. The nurse revealed he did document as a trainer however he did not know what happened to the form once the orientee completed floor orientation. He stated new nurses oriented for five (5) to seven (7) days, and experienced nurses oriented three (3) to four (4) days with different preceptors. LPN #2 revealed he was asked how the orientee was doing and if they needed more time, however could not recall who asked him. He further revealed he did not follow up or supervise the orientee after orientation. He stated RNAs and LPNA had not passed the licensure exam. Interview, on 03/10/2021 at 11:16 AM, with RN #1 revealed she worked for the facility about one (1) month. She stated she had three (3) days floor orientation and had worked as an RN before her employment with the facility. She stated she had a document for the preceptor to sign in her orientation, however she had not turned it in. The RN revealed she did not know who or where to turn in the form. Interview with LPN #6, on 03/11/2021 at 4:12 AM, revealed she was employed with the facility for five (5) shifts. She stated she was oriented for three (3) shifts and was not provided with an orientation checklist to complete. Interview, on 03/06/2021 at 4:15 PM, with the Director of Nursing Services (DNS), revealed he was unsure how the RNAs and LPNA were trained before he began employment at the facility. He stated after the initial corporate orientation was completed, he would expect the RNAs and LPNA received adequate floor orientation. The DNS stated the facility did not have a Staff Development Coordinator (SDC) for a time and was unsure if the RNAs and LPNA had completed the floor orientation checklist. He further stated the preceptor should have checked off on the RNAs and LPNA skills and if issues came up, they would be addressed by the preceptor or SDC. He revealed once the RNAs and LPNA were checked off, and they and their preceptor felt comfortable, the RNAs and LPNA would be scheduled by themselves. He stated a seasoned nurse received three (3) days of floor orientation and a new nurse received a longer orientation period. The DNS revealed the facility had complex residents who required care of g-tubes, [CONDITION(S)]. On 03/10/2021 at 10:48 AM, int [TRUNCATED]

Based on interview, record review, and review of the facility's policy, 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 of each resident. The failure to identify potential or actual system failure or deficient practice, which could or has led to potential or actual harm. (Refer to F656, F689, F692, F693, F726, F755, F835, F837, and F865). In addition, the facility failed to maintain standard levels of care and services to the residents. Total census 90. (Refer to F584, F606, F656, F689 and F759. The facility's failure to provide an effective administration to ensure care and services related to state and federal regulations guideline for the care and services to the residents has caused or is likely to cause serious injury, harm, impairment or death to residents. An abbreviated survey was initiated 03/03/2021 to investigate KY , KY , KY , KY , KY , KY , KY , KY , KY , KY , and KY . Immediate jeopardy was identified on 03/07/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of J; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of L. Substandard quality of care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the immediate jeopardies on 03/07/2021. The abbreviated survey transitioned to a standard health Recertification survey on 03/09/2021. Additional complaints were investigated, including KY , KY , KY , and KY . Immediate Jeopardy was identified on 03/21/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of J and F693 Tube Feeding Management/Restore Eating Skills at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of K; 42 CFR 483.70 Administration, F835 Administration at a S/S of L; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities at a S/S of L. Substandard Quality of Care was identified at 42 CFR 483.25, F692 Nutrition/Hydration Status Maintenance, and F693 Tube Feeding Management/Restore Eating Skills. The facility was notified of these immediate jeopardies on 03/21/2021. After supervisory review immediate jeopardy was identified on 03/24/2021 and determined to exist on 07/09/2020 in the area of 42 CFR 483.70 Administration, F837 Governing Body at a S/S of L. Additional deficiencies were cited in the areas of 42 CFR 483.10 Resident Rights, F550 Resident Rights/Exercise of Rights at a S/S of D, F553 Right to Participate in Planning Care at a S/S of D, F558 Reasonable Accommodations of Needs/Preferences at a S/S of E, F583 Personal Privacy/Confidentiality of Records at a S/S of D, and F584 Safe/Clean/comfortable/Homelike Environment at a S/S of F; 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F606 Not Employ/Engage Staff with Adverse Actions at a S/S of F, and F609 Reporting of Alleged Violations at a S/S of D; 42 CFR 483.20 Resident Assessments, F641 Accuracy of Assessments at a S/S of E; 42 Comprehensive Resident Centered Care Plans, F657 Care Plan Timing and Revision at a S/S of D; 42 CFR 483.24 Quality of Life, F677 ADL Care Provided for Dependent Residents at a S/S of D; 42 CFR 483.35 Nursing Services, F725 Sufficient Nursing Staff at a SS of E; 42 CFR 483.45 Pharmacy Services, F759 Free of Medication Error Rates of 5% or More at a S/S of F and F761 Label/Store Drugs & Biologicals at a S/S F; 42 CFR 483.60 Food and Nutrition Services, F812 Food Procurement, Store/Prepare/Serve - Sanitary at S/S of F; and 42 CFR 483.80 Infection Control, F880 Infection Prevention and Control at a S/S of F. Additional substandard quality of care was identified at 42 CFR 483.10 Resident Rights, F584 Safe/Clean/Comfortable/Homelike Environment; 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F606 Not Employ/Engage Staff with Adverse Events; and F759 42 CFR 483.45 Pharmacy Services. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified, on 03/07/2021, and was determined to exist on 12/17/2020, in the areas of 42 CFR 483.25 Quality of Care (F689 at S/S of J); and, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 at S/S of K). The facility provided an acceptable Credible Allegation of Compliance (AoC) on 03/30/2021, alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency determined the Immediate Jeopardy had been removed 03/30/2021, as alleged, prior to exit on 04/03/2021, with remaining non-compliance at a Scope and Severity of a F while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Executive Director (ED) job description, dated August 2019, revealed the ED responsibilities included to administer an efficient compliance with the company's policies and procedures as well as Federal and State regulations. The ED strived to provide the highest quality of care as possible to the community. In addition, the ED was responsible to lead an effective QAPI Program. Review of the facility untitled policy statement, undated, revealed the facility QAPI process included to monitor, evaluate, and have appropriate follow-up action. The ED was the head of the committee who with the facility management team identified opportunities for improvement, addressed system break down or process, then developed, implemented, and monitored the effectiveness of the interventions. Under heading of Governing Body (GB), the body responsibilities included to develop and implement the QAPI program. The GB included the Regional Vice President of Operations (VPO), Regional Director of Operations (RDO), Medical Directors (MD), ED and the Director of Clinical Services (DNS). Review of the facility's policy Administrative Management, revised October 2017 revealed the management was responsible for the operation of the facility. The GB responsibility included oversight of the care and services in accordance with professional standards of practice, principles, and establishment with ongoing review of the programs for the facility's management, operations, and QAPI. Interview with the DNS, on 03/2/2021 at 12:58 PM, revealed as DNS he identified numerous issues with care and services. However, he had only been in the position since first of February 2021. He stated the facility initiated automatic refills first of February for daily medications which did not need a prescription after numerous resident's complaints. He stated the facility identified care issues through review of the electronic chart, review of nurse's notes, assessments, medication administration review, admission review, and review of reported concerns. He stated the facility did not identify system issues other than F755. However, he stated as the new DNS he expected staff to provide the care and services ordered, provide standard nursing care, to take initiative, and he would not allow staff to be complacent in regard to their responsibilities to the residents because this was the resident's home, and they gave up everything in order to receive the care they required. Interview with the ED, on 04/03/2021 at 2:00 PM, revealed the facility did not identify issues to which the facility received immediate jeopardy, care issues, staffing, or infection control. The ED stated the facility had areas in need of improvement. She stated the facility worked with the consultation agency to help identify and develop improvement plans to address identified concerns. She stated the consultant agency were members of the GB. The ED stated the facility identified concerns through, complaints, grievance, review of reports, interviews with staff and residents, and the discussion of care and services with the Interdepartmental Team (IDT) daily meeting. She stated as Executive Director, she oversaw the QAPI meetings. However, she stated she did not review or have the State and Federal Regulations for reference to ensure the facility-maintained compliance or could develop a Performance Improvement (PI) plan to ensure the facility met compliance after an identification of an issue. In addition, she stated she knew she had room for improvement as an Executive Director and to become more knowledgeable to be an effective Executive Director. She further stated the DNS, MD's, RDO, and VPO oversaw the Administrative management and the services provided by staff, which followed policies and regulations for resident care. Furthermore, other than the reporting to the consultants, she did not know who she would report to or be held accountable by as the facility was its own entity. Interview with the MD, on 03/20/2021 at 12:01 AM, revealed he identified issues of care and services when he first came to the facility a year ago. He stated he worked with the facility Executive Director and discussed in QAPI identified issues to which the facility made an Improvement Plan (IP) and the facility had made some improvements. However, he described the Executive Director as young, inexperienced, and the facility had a long way to go to become a good the facility he envisioned. He further stated as the Medical Director he had high standards for care and services for all residents, and the facility continued to try identify issues and work toward higher standards of care for the residents. Interview with the RDO, 04/02/2021 at 11:16 AM, revealed the RDO had responsibility for the oversite of the facility with consultation from Administration. She stated the RDO responsibilities included to help identify issues in the facility with the Administration and set a plan to correct the issue. She stated the Administration held monthly QAPI meetings in part to identify issues which may affect resident care and complete audit review of previously identified issues. The RDO stated the facility did not identify care issues identified by the survey team. She stated the Administration reported to her. However, she was not employed under the facility, but rather a consultant agency which worked with facilities to help improve the care and service to residents. Interview with the VPO, on 04/03/2021 at 9:11 AM, revealed the facility did not have over site from the Chief Operating Officer or Chief Executive Officer or a Board of Directors to which the Administration had accountability. She stated the RDO and herself oversaw the facility Administration for effectiveness of services provided. She stated as VPO, further decision needed to be weighted whether the current Executive Director could effectively manage a facility with a bed count of one-hundred and seven (107). However, an effective Administration had not been identified before survey. The facility alleged it implemented the following actions to remove immediacy: 1. The facility clinical team assessed Resident's #23, #33, #39, #46, #60, #85, AND #90 with care plan review for the residents completed by the Regional Clinician. 2. The Registered Dietician evaluated Resident's, #60, #85, and #90. 3. The Regional MDS Coordinator reviewed resident care plans for Nutrition/Hydration and pain, on 03/24/2021 4. The VPO completed education to the ED related to Quality Assurance (QA) meetings, and monitoring, and reviewed the need for additional QAPI meetings and the timeliness and necessity to meet with the Governing Body, on 03/29/2021. 5. The Regional Clinical Coordinator (RCC) completed education to the ED and DNS with regard to how to monitor Care Plans, Nutrition/Hydration, and Enteral Feeding, on 03/29/2021. 6. The facility removed the provisional nurses on 03/09/2021. 7. The facility initiated, on 03/24/2021, the IDT committee review would include nursing notes, new admissions, readmission, daily clinical alerts, new exit seeking behaviors, diet changes, weights obtained upon entry to the facility, and review of the resident's care plan for update as needed with the five day a week clinical review. 8. The facility would review for weight changes weekly by the IDT at the Nutrition at Risk (NAR) meeting with care plan updates as needed. 9. The facility initiated, on 03/24/2021, comprehensive care plan audits by a licensed nurse two times a week. Then the facility would audit for four weeks and then weekly for four months. 10. The facility assessed Resident's #23, #33, #39, and #46 were assessed by the nurse for pharmacy services and notified the MD. 11. The pharmacy consultant audited all medication carts to ensure medications were available to the residents, completed on 03/23/2021. 12. The ED, DNS, and IDT received education by the RCC on 03/23/2021, on the policy for medications. 13. The pharmacy consultant provided education to all nurses for reordering when a medication was not available, completed on 03/23/2021 14. After 03/23/2021, the RCC continued education for nurses for the process of reordering medications. 15. The IDT reviewed all notes entered by nurses, new admissions, readmissions and Medication Administration Records (MAR) seven days a week to ensure residents received the medication, initiated on 03/24/2021. 16. The facility QAPI committee meeting were to be held twice a week until abatement was achieved. Then, the meetings would occur weekly for four weeks, and then monthly until the interventions were maintained. 17. The Regional designee would attend the facility QAPI meeting at least weekly until abatement and then monthly. The ED would forward all meeting minutes to the Governing Body and the corporate compliance officer for review of all audits, results, and to ensure they are completed as the QAPI calendar indicated. The SSA validated the facility implemented the following actions: 1. Clinical record reviews of resident care plans revealed care plans were reviewed and revisions noted. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed Resident's #23, #33, #39, #46, #60, #85, and #90 care plans were reviewed with the IDT committee for pain, nutritional needs, and enteral feeding. The DNS stated the Regional MDS coordinator assisted the facility with the review. 2. Interview with the Registered Dietician, on 04/01/2021 at 10:21 AM, revealed review of Resident #60, #85, and #90 diet order and nutritional status were completed on 03/23/2021. She stated the resident care plan were revised as indicated. Record review on, 04/01/2021, revealed the facility completed review of the resident's care plans with revision noted for Resident #90. 3. Interview with the Regional Material Data Set (MDS) coordinator, on 04/03/2021 at 09:19 AM, revealed she reviewed and revised resident's care plans for accuracy. Record review of care plan audits revealed care plans were reviewed on 03/24/2021 4. Interview with the ED, on 04/03/2021 at 2:00 PM, revealed the VPO provided education one to one for QA, monitoring, and schedule of Governing Body Meetings. She revealed the QAPI process was reviewed, use of the fishbone diagram for root cause analysis, and outcome for root cause, on 03/29/2021. Interview with the VPO, on 04/02/2021 at 11:25 AM, revealed she provided education to the ED for administrative duties for the facility and QA within the facility to ensure regulations were followed. She stated the QAPI process was also reviewed. In addition, record review revealed the ED signed an education in service for 03/29/2021, titled QAPI Governing Body. 5. Interview with the ED, on 04/03/2021 at 2:00 PM, and the DNS on 04/03/2021 at 2:50 PM, revealed they completed, on 03/29/2021, education with the Regional Clinical Coordinator (RCC), on the topics of care plans, nutrition, hydration, and enteral feedings. Record review, dated 03/29/2021, revealed the RCC completed an in-service with the ED and DNS. 6. Record review of the facility schedules, on 04/01/2021 at 1:45 PM, revealed schedules from 03/10/2021 through 03/31/2021 did not have provisional nurses on the schedules. Interview with the staff scheduler, on 04/01/2021 at 1:55 PM, revealed on 03/09/2021 the ED instructed him to remove the clinical applicants from the facility schedule and he completed as directed. 7. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed on a daily basis the facility clinical team review included all notes, alerts, admissions, weight obtainment, and new behaviors for exit seeking. He stated the resident would be reassessed and the care plan updated for new interventions or to initiate elopement precautions. He stated this would be done 5 days a week. He stated residents on the nutritional risk listing were reviewed weekly. Interview with the ED, on 04/02/2021 at 2:00 PM, revealed the RDO and VPO met with the facility on 03/23/2021, discussed with the administrative team the areas of concern and formulated audits for abatement and monitoring after abatement. The ED stated the clinical administration reviewed the clinical portion of the audits five times a week. 8. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed the Regional MDS initially reviewed care plans for accuracy and updated as needed, on 03/24/2021. He stated clinical nursing will continue to conduct reviews twice a week for four weeks and then weekly to ensure the care plans are accurate and followed. There were no audits for review. He stated the audits would be reviewed by the IDT in QAPI with the determination of weekly progress. In addition, the facility would continue to review NAR weekly. The DNS revealed the IDT reviewed the NAR list to ensure it was accurate. 9. Review of care plan audit tool revealed on, 03//24/2021, and the regional MDS coordinator documented review of resident care plans for accuracy. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed the IDT team reviewed care plans at the IDT morning meeting with review of new orders, treatment changes, and changes of conditions. 10. Review of the pharmacy consultant audit revealed Resident's #23, #33, #39, and #46 medications for the cart audits were completed on 03/24/2021. Interview with the DNS on 04/03/2021 at 2:50 PM, revealed Residents #23, #33, #39 and #46 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. Review of the pharmacy consultant audit revealed all medication cart audits were completed on 03/24/2021 and 03/25/2021. Interview with the Consultant Pharmacist, on 04/01/2021 at 2:38 PM, revealed the audits were completed by two (2) Senior Clinical Consultants from a third party with the Consultant Pharmacist was to help facilitate reordering medications and assisted with house-stock. 12. Interviews with ED on 04/02/2021 at 2:21 PM and DNS on 04/03/2021 at 2:50 PM revealed they completed education by the RCC on 03/23/2021, on the policy for medications. Record review revealed the ED, DNS, and ADNS signed the in-services form, dated 03/23/2021, titled Weights. 13. Record review of the education and sign-in sheet revealed the Pharmacy Consultant educated all nurses on the medication reorder process and how to use the Nexus System to reorder, on 03/23/2021. Interview with LPN #1, on 04/02/2021 at 8:36 AM, she received education from the Regional Nurse Consultant and Pharmacy consultant on alternate ways to reach to pharmacy. Continued interview revealed the in-service was discussed verbally and hand-outs were given. The LPN revealed the Pharmacy Consultant educated her on how to use the Nexus system. Additionally, she revealed if a medication is not available to look for alternate orders, reach out to pharmacy, and document findings. 14. Interview with the RCC, on 04/01/2021 at 11:42 AM, revealed she completed education to the Executive Director and IDT committee regarding the medication policy. The RCC stated education for reordering would continue to staff nurses as needed. 15. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed the IDT team morning meeting reviewed daily nurses notes, the one new admission, and printed the MAR morning report to review for red flag warnings for missed doses of medications daily since 03/24/2021. Review of facility IDT morning packets revealed the facility printed out the daily morning report for medications and nurses notes with noted documentation to the side of how addressed. Interview with the RCC, on 04/01/2021 at 11:42 AM, revealed when the IDT identified issues with residents not receiving medications she went to the medication cart to review if the medication was or was not available, if it was reordered, and immediately educated staff involved in regard to what she found with her investigation. 16. Interview with DNS, on 04/03/2021 at 2:50 PM, revealed the committee held a QAPI meeting almost daily with the AoC. He stated the meeting continued weekly after abatement until the facility achieved the goals set by the committee. Interview the ED, on 04/02/2021 at 2:21 PM, revealed the facility held daily QAPI meetings while working on the AoC and would work weekly when abatement occurred. She stated then the committee would meet weekly until the goals were obtained and maintained with all reports forwarded to the RDO. Interview with MD, on 04/02/2020 at 11:16 AM, revealed the facility updated him daily on the QAPI, education, and audit process. He stated the committee would meet weekly until the facility met the goals set by the committee and then return to monthly. He stated he attended by phone if he was not in the building. The facility declined the survey team to review the QAPI notes/meeting documentation. Review of the QAPI sign in sheets, dated 03/24/2021 and 03/25/2021 revealed the RDO, ED, DNS, ADNS and department heads attended 03/24/2021 and RDO, ED, DNS and ADNS met on 03/25/2021. 17. Interview with the RDO, on 04/03/2021 at 9:11 AM, revealed the QAPI meet on 03/24/2021 and 03/25/2021 with daily review to discuss the immediacy notification. She further revealed the facility increased the QAPI meetings to twice a week, then weekly, then twice a month for three months and then return to the monthly schedule. She revealed the GB committee would meet every three months and have the information provided monthly to each participant. She stated all meetings would be forwarded to her for review and she would attended monthly meetings with the facility to ensure all meetings scheduled where held as planned. Interview with the VPO, on 04/02/2021 at 11:25 AM, revealed she attended all meetings in the facility during the abatement formulation process. She revealed the facility increased QAPI meetings and the RDO would meet with the facility monthly at the QAPI meeting. She revealed the RDO would be in all QAPI meeting information and documentation would be sent to her, she would review reports submitted and forward the information to the Corporate Compliance Officer for further.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to develop or implement the resident care plan for sixteen (16) of sixty-nine (69) sampled residents, Residents #8, #23, #28, #33, #39, #46, #54, #60, #82, #84, #85, #90, #248, #445, and #447. 1. Review of Resident #248's care plan revealed an intervention to maintain a safe environment. However, on 12/17/2020, Resident #248 eloped from the facility without staff knowledge and was discovered by staff from another facility on the ground in the parking lot. 2. The facility initally admitted Resident #85 on 04/10/2020. He/she was assessed to be at nutritional risk. However, there was no developed care plan in place to ensure his/her fluids were monitored or received. In addition, the facility failed to implement Resident 85's care plan related to lab test ordered and follow up as needed. On 03/09/2021 a critical BUN was reported to the facility which revealed a Blood Urea Nitrogen (BUN) level of 111 Critical (reference range 7mg/dL to 25mg/dL ) indicating dehydration, and intravenous (IV) fluids were ordered. Intravenous fluids were not started for approximately 15 hours after orders were received. 3. The facility Care Plan for Resident #90 identified a potential nutritional risk and the facility would provide altered fluid consistency and diet as ordered. However, there were no interventions for the special needs for assistance with meals, consistency of the fluid, special utensils, or weight monitoring. The resident exhibited behavior symptoms of eating inappropriate objects and the facility would maintain a safe environment for the resident, however items were left in reach of the resident who attempted to eat non-edible items. 4. The facility failed to implement Resident #60's care plan to monitor for hydration and nutritional status related to enteral feedings. Record review revealed a weight of 127 pounds (lbs.) documented on 01/05/2021 and 101 lbs. on 03/03/2021. Resident #60 was transferred to the hospital on 12/09/2020, returned on 12/15/2020 and did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ., which was an 11.4% weight loss in 68 days identified by the facility on 03/16/2021. 5. The facility failed to develop a care plan related to pain associated with [CONDITION(S)] for Resident #39. Review of Resident #39's comprehensive care plan, dated 12/31/2020, revealed he/she was not care planned for [CONDITION(S)] or Pain associated with [CONDITION(S)] nor was the care plan revised when Resident #39 experienced pain related to missing 19 doses of his/her [MEDICATION(S)] (refer to F755) . Review of the Care Area Assessment Summary (CAAS) revealed Resident #39 was not triggered for pain for his/her care plan. 6. Review of the Resident #46's Care Plan for Actual Chronic Pain revealed the facility would administer medications as ordered. However, review of Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Review of the Resident #23's Care Plan for Chronic Pain revealed the facility would administer pain medication as ordered. Review of Resident #23's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident experienced pain when staff did not adminsiter the ordered [MEDICATION(S)]. 8. Review of the Baseline Care Plan, revised on 08/20/2020, revealed Resident #28 fell on [DATE]. The facility added Resident Specific Fall Interventions to the care plan after fall. The interventions included to have non-skid strips at bedside. Observation on, 03/18/2021 at 10:38 AM, revealed that Resident #28 did not have any fall strips on his/her floor. The resident experienced a fall after the care plan intervention of non-skid strips was developed, however he/she did not sustain any injury. 9. Review of the Resident #33's Care Plan for at risk for Alterations in Mood revealed the facility would administer medications as ordered. However, the resident missed eighteen (18) doses since December 2020 of his/her anxiety medicaiton per the plan of care. The facility care plan for Resident #33's Activities of Daily Living (ADL's), revised 01/19/2021, revealed the resident would have his/her care needs met daily with assistance of staff. However, there were no intervention(s) related to ADL needs for bathing. The resident had to tell the Certified Nursing Assistant (CNA) when he/she wanted to shower. 10. The ADL Care Plan, revised 11/18/19, revealed Resident #82 needed assistance with ADL's, included bathing and showering, due to [CONDITION(S)], Chronic Fatigue, and Arthritis. However, resident interview revealed the facility did not provide routine showers and his/her last shower was in November 2020 as staff stated they did not have time. 11. Review Resident #84's ADL Care Plan, initiated 12/27/19, revealed the resident needed assistance with ADL's related to [CONDITION(S)], [CONDITION(S)], and a history of falls. The care plan included an intervention for staff to assist with bathing/showering. However, interview with Resident #84, on 03/09/2021 at 9:56 AM, revealed the facility had not assisted him/her to shower in a couple of weeks. 12. Resident #54 was care planned for communication deficit due to English as a second language, but observation revealed the communication board listed on the care plan was not present in the resident's room. 13. Review of the Baseline Care Plan for Resident #445, revised 03/17/2021, revealed staff assessed the resident with difficulty with communication due to a language barrier. Interventions included anticipate needs and provide translator as necessary to communicate with resident. The translator would be Spanish-speaking staff. Observation revealed Resident #445 went to the desk to ask for assistance. When the resident would have a non-Spanish speaking nurse, the resident would go to the desk and what appeared to be repeatedly ask the same thing many times, and the resident did not appear to understand the nurse's answer to the question. The State Survey Agency (SSA) was unable to interview the resident for additional information due to the language barrier. 14. Review of Resident #8's clinical record revealed the facility admitted the resident, on 10/25/2018, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on, 03/10/2021, at 3:25 PM, revealed Resident #8 entered a code into the keypad on the wall and opened the courtyard door. Observation of the C/D courtyard, on 03/10/2021 at 3:05 PM, revealed two (2) unlocked gates. One (1) gate revealed a steep concrete staircase that led to a door. Items on the staircase included threaded nails for a nail gun with the sharp edges facing upwards, two (2) propane gas tanks half off the second stair, flower pots, and two (2) large deck umbrellas. The second unlocked second gate on the opposite side caontained various seasonal items and a recessed window well. Continued observations revealed copious metal nails on the sidewalk and bricks raised up in several places which could cause a tripping hazard. Review of Resident #8's Comprehensive Care Plan revealed the facility did not initiate on admission a care plan for Dementia or for Activities which would include access to the courtyard with continued reassessments for MDS evaluations. 15. Review of Resident #14's comprehensive care plan for bladder and bowel, dated 12/12/2019, revealed the resident experienced episodes of incontinence. Review revealed the care plan interventions address to check and provide incontinence care as needed. However, record review revealed the resident's use of the rest room which may require assistance and safety over site was not addressed. Interview with Resident #14, on 03/12/2021 at 11:08 AM, revealed he/she could toilet independent with occasional assistance in the bath room. The resident revealed he/she wanted to maintain independence as much as possible. The resident revealed he/she used a brief for occasional accidents when in bed because he/she required help to get out of bed. 16. Review of Resident #447's clinical record revealed the facility admitted the resident on 03/06/2021, with diagnoses, which included Cerebral Infarction and Dementia. The Baseline Care Plan, revised 03/11/2021, revealed the resident exhibited behavior symptoms of physical and verbal aggression, such as yelling, pounding on walls/windows, and attempt to tear down blinds. An intervention included administer medications as ordered. However, the physician's orders in the computer system compared to the hand written order revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was written for 0.5 mg in the morning and 1 mg at night The order was entered into the computer as 1 mg in the morning and at night. The facility's failure to develop/implement resident's plan of care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of K; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of L. Substandard quality of care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the immediate jeopardies on 03/07/2021. Immediate Jeopardy was identified on 03/21/2021 and determined to exist on 07/09/2020. Immediate Jeopardy was identified in the areas of 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of J and F693 Tube Feeding Management/Restore Eating Skills at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of K; 42 CFR 483.70 Administration, F835 Administration at a S/S of L; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F865 QAPI Program/Plan, disclosure/Good Faith Attempt at a S/S of L. Substandard Quality of Care was identified at 42 CFR 483.25, F692 Nutrition/Hydration Status Maintenance and F693 Tube Feeding Managment/Restore Eating Skills. The facility was notified of these immediate jeopardies on 03/21/2021. After supervisory review immediate jeopardy was identified on 03/24/2021 and determined to exist on 07/09/2020 in the area of 42 CFR 483.70 Administration, F837 Governing Body at a S/S of L. The facility provided an acceptable Allegation of Compliance (AoC) on 03/30/2021 alleging removal of immediate jeopardy on 03/30/2021. The State Survey Agency determined the facility implemented their AoC as alleged by 03/30/2021, prior to exit on 04/03/2021 with the remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of E; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of D; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of F; 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of D and F693 Tube Feeding Management/Restore Eating Skills at a S/S of D; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of E; 42 CFR 483.70 Administration, F835 Administration at a S/S of F; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F865 QAPI Program/Plan, disclosure/Good Faith Attempt at a S/S of F, and, 42 CFR 483.70 Administration, F837 Governing Body at a S/S of F, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: 1. Review of the facility policy Care Plans, Comprehensive Person-Centered, dated December 2016, revealed the care plan was developed and implemented for each resident. The care plan included measurable objectives to meet the resident's physical, psychosocial and functional needs. A care plan would include identified problem areas and risk factors associated with the identified problems. The facility was unable to provide a policy regarding resident behaviors. Review of Resident #248's closed clinical record revealed the facility admitted the resident on 11/12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed a Wandering/Elopement Risk Scale, dated 11/12/2020, and found the resident was non-ambulatory or unable to self-propel in a wheelchair (w/c) and at Low Risk for elopement. The Baseline Care Plan, not dated, revealed the resident used a walker and w/c, was not at risk for elopement, and cognitively impaired with Dementia and confusion noted. Review of a progress note, dated 11/13/2020 at 11:36 AM, revealed the night nurse reported to the day nurse Resident #248 could not be located in his/her room and a nurse from another hallway brought the nurse back to his/her unit. During the first med pass, staff saw the resident in the hallway and escorted the resident back to his/her room. Additionally, the note revealed a housekeeper informed the nurse Resident #248 was in the hallway, and the nurse escorted the resident back to his/her room. At 11:30 AM, a nurse from another unit informed the resident's nurse that Resident #248 was on the other unit. The resident's nurse returned Resident #248 back to his/her room. Review of a significant change in condition Wandering/Elopement Risk Scale, dated 11/13/2020 at 6:26 PM, revealed the resident was ambulatory or able to propel him/herself in a w/c. The assessment revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note, dated 11/13/2020 at 6:28 PM, revealed the resident wandered into the hallway twice and remained confused. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #248 was unable to complete the Brief Interview Mental Status (BIMS) and staff assessed the resident was Moderately impaired. The facility assessed the resident wandered for one (1) to three (3) days, and used a walker and w/c. Review of the care plan for Resident #248, dated 11/24/2020, revealed the resident exhibited behavior symptoms of wandering and at risk of injury, with an intervention to maintain a safe environment. Review of the communication binder for the Nurse Practitioner (NP) revealed, on 12/16/2020, Resident #248 was listed for the provider to visit the resident as he/she had behaviors during the shift. The Nurse Practitioner (NP) initialed and dated 12/17/2020. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP noted the resident cried a lot without reason and needed a psychiatric evaluation for inappropriate crying and behaviors. Review of an incident note, dated 12/17/2020 at 8:08 PM, by Registered Nurse (RN) #8 revealed Resident #248 was found sitting on the ground outside in the parking lot. The resident was no longer in the facility and discharged on [DATE]. Interview, on 03/04/2021 at 2:25 PM, with RN #8, revealed she provided care to Resident #248 the day the resident eloped. She stated she and the other nurse working the E/F Unit were with another resident providing care at the time of the elopement. The RN revealed she was unsure how many Certified Nurse Aides (CNA) worked at that time. She stated she was unaware of the resident's care plan interventions before the elopement. The nurse stated the purpose of the care plan was to identify how to care for the resident. She revealed the facility tried to do something for the resident per the care plan, however it was not possible to eliminate risk for the resident. On 03/04/2021 at 3:30 PM, interview with CNA #12, revealed he heard Resident #248 eloped when he returned to the E/F Unit with the dinner tray cart. He stated usually there were two (2) nurses and two (2) CNAs on the E/F Unit. The aide revealed when he left the unit to get the dinner cart, he was unaware of the location of the other CNA on the unit. The CNA further revealed the resident care plan was at the nurse's station, however the facility did not use a Kardex (CNA care plan). Interview with the MDS Coordinator, on 03/06/2021 at 3:03 PM, revealed Resident #248's care plan intervention to maintain a safe environment referred to the entire facility environment. However, the intervention did not provide information on how to maintain a safe environment. She stated at the time the resident eloped, the CNAs carried resident care records, similar to a Kardex. The MDS Coordinator revealed if the resident care plan was not followed, a resident could elope and could be harmed. She stated the care plan was a nursing duty, however, she was unsure of nurses were trained on resident care plans. Interview, on 03/06/2021 at 4:15 PM, with the Director of Nursing Services (DNS), revealed he was not employed at the facility when Resident #248 eloped on 12/17/2020. He stated the purpose of the care plan was to place all staff in the facility on the same page, what the plan of care for the resident was, and how to achieve that goal. The DNS revealed the care plan interventions were how the facility would accomplish those goals. He further revealed to follow the care plan intervention to maintain a safe environment included to ensure the resident did not get to the door. The DNS stated staff did everything they could to keep the resident safe and there were times no one was available to maintain a safe environment due to everyone was providing care to other residents. Continued interview with the DNS, on 03/20/2021 at 4:18 PM, revealed the care plan was a blueprint for what staff were to do for the resident. He stated staff were expected to follow the resident's care plan at all times. He revealed staff were responsible to review the care plan at the beginning of the shift and as needed. The DNS stated if the care plan was not followed, then staff were not following the resident's plan of care. He further stated the facility should keep residents safe to reduce harm. On 03/06/2021 at 5:44 PM, interview with the Executive Director (ED), revealed the care plan should be followed by all staff, and staff were trained to follow the resident's care plan. She stated Resident #248's care plan intervention to maintain a safe environment meant to ensure safety around the resident. The ED revealed RN #8 and RNA #4 were providing care for another resident, CNA #12 left the unit to get the dinner tray cart, and was unaware where CNA #13 was located when Resident #248 eloped. The ED further revealed she and Medical Records were also both on the unit to see other residents at the time of the elopement. She stated although they were all with other residents, Medical Records, RNA #4, and the other staff on the unit were accessible to maintain a safe environment for Resident #248. She further stated as no one heard the door alarm sound, and she was unsure how the resident got out. 2. Review of Resident #85 clinical record revealed the facility initially admitted the resident on 04/10/2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview of Metal Status (BIMS) of four (4). Review of Resident #85's Comprehensive Care Plan, initiated 05/01/2020, revealed the resident had a potential for nutritional risk related to reliance on therapeutic enteral feeding for nutrition, significant weight loss, altered skin integrity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan was last revised on 01/25/2021. The goal stated the resident would receive adequate nutrition and hydration with an initiation date of 11/04/2020. Interventions included lab/diagnostic tests as ordered, report results to MD and follow up as indicated; provide tube feeding as ordered; Registered Dietician (RD) to evaluate and make diet change recommendations as needed; therapy to screen quarterly as needed; weights as ordered/indicated, notify provider and family of significant weight changes. Review of Physician/ Prescriber order written by Nurse Practitioner sheet, dated 03/09/2021 and untimed, revealed orders were written to: 1) hold [MEDICATION(S)] 03/14/2021-03/16/2021, resume on 03/17/2021 2) Place midline/ PICC line 3) administer D5W at 100 cc/hour continuous 4) BMP in AM. Review of Physician/ Prescriber orders in Point Click Care (PCC), dated 03/09/2021 reflected the orders were placed into the system at 4:14 PM approximately 15 hours after the critical lab was called to the facility by LPN #11. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #85 was transferred to an acute care facility on 03/10/2021 and was not in the facility during the investigation. Admission hospital records, dated 03/18/2021 at 12:31 PM, indicated the primary admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical records show no documentation of free water or flushes for Resident #85. Interview with Licensed Practical Nurse (LPN) #11 on 03/18/2021 at 3:18 PM, revealed she was familiar with Resident #85' plan of care and had taken care of him/her on second (2nd ) shift (3:00 PM-11:00 PM) on 03/08/2021 and 03/09/2021, prior to hospitalization on [DATE]. LPN #11 stated Resident #85 was ordered free water flushes of 1500mL per day or 62 mL/hour. She stated she delivered 62mL every hour manually with a syringe. She additionally stated she had put the order into the system but did not recall if the order came up on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Further interview with LPN #11 revealed she was aware Resident #85 was sent out due to critical labs and identified the resident was on routine lab draws. She stated she did not initially administer the ordered D5W on her shift, per the plan of care, because she was waiting on pharmacy to deliver a pump. She further indicated flow regulators were in the emergency kit box and could have been used, however, she thought the pump was on the way. Interview with LPN #6, on 03/18/21 at 2:27 PM, revealed there were no orders in the computer showing on the MAR/TAR for Resident #85 to receive free water to ensure the resident was hydrated, per the plan of care. She stated on night shift from 11:00 PM to 7:00 AM, however, she would flush his/her PEG tube with 60ml of water when she changed his/her feeding bag. An additional interview with LPN #6, on 03/17/2021 at 10:57 AM, revealed she was new to the facility. She stated the night of 03/09/2021 was her first shift off orientation and she worked from 11:00 PM to 7:00AM. She indicated during shift handoff report, she was told Resident #85 was dehydrated and had intravenous (IV) fluids ordered to be started, per the plan of care. However, the IV pump had not arrived from pharmacy. She further detailed she was unfamiliar with the IV pump and had limited resources. LPN #6 stated the oncoming day shift nurse, LPN #4, started the IV fluids. Furthermore, LPN #6 stated critical lab BUN of 11 could impact the kidneys and heart and could lead to death. Interview with LPN #4, on 03/17/2021 at 2:41 PM, revealed per the plan of care, there was an order received, on 03/09/2021 to start D5W on Resident #85. The night shift nurse, LPN #6, relayed at shift change approximately 7:00 AM the fluids should have started on the previous shift, however the pump had not arrived during second shift (3:00PM-11:00PM). LPN #4 further stated LPN #6 was new to the facility and not familiar with the pump. In addition, LPN #4 indicated the facility also had dial up (manual regulator) and was not sure why it was not used. LPN #4 stated all the supplies were available. She started the D5W at the beginning of her shift on 03/10/2021. She stated she later received call on her cell phone from NP. NP indicated she had seen the labs and asked why fluids were not started for two (2) shifts. NP then instructed to send Resident #85 to the emergency room (ER). LPN #4 indicated the NP spoke with the ED and DNS to make them aware the fluid have not been started resulting in delay in treatment. Interview with the Registered Dietician (RD), on 03/18/2021 at 2:42 PM, revealed she calculated the tube feed and free water needs and would give suggested orders. The Dietician stated feeding pumps were discussed in clinical meeting, and dual pumps had pre-programmed amounts to ensure the resident received free water to potentially prevent elevated labs or dehydration. She also indicated Resident #85 was last assessed as a Nutrition at Risk (NAR) resident on 02/24/2021 and per the plan of care she suggested the resident receive 300 ml of free water every four (4) hours. Interview with the ED, on 03/21/2021 at 2:26 PM, revealed the facility had not identified any issues with, resident's plans of care related to hydration or free water for residents with tube feedings. She stated residents with g-tubes were higher acuity residents and their intakes were reviewed weekly in the Nutrition At Risk (NAR) meeting. She revealed if the resident was newly admitted , or a current resident had a decline, the NAR meeting would begin to monitor the resident. The Administrator revealed if a resident was stable, the NAR committee would take a resident off weekly NAR monitoring. She further revealed physician orders were reviewed on admission and when changed, for free water. She stated the Dietician reviewed free water, however she was unsure of the frequency of those reviews. The ED revealed she was unsure how free water was missed for the resident, as the clinical meeting should have identified if there was an issue for free water for a resident with a g-tube. 3. Review of the clinical record revealed the facility admitted Resident #90 on 02/12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #90 unable to complete a Brief Interview of Mental Status (BIMS) due to severe impaired cognitive skills for daily decisions. Review of the Care Plan for Potential Nutritional Risk, dated 02/19/2021, revealed the facility would provide the altered fluid consistency, provide, and serve diet as ordered. However, there was no interventions for the special needs for assistance with meals, consistency of the fluid, special utensils, or weight monitoring. Continued review of the care plan for Behavior Symptoms of eating inappropriate objects revealed the facility would maintain a safe environment for the resident. In addition, review of the care plan for Communication revealed the staff would speak on an adult level to the resident. Review of Dietary Order, on 02/19/2021, revealed the facility should provide the fluid consistency of Nectar Thick Liquids (NTL) Interview with Family #3, on 03/15/2021 at 9:11 AM, revealed they informed the facility the resident required maximum assistance with meals, could cue to eat food with the assist of loading a spoon, then tap the top of the residents hand, and the resident could mostly feed him/herself. The family stated the resident could drink with a two sided handled cup with minimal assistance. The family stated they requested a weekly weight on the resident because the resident looked like he/she lost weight. The family stated Resident #90 could follow simple cues for tasks. However, the resident could not speak, make needs known, and did not have safety awareness. Furthermore, the family stated Resident #90 had [NAME]. The family stated [NAME] involved putting any object in the mouth to chew and swallow. The family stated they informed the facility it needed to ensure all objects or food could not be obtained by Resident #90 because he/she would eat it. However, the Nutritional care plan did not reflect the specific needs of the resident and the Behavior plan did not reflect the need for objects to be out of reach. Observation, on 03/11/2021 at 12:40 PM, revealed a facility meal ticket included thin liquids. The tray contained a glass cup of thin yellow liquid. Staff fed Resident #90 without assistance from the resident. Staff fed the resident the drink from the glass cup. Resident #90 grabbed at or reached for the food on the tray situated on the other side of the aide. The facility stacked food brought by family on the low rise table in the resident's room. However, the staff did not allow the resident to be involved with the meal, provide special utensils, or remove the boxes of food from the residents reach. In addition, the facility did not provide the NTL's as ordered. Continued observation, on 03/12/2021 at 8:52 AM, revealed the tray ticket revealed thin liquids. The resident continued to reach for the food while staff tried to feed the resident. Staff identified the liquid in the glass cup as thin apple juice. Staff called the resident boy-boy and continued with baby talk when the resident continued to reach for food while they fed the resident. Observations revealed food remained stacked in boxes and bags on the low rise table. However, facility did not maintain an adult conversation, provide NTL's, allow the resident to assist with meal intake or maintain a safe environment. Observation on, 03/13/2021 at 8:32 AM, revealed Resident #90 in a wheelchair and mobile. An open package of briefs laid on the chair, a package of cleaning wipes laid on the side table of the bed, three (3) opened boxes of gloves on the table, and continued presence of the boxes and bags of food on the low rise table. However, the facility did not maintain a safe environment for the resident. Further observation, on 03/14/2021 at 9:31 AM, revealed Resident #90 ripped open boxes of food at the low rise table, obtained two to three packages of food, and placed the package and food into his/her mouth and started to consume the products. Survey staff alerted facility staff because there were not staff in or around the resident's room, which at the time staff removed the food and placed the food in the closet. However, the facility did not maintain a safe environment to ensure the resident did not consume non-food items. Interview with CNA #3, on 03/19/2021 at 10:34 AM, revealed the aides followed the resident tasks in the computer. The aide stated previously aides referred to a resident care list. However, the care list went by the wayside with the computer charting. The aide stated the previous resident care list gave detail to what the residents' needed. The aide stated the task in the computer contained basic information. The aide stated the facility should follow the CNA care plan to ensure the resident get their care. The aide stated if residents' do not get their care the resident could fall and not get what they need to get to get better. Interview with CNA #19, on 03/14/2021 at 9:31 AM, revealed the facility CNA tasks were located on the KIOSK (electronic charting), which was on the wall. The aide stated the tasks for aides were located there. She stated any specialty need would be communicated between staff. The [TRUNCATED]

Based on observations, interviews, record reviews and review of the facility's policies it was determined the facility failed to provide and maintain pharmaceutical services to meet residents needs related to medications not being available, medication orders not initiated and/or medication errors for five (5) out of sixty-nine (69) sampled residents (Resident #23, Resident #33, Resident #39, Resident #46, and Resident #447). In addition, the facility failed to maintain proper infection control during medication pass for three (3) of four (4) halls. The facility failed to obtain a prescription for [MEDICATION(S)] (medication used to treat pain associated with [CONDITION(S)]) timely and failed to obtain the medication through the emergency drug system. The facility failed to administer Resident #39 nineteen (19) doses of [MEDICATION(S)], from 01/21/2021 through 01/27/2021. Additionally, the facility failed to obtain/provide medications as ordered for Resident #23 ([MEDICATION(S)]), Resident #33 (anti-anxiety medication), and Resident #46 (pain medication). Review of the record revealed the facility duplicated Resident #447's medication order for [MEDICATION(S)]. Observations during survey revealed staff failed to utilize infection control practices regarding medication storage, and medication administration. The facility's failure to provide and maintain pharmaceutical services to meet residents' needs has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified, on 03/21/2021, and was determined to exist on 01/21/2021, in the areas of 42 CFR 483.45 Pharmacy Services (F755 at S/S of K). The facility was notified of the Immediate Jeopardy on 03/21/2021. An acceptable Allegation of Compliance was received on 03/30/2021, which alleged removal of Immediate Jeopardy on 03/30/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 03/30/2021 as alleged, before exit on 04/03/2021, which lowered the scope and severity to a F while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. Review of the facility's policy Pain Management, dated 01/2020, revealed it is the policy of the facility to provide necessary care to allow a resident to be as pain free as possible. Review of the facility's policy Provider Pharmacy Requirements, revised 08/2020, revealed the provider pharmacy agreed to provide routine and timely pharmacy service as contracted, as well as emergency pharmacy services 24 hours per day, seven days per week. Continued review revealed new medication orders are available for administration on the next day routine delivery, unless otherwise requested by facility staff. Medication will be delivered by the primary pharmacy or back-up pharmacy or was available from the emergency medication kit/back-up medication supply. Review of the facility's policy, Ordering and Receiving Non-Controlled Medications, revised 08/2020, revealed when phoning in, sending electronically, or faxing a medication order to the pharmacy, the following information must be given: residents name, medication name, complete order if a new medication order or direction change(s) to a previous order, name of prescriber if different from the attending physician, indication for use and name of person calling in the order. Review of the facility's policy, Medication Therapy, revised 04/2007, revealed medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. Continued review revealed periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for possible adverse consequences. Further review revealed the Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner or when a clinically significant adverse consequence is confirmed or suspected. Additionally, the facility shall review medication-related issues as part of its Quality Assurance Committee and activities. Review of the contract with the provider pharmacy Form of Pharmaceutical Services Contract, dated 08/29/2019, revealed all pharmacy medication and related services required by the Residents including prescription and non-prescription drugs, intravenous drugs and pharmaceutical supplies as ordered by physicians and other health care professionals. Continued review revealed the pharmacy shall provide medications to the facility in a thirty (30)-dose bingo drug dispensing system. Further review revealed the pharmacy shall establish an emergency system for backup and/or interim order dispensing. Additionally during each month of the term, the pharmacy shall review Medication Administration Records (MAR) and Treatment Administration Records (TAR) for accuracy and the facility shall ensure that all documents are reviewed for accuracy. Review of the facility's contract Consultant Pharmacist Services Agreement, dated 10/01/2019, revealed the consulting pharmacist will provide the facility with regularly scheduled consulting services. Continued review revealed the consulting pharmacist will consult with the facility's staff as to each client's drug regimen and provide a written report of concerns of inappropriate utilization patterns to the facility's Executive Director, Director of Nursing Services or the client's Physician. Further review revealed this contract was not signed and dated by the facility nor the consulting pharmacy. Review of the Emergency Drug System inventory revealed there were five (5) capsules of 300 mg (milligram) [MEDICATION(S)] available for the facility to use. The facility failed to provide documentation related to medication cart audits, medication room audits and medication refrigerator audits. The facility failed to provide documentation related to the 24 hour Shift Reports that were reviewed in the morning meeting and the Communication Log for January 2021 that was utilized by staff to communicate concerns with the NP (Nurse Practitioner) related to Resident #39's missed [MEDICATION(S)]. Interview with the Executive Director, on 03/16/2021 at 9:20 AM, revealed the 24 hour Shift Reports and the communication logs were not retained due to not being part of the medical records. 1. Record review revealed the facility admitted Resident #39 on 12/30/2020 with diagnoses to include: Type II Diabetes Mellitus with [CONDITION(S)], Chronic [CONDITION(S)], [CONDITION(S)] (PVD), Heart Failure, Hypertension, and a history of [CONDITION(S)] (MI). Further review revealed Resident #39 was admitted for rehabilitation with the potential for discharging home. Review of Resident #39's Minimum Data Set (MDS), dated [DATE], revealed his/her Brief Interview for Mental Status (BIMS) was assessed to be fifteen (15). The facility determined the resident was interviewable. Continued review revealed the resident's diagnoses included Diabetes Mellitus. Further review revealed Resident #39 was assessed to have been administered pain medication on a scheduled regimen and to occasionally have experienced pain. Review of the Physical Therapy (PT) notes, dated 01/25/2021, revealed Resident #39 reported to PT that he/she had not received medication for [CONDITION(S)] pain (related to Diabetes Mellitus) throughout the weekend. Continued review revealed Resident #39 verbalized his/her pain limited the resident's functional status. Further review revealed Resident #39 reported numbness and tingling in his/her feet, legs, arms, and hands. Additionally it was revealed Resident #39 refused PT treatment due to increased pain. Resident #39 related that he/she had very little sleep last night and over the weekend due to the [CONDITION(S)] pain. Review of Resident #39's care plan, dated 12/31/2020, revealed he/she was not care planned for [CONDITION(S)] or pain associated with [CONDITION(S)]. Record review revealed Resident #39 was admitted with a prescription from the hospital, dated 12/28/2020 for [MEDICATION(S)] 300 mg with instructions to take two (2) capsules by mouth three (3) times daily. Record review revealed a Physician's Order for the [MEDICATION(S)]. Further review revealed the Nurse Practitioner (NP) wrote a prescription upon Resident #39's admission to the facility, dated 12/30/2020, for [MEDICATION(S)] 300 mg (milligram) capsules with instructions to take two (2) capsules by mouth three (3) times a daily, quantity of 180 capsules. Record review revealed a new prescription written for [MEDICATION(S)] 300 mg, two (2) capsules three (3) times a day by the NP on 01/25/2021. Interview with the Pharmacy Technician, on 03/12/2021 at 9:17 AM, revealed the pharmacy received a fax for the 01/25/2021 prescription on 01/27/2021 at 8:36 AM and the [MEDICATION(S)] was received at the facility on 01/27/2021 at 4:21 PM. Review of Resident #39's Medication Administration Record (MAR), dated 01/01/2021 through 01/05/2021, revealed the [MEDICATION(S)] 300 mg, two (2) capsules, three (3) times a day, scheduled at 8:00 AM, 2:00 PM and 6:00 PM were documented as administered. Continued review revealed on 01/05/2021, the [MEDICATION(S)] order that was entered on 12/30/2020 was discontinued and a new order for [MEDICATION(S)] was ordered with the same dose and frequency, but the administration times were changed to reflect every eight (8) hours; Midnight, 8:00 AM and 4:00 PM, per Resident #39's request. Further review of Resident #39's MAR revealed the facility failed to administer nineteen (19) doses of the scheduled [MEDICATION(S)] starting on 01/21/2021 at 4:00 PM through 01/27/2021 at 4:00 PM. Further review revealed some administration times were not charted (01/23/2021 at Midnight, 01/25/2021 at 8:00 AM and 4:00 PM) and some administration times were charted that the resident received his/her [MEDICATION(S)] as ordered (01/24/2021 at 8:00 AM and 4:00 PM and 01/26/2021 at Midnight and 8:00 AM) but there was no documented evidence that staff used the emergency drug kit available in the facility. Review of Resident #39's January 2021 [MEDICATION(S)] Narcotic sheets revealed he/she received [MEDICATION(S)] on 01/21/2021 at 8:00 AM and did not receive another dose until 01/27/2021 at 12:00 AM. Additionally, review of the Nexsus January 2021 Transaction List revealed staff did not request to obtain [MEDICATION(S)] at any time from 01/21/2021 through 01/27/2021. Review of the Progress Notes, dated 01/21/2021 through 01/27/2021, revealed the [MEDICATION(S)] medication was not available for administration on 01/21/2021 at 5:42 PM, 01/22/2021 at 1:25 AM, 01/22/2021 at 1:12 PM, 01/22/2021 at 5:44 PM, 01/23/2021 at 9:41 AM, 01/23/2021 at 3:43 PM, 01/23/2021 at 11:45 PM, 01/25/2021 at 2:30 AM, 01/26/2021 4:49 PM, 01/27/2021 at 1:51 AM, 01/27/2021 at 8:16 AM, and 01/27/2021 at 3:57 PM. Review of the vital signs dated, 01/2021 through 03/2021, revealed there was no blood pressure, heart rate or respiration rate documented for Resident #39 from 01/11/2021 through 02/05/2021. Interview with the Quality Assurance Director of the provider pharmacy, on 03/17/2021 at 9:50 AM, revealed the pharmacy received a hospital prescription for the ordered [MEDICATION(S)] on 12/30/2020 and the medication was delivered to the facility on [DATE]. Continued interview revealed the NP's prescription for [MEDICATION(S)] was faxed to the pharmacy on 12/30/2020 and placed on hold due to having a valid prescription (from the hospital) on file already. Further interview revealed after the hospital prescription was exhausted and the pharmacy sent 90 of the 180 [MEDICATION(S)] capsules from the NP prescription on 01/04/2021, delivering the medication to the facility on [DATE]. Additionally, it was revealed when staff entered the new order for [MEDICATION(S)] on 01/05/2021 related to the change of administration times, it voided the remaining 90 capsules of the NP's prescription, therefore needing a new valid prescription from the provider. Further interview with the Quality Assurance Director revealed no requests had been sent to the pharmacy from the facility during that time period for use of the [MEDICATION(S)] that was stocked in the emergency drug system. Per review of the facility's Nexus Inventory provided by the provider pharamcys QA Director, the facility had five (5) 300mg [MEDICATION(S)] capsules available to use. Interview with Resident #39, on 03/03/2021 at 3:00 PM, revealed he/she missed five (5) or six (6) days of his/her scheduled [MEDICATION(S)] toward the end of January but was unsure of the exact dates. Continued interview revealed the nurse notified him/her that the medication was out. Further interview revealed his/her [CONDITION(S)] had the potential to be bad if it was not treated. He/she continued that when he/she missed those doses the [CONDITION(S)] felt like the sensation of a second degree sunburn on his/her thighs, back, head and arms and the only relief from the pain was to stay covered from neck to toes with a blanket because the weight dulled the sensation. Interview with Resident #39, on 03/10/2021 at 9:05 AM, revealed he/she was less inclined to do therapy during this period and skipped a few meals because he/she would rather stay cocooned in the blankets. Additionally, Resident #39 revealed he/she was able to ask for his/her as needed (PRN) pain medication and the nurse would administer the medication timely. He/she stated the PRN pain medication would soothe the burning sensation caused by the [CONDITION(S)]. Interview with Certified Nurse Assistant (CNA) #20, on 03/12/2021 at 1:26 PM, revealed Resident #39 would occasionally request pain medication, and she would ensure the nurse went in to his/her room and followed up with him/her. Continued interview revealed she would work 3 PM-11 PM shift and at times Resident #39 would complain of his/her hands hurting and not wanting to eat. Interview with Licensed Practical Nurse (LPN) #16 on 03/13/2021 at 9:27 AM, revealed if a medication was out she would notify pharmacy. LPN #16 stated regarding Resident #39, a new prescription was needed. She revealed she did not know who was on call that shift and she didn't recall if she notified the provider. Continued interview revealed the facility told staff not to bother the providers on night shift for narcotic prescriptions. LPN #16 revealed that the blister pack the medications come packaged in were marked at a certain place to remind staff to reorder the medication. Further interview revealed she would not notify the provider at night time for a prescription, she would relay that to the dayshift nurse to pass on to the provider. She revealed pain regarding [CONDITION(S)] would be a complication from Resident #39 not receiving his/her ordered medication. Interview with Medical Records, on 03/13/2021 at 1:30 PM, revealed when needed, she would work on the unit taking a medication cart. Continued interview revealed there was a reorder box that could be checked in the computer system. She stated medications should be reordered when the medication was down to the last five (5) doses. Further interview revealed medications that were not available could also be pulled from the emergency drug system in the facility and if the medication was not available, a call to pharmacy could be placed to have the missing medication sent over STAT (as soon as possible). Additionally, she revealed staff would need to notify the provider of the missing medication and family. She continued it should be noted in the progress notes that the medication was not available and notifications were made. Further interview with the Medical Records revealed she did not recall Resident #39's [MEDICATION(S)] not being available or if she made any notifications regarding reordering the medication. Interview with Registered Nurse (RN) #14, on 03/13/2021 at 9:43 AM, revealed staff would normally reorder a medication when there was a few doses left. She revealed there was a sticker on the card that you pulled out and placed on a sheet and faxed to pharmacy for refills. Continued interview revealed if a new prescription was needed, a call to the provider would need to be made and the provider could call in to the pharmacy with the new prescription or send in a new one. She revealed that if a resident was out of a medication she would document she notified the pharmacy and notified the provider and Director of Nursing Services (DNS) of the missing dose. Further interview revealed when a medication was not administered it was considered a medication error. Additionally, she could not recall if she gave Resident #39 his/her last dose of [MEDICATION(S)] on 01/21/2021, nor could she recall if she sent a reorder request to the pharmacy or made any notifications. Attempts were made to contact an RN Agency Nurse, on 03/12/2021 at 10:16 AM and 03/13/2021 at 9:16 AM. Attempts were made to contact another agency nurse. Attempts were made on 03/10/2021 at 8:15 AM and 03/11/2021 at 8:30 AM to contact an agency nurse but the calls were not returned. Further attempts were made to contact an agency nurse on 03/16/2021 at 10:54 and an email was sent to the agency on 11:01 for assistance reaching out. Additionally, attempts were made to contact a CNA on 03/12/2021 at 9:45 AM and 1:23 PM to no avail. Interview with the Quality Assurance Director of the provider pharmacy, on 03/15/2021 at 9:24 AM, revealed withdrawal-like symptoms from [MEDICATION(S)] would start to appear anywhere from 12 hours up to seven (7) days after the last dose was administered. Continued interview revealed withdrawal symptoms could be sweating, stomach issues, tremors, increased blood pressure, and [CONDITION(S)]. Further interview revealed with Resident #39 missing 19 doses of [MEDICATION(S)] he/she would have been symptomatic for pain. Interview with the Quality Assurance Director of the provider pharmacy, on 03/16/2021 at 1:00 PM, revealed the representative did not perform any routine audits during their facility visits. However, the facility's consultant pharmacist did perform scheduled audits. Additionally, the pharmacy representative had not observed or witnessed missed doses for any residents at the facility. Interview with the Consultant Pharmacist, on 03/16/2021 at 3:45 PM, revealed she reviewed charts remotely. Continued interview revealed she performed the drug regimen review as defined by Centers for Medicare and Medicaid Services (CMS). Further interview revealed she sends the facility and a member of the corporate team reports of the reviews she performed. Additionally, she revealed she did not perform audits and the pharmacy that provides the facility with medications would do the audits. She continued that sometimes she reviewed the MARs for holes but it was difficult to identify concerns because staff could mark that they gave a medication when in fact they did not. The consultant Pharmacist continued to say she did not recall reviewing Resident #39's chart and his/her 19 missed doses of medication. Interview with the NP, on 03/15/2021 at 8:27 AM, revealed the facility was supposed to give the provider a few days notice that a new prescription was needed so the resident did not go without ordered medication. She revealed at times she was told at the last minute that a new prescription was needed and may not be available right then to write it and send it to pharmacy. Continued interview revealed she expected staff to notify her when a medication was not available to be administered. She continued that if Resident #39 missed his/her Gabapenti he/she would have an increase of [CONDITION(S)] pain but, she was not sure of the withdrawal symptoms. Further interview revealed she was not notified that Resident #39 missed 19 doses of his/her [MEDICATION(S)] and she should have been. Additional interview on 03/16/2021 at 9:40 AM, revealed she could not recall when she was notified of Resident #39 needing a new prescription but she believed she was notified when she was in the facility making her rounds. Further interview revealed she could not recall if she was notified when Resident #39 requested to have the administration times changed for [MEDICATION(S)]. She stated as long as the dose and frequency was not changed, a new order was not needed. Interview with Interim DNS #1, on 03/18/2021 at 11:25 AM, revealed she was in the facility for the weeks of 01/13/2021 through 01/17/2021 and 01/27/2021 through 01/29/2021. She revealed she was in the facility from 01/13-01/17 then was on-call and could be called for guidance before returning to the facility on [DATE]. Continued interview revealed the DNS duties included oversight of the clinical side of the facility. Further interview revealed she did participate in morning meeting Monday through Friday while she was the Interim DNS. She stated the team would review progress notes, admissions, readmissions, any falls incidents, new orders, lab results and any x-rays. Additionally, she could not recall any specifics about Resident #39 missing 19 doses of [MEDICATION(S)], but that would have been something reviewed and discussed in morning meeting. Interview with Interim DNS #2, on 03/18/2021 at 11:34 AM, revealed she was in the facility from 01/18/2021 through 01/26/2021. Further interview revealed she could not recall discusses related to Resident #39 missing doses of [MEDICATION(S)], nor recall identifying concerns with residents not receiving their medications. Interview with the DNS, on 03/18/2021 at 10:09 AM, revealed his first day as DNS was 02/01/2021. He stated any licensed nurse in the facility could reorder medications. He stated per the Director of Operations, all medications have been on autofill since 02/01/2021. Continued interview revealed he was made aware if requests were made to early and addressed the concern accordingly. He revealed there have been concerns identified with initial medication orders and narcotic prescriptions, and plans were being made to address those concerns. Further interview revealed narcotic/controlled medications would need to be reorders by the date set by the pharmacy and staff should not wait until the last minute to reorder medications requiring prescriptions. He stated that would be the expectation of staff to reorder the medications as indicated on the blister pack. The DNS revealed there were many different ways to reorder medications but reordering through the portal was the most streamline, efficient and preferred method. Continued interview revealed if a controlled medication was not available, it may be available in the emergency drug system and an access code would be needed from the pharmacy. Further interview with the DNS on 03/15/2021 at 8:27 AM revealed if a resident missed a dose the nurse should call the provider for further instruction, family, and pharmacy. He stated it was important for the nurse to do due diligence and figure out why the medication was not available and address it. Further interview revealed the nurse should document the missed medication and notifications in the progress notes. Continued interview revealed during the meetings the 24 Hour Report was reviewed through the computer system, along with progress notes. The DNS stated when the nurse would call the pharmacy to request a refill of a controlled medication, pharmacy would notify them that a new prescription was needed therefore, prompting the nurse to call the provider. Continued interview revealed when medications were not given, it was considered a medication error and the IDT would discuss during the morning clinical meeting. He revealed audits were not completed on narcotic books, and the facility relied on the nurses to be honest and forthcoming with issues. The DNS revealed medication errors prompted some level of coaching and education or disciplinary actions. He revealed he had not done any facility wide training but had provided one-on-one education to a nurse when he identified a medication error. Further interview revealed there was a pain assessment in the system the nurse could use but, he believed it was not being utilized effectively. He stated it would make it easier to track and trend pain for residents to identify concerns and notify the provider for adjustments if needed. Additionally, the DNS revealed if [MEDICATION(S)] was not given as ordered, the underlying reason why it was ordered was not being treated effectively. Interview with the Executive Director, on 03/18/2021 at 11:00 AM, revealed her expectation with staff reordering medications was to follow the facility's protocol and that the proper notifications to family and the provider are made. Continued interview revealed she was not aware of any audits completed by the pharmacy or the facility regarding medication administration, therefore no concerns were identified. 2. Review of Resident #23's clinical record revealed the facility admitted the resident, on 06/29/2018, with the diagnoses of [CONDITION(S)] disease, [CONDITION(S)], and Pain. Review of the Minimum Data Set, dated dated [DATE], revealed the facility assessed for cognitive patterns with the Brief Interview for Mental Status (BIMS) with a score of eleven (11) and determined the resident was interviewable. Further review revealed the facility assessed the resident's pain as frequent pain with limited day to day activity and the resident received scheduled pain medications. Review of Resident #23's order summary report revealed the provider ordered [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) five (5) three hundred and twenty-five (325) milligram (mg), give half a tablet every twelve (12) hours for pain as needed, [MEDICATION(S)] one hundred (100) mg two (2) times a day for [CONDITION(S)] (nerve damage), and [MEDICATION(S)] to both eyes every six (6) hour for dry eyes. Review of Resident #23's Medication Administration Record (MAR) revealed the facility failed to administer the dose of [MEDICATION(S)] 100 mg for March 2021 on 03/10/21 PM dose, 03/12/2021 AM dose, 03/12 PM dose, 03/13/201 AM dose, 03/13/2021 PM dose, and the 03/14/2021 AM dose. Interview with Resident #23, on 03/09/2021 at 9:00 AM, revealed he/she missed doses of [MEDICATION(S)] because the facility did not keep the medications in stock. He/she stated staff's explanation included no medication on the cart; needed to order; or needed to obtain a prescription. He/she stated when the facility did not have the [MEDICATION(S)] in stock his/her feet and lower legs burned and hurt. Resident #23 stated the pain kept him/her from sleeping. Review of Resident #23's Progress Notes, dated 03/10/2021 at 10:36 PM, revealed the staff documented the [MEDICATION(S)] not available with a plan to call pharmacy to reorder. Continued review, on 03/12/2021 at 11:02 PM, revealed the facility sent a new prescription to the pharmacy for the resident's [MEDICATION(S)] reorder. Further review revealed staff documented on, 03/14/2021 at 10:31 PM, the facility awaited the pharmacy to deliver the [MEDICATION(S)]. Continued interview with Resident #23, on 03/13/2021 at 9:30 AM, revealed the facility did not have his/her nerve medication. He/she stated the staff gave multiple excuses, which included to not have a prescription. He/she stated the ordered over the counter pain reliever and as needed [MEDICATION(S)] did not help his/her pain in his/her feet. He/she further stated he/she had difficulty with sleep in general and did not sleep throughout the night because his/her feet burned. 3. Record review revealed the facility admitted Resident #33 on 10/25/2018 with the diagnoses of Spinal Stenosis, Depression, and Anxiety. Review of the MDS, dated [DATE], revealed the facility assessed for cognitive patterns with the BIMS with a score of eleven (11). The facility assessed the resident to be interviewable. Review of the medication section revealed the resident received seven (7) of seven (7) days of anti-anxiety medication. Further review of Resident #33's Order Summary Report revealed the provider ordered [MEDICATION(S)] (a medication to decrease anxiety) zero point two five (0.25) mg twice a day. Interview with Resident #33, on 03/14/2021 at 11:14 AM, revealed he/she missed medications frequently. He/she stated the provider ordered medication for his/her anxiety. Resident #33 stated the staff's excuse included no prescription for a refill or the previous staff did not reorder. He/she stated when they did not have the medication his/her anxiety increased. Review of Resident #33's MAR revealed the facility failed to administer the resident's ordered [MEDICATION(S)] in December 2020 on 12/02/2020 AM and PM doses; 12/15/2020 AM and PM doses; 12/16/2020 AM dose; 12/27/2020 AM and PM doses; and, on 12/29/2020 AM dose. Review for the January of 2021 MAR revealed the missed doses included 01/07/2021 PM dose; 01/08/2021 AM and PM doses; 01/09/2021 AM dose; and, on 01/24/2021 AM dose. Review of the February 2021 MAR revealed the missed doses included 02/16/2021 AM and PM doses. Review of the March 2021 MAR revealed the missed doses included 03/02/2021 AM dose; 03/12/2021 AM and PM doses; and. 03/16/2021 AM and PM doses. 4. Record review revealed the facility admitted the Resident #46 on 12/15/2020 with the diagnoses of [CONDITION(S)], Chronic Pain, and Diabetes. Review of MDS, dated [DATE] revealed the facility assessed for cognitive patterns with the BIMS with a score of fourteen (14) and determined the resident was interviewable. Review of medication section revealed the resident received seven (7) of seven (7) days of pain medication with a pain score of nine (9) out of ten (10). Review of Resident #46's Order Summary Report revealed the provider ordered [MEDICATION(S)] (for muscle spasms) twenty (20) mg, two (2) tablets every six (6) hours for chronic pain. Interview with Resident #46, on 03/09/2021 at 10:54 AM, revealed the facility did not have his/her medication over the weekend and on 03/07/2021. He/she stated the nurses explained the last staff did not reorder the medication and the facility did not have a current prescription. However, the resident stated he/she spoke to the provider the day before and requested the provider to check to see if a new prescription would be required. Resident #46 stated the facility did not have a system to order medications, one nurse thinks the other nurse reordered or did not ask for the prescription. He/she stated when they do not get the pain medication, his/her legs jumps constantly which caused pain. Resident #46 further stated he/she laid under the bed covers all day while in unrelieved pain. Review of Resident #46's MAR revealed the facility failed do provide and administer the resident's ordered [MEDICATION(S)] for January of 2021 included: 01/07/2021 at 6:00 AM and 6:00 PM; 01/25/2021 at 6:00 AM; and, 01/30/2021 at 6:00 AM. Review of the February 2021 MAR revealed the missed doses included 02/06/2021 at 6:00 AM; 02/18/2021 at 6:00 AM; and, on 02/28/2021 at 6:00 PM. Review of March 2021 MAR revealed the missed doses included 03/10/2021 at 12:00 PM and 6:00 PM; 03/13/2021 at 6:00 PM; and on 03/14/2021 at 12:00 PM and 6:00 PM. Interview with Registered Nurse (RN) #11, on 03/13/2021 at 8:47 AM, revealed the night shift staffs' responsibilities included to review residents' medication cards to reorder medication and list needed prescriptions on the unit report log for the providers. The RN stated staff was able to review in the Electronic Medical Record (EMR) when the last reorder occurred and how many tablets were left for the scheduled medications for reorder. He stated if the reorder amount was zero (0) for a scheduled drug, then the pharmacy required a new prescription. On weekends, the provider may or may not respond to a text message for a requested need of a prescription. The RN stated the provider could order a three (3) day emergency refill. RN #11 stated agency staff did not take the time, and did not know how to reorder or ask for a new prescription. The RN stated he often finds empty scheduled medication cards. The RN stated residents go without the scheduled medication if the medication was not in the P

Based on observation, interview, record review, and review of the facility's policy, www.timeanddate.com and Googles Maps, it was determined the facility failed to provide an environment that was free from accident hazards as possible for four (4) of sixty- nine (69) sampled residents (Residents #8, #28, #90, and #248). The facility assessed Resident #248 to be at risk of wandering and elopement on [DATE], and initiated care plan interventions on [DATE] which included to maintain a safe environment. The facility utilized a wander management system, Accutech. However, the facility did not place a wander bracelet on the resident. On [DATE], Resident #248 exited the facility without staff knowledge. Around 5:30 PM, staff from another facility discovered Resident #248 on the ground in the parking lot adjacent to the facility. Staff from the other facility contacted the Long Term Care (LTC) facility's staff and informed them a resident was in the parking lot. The LTC facility staff was unaware Resident #248 had eloped from the facility until they were notified by staff from the other facility. The facility failed to ensure the C/D Unit garden tow (2) patio gates were secure. The gates led to a stair case and a storage area with a depressed window encasement. Resident #8, who was assessed to have dementia and required supervision with transfers, accessed the locked door with the door code and went outside unsupervised. Resident #90, has the diagnosis of [NAME] (an eating disorder). The facility failed to ensure adequate supervision, and failed to secure boxes and packages of food, and supplies for resident care were removed from the room, not assessable to Resident #90 In addition, the facility failed to ensure non-skid strips were placed to the floor for Resident #28 after a fall. Immediate Jeopardy was identified in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of K; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of L. Substandard quality of care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. The facility was notified of the immediate jeopardies on [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. Immediate Jeopardy was identified in the areas of 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of J and F693 Tube Feeding Management/Restore Eating Skills at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of K; 42 CFR 483.70 Administration, F835 Administration at a S/S of L; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F865 QAPI Program/Plan, disclosure/Good Faith Attempt at a S/S of L. Substandard Quality of Care was identified at 42 CFR 483.25, F692 Nutrition/Hydration Status Maintenance and F693 Tube Feeding Managment/Restore Eating Skills. The facility was notified of these immediate jeopardies on [DATE]. After supervisory review immediate jeopardy was identified on [DATE] and determined to exist on [DATE] in the area of 42 CFR 483.70 Administration, F837 Governing Body at a S/S of L. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE] alleging removal of immediate jeopardy on [DATE]. The facility provided an acceptable Credible Allegation of Compliance (AoC) on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the facility implemented their AoC as alleged by [DATE], prior to exit on [DATE] with the remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plan at scope and severity (S/S) of E; 42 CFR 483.25 Quality of Care F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of D; and 42 CFR 483.35 Nursing Services F726 Competent Nursing Staff at a S/S of F; 42 CFR 483.25 Quality of Care, F692 Nutrition/Hydration Status Maintenance at a S/S of D and F693 Tube Feeding Management/Restore Eating Skills at a S/S of D; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedures/Pharmacist/Records at a S/S of E; 42 CFR 483.70 Administration, F835 Administration at a S/S of F; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F865 QAPI Program/Plan, disclosure/Good Faith Attempt at a S/S of F, and, 42 CFR 483.70 Administration, F837 Governing Body at a S/S of F, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systematic changes. The findings include: 1. Review of the facility's policy, Wandering, Unsafe Resident, revised [DATE], revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents at risk of elopement. Facility staff would identify residents at risk of harm because of unsafe wandering, including elopement. Review of the facility's policy Elopement (Risk and Missing Resident), dated [DATE], revealed care team members were responsible for knowing the location of residents under their care. Residents identified at risk for elopement may utilize a security bracelet if the facility utilized an electronic monitoring system and need for the device was on the care plan. Care team members would teach staff to check the outside environment to ensure no resident had exited the building, when an alarm sounded. The facility was unable to provide policies for resident behaviors, the Accutech door alarm system, or the Accutech code alert security bracelet. Review of the staff schedule, dated [DATE], revealed one (1) nurse and one (1) aide scheduled on the E Hall from 3:00 PM to 11:00 PM; and, on the F Hall one (1) nurse from 7:00 AM to 7:00 PM and one (1) aide from 3:00 PM to 11:00 PM were scheduled. 1. Review of the closed clinical record for Resident #248 revealed the facility admitted the resident on [DATE] with diagnoses of Dementia without Behaviors, Repeated Falls, and Fracture of Sacrum. The facility completed a Wandering/Elopement Risk Scale, dated [DATE], and found the resident was non-ambulatory or unable to self-propel in a wheelchair (w/c) and at Low Risk for elopement. The Baseline Care Plan, not dated, revealed the resident used a walker and w/c, was not at risk for elopement, and was cognitively impaired with Dementia and confusion was noted. Review of a Progress Note, dated [DATE] at 11:36 AM, revealed the night nurse reported to the day nurse that Resident #248 could not be located in his/her room. A nurse from another hallway brought the resident back to his/her unit. During the first medication pass, staff saw the resident in the hallway and escorted the resident back to his/her room. The housekeeper informed the nurse the resident was in the hallway, and the nurse escorted the resident back to his/her room and changed the resident's brief. Further review revealed, at 11:30 AM, a nurse from another unit informed the resident's nurse that Resident #248 was on the other unit. The resident's nurse brought Resident #248 back to his/her room. Record review revealed no documented evidence the facility increased the resident's supervision. Review of a Wandering/Elopement Risk Scale, dated [DATE] at 6:26 PM, revealed a significant change in condition, the resident was ambulatory or able to propel himself/herself in a w/c, and the resident had a history of wandering with exit seeking behaviors. Further review revealed the facility assessed Resident #248 at High Risk to Wander and High Risk for Elopement. Review of a Progress Note, dated [DATE] at 6:28 PM, revealed the resident wandered into the hallway twice and remained confused. The facility utilized a wander management system, Accutech. However, the facility did not place a wander bracelet on the resident. Record review revealed there was no documented evidence the facility increased the resident's supervision. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed that Resident #248 was unable to complete the Brief Interview for Mental Status (BIMS) and assessed the resident to be cognitively moderately impaired. The facility assessed the resident wandered one (1) to three (3) days, and used a walker and w/c. Review of the care plan for Resident #248, dated [DATE], revealed the resident exhibited behavior symptoms of wandering and was at risk of injury. Further review revealed an intervention to maintain a safe environment. However, record review revealed no documented evidence the facility increased the supervision for Resident #248. Review of an incident note, dated [DATE] at 8:08 PM, by Registered Nurse (RN) #8 revealed Resident #248 was found outside sitting on the ground. The note revealed staff warmed the resident and no injuries were noted. Review of the temperature record, for [DATE] at 6:00 PM, on www.timeanddate.com revealed the temperature was 34 degrees Fahrenheit. Review of Google Maps revealed the distance from the E/F Unit nurse's station door, followed along the parking lot to the other facility's parking lot location where Resident #248 was discovered, was approximately 262 feet. Review of an IDT (interdisciplinary team) note, dated [DATE] at 9:57 AM, revealed on [DATE] Resident #248 was observed sitting on the ground outside. The facility assessed the resident without injury and assisted the resident into his/her w/c. The note further revealed environmental factors were not noted at the time of the event, and the resident could not provide a statement of the event. Record review revealed Resident #248 was no longer in the facility and had been discharged on [DATE]. Observation, on [DATE] at 9:10 AM, of the E/F Unit nurse's station revealed a common area with an exterior door to the side parking lot. A sign on the door noted to push until the alarm sounded, the door could be opened in fifteen (15) seconds. Further observation revealed a sign posted that stated not to use the door, please use front entrance. On [DATE] at 2:49 PM, observation of the E/F exterior door at the nurse's station alarmed. At 2:58 PM, the Executive Director silenced the alarm. The alarm then sounded again and the Executive Director silenced the door alarm again, walked toward the E/F nurse's station and asked the four (4) staff at the nurse's station if they heard the alarm. According to the facility's policy, staff would check outside to ensure no resident had exited the building when an alarm sounded. Observation of the E/F Unit nurse's station door, on [DATE] at 2:00 PM, with the Scheduler, revealed the resident was found on the ground in the parking lot of the other facility adjacent to the LTC facility. Observation revealed the E/F Unit nurse's station door exited out to a patio area that led to a parking area. To the left of the patio, the drive led to two (2) dumpsters and around the back of the building. Straight ahead of the patio past the parking lot was the other facility building. To the left of the patio, approximately ten (10) parking spaces down was a speed bump. Just past the speed bump was a turn to enter the other facility's parking lot. Approximately eight (8) parking spaces down, the resident was witnessed to fall (the other facility's staff witnessed). The handicap space where the resident fell was visible to the other facility's main entrance. Observation, on [DATE] at 1:45 PM, with the Maintenance Director, of the E/F Unit nurse's station exit door revealed the Accutech keypad, a sound box, and a code alert antenna under the keypad. Continued observation, on [DATE] at 1:52 PM, with the Maintenance Director revealed an alarm sounded when a code alert device was nearby. The State Survey Agency (SSA) heard the alarm down the E Hall to room E4, two (2) rooms down the hall from the nurse's station. The Maintenance Director, without the code device alert, pushed on the E/F Unit door and an alarm sounded, and the door opened after fifteen (15) seconds. The fifteen (15) second alarm sounded similar to the call lights ringing at the E/F Unit nurse's station right in front of the door. On [DATE] at 4:15 AM, observation of the delivery door near the kitchen revealed the fifteen (15) second alarm sounded. At 4:17 AM, CNA #14 exited the kitchen near the delivery door, silenced the alarm and stepped away from the door. The CNA did not check the environment outside to ensure no resident had exited, per the facility's policy. Observation of the E/F Unit nurse's station, on [DATE] at 4:29 AM, revealed no staff was visible at the nurse's station or down either the E or F Halls. Interview with elopement Witness #1, on [DATE] at 10:43 AM, revealed she worked near the LTC facility. She stated the receptionist at her work site reported to her that she saw the resident fall in their parking lot, around mealtime. The witness revealed she and another coworker went outside to the resident. She stated it was dark outside and there was no walker or w/c present. Witness #1 stated she was unable to reach the Executive Director of the LTC facility when she called, so she spoke to the Scheduler. The witness stated the LTC staff brought out a w/c for the resident, and returned the resident to the LTC facility. On [DATE] at 11:09 AM, interview with Certified Nurse Aide (CNA) #11 revealed Resident #248 liked to wander and was able to walk. She stated the E/F Unit nurse's station door had a wander alert (Accutech) alarm; however, not all of the facility's doors had the Accutech alarm. CNA #11 stated the purpose of the alarm was to ensure residents did not leave the facility and if the alarm sounded, the facility should check to ensure they accounted for all the residents. She revealed it was unsafe if a resident left the facility. CNA #11 stated the resident could get into an accident or die. Interview with the Scheduler, on [DATE] at 11:30 AM, revealed staff from another facility called and reported to him that a LTC resident was in the parking lot sometime after 5:00 PM. He stated he had already left the facility and was only five (5) minutes away, and returned to the facility. Further interview revealed when he returned he found the Witness and her coworker with Resident #248 outside. The Scheduler stated the temperature was freezing cold, and the resident was sitting on the ground. He stated the resident was crying, and stated that he/she wanted to go home, and was trying to get to his/her kids. The Scheduler stated the resident had a blanket and had walked on his/her own to where he/she had fallen as the resident's w/c nor walker were outside. Continued interview revealed Registered Nurse Applicant (RNA) #4 brought the resident's w/c to return the resident to the facility. The Scheduler stated he thought the resident exited through the E/F Unit nurse's station door. RNA #4 stated he could not recall if the alarm sounded. Interview, on [DATE] at 2:25 PM, with Registered Nurse (RN) #8 revealed she was the nurse assigned to care for Resident #248. RN #8 revealed the resident did not wear a code alert device. She stated she last saw the resident around 5:20 PM or 5:30 PM in the hallway at his/her room, in his/her w/c. The RN stated the resident tried to stand and she assisted the resident back into his/her room, then went to another resident's room to administer an intravenous (IV) medication and transfer a COVID-19 positive resident to the COVID Unit on the G Hall. The nurse stated she discovered the resident had eloped when she returned to the E/F Unit. She stated the Scheduler and two (2) other people were with the resident in the other facility's parking lot. Continued interview revealed the resident had walked on his/her own, as there were no assistive devices with the resident. The nurse stated she saw Resident #248 walk independently a few times before the elopement. She stated that RNA #4 assisted her to transfer the resident to the COVID Unit, and they were the only nurses on the E/F Unit. RN #8 stated she and RNA #4 took the resident's w/c and blankets out with them and returned the resident to the facility. The RN stated it was cold outside. RN #8 stated she did not hear an alarm sound. On [DATE] at 3:30 PM, interview with CNA #12 revealed he worked with Resident #248. He stated he and one (1) other CNA were assigned to work the E/F Unit, the day the resident eloped. He stated he left the unit to get the dinner tray cart around 5:30 PM and when he returned to the unit the resident had already eloped. CNA #12 stated he thought the resident had a code alert bracelet at the time he/she eloped, but could not recall if the door alarm sounded. He stated the doors were alarmed to alert staff of a potential elopement. On [DATE] at 10:55 AM, interview with RNA (Registered Nurse Applicant) #4 revealed she worked the E Hall when Resident #248 eloped. She stated she last saw the resident around 5:20 PM when she assisted the other E/F Unit nurse with an IV (intravenous) in room F5 or F6, and moved a resident to the G Hall. The RNA stated about ten (10) minutes later the Scheduler and Executive Director informed them Resident #248 was not in the building. She stated the resident did not have his/her w/c, and she took the resident's w/c to the parking lot and saw the resident on the ground. The RNA stated it was cold and wet outside. She further revealed she and RN #8 brought the resident back into the building in his/her w/c. The RNA stated she assisted the resident change out of his/her wet clothes into dry clothing. RNA #4 stated she did not hear a door alarm. Interview, on [DATE] at 1:17 PM, with the Maintenance Director revealed the Executive Director called him while he was on his way home, around 5:30 PM, of an elopement. He stated he returned to the facility, around 5:40 PM, and found the door alarms worked properly when he checked them. Further interview revealed he thought someone let the resident out. He stated when a resident with the code alert device walked up to the door it would alarm unless the alarm was reset by the keypad, and the door could then open via keypad override. The Maintenance Director stated someone could still exit the E/F Unit nurse's station door by pushing on the door for fifteen (15) seconds. He stated staff would have to enter a code on the keypad to reset the alarm. He further stated the fifteen (15) second egress alarm could only be heard at the particular door that alarmed and would not be heard building wide. Continued interview with the Maintenance Director, during observation of the door alarms, on [DATE] at 1:52 PM, revealed the fifteen (15) second door alarm sounded like the call lights beeping. He stated he could see how staff could get confused, as he often did, as the two (2) sounds were the same. Interview with CNA #13, on [DATE] at 3:21 PM, revealed he had worked with Resident #248 in the past. He stated he worked the E Hall and did not see Resident #248 the day he/she eloped. He stated he was in a resident's room at the end of the hallway providing care when the resident eloped. He further stated the resident's door was closed, and he spent about twenty (20) to twenty-five (25) minutes cleaning and changing the resident and bed linens. The aide revealed when he left the resident's room, around 5:30 PM, staff were returning the resident to the facility. The CNA further revealed if he had been closer, he could have heard the door alarm. However, there was no one at the nurse's station to stop the resident. He stated because no one was at the nurse's station, the resident was able to get up and leave. Interview on [DATE] at 1:22 PM, with CNA #17 revealed she had worked with Resident #248 a few times, however she was not working when the resident eloped. She stated she heard the resident followed staff on their way out of the building to smoke. The aide revealed staff used to take trash out the E/F Unit door before the elopement. Interview with the Director of Nursing Services (DNS), on [DATE] at 4:15 PM, revealed he began employment on [DATE] and did not work at the facility when the resident eloped. The DNS revealed he expected a wander risk assessment completed and interventions immediately put in place to prevent elopement. He revealed if a resident was at risk of elopement, the facility should place a code alert bracelet on the resident. The DNS stated the code alert device helped assure the resident was in the facility and safe. He further stated if a resident eloped, the resident was at risk of injury or worse. The DNS stated the code alert device did not relieve staff of resident supervision, as it was only a tool. He stated LTC operated on bare minimum for staffing. Continued interview with the DNS revealed the facility could try to do everything they could to keep a resident safe; however, there were times no one would be at the nurse's station because they were all providing resident care. He stated the code alert bracelet would alarm which would alert the nurses of an attempt by a resident to leave. Interview, on [DATE] at 5:44 PM, with the Executive Director revealed when she went to another resident's room she saw RNA #4 and RN #8 with another resident providing care related to an IV and CNA #12 reported to her he was on the way to get the dinner cart. The Executive Director stated while she was in the other resident's room, she missed two (2) calls from the Witness. She stated the scheduler called her and reported that Resident #248 was in the parking lot. The Executive Director stated when she left the other resident's room, she saw Medical Records and RNA #4. She further stated RNA #4 and RN #8 retrieved the resident's w/c from the resident's doorway to his/her room and went out to the resident in the parking lot. Further interview revealed when she left the other resident's room, she did not hear a door alarm sound. She further stated the door alarm did not sound when Resident #248 exited the building. She stated it was possible to enter a code to the keypad to exit the E/F Unit nurse's station door. The Executive Director stated she did not have to push in a code to silence a door alarm, and the facility did not have a log to track when a code was entered. She stated she went outside and saw the resident on his/her knees in the parking lot and the nurse assisted the resident to a sitting position. She stated the temperature was around thirty-four (34) to thirty-six (36) degrees (F) outside and it was dark, around 5:45 PM. The Executive Director stated she requested the prior DNS place a code alert bracelet on Resident #248 on [DATE], when the facility assessed the resident to be at risk for elopement. However, she stated that did not occur as the resident did not have a code alert bracelet on when he/she returned to the facility. Additionally, the Executive Director stated when she silenced the E/F nurse's station door alarm (on [DATE]) she did not implement a Code Silver and check outside as the facility only initiated a Code Silver when the Accutech device alarm sounded. She revealed the Code Silver was not necessary for the fifteen (15) second egress alarm. The Executive Director stated if a resident left the facility without informing staff, the resident eloped. Continued interview with the Maintenance Director, on [DATE] at 3:30 PM, revealed only three (3) doors in the facility had code alert alarms. He stated he only had one (1) issue with the fifteen (15) second alarm on the E/F Unit nurse's station door, in [DATE], with a loose screw. Interview, on [DATE] at 4:17 AM, with CNA #14 revealed anyone could get out when they pushed on the door. She stated a resident could get out, or someone could get in if the door was not secured and alarmed. She stated if someone pulled on the door from the outside, it would also trigger the alarm. On [DATE] at 10:48 AM, interview with the former DNS #1 revealed she was on her way home when either the Scheduler or Executive Director informed her Resident #248 had eloped. She stated she recalled the assessment on [DATE] when the resident came out of his/her room. The former DNS stated the resident was not exit seeking but came out to the common area. She stated the facility did not discuss or place a code alert bracelet on the resident as he/she was not exit seeking. She stated the resident was confused as he/she was a new admission to the facility. The facility alleged it implemented the following actions to remove immediacy: 1. A nurse assessed Resident #248 upon return to the building, on [DATE]. 2. The Maintenance Director checked all doors for function, on [DATE], [DATE], and [DATE]. 3. On [DATE], the Maintenance Director stationed at the E/F Unit door until the alarm company arrived to validate door function. The alarm company checked all exit doors and alarms worked properly, on [DATE] and [DATE]. 4. A nurse placed an Accutech bracelet on Resident #248, on [DATE], upon return to the facility, and checked placement and function. 5. The Director of Nursing Services (DNS), on [DATE], reviewed and revised Resident #248's care plan. 6. The Executive Director notified the physician and resident representative, of the elopement on [DATE]. 7. A nurse completed an elopement risk assessment, on [DATE], for Resident #248. 8. A nurse checked the Accutech bracelet each shift for Resident #248 until discharge, which began on [DATE]. 9. The facility discharged Resident #248, on [DATE]. 10. The facility completed a head count of all residents, on [DATE]. 11. The facility completed new elopement risk assessments and care plans were updated for all residents. This was initiated on [DATE] and completed on [DATE]. An Accutech bracelet was placed on anyone identified at high risk, order obtained, and care plan updated. 12. The facility checked all Accutech bracelets in use, on [DATE], for placement and function. 13. The Executive Director audited all elopement binders for accurate information and photos, on [DATE] and [DATE]. 14. The facility conducted an elopement drill on each shift on [DATE], [DATE], [DATE], and [DATE]. 15. On [DATE], the Regional Clinical Nurse audited all elopement assessments, elopement books and photos to ensure they were complete and accurate. 16. A nurse checked all Accutech bracelets in use, for placement and function, on [DATE]. 17. A nurse reviewed the wander risk evaluation report to identify if the resident was at risk for elopement with appropriate intervention reflected on the care plan and Kardex; if an Accutech bracelet was appropriate; and reviewed the Physician's Order. 18. All staff was re-educated on: elopement care guidelines; Accutech bracelet placement and function; and utilize only the front entrance to enter and exit. A post test was given. On [DATE], no facility or agency staff worked until they received the education. The DNS, ADNS, and Regional Clinical Nurse educated staff on the elopement drill, elopement assessments, and staff's need to respond to alarms, with no staff working after [DATE] until educated. 19. All nurses were educated on completion of elopement assessments and actions if identified at risk, with post-test. On [DATE], no facility or agency nurse worked without education. 20. All nursing team members (LPNs, RNs, KMA, CNA) were educated on documentation in the medical record related to exit seeking behavior or remarks, with post-test. On [DATE], no nurse worked without education. 21. Elopement drills were conducted once per shift, per month or three (3) months, then monthly until staff's response was satisfactory, beginning [DATE] and [DATE]. 22. The Maintenance Director conducted door alarm function audits five (5) times a week for three (3) weeks, then weekly. The DNS conducted weekly audits for placement and function for all Accutech bracelets for residents with orders, on [DATE] and [DATE]. 23. The Interdisciplinary Team (IDT) reviewed nursing notes and new admissions during daily clinical start up meeting seven (7) days a week for exit seeking behaviors and elopement assessments completed. On [DATE], IDT began review five (5) days a week. 24. The Maintenance Director stopped external doors to exit for staff in resident care areas, except the front door, on [DATE]. 25. On [DATE], the RDO and Regional Clinical Nurse educated the Executive Director, DNS, and ADNS on the elopement drill, how to complete elopement assessments, and that staff needed to be available and respond to alarms. 26. The Executive Director and DNS educated the IDT, on [DATE], regarding the elopement drill, elopement assessments, and staff needed to respond. 27. The DNS audited residents at risk for elopement, on [DATE] through [DATE], to ensure each resident at risk had an unexpired Accutech bracelet that functioned, the facility had an order for the Accutech bracelet checked for placement and function each shift, behavior monitoring for wandering, and a care plan for wandering/exit seeking. Audits continued for three (3) weeks, then monthly for six (6) months. 28. The DNS checked function of all Accutech bracelets, on [DATE], and on [DATE], and continued for three (3) weeks. 29. All audits were forwarded to the Executive Director and QAPI twice a week until the IJ was abated, then weekly for four (4) weeks, and monthly thereafter. 30. The QAPI committee met, on [DATE] and [DATE], with the Medical Director, DNS, and Executive Director, to review audits and discuss actions. QAPI meetings, on [DATE] and [DATE], reviewed all audits. 31. On [DATE], the DNS/ADNS/Medical Records audited residents at risk of elopement to ensure they had an order for an Accutech bracelet if appropriate and interventions were on the care plan. 32. An Ad Hoc QAPI Committee meeting was held with the Medical Director, DNS, and Executive Director, on [DATE], to review the incident, action plan, and findings. QAPI met on [DATE] to discuss audits and actions. 33. All audits would be forwarded to the Executive Director and QAPI Committee twice a week until abatement, then weekly for four (4) weeks, and monthly thereafter, for a minimum of three (3) months. The SSA validated the facility implemented the following actions: 1. Interview, on [DATE] at 11:37 AM, with Registered Nurse (RN) #8 revealed she found Resident #248 outside and conducted a head to toe assessment. Review of a Progress Note, dated [DATE], revealed Resident #248 sat outside the building. The nurse completed a head to toe assessment. 2. On [DATE] at 3:16 PM, interview with the Maintenance Director revealed he checked all of the exit doors on [DATE], on [DATE], and again around [DATE]. Review of the Weekly Door Alarm Test, dated [DATE], [DATE], and [DATE], revealed all eleven (11) exit doors were checked by the Maintenance Director. 3. Interview with the Maintenance Director, on [DATE] at 3:16 PM, revealed he stayed at the E/F Unit nurse's station door until the alarm company checked it that evening after the elopement, on [DATE]. He stated the alarm company returned to the facility to check all doors to ensure they functioned, sometime early [DATE]. Review of the Service Work Order from the alarm company, dated [DATE] and [DATE], revealed all doors functioned properly. 4. Interview, on [DATE] at 11:31 AM, with former Director of Nursing Services (DNS) #1 revealed after the resident returned, a nurse placed an Accutech brace [TRUNCATED]

Based on observations, interviews, record reviews and review of the facility's policy it was determined the facility failed to ensure residents identified at nutritional risk were monitored and provided nutritional services to meet the needs of the resident to prevent excessive weight loss for two (2) of sixty-nine (69) sampled residents (Resident #60 and Resident #90). The facility admitted Resident #90, on 02/12/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not record an admission weight. However, review of the resident's hospital discharge record revealed the resident's weight was seventy-four (74) kilograms (kg) or one hundred and sixty-three (163) pounds (lb.). Resident #90 was on a Nectar Thick Liquid (NTL/consistency of an applesauce) diet. According to the facility's policy, residents were to be weighted on admission and weekly for four (4) weeks. On 02/19/2021, the facility assessed the resident with swallowing disorders with loss of liquids/solids with eating/drinking and held food in his/her mouth. Resident #90's record review revealed, on 02/16/2021, the Speech Therapist (ST) completed the resident's initial assessment with the notation of a thin liquid consistency and ordered thin liquids. On 02/19/2021, the Speech Therapist changed the order to NTL and noted the resident's weight was one-hundred and fifty-four (154) pounds, eight (8) days after admission. On 03/14/2021, the facility documented the resident's next weight of 113.6 lbs. Record review revealed from 02/26/2021 to 03/06/2021, the facility did not record the resident's intake for any meal. Observations revealed the Certified Nursing Assistant (CNA) #3 and Registered Nurse (RN) #11 obtained Resident's #90's weight on 03/01/2021 with a noted weight of one hundred and nine point one (109.1) lb., with a re-weigh of the same weight. The resident had a weight loss of forty-five (45) pounds or twenty-nine (29) percent (percentage) weight loss in four (4) weeks. Interview with Resident #90's family revealed the family spoke to the facility numerous times related to concerns of the resident's appearance of weight loss. Interview revealed the family requested weight reports daily with multiple requests to the Executive Director (ED), unanswered. The facility admitted Resident #60, on 08/11/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60's nutritional status included enteral feedings and nothing by mouth (NPO). The facility transferred Resident #60 to the hospital on 12/09/2020 and he/she returned to the facility on [DATE]. However, the previously ordered water flushes of 200 milliliters (ml) every six (6) hours was not reordered. Resident did not have an active order for water flushes via gastrostomy (g-tube) for a total of ninety (90) days. Review of Resident #60's weights revealed the facility assessed the resident's weight to be 157 lbs. on 12/05/2020; 151 lbs. on 01/05/2021; and 133.4 lbs. on 03/16/2021. The 03/16/2021 weight of 133.4 lbs. revealed 17.6 lbs. weight loss in 68 days. Immediate Jeopardy and Substandard Quality of Care (SQC) were identified on 03/21/2021 and determined to exist on 12/15/2020. The facility's failure to have an effective system in place to ensure each resident received adequate nutrition and diets to prevent excessive weight loss has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified at 42 CFR 483.25 Quality of Care (F692 at S/S of J) and Substandard Quality of Care (SQC) 42 CFR 483.21 Comprehensive Person Centered Care Plan (F656 at S/S of K) were identified on 03/21/2021 and determined to exist on 12/15/2021. The facility provided an acceptable credible Allegation of Compliance (AoC) on 03/30/2021 alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/30/2021, prior to exit on 04/03/2021, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy Resident Weight Monitoring dated 10/2018, revealed upon admission or re-admission, the facility would weigh the resident; and, for four (4) weeks after admission with documentation in the EMR (electronic medical record). A significant weight change included 5% (percent) in 30 days, 7.5% in 90 days, and 10% in three (3) months. Review of the facility's policy IDT (interdisciplinary) Risk Review dated 07/2020 revealed weekly weights would be obtained and monitored. The purpose included to identify residents at risk for weight loss. Review of the facility's policy, Activities of Daily Living (ADL's) Supporting, revised 03/2018, revealed the facility's responsibility for residents' identified as unable to carry out ADL's independently included to receive the necessary services to maintain good nutrition, grooming, and hygiene. Review of the Resident Weight Monitoring Policy, dated 10/18, revealed monthly weights were to be completed by the fifth (5th) of every month and documented in the electronic medical records vital signs section. For residents with a change of greater than or less than five (5) pound difference, the staff would obtain a reweigh by the sixth (6th) of every month. Review of the Registered Dietician Recommendations Policy, dated 10/18, revealed the Registered Dietician (RD) would routinely review the nutritional status of residents and make recommendations to maintain or improve nutritional status. Review of the Registered Dietician job description, dated 02/2020, revealed the Registered Dietician's primary responsibility included completion of comprehensive nutritional assessments and incorporation of nutritional interventions in the resident's individualized care plan to meet professional standards of practice. 1. Record review revealed the facility admitted Resident #90, on 02/12/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 02/19/2021, revealed the facility assessed the resident as severely impaired to make decisions. The facility assessed the resident's eating status as independence with the assistance of one. The facility noted the resident's weight was 154 lbs. Review of Resident #90's Admission Report, dated 02/12/2021 at 10:41 AM, revealed the resident's weight was seventy-four (74) kilograms (kg) or one hundred and sixty-three (163) pounds (lb.). The report noted the resident was to have NTL (nectar thick liquids), no straws, and one on one supervision with oral intake. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #90's recorded meal intake revealed the facility failed to document meal intake for twenty-three (23) occurrences from 02/13/2021 to 02/28/2021. The facility failed to document any intake from 02/26/2021 through 03/07/2021. Further review revealed the facility had one hundred and eighty-four (184) opportunities to document the resident's meal intake from 02/13/2021 to 03/08/2021. The facility documented forty-seven (47) instances of meal intake for Resident #90. The resident's meal intake varied with 0% to 25%, a total of twelve (12) time; 26% to 50% six (6) times: 51% to 75% nine (9) times; 76% to 100% ten (10) times; and, five (5) refusals. Record review revealed on 02/12/2021 the report from the discharge hospital noted the resident's weight was seventy-four (74) kilograms (kg) or one hundred and sixty-three (163) pounds (lb.). Review of Resident #90's weight history revealed the facility documented on 02/19/2021 a weight of 154 lbs., eight (8) days after admission. The facility recorded the resident's next weight on 03/13/2021 at 113 lbs., which was twenty-two (22) days after the first recorded weight. However, per the facility's policy, the facility would weigh the resident upon admission and weekly for four (4) weeks and then monthly. Review of Resident #90's Order Summary Sheet, dated 03/17/2021, revealed, on 02/19/2021 the facility initiated with an active order for a pureed texture diet, nectar consistency liquids with supervision and swallow precautions. Further review revealed the facility did not initiate the nutritional supplementation for caloric intake and appetite stimulation therapy until 03/15/2021. Observation, on 03/11/2021 at 12:40 PM, revealed a sign above Resident #90's headboard, which revealed Nectar Thick Liquids only, mechanical soft food by ST only. Continued observation, on 12:40 PM, revealed a tray next to the CNA (certified nurse aide), and the resident on the opposite side of the CNA. Review of the meal ticket, dated 03/11/2021, revealed pureed as the diet and thin liquids. Continued observation revealed staff offered the entire cup of fluids at one time to the resident. Observation revealed the liquid ran over the lip of the cup onto the resident. The liquid was noted to have a thin consistency. The observation revealed the resident produced an immediate cough with each intake of the fluid. Interview with CNA #3 revealed the resident did eat well at breakfast. Resident #90 constantly reached for the tray reaching around the CNA, attempted to grab the food, and the CNA pushed the resident's hands away from the tray. Personal Care Assistant (PCA) #1 entered the room, and CNA #3 requested help with keeping the resident's hands out of the way. PCA #1 placed their hands to the resident's shoulders, slid her hand onto the upper arms and pulled the resident's arms down which also placed the resident shoulders back on the chair. The resident continued to attempt to reach for the food at this time while CNA #3 attempted to fully assist the resident to eat. The PCA released the resident after CNA #3 revealed the resident would not eat the pureed food. Further observation revealed the PCA obtained two (2) boxes of chocolate milk and served both boxes to the resident. Again, the resident excessively coughed with the quick intake of the fluids. Observation of the table revealed boxes of Nutra-grain bars, fruit cups of several types, bananas, and cookies. Interview with CNA #3, on 03/11/2021 at 12:51 PM revealed the CNA locked the wheel chair to keep the resident from obtaining items due to his/her [NAME]. The CNA revealed the resident ate anything, and pointed to the wall. She revealed the gouges in the wall above the bedside table resulted from when the resident dug into the plaster and ate the matter he/she picked out of the hole, which she observed. However, she did not report it to anybody above the nurse. The CNA revealed the family came to the window and instructed staff how to feed the resident and other care routines. CNA #3 revealed the resident's level of care required full assistance with meals. Continued interview with CNA #3 on 03/11/2021 at 12:51 PM revealed the kitchen did not always send powdered packets for thickener on the meal tray. She revealed if the tray did not have a packet, the nurses had packets in the medication cart. CNA #3 revealed staff provided extra milk when the resident did not eat well for the calories. She revealed if a resident coughed when they drank it meant the resident aspirated. Further interview revealed Resident #90 coughed after every intake of the apple juice, which she stated, appeared to be thin in consistency. CNA #3 identified the date on the lunch ticket as 03/11/2021, and the tray had pureed foods and thin liquids. However, the CNA revealed the resident should receive NTL. The CNA revealed the aides reported to the nurse on the unit each time the resident did not eat up to half of the meal. Review of meal intake documentation for 03/11/2021 revealed the CNA documented two (2) lunch intakes as 0 %-25 % eaten and, 26%-50%, both intakes were entered at 2:40 PM. Further observation, on 03/12/2021 at 8:52 AM, revealed CNA #3 loaded Resident #90's pureed breakfast food items on the utensil and attempted to feed the resident. Resident #90 continued to reach for the tray which was placed on the opposite side of the CNA away from the resident. The CNA called the resident boy-boy while she encouraged the resident to eat. Observation of the printed tray ticket, dated 03/12/2020, revealed Resident #90's meal included pureed foods and thin liquids. The aide identified the liquid in the cup as thin. Continued observation revealed the resident constantly coughed with every intake of the fluid. PCA #1 entered the room; held the resident's hands and stood in front of him/her, as directed by CNA #3, to prevent the resident from reaching for the tray. CNA #19 entered the room with a pudding cup, staff gave two-thirds (2/3) of the pudding, announced the meal was done and removed the tray at 9:00 AM. CNA #3 then locked the resident's brakes to the wheelchair, and gave some items to the resident to hold. The resident's tray consisted of a scoop of ground eggs and meat, one (1) bowl of creamed cereal, 1 cup of a pudding type substance, and 1 cup of a yellow liquid. The resident accepted three (3) spoonful's of the egg/meal mixture and drank one-half (1/2) cup of a yellow fluids. Review of meal intake documentation CNA #3, on 03/12/2021, at breakfast revealed the aide documented 0-25 percent (%) as the amount eaten. Interview with Family #3, on 03/11/2021 at 11:54 AM, revealed, when she requested, the facility could not provide the family, an admission weight and daily weights. However, she revealed the Executive Director (ED) cited the facility's lack of staff and that the family's request was an unreasonable request. The Family revealed they spoke to the ED because the facility did not have a DNE in the building for several weeks. Family #3 revealed the ED informed them the minimum requirement for weights included monthly weights or as directed by the provider. The family revealed the ED reported his/her weekly lab work would identify dehydration or malnutrition after they voiced their concern of intake and the resident's appearance of weight loss. Continued interview on 03/11/2021 at 11:54 AM, with Family #3 revealed the facility provided a weight after numerous requests. On, 03/09/2021, the ED notified the family of a weight of 109 lbs. and reported the scale was possibly broken as a reason for the weight. Interview revealed the family expressed to the ED they feared for the resident's safety. She revealed RN #11 reported a weight of 109.1 pounds on 03/12/2021 when the family inquired the day's weight. Continued interview revealed RN #11 reported to have re-weighed the resident and remarked the weight as accurate with the weight of the wheelchair subtracted. Continued interview on 03/11/2021 at 11:54 AM with the family revealed she spoke to the ED, on 03/09/2021. Interview revealed the family felt the facility placed Resident #90's life in jeopardy because the facility did not meet the resident's required care needs. According to the family, the facility's administration knew before the resident was admitted , after several lengthy conversations with the ED. Interview, on 03/15/2021 at 9:11 AM, revealed the family vocalized to the ED that the facility did not have a systematic process to obtain weights. The family revealed they observed Resident #90's attempts to open packages left in the open and they had reported to the facility that the behavior could mean hunger. During further interview, the family revealed the facility could not produce records of the resident's meal intake when requested as the facility voiced their requests were unreasonable. The family revealed they felt the resident remained hungry throughout the day. Further interview on 03/11/2021 at 11:54 AM revealed with the family revealed they had gone into detail with the ST, RN and CNA's how to allow the resident to feed himself/herself. This included staff to allow the resident to hold a regular spoon, assist with load of food to the spoon, tap the top of the resident's hand as the cue to put the food in his/her mouth. Staff were to place a small amount of liquid in a cup as the resident could drink without assistance. The family revealed they informed the ED that the facility accepted the resident with full knowledge of his/her high needs. Continued interview revealed after several meetings, the facility accepted the resident. She revealed the facility's responsibility included to ensure the care given to the resident met his/her needs. Furthermore, the family revealed they felt the facility neglected the resident's nutritional requirements because of the excessive weight loss. Interview with Personal Care Aide (PCA) #1, on 03/18/2021 at 3:52 PM, revealed the PCA retrieved pudding, chocolate milk and house shakes for staff to give to Resident #90 because the resident did not like the pureed texture of the food. The PCA revealed occasionally the resident would eat an entire meal, usually breakfast. PCA #1 revealed the kitchen sent regular drinks for the resident. However, there was not always a packet of thickener on the tray, and staff did not ask her to ask the nurse for a packet. The PCA revealed the CNA's notify the nurse when the resident did not eat well. Interview with CNA #3, on 03/19/2021 at 10:34 AM, revealed the facility's policy for weights included to have the CNA's obtained residents' weights on admission and then monthly. The CNA revealed the facility sent a list to each unit each month to notify staff of the residents that needed weights obtained. CNA #3 revealed Resident #90 had not been at the facility a full month therefore the resident's weight had not been taken met the month threshold until last week. The CNA revealed aides put the amount eaten in the EMR each meal and reported poor intake at each occurrence to the nurses. CNA #3 revealed if the facility identified a concern with meal intakes, the nurse would get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #3 revealed the facility changed the fluids because the resident coughed with every swallow of the thin liquid. The CNA revealed the ST first instructed her on 03/17/2021, on proper feeding techniques and how to offer liquid with small amounts in a separate cup. She revealed the facility increased the resident's weights to daily because the facility identified the resident's lost weight since admission. Furthermore, the CNA revealed if the facility had obtained weekly weights, the weight loss could have been identified sooner and initiated the supplements to prevent further weight loss. Record review of a three ring binder, untitled, on 03/31/2021, revealed the facility initiated a monitor sheet for Resident #90 which included daily weights, intake for meals, snacks, fluids, and was located in the nurse's station on the A/B unit. The facility's first date of the daily monitor sheet was 03/15/2021. Interview with Licensed Practical Nurse (LPN) #2, on 03/20/2021 at 7:45 AM, revealed the facility obtained residents' weights on admission and then the facility obtained the residents' weights monthly unless the provider ordered an alternative schedule. The LPN revealed they received report and admitted Resident #90. LPN #2 revealed the resident came to the facility with NTL ordered with a pureed diet. She revealed the aide obtained the resident's weight and the LPN subtracted the weight of the wheelchair. Continued interview with LPN #2, on 03/20/2021 at 7:45 AM, revealed Resident #90 ate well at breakfast and had poor intake the rest of the day. The LPN revealed the facility had not reported concerns with the resident's weight. However, the sister expressed to the aides, nurses and the ED the facility could not tell the family how much the resident weighed because the monthly weight had not occurred yet. However, the LPN revealed he could not provide the family the daily intake. LPN #2 stated the family revealed he facility told them the facility's protocol included monthly weights for all residents' after admission. The LPN revealed if the facility did not follow its policy then residents with weight loss could not be identified early. The LPN revealed the facility did not have a standard of practice of writing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN reviewed the facility's weight policy with the surveyor and revealed when residents were admitted staff did not generate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN revealed RN #11 expressed the resident would not eat on the COVID Unit when he inquired about the resident's eating pattern. The LPN revealed they reported to the RN the resident ate well at breakfast but not at the other meals. LPN #2 revealed staff did not report abnormal issues with poor intake with meals. The LPN revealed they did not routinely review weight documentation in the EMR. Continued interview with LPN #2 revealed he was unaware the meals brought to the room included thin liquids. The LPN revealed the facility needed to monitor at risk for weight loss residents more closely. LPN #2 revealed when the facility did not identify loss of weight the resident could become weak, fall, have poor therapies, and decline in general. The LPN further revealed the incorrect diet order placed the resident at risk for aspiration pneumonia. Interview with RN #11, on 03/18/2021 at 2:03 PM, revealed the facility weighed new residents on admission day. However, the RN revealed they did not know the rest of the protocol for new admissions as referenced to weight monitoring. The RN revealed the resident remained at risk for aspiration with thin fluids and any intake with fluids required an added packet of NTL. The RN revealed the CNAs recorded meal intakes and then reported to the nurses the poor intake. He revealed CNA's reported sporadic poor intake with Resident #90 because the resident did not like the pureed diet. RN #11 revealed with care for COVID, the resident went 2 days without eating or drinking. The RN revealed staff notified the DNE after several episodes of poor intake but not on a daily basis. In addition, the facility did not have a real DNE so staff could not report issues with concerns for resident's meal intake for several weeks. RN #11 revealed the family called daily to the unit and voiced to staff the concern for the resident's weight. However, he could only provide the weight on 02/09/2021 as no other documentation of weights had been recorded. The RN revealed the family revealed the resident appeared thin as to his/her regular appearance. Observation on 03/12/2021 at 11:30 AM, revealed staff obtained the resident's weight which was 109.1 pound; this was also reported to the family. However, continued interview with the RN, on 03/18/2021 at 2:03 PM, revealed he could not remember if the weight had been recorded. The RN revealed when the facility did not closely monitor meals and weights for high-risk residents the resident may lose weight, become weak, and unable to complete therapy. The RN revealed he thought COVID effected the resident's appetite. However, the facility did not initiate food supplementation for caloric intake until 03/15/2021. Record review revealed no documented evidence RN #11 entered the weight obtained on 03/12/2021 into Resident #90's EMR. Review of ST initial assessment, dated 02/16/2021, revealed the facility assessment included Resident #90's diet as Pureed with thin liquids. The ST noted Dysphagia, an increased risk for aspiration, the resident held food in his/her mouth, would require full assistance with meals with specific meal requirements. The requirements included small bites of the pureed diet and minimum liquids in a cup due to increased risk of aspiration. The ST noted the resident would require a large time block to feed. Further review of the ST Therapy Note, dated 02/19/2021, revealed the ST changed the resident's diet order from thin liquids to NTL. Interview with ST, on 03/16/2021 at 1:46 PM, revealed the ST completed a bedside evaluation on 02/16/2021 and ordered pureed with thin liquids because she did not know about the NTL until she reviewed Resident #90's hospital notes. She revealed on 02/19/2021 she wrote new recommendations for NTL, placed it on a Dietary order, and spoke to staff on the unit for the noted diet change. The ST revealed she notified the Dietary Manager (DM) and notified staff on the nursing unit verbally. She revealed the resident required full assistance with feeding. However, if you put small amounts of NTL in a separate cup he/she could drink by himself/herself; and, would drink slower. Therefore, decreased the cough with the intake. She revealed a resident's cough with intake meant he/she choked on the liquid. The ST revealed this could lead to aspiration Pneumonia (PNA). She revealed she placed a sign above the bed to ensure the resident had NTL. Continued interview revealed she had spoken with CNA #3, LPN #2, and RN #11 about the resident's dietary changes on the unit on 02/19/2021. She revealed she took the dietary ticket to the Dietary Manager (DM). The ST revealed she did not observe or audit staff's meal assistance to ensure staff completed the task as directed after the resident returned from the COVID Unit. However, she revealed she was confident the resident received NTL from the kitchen and staff could provide NTL because staff placed the packets on the mediation carts. She revealed the directions to staff included small bites, small sips of NTL in a separate cup, food or items out of site and reach at all times, and no thin liquids. She revealed she did not write the instructions for staff or place them on the residents' Treatment Administration Record (TAR) to ensure staff followed the instructions. She further revealed she checked Resident #90's meal tray ticket if she passed his/her room at meals and she had not identified issues with the ticket. The ST further revealed she did not review the resident for potential or actual weight loss. She revealed staff had not alerted her to concerns of sporadic or poor intake and concerns of weight loss for the resident. Review of ST notes, on 02/19/2021 revealed the ST completed a new meal slip for NTL. Review of Resident #90's swallow exam at the hospital revealed the facility placed the resident on NTL and the resident entered the facility with the same. Further review revealed a dietary change slip dated 02/19/2021 for NTL, signed by the ST and without the yellow back copy. Review of the Dietitian Review, dated 02/19/2021 at 1:37 PM, revealed Resident #90's assessment included the identification of a potential nutritional risk related to the resident's mechanical altered diet, diagnoses, and pureed diet. The DM review assessed the resident as an extensive assistance at meals. The DM documented the resident's weight as 154 lbs., and checked the box for healthy weight with a Body Mass Index (BMI) of twenty-one point five (21.5). The DM noted the ST evaluation of loss of solids and fluids from mouth, food held in mouth/cheeks, coughed, and choked with thin liquids and mechanical soft foods. Interview with the Dietitian, on 03/18/2021 at 1:32 PM, revealed she completed assessments upon admission, change, and annual assessments. She revealed if a resident came to the facility with a special diet from an outside facility, then the facility should follow the same diet. She revealed her conference with ST, did not provide detail information regarding Resident #90. She revealed the facility's process to monitor weight included to weigh at admission and then monthly unless the provider ordered an increased weight monitor schedule. She revealed the facility reviewed new admissions for weight loss at the first month after admission. She revealed the facility initially monitored Resident #90's intake because it was variable. She further revealed Resident #90's nutritional support requirements, diagnoses, and short term medical history should have identified the resident at as a higher nutritional risk. However, the facility did not place the resident on the weekly Nutritional at Risk (NAR) review on admission. She revealed the facility reported the family and guardian expressed concern of possible weight loss after visits with the resident at the window. The Dietician revealed the facility identified weight loss on 03/15/2021. She revealed the facility questioned the 45-pound weight loss as actual loss because the facility questioned the scale calibration. Continued interview revealed when the clinical team reviewed Resident #90's weight at one month, the facility identified weight loss on 03/15/2021. She revealed aspiration of liquids could be identified through constant coughing with liquid intake. She revealed Resident #90 could not express or vocalize hunger. Further interview revealed unaddressed weight loss could lead to a resident's weakness, and affect the ability to complete therapy or tasks. Interview with the DM, on 03/02/0221 at 9:21 AM, revealed upon admission the staff placed the discharge diet in the computer and sent a ticket to the kitchen. The DM revealed upon receipt she placed the information into the dietary electronic program. The DM revealed initially the facility placed Resident #90 on thin liquids. Continued interview revealed on 02/19/2021, the Dietician and ST sent a new order for NTL after further review of the admission documentation. The DM revealed the kitchen received the new ticket and made updates into the program. The DM revealed staff checked the trays three times (3) to ensure the resident received the proper diet. She revealed the three (3) checks included the cook and assistance dietary staff who completed the ticket; and, the floor staff checked the ticket and food when it was delivered. The DM revealed the kitchen had not been notified the resident received and was given thin liquids. She revealed her responsibility included to ensure the correct diet reached the resident. The DM revealed the resident did not receive supplements until 03/16/2021, after the facility's review of the resident found weight loss. Interview with the DNE, on 03/20/ at 12:51 PM, revealed the facility needed to establish residents' weight upon admission to ensure the facility documented an accurate weight. The DNE revealed after the initial weight, the facility followed the provider's orders for weight obtainment. The DNE revealed the AM Clinical Staff met the next day to review new admissions charts and EMR to ensure staff completed all required documentation or assessments. Further review of the DNE revealed the minimum weight monitor requirement included monthly weights by the fifth of every month. He revealed the Dietician followed residents' intake of meals, tracked trends, and made recommendations. The DNE revealed he expected floor staff to audit meal trays to ensure residents received the correct diet. Continued interview revealed he was unaware of the recent dietary ticket audits for accuracy. The DNE revealed if the resident received the wrong diet, which included the consistency of the fluids the resident could choke. He revealed he expected all staff to recognize a constant cough with fluid intake as a symptom of choking with possible aspiration. Furthermore, if the facility did not obtain an admission weight, the facility could not identify weight loss. The DNE revealed the resident could have abnormal labs due to the weight loss. He further revealed the nurses' responsibilities included to review the resident's last weight to monitor and notify the provider if weight loss occurred. He revealed then the facility needed to identify why the weight loss occurred. The DNE revealed the NAR met weekly to review new residents with conditions at admission who may need

Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure hydration for one (1) of sixty-nine (69) sampled residents (Resident #85). The facility admitted Resident #85 on 04/10/2020, and assessed him/her to be at nutritional risk. Resident #85 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP (Nurse Practitioner) wrote the orders based on continuous free water provided by a dual pump. However, the dual pump was broken. There was no documented evidence the facility monitored or provided the free water as ordered. On 03/09/2021 the facility was notified of a critical lab report for Resident #85 which revealed a Blood Urea Nitrogen (BUN) level of 111 Critical (reference range 7 mg/dL to 25 mg/dL ) indicating dehydration. Intravenous (IV) fluids were ordered. However, the facility did not start the intravenous fluids for approximately 15 hours after the orders were received. 24 hours later the resident's BUN was 122 mg/dL. Resident #85 was transferred to an acute care facility and diagnosed with dehydration. The facility's failure to have an effective system in place to ensure residents maintained acceptable parameters of nutritional and hydration status has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/21/2021, and determined to exist on 02/24/2021 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 Develop / Implement Comprehensive Care Plan at S/S of K) with Substandard Quality of Care identified at 42 CFR 483.25 Quality of Care (F693 Tube Feeding Management at S/S of J). The facility was notified of the Immediate Jeopardy on 03/21/2021. The facility provided an acceptable credible Allegation of Compliance (AoC) on 03/30/2021 alleging removal of the Immediate Jeopardy on 03/30/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/30/2021, prior to exit on 04/03/2021, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Change in Condition, dated October 2019, revealed any serious change in condition should be communicated to the physician and the responsible party. Review of the facility's policy, Hydration - Clinical Protocol, reviewed/revised 03/21/2011, revealed the physician would manage significant fluid and electrolyte imbalance and the associated risk in a timely manner. The timeliness would depend on the severity, nature and cause. For severe or complicated fluid electrolyte imbalance, subcutaneous or IV hydration may be needed. Review of the Enteral Nutrition policy, revised November 2018, revealed adequate nutritional support through enteral nutrition is provided to residents as ordered. The dietician with input from the provider and nurse will estimate fluid needs, recommend special food formulations and calculate fluids beyond free fluids in formula to be provided. The nursing staff and provider will monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo or [CONDITION(S)] (low or high blood sugar), and altered electrolytes. Additionally, monitor the resident for worsening of conditions. Review of Resident #85 clinical record revealed the facility initially admitted the resident on 04/10/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview of Metal Status (BIMS) of four (4). Review of Resident #85's Comprehensive Care Plan, initiated 05/01/2020 with a focus of resident presents with a potential for nutritional risk related to reliance on therapeutic enteral feeding for nutrition, significant weight loss, altered skin integrity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal stated the resident would not exhibit unplanned significant weight change thought the next review and the resident would receive adequate nutrition and hydration with a target date of 04/29/2021. Interventions included lab/diagnostic tests as ordered, report results to MD and follow up as indicated; provide tube feeding as ordered; Registered Dietician (RD) to evaluate and make diet change recommendations as needed; therapy to screen quarterly as needed; weights as ordered/indicated, notify provider and family of significant weight changes. Review of Resident #85's Nutrition at Risk (NAR) review effective 02/24/2021 at 10:04 AM revealed Resident #85 was on NAR related to G-tube feeding, high potassium and significant weight loss. Resident #85 received Nepro 50 ml/hour (milliliter per hour) continuous and free water ordered for 300 ml every four (4) hours. Weight changes were anticipated related to [MEDICATION(S)] (diuretic). Resident's skin was intact with noted [CONDITION(S)]. Review of the clinical records revealed no documented evidence of free water or flushes for Resident #85 from 12/28/2020-03/10/2021, when Resident #85 was sent to the hospital. Review of a Physician's Progress Note dated 03/09/2021 at 4:14 PM written by the NP (Nurse Practitioner), revealed Resident #85's review of systems was at baseline and assessed for 1) [CONDITION(S)]; 2) fluid volume deficit; 3) Chronic Kidney Disease; and, 4) Dementia. Review of the American Health Associates (AHA) Lab call times reflect an approximate 12 hours delay before the labs were reported to the facility due to the inability to reach floor staff. Interview with the American Health Associates (AHA) Lab call representative on 03/18/2021 at 8:38 AM revealed there was a Basic Metabolic Panel (BMP) collected on 03/08/2021 and reported on 03/09/2021 to CMT at 1:05 AM. She further revealed two (2) additional calls were made on 03/08/2021 at 1:34 PM and 03/08/2021 at 9:22 PM with no answer. Interview with Certified Medication Technician (CMT) on 03/20/2021 at 11:12 AM revealed she was new to the facility and was assigned to G Hall the evening of 03/09/2021 with her shift beginning at 7:00 PM. She recalled she had received a call for a critical lab for BUN of 111 for Resident #85. The nurse assigned to the G Hall was attending to a resident and unavailable to answer the call. The CMT stated she immediately reported to the nurse on the A Hall assigned to Resident #85. Review of the Lab Results Report for Resident #85 revealed the normal range for Blood Urea Nitrogen (BUN) was 7 mg-dL to 25 mg/dL. On 02/15/2021 Resident #85's BUN was 47 mg/dL. On 02/22/2021, Resident #85's BUN was 68 mg/dL. On 03/05/2021, Resident #85's BUN was 95 mg/dL. Further review revealed on 03/08/2021, Resident #85's BUN reached a critical level of 111 mg/dL. Review of a Physician/ Prescriber Order written by the Nurse Practitioner dated 03/09/2021 untimed, revealed orders were written to: 1) hold [MEDICATION(S)] 03/14/2021-03/16/2021, resume on 03/17/2021; 2) Place midline/Peripherally inserted central catheter (PICC) line; 3) D5W at 100 cc/hour continuous; and, 4) BMP (basic metabolic panel). Review of Physician/Prescriber orders in Point Click Care (PCC) reflected the orders were placed into the system at 4:14 PM on 03/09/2021 by Licensed Practical Nurse (LPN) #11, approximately 15 hours after the critical lab was called to the facility. Review of Vascular Access Inc. report dated 03/09/2021, revealed they (a third party contractor) received a call at 5:00 PM for placement of a midline, arrived at 6:50 PM and departed the facility at 7:15 PM. A midline IV was placed in the resident's left arm. Review of the Medication Administration Record (MAR) revealed the order for D5W (intravenous sugar solution given to rehydrate) was administered on 03/10/2021 at 8:00 AM, approximately 15 hours after the order was entered into the PCC. Record review revealed on 03/10/2021 Resident #85's BUN was critical at 122 mg/dL. Resident #85 was transferred to an acute care facility and admitted . Review of Resident #85's Hospital records, revealed the resident was admitted to the hospital on 03/10/2021 at 12:35 PM with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital labs, dated 03/10/2021 at 12:56 PM, revealed a BUN lab value of 123 mg/dL (reference range 7-20 mg/deciliter (dL)), (The BUN test measures the level of nitrogen in the blood to assess the functions of the kidneys and liver) and Sodium of 155 mmol/L (reference range 137-145 mmol/L). Interview with the Registered Dietician (RD) on 03/18/2021 at 2:42 PM revealed she calculated the tube feed and free water needs and would give suggested orders. However, sometimes the Advanced Practice Registered Nurse (APRN) would also give orders for free water. The Dietician stated feeding pumps were discussed in clinical meeting, and dual pumps had pre-programmed amounts to ensure the resident received free water to potentially prevent elevated labs or dehydration. She also indicated Resident #85 was last assessed as a Nutrition at Risk (NAR) resident on 02/24/2021 and was suggested to receive 300 ml of free water every four (4) hours. Interview with Licensed Practical Nurse (LPN) #4 on 03/18/2021 at 10:40 AM and 1:46 PM, revealed the dual feeding machine used to deliver both the tube feed and free water had recently stopped working at the end of February or beginning of March. She indicated Central Supply was aware. LPN #4 stated she was advised to use the feeding pump machine, which held one (1) bag. She further explained free water was then delivered manually every three (3) hours using a syringe to deliver approximately 180 ml every four (4) hours. In addition, she stated there was nowhere to document the free water given to the resident on the MAR/TAR. LPN #4 indicated this made it hard to ensure the resident received continuous, consistent hydration because it could be forgotten or easily missed and could result in dehydration. Interview with Scheduler/Central Supply on 03/18/2021 at 2:01 PM, revealed LPN #4 had brought a broken dual feeding pump to him around the end February. He stated LPN #4 had explained the pump was important to prevent dehydration of the resident because it could provide consistent hydration. He additionally stated, he had replaced it with a single feeding pump because the dual pump was not available from corporate. However he had informed the ED on 02/24/2021 of a suggested replacement dual pump. Interview with LPN #6 on 03/18/2021 at 2:27 PM revealed there were no orders in the computer that would reflect on the MAR/TAR for Resident #85 to receive free water. She stated on night shift from 11:00 PM to 7:00 AM she would flush his/her PEG (feeding tube) tube with 60 ml of water when she changed his/her feeding bag. Interview with LPN #12 on 03/20/2021 at 10:47 AM, revealed she worked at facility for a month and was familiar with Resident #85. She stated typically she worked the A/B Hall from 7:00 PM-7:00 AM and after 11:00 PM she additionally picked up the C/D Hall until 7:00 AM. She said on 03/09/2021, staff working on the G Hall brought a critical lab to her. She did not recall the time but indicated it was in the middle of the night. LPN #12 then explained she immediately called the NP. LPN #12 indicated the NP said she would address the critical lab BUN of 111 when she came in the morning and did not give any orders during the call. She additionally reported she checked on Resident #85. He/she was sleeping and vital signs were good. She reported she replaced his/her enteral feeding and flushed with water. An additional interview with LPN #6 on 03/17/2021 at 10:57 AM revealed she was new to the facility. The night of 03/09/2021 was her first shift off orientation and she was oriented by a non-licensed nurse. She stated she worked from 11:00 PM to 7:00 AM. She reported that during daily shift handoff report, she was told Resident #85 was dehydrated and had intravenous (IV) fluids ordered to be started; however the IV pump had not arrived from pharmacy. LPN #6 stated she was not told of any critical value. She further detailed Resident #85 had a midline and all the other IV equipment was in the room. LPN #6 indicated she called the pharmacy and was told the IV pump would arrive at 1:00 AM. She further revealed there was a dial regulator IV pump available. However, she had not received any training on how to use it and was unfamiliar with the equipment, protocols, and resources of the facility. Additionally, she stated there was not a Night Supervisor the evening of 03/09/2021 and she did not have resources to reach out for assistance. LPN #6 explained the IV pump arrived in the morning and the oncoming day shift nurse, LPN #4, started the IV fluids. LPN #6 stated Resident #85 just slept during the night and showed no signs of distress. Furthermore, LPN #6 explained critical lab BUN of 111 could impact the kidneys and heart and could lead to death. An additional interview with LPN #4 on 03/17/2021 at 2:41 PM revealed she sent Resident #85 to an acute care facility on 03/10/2021 between 11:00 AM and 12:00 PM. She stated there was an order on 03/09/2021 to start D5W on Resident #85. The night shift nurse, LPN #6, relayed at shift change at approximately 7:00 AM, that the fluids should have started on second shift. However, the pump had not arrived during second shift (3:00 PM-11:00 PM). LPN #4 further stated LPN #6 was new to the facility and not familiar with the pump. In addition, LPN #4 indicated the facility also had dial up (manual regulator) and was not sure why it was not used. LPN #4 stated all the supplies were available. LPN #4 started the D5W at the start of her shift on 03/10/2021. She stated she later received a call from the NP, who stated she had seen the labs and asked why the fluids had not been started for two (2) shifts. LPN #4 stated the NP then instructed her to send Resident #85 to the emergency room (ER). LPN #4 indicated the NP spoke with the ED and DNS to make them aware the fluids had not been started resulting in delay in treatment. Further interview with LPN #4 on 03/17/2021 at 2:41 PM revealed Resident #85's BUN was 122 indicating the resident was severely dehydrated. LPN #4 stated there was potential he/she could go unconscious or die. She stated he/she did not look right but was able to answer questions. The LPN stated she was familiar with the resident and could tell he/she was not quite right by his/her mannerisms. She additionally indicated she called the family and informed the family Resident #85 was sent to the ER due to critical labs. Interview with the Scheduler/Central Supply on 03/19/2021 at 10:57 AM revealed there was no Night House Supervisor on 03/09/2021- 03/10/2021. Additionally, he stated there were three (3) LPNs working the night of 03/09/2021; one agency, one new hire, and one established to the facility. The LPN established to the facility would be considered the nurse in charge; however, this nurse still had a group assigned. Interview with Resident #85's family member on 03/17/2021 at 3:03 PM revealed he/she was notified of a change in condition by a nurse who stated Resident #85 was being sent out due to critical labs that were worse than the day before. Interview with the Nurse Practitioner (NP) on 03/18/2021 at 10:50 AM and on 03/20/21 at 3:40 PM, revealed Resident #85 had a Foley (brand name for an indwelling catheter) catheter and was reliant on tube feed. She stated the resident had recently been switched to Nepro tube feeding and went back and forth with the amount of free water ordered. The NP explained free water was the extra water given to residents with tube feedings to meet their daily hydration needs. She indicated sometimes there were multiple orders for free water and flushes and she may have overlooked and overridden the previous order for 300 ml every four (4) hours. Continued interview with the NP revealed her expectation for Resident #85 was to receive free water through his/her dual feeding pump at a rate of 1500 cc every 24 hour or 62 cc/hour as the resident had a dual pump that delivered water separate from the tube feed. Continued interview with the NP on 03/18/2021 at 10:50 AM and on 03/20/21 at 3:40 PM revealed she could not recall the day or time the first critical lab was received. However, she stated she was aware of the critical lab and remembered writing orders probably mid-morning or early afternoon. She also indicated sometimes the facility called or texted with a critical lab at night, but staff had the option to call other providers. She further stated, Usually if it is critical they call me. The NP stated for a BUN of 111 she would have written orders when rounding on Monday or Thursday, as she received lab results typically before they were reported to the facility. In addition, she indicated the causes of the elevated BUN would be Chronic Kidney Disease, dehydration, and kidney failure. She stated her expectations were the IV fluids should be administered as soon as possible. However it was communicated that the fluid were not started until the first (1st) shift the following day. The NP further stated the potential outcome of not receiving fluids timely was kidney failure. Interview with LPN #11 on 03/18/2021 at 3:18 PM, revealed she was familiar with Resident #85 and had taken care of him/her on second shift (3:00 PM-11:00 PM) on 03/08/2021 and 03/09/2021 prior to the hospitalization on [DATE]. LPN #11 stated Resident #85 was ordered free water flushes of 1500 cc per day or 62 ml/hour. She stated she delivered 62 cc every hour manually with a syringe. She additionally stated she had put the order into the system but did not recall if the order came up on the MAR to document. Further interview with LPN #11 on 03/18/2021 at 3:18 PM, revealed Resident #85 was not acting out of the norm and did not show any signs of distress. LPN #11 identified critical labs as labs in a range, which could be threatening for the resident. She further stated the lab company typically called to the floor to report critical lab, however she did not recall missing any calls during her shifts. In addition, she stated potential outcomes for not treating critical labs could be system failures and added labs would not improve on their own. She also indicated Vascular Assess inserted a Midline intravenous (IV) catheter on 03/09/2021 in the resident's left upper arm. She further stated she did not start the ordered fluids on her shift, because she called pharmacy and they were sending a pump. She further indicated flow regulators were in the emergency kit box and could have been used, however, she thought the pump was on the way. Interview with Director of Nursing Services (DNS) on 03/19/2021 at 11:40 AM, revealed free water or flushes were calculated by the Registered Dietician (RD) and she made recommendations. However, the order would need to come from the provider. He additionally indicated free water or flushes should show on the MAR and staff should document the frequency and amount the resident received, adding, if it's not on the MAR the nurse wouldn't know to do it. He additionally added that not receiving hydration could lead to a clogged G -tube or would be a potential for dehydration. Further interview with the DNS, on 03/19/2021 at 11:40 AM, revealed there was a Night House Manager (Supervisor) who should not carry a team assignment. In addition, he stated he was unaware if there was a House Manager on 03/09/2021. He further stated, he was unsure of the official policy for reporting critical labs to the provider and added, the phone systems had been recently been serviced. The DNS stated there were times it was difficult to reach the facility; however, he was unaware the critical lab reported for Resident #85 had taken three (3) attempts to reach the facility. He further stated critical labs should be reported to a nurse, not a CNA or CMT. He added critical labs were also faxed to the facility and uploaded to Point Click Care (PCC). Additionally, he was unsure if education was provided for reporting critical labs and expanded by stating he did not know if it would be covered on floor orientation. He indicated there was a checklist, but he did not know if it has been utilized. He explained it should be used, because it ensured competency. The DNS stated the checklist may need to be expanded to include critical lab notification because the implementation of provider orders could be delayed. Continued interview revealed the DNS, on 03/19/2021 at 11:40 AM, revealed he was not aware of the two (2) shift delay in Resident #85 receiving maintenance fluids due to pump availability and staff knowledge of the IV pumps. He stated the pharmacy had several types of IV pumps and they were responsible to ensure staff was trained on their use. Additionally, he stated, the facility also had dial flow regulators, which could have been utilized for maintenance fluids. He said they were simple to use and he could have provided training quickly. In addition, he said treatment should have begun as soon as the IV access was obtained and that should not have been an issue. The DNS stated the potential outcome for a BUN of 111 mg/dL could be kidney injury. Interview with the Executive Director, on 03/21/2021 at 2:26 PM, revealed the facility had not identified any issues with hydration and free water for residents with tube feedings. She stated residents with g-tubes were higher acuity residents and their intakes were reviewed weekly in the Nutrition at Risk (NAR) meeting. She stated if the resident was newly admitted , or if a current resident had a decline, the NAR meeting would begin to monitor the resident. The Executive Director revealed if a resident was stable, the NAR Committee would take the resident off weekly NAR monitoring. She further stated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the Dietician reviewed free water, however she was unsure of the frequency of those reviews. The Executive Director stated she was unsure how free water was missed for the resident, as the clinical meeting should have identified if there was an issue for free water for a resident with a g-tube. The facility alleged it implemented the following actions to remove immediacy: 1. On 03/22/2021, the Registered Dietician and clinical nursing evaluated Residents #60, #85, and #90. 2. On 03/23/2021, the Registered Dietician reviewed all diet orders, enteral feeding orders, and enteral feeding flushes with water. 3. The Registered Dietician reviewed all residents for nutrition/status on 03/24/2021. The Registered Dietician reviewed and revised as needed, all residents receiving enteral feedings and water flushes on 03/23/2021. 4. The ED, DNS, and IDT Committee were educated on 03/23/2021 regarding policies for weight loss/nutritional risk/hydration and included enteral feedings and water flushes. 5. All nurses and CNA's were educated on the proper use of mechanical/wheelchair scales, and the weight policy, which included weights on admission and as per policy, was initiated on 03/23/2021 and was ongoing. Nurses were educated on the operation of the enteral feeding pumps, initiated on 03/23/2021 and was ongoing. 6. The IDT was educated regarding the policy for enteral flushes and nurses were to be educated on the policy and how to provide flushes. Education was provided to all nursing staff on how to operate an enteral feeding pump, on 03/23/2021, and was ongoing. 7. The DNS or the Assistant DNS would audit the resident weight lists weekly to ensure weights were obtained by staff as per policy. 8. The IDT team reviewed all nursing notes, orders, new admissions, readmission and diet changes. Weights were obtained and reviewed for changes during the clinical start-up meetings five (5) days a week with additional interventions discussed as needed, on 03/24/2021. 9. The IDT reviewed the weight changes weekly during the Nutrition At Risk (NAR) meeting. 10. All audits were forwarded to the Executive Director upon completion and reviewed by the QAPI Committee. The committee members included the Executive Director, Medical Director, Director of Nursing Services, and a minimum of three (3) department managers. The audits will be reviewed twice a week until abatement, then weekly for four (4) weeks, and then monthly to ensure the facility sustained the interventions. The SSA validated the facility implemented the following actions: 1. Interview with the Registered Dietician, on 04/01/2021 at 10:21 AM, revealed she reviewed Residents' #60, #85, and #90's nutritional status including diet, hydration status, and water flushes with revisions as indicated. Record review revealed the Registered Dietician conducted a nutritional assessment for Residents #60 and #90. Resident #85 was in the hospital and remained in the hospital during validation of AOC. 2. Interview with the Registered Dietician, on 04/01/2021 at 10:21 AM, revealed she reviewed all diet orders, enteral feeding orders, and enteral feeding flushes with water for all residents in the facility on 03/23/2021. She stated the use of a facility census to review diet, enteral feeding, and enteral water flush orders was used. 3. Interview with the Registered Dietician, on 04/01/2021 at 10:21 AM, revealed she reviewed and revised as needed for residents receiving enteral feedings and water flushes on 03/23/2021. The Registered Dietician stated she performed a nutrition/hydration audit for the fifteen (15) residents receiving enteral nutrition or residents at risk for issues with nutrition/hydration. Record review, on 04/01/2021, revealed nutrition/hydration audits on 03/23/2021 for the residents receiving enteral nutrition, residents at risk, or those on the Nutritionally at Risk (NAR) list. The audit documented if the resident was on the NAR list, presence of weight loss, hydration status, and tube feeding with water flushes. Record review, on 04/01/2021, revealed all residents' diet orders and enteral feeding orders that included water flushes were reviewed on 03/23/2021. Interview with the DNS, on 04/03/2021 at 2:50 PM, revealed the floor staff assessed the residents for hydration and diet orders. 4. Interview, on 04/02/2021 at 11:25 AM, with the RDO revealed the ED, DNS, and ADNS were educated on weight loss, hydration, and monitoring at risk residents with or without feeding tubes, on 03/23/2021. Record review revealed a sign in sheet dated 03/23/2021 titled, Weights, Hydration, and Monitoring was signed by the ED, DNS, and ADNS. She stated the floor staff received education presented by the Regional Clinical Coordinator (RCC) on 03/24/2021. 5. Interview with CNA #7, on 03/31/2021 at 10:35 AM, revealed she received education for the weight policy, resident hydration, and use of lift/wheelchair scales with a return demonstration. Interview with CNA #9, on 03/31/2021 at 11:47 AM, revealed the facility provided in-services for the weight policy, use of Hoyer lift/wheelchair scale, and hydration management. Interview with LPN #24, on 04/01/2021 at 2:42 PM, revealed she attended an in-service that discussed the facility's weight policy, enteral feeding pump, enteral flushes, and resident hydration. Interview with the Regional Clinical Coordinator (RCC), on 04/02/2021 at 11:42 AM, revealed she educated staff about weights, hydration, mechanical lift operation, and feeding pump operation. She stated educating staff was an ongoing process. The RCC stated the schedule for the next day was reviewed to ensure staff education was not needed and was kept on a master list. Review of the facility's education sign in sheet, revealed staff education was initiated on 03/23/2021. 6. Interview with the IDT team members, on 04/03/2021 at 8:33 AM, revealed Medical Records, Minimum Data Set Coordinator, ADNS, DNS, Maintenance Director, Activities Director, Dietary Manager, Business Office Manager, Director of Rehabilitation Services, Admissions Director, and Human Resources Manager received education for enteral flush policy and nursing staff education for enteral flushes. 7. Interview with the DNS, on 04/01/2021 at 4:10 PM, revealed he received education for the facility's weight policy for monitoring weight loss, nutritional risk, and hydration including residents that received enteral feedings and flushes. 8. Interview with the DNS, on 04/01/2021 at 4:10 PM, revealed during the five (5) day a week IDT meeting, admissions, readmits, Nurses' Notes, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated the morning meeting was a review for the weight list and the afternoon meeting he reviewed them again to ensure weights were completed. 9. Interview with the ADNS, on 04/01/2021 at 1:42 PM, revealed during the weekly NAR meetings residents were reviewed for weight changes. Interview with the DNS, on 04/01/2021 at 4:10 PM, revealed weights were reviewed during the weekly NAR meetings. Interview with the Registered Dietician, on 04/01/2021 at 10:21 AM, revealed they reviewed the weights of the residents on the NAR list. 10. Interview with the Medical Director, on 04/02/021 at 11:16 AM, revealed the facility held a QAPI meeting on 03/23/2021. He stated the facility initiated administrative staff education on 03/23/2021. Further interview revealed the facility maintained daily contact with him for the audit updates and/or identified concerns. Interview with the ED, on 04/03/2021 at 2:00 PM, revealed she received education on the facility's weight policy and how the clinical team monitored for weight loss and hydration. Further interview with the ED revealed the QAPI committee completed a fish bone diagram to address the concerns that included nutrition, weight loss, and hydration. She stated a plan and audit tools were developed by the QAPI committee and included observation, education, record reviews, and actions taken to correct the identified issues. The ED stated she reviewed the completed audits and was provided with a daily update for the plan of correction. She stated audits were conducted twice weekly until abatement was achieved, then weekly for four (4) weeks and monthly to ensure facility staff addressed and monitored concerns with nutrition, hydration, and weight loss.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were treated in a dignified manner for two (2) of sixty-nine (69) sampled residents (Residents #14 and #90). Interview and observations revealed Resident #14 was transferred from a room which he/she could enter a bathroom to a room in which the size of his/her wheelchair prohibited access to the bathroom. The sink and toilet were not accessible to Resident #14. The facility provided Resident #14 a bedside commode, placed near a window leaving the resident exposed to the outside. Resident #14 was still unable to wash his/her hands. In addition, observations revealed facility staff used baby talk when talking with Resident #90. Resident #90, was able to feed himself/herself. However, staff held the resident's hands or shoulders while other staff fed him/her to prevent interference from the resident's hands and arms. The findings include: Review of the facility's policy, Quality of Life-Dignity, revised August 2019, revealed staff would promote, maintain, and protect resident privacy and dignity,which included bodily privacy. Review of the facility's policy, Quality of Life - Accommodation of Needs, revised August 2009, revealed the resident's individual needs and preferences would be accommodated to the extent possible. Review of the facility's policy, Appointing a Resident Representative, revised December 2016, revealed a resident who had not been found to be incompetent had a right to appoint a representative who may exercise the resident's right to the extent provided by state law. The representative acted on behalf of the resident to support the resident's decisions. The facility treated the representative's decisions as the decision of the resident. 1. Review of Resident #14's clinical record revealed the facility admitted Resident #14, on 04/18/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #14 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) and determined he/she was interviewable. Continued review revealed the resident used a w/c for locomotion. Further review revealed the resident's bed status in the facility, on 02/12/2021, included the transfer of the resident from the C Unit room nine (9) to the B Unit room seven (7). Observations, on 03/12/2021 at 11:08 AM, revealed the facility transferred Resident #14 to room B-7. Observations revealed the resident transferred independently from the chair to an extra wide wheelchair (w/c); wheeled self to the bathroom door, and attempted unsuccessfully to enter the bathroom. Continued observations revealed the bathroom door opened against the wall, therefore it only opened at a forty-five (45) degree angle. A standard size beside commode sat against the wall by the opened windows with toilet paper on the windowsill. Interview with Resident #14, on 03/12/2021 at 11:08 AM, revealed the facility moved him/her to the room after notification of the facility's transition of room C-9 to a semi-private room. The resident stated his/her POA instructed the facility not to move him/her. The resident stated he/she was fearful the facility would discharge him/her if he/she did not move. The resident stated staff brought him/her to look at the room. However, he/she did not attempt to go into the bathroom. He/she stated one would think the facility assessed the bathroom door to ensure he/she could fit into the room with the oversized wheelchair. Resident #14 stated within one (1) hour of the move he/she attempted to toilet with the realization the w/c did not fit through the door. The resident stated he/she notified staff with requests to return to the original room. The resident stated on 02/13/2021, the therapist came to the new room, evaluated his/her ability to pass through the door in the w/c, and determined it was unsafe for the resident to attempt to take the several steps into the room to toilet and notified the Executive Director. Resident #14 stated, on 02/13/2021, the facility staff brought him/her a BSC for use. He/she stated because the facility did not bring the BSC, on 02/12/2021, he/she had to use the brief to toilet for the remainder of the day. Resident #14 stated he/she felt the facility did not care about his/her desire to use a real toilet. The resident stated he/she had to use the chair in an open room, staff had to now assist him/her with cleaning, and he/she felt afraid someone would see him/her exposed because of the windows. Furthermore, he/she stated the BSC was to small and she/he remained fearful of injury. Interview with Family Member (FM) #6, on, 03/13/2021 at 1:35 PM, revealed Resident #14 told her often he/she could not get into the bathroom to toilet or to wash his/her hands after toileting or before meals. The FM stated the resident stated they used a warm cloth or used bacterial gel for hand hygiene. Continued interview revealed the FM stated Resident #14 felt humiliated because he/she could not access the bathroom and wanted to remain independent. FM #6 stated the other room (he/she had moved from) had a wide entrance and the door fully opened. The FM stated the family voiced and wrote not to move the resident. FM #6 stated the resident expressed anger and fear of body exposure to the outside. Interview with FM #7, on 03/13/2021 at 1:59 PM, revealed the facility continually asked the resident to move and the FM told the Executive Director they attempted to bully the resident to move. The FM stated they informed the Executive Director through phone conversations and mail that as the POA (Power of Attorney) for Resident #14, the facility may not move Resident #14. FM #6 stated they were informed of the move when the resident called them about the move and said he/she could not get into the bathroom in the new room. The FM stated the resident reported the facility staff left the BSC full of waste and the entire room smelled of the waste often. He further stated, the Therapy Department informed the facility about the safety concerns for the resident's inability to get into the bathroom and the use of the BSC because it was too small. FM #6 stated the resident expressed fear of exposure due to the commode placement by the window. The FM further stated all conversations fell on deaf ears with the Executive Director. Review of FM #7's letter to the facility Executive Director, dated 02/03/2021, revealed FM #7 notified the Executive Director, as the representative for Resident #14. The FM requested the facility not move the resident to a new room without consent or input. Review of the Progress Notes, dated 02/12/2021 at 12: 08 PM, revealed the facility moved the resident to room B-7 around 11:00 AM. Further review of the clinical record revealed no documented evidence the facility notified the POA of the resident's room change. Record review revealed the facility admitted Resident #78 on 08/14/2020 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly MDS assessment, dated 02/12/2021, revealed the resident used a wheelchair for locomotion, and required minimal assist of one for toileting. Review of Resident #78's Progress Notes, dated 02/12/2021 at 1:10 PM, revealed the facility moved the resident to room C-9. Room C-9 was the room Resident #14 had resided before he/she was moved. Interview with Certified Nursing Aide (CNA) #18, on 03/14/2021 at 11:20 AM, revealed the CNA assisted the Resident #14 on both units. The CNA stated when Resident #14 lived on the C unit, the resident could transfer from the wheel chair, toilet independently, and take care of his/her cleansing after use of the toilet. The CNA stated when the resident remained in bed they required extensive help to clean and change the brief. CNA #18 stated Resident #14 was independent with minor assistance. However, the resident required help in the room on the B Wing. The CNA stated the resident could not reach to clean himself/herself, required assistance on and off the commode. The CNA stated Resident #14 wanted to remain independent. The CNA stated if they were moved to a room and had to use a commode after having a bathroom they would be very angry and may become more depressed. Interview with Licensed Practical Nurse (LPN) #2, on 03/20/2021 at 7:45 AM, revealed Resident #14 expressed the fear of exposure to other people in or outside of the facility. The LPN stated the resident could not pull the room curtain or shut the blinds to provide privacy when he/she toileted on the BSC. The LPN further stated it was a privacy issue and people liked to keep independent and private to the best of their ability. Interview with the Occupational Therapist (OT), on 03/15/2021 at 3:41 PM, revealed the OT worked with Resident #14 on the B and C Units. The OT stated he met Resident #14 in the new room in B-7 on 02/13/2021 for therapy. The OT stated the resident remarked the w/c could not fit into the bathroom. Further interview revealed the OT stated the resident told him he/she had used the briefs since transfer to the room for toileting. The OT stated the resident remarked he/she felt worthless because the facility would not listen to him/her about the bathroom. The OT stated they informed the Executive Director of Resident #14's comments and concern for the resident's safety if the resident attempted to go into the bathroom. The OT further stated when they returned to the resident the next day the resident stated the facility had provided a BSC and appeared very upset. He stated he would feel worthless if the facility provided a BSC when he could use a toilet. Interview with the Maintenance Director, 03/13/2021 at 3:30 PM, revealed he assisted the facility to move Resident #14 to room B-7. He stated the facility gave the resident a BSC because the bathroom door was too small for the resident's wheelchair. He stated the resident expressed that he/she was upset to have to use the BSC and that the facility did not care how he/she felt. He stated he would not feel good to use a BSC when the other room allowed the person to use a full bathroom. 2. Record review revealed the facility admitted Resident #90 on 02/12/2021 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial MDS assessment, dated 02/19/2021, revealed the resident required full assistance with all Activity of Daily Living (ADL) care. Further review revealed the resident required one assist with meals. Interview with Family Member (FM) #3, on 03/11/2021 at 11:54 AM, revealed the facility was provided full instruction by the family and care givers from the group home for the resident's care. The FM stated the resident fed himself/herself with required assistance to place the food onto the utensil. She stated the resident's meals were a messy event. However, they informed the facility to allow the resident to remain involved in order to not lose his/her skills. Observation, on 03/11/2021 at 12:40 PM, revealed CNA #3 assisted Resident #90 with lunch. The staff attempted to fully feed the resident who actively reached for the food on the tray. The resident did not have a personal protector in place to prevent spillage onto clothing. Personal Care Assistant (PCA) #1 entered the room and CNA #3 requested help to keep the resident's hands out of the way. The PCA placed their hands on top and forward onto the resident's shoulders and kept both of the resident's arms from reaching for the tray. The PCA continued until the CNA stated the resident did not want the meal. Further observation, on 03/12/2021 at 8:52 AM, revealed CNA #3 fed Resident #90 breakfast while conversing to with the resident. The resident constantly reached for the tray, which was placed on the opposite side of the CNA. The CNA called the resident boy-boy while the aide encouraged him/her to eat with other baby talk. In addition, observations revealed PCA #1 entered to assist the CNA. The PCA stood in front of the resident and held the resident's hands while the CNA continued feeding and encouraging the resident. The resident did not have a cloth protector with the meal. Interview with Personal Care Aide (PCA) #1, on 03/18/2021 at 3:52 PM, revealed the PCA worked to assist the CNA's in the facility. The PCA stated Resident #90's mind was like a baby, and he/she reached for everything. The PCA stated at times CNA #3 would ask to have the resident's hands held because the resident pushed the aides hands away or constantly reached for the tray. PCA #1 stated when an elder resident constantly reached or pushed away, the staff would not hold their hands in order to feed the resident. However, she stated the difference between an elder and Resident #90 was the resident's cognitive level was that of a two (2) year old. PCA #1 stated the facility educated staff on abuse and resident's rights. She stated staff was to ensure resident's rights were protected. However, the PCA stated she did not know if holding a resident's hands down or arms to prevent grabbing or reaching could be a dignity concern with the rights of a resident. Interview with CNA #3, on 03/19/2021 at 10:34 AM, revealed the facility trained staff on abuse, dignity and resident rights. The CNA stated staff needed assistance to keep Resident #90's hands out of the way when they fed him/her. CNA #3 stated the resident became agitated when she attempted to feed him/her. The CNA stated the resident was on a level of a toddler and she attempted to meet the needs of the resident's on his/her cognitive level. Interview with CNA #19, on 03/19/2021 at 11:18 AM, revealed the facility educated staff of resident rights, which included abuse and dignity. The CNA stated when they fed Resident #90 the resident could get agitated. However, the CNA stated they would stop attempting to feed the resident, distract the resident and retry to feed the resident. The CNA stated staff were not to hold Resident #90's hands or prevent his/her arms from reaching or pushing away the food. The CNA stated when staff spoke to the resident they should speak to him/her like you would any other adult. The aide stated baby talk and nick names were disrespectful to the resident. Interview with LPN #2, on 03/20/2021 at 7:45 AM, revealed the facility was to ensure all residents were treated as family. The LPN stated residents should be treated like family which included respect and dignity. The LPN stated all residents were to be spoken to as an adult. He stated Resident #90 followed normal talk, simple commands and did not require baby type language. He further stated the facility provided education to staff for abuse, resident rights, and how to treat residents with dignity. Interview with the DNS (Director of Nursing Services) on 03/20/ at 12:51 PM, revealed staff should treat all residents in the facility like family, therefore respect and dignity should occur at all times. He stated he was not in the facility when staff moved Resident #14 to the new room and the facility was attempting to find suitable arrangements for a new room. However, he stated the use of a BSC when someone could toilet would make someone feel more depressed. In addition, he stated he expected staff to meet Resident #90's needs in a professional manner. He stated this included speaking to residents like an adult. In addition, he stated as the new DNS, moving forward included providing good care to the residents at all times because the facility was there to provide care. Interview with the Executive Director (ED), on 04/031/21 at 2:00 PM, revealed the facility had not identified issues with dignity toward residents. She stated the facility had applied for the transition of single rooms to double occupancy. However, to date the State had not notified the facility of approval. She stated conversations with Resident #14's family included not to move the resident to a semi-private room. However, Resident #14 was cognitively intact to make his/her own decisions without his/her POA and approved the room move. The ED stated the OT notified her of the inability of Resident #14 to use the restroom and the facility provided a BSC because the facility attempted to ensure the resident remained in a private room as requested. Continued interview revealed she would not know what she would feel if she had to use a BSC in an open room with possible exposure of her body. The ED stated she expected staff to talk respectful to all residents at all times. She stated she would not want to be spoken to in a negative or derogatory manner by staff. In addition, she expected staff to use diversional activities if needed, when they assisted residents with a meal. The ED stated everyone was human and were to be treated with respect and dignity at all times.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure reasonable accommodation of needs for five (5) of sixty-nine (69) sampled residents (Residents #14, #54, #56, #82, and #445). Interviews revealed the facility moved Resident #14 from a room with an accessible rest room to a room in which the rest room door did not accommodate the resident's wheel chair. Interviews revealed the resident reported to the facility on [DATE] he/she could not get into the bathroom immediately after the facility transferred him/her to a new room. However, the facility did not address the need to use the bathroom until 02/13/2021 when the facility provided Resident #14 with a bedside commode. Resident #14 had to use a brief when the facility did not respond for twenty-four (24) hours. Resident #14 stated he/she felt invisible and uncared for by the facility. Staff reported the resident appeared upset, sad, and angry when the facility provided the BSC instead of the use of a bathroom. Observation and interviews revealed the facility failed to provide translation services for communication with staff for Residents #54, #56, and #445, whose primary language was not English. Resident #445's primary language was Spanish and Residents #54's and #56's primary language was Russian. Observation and interviews revealed Resident #82 could not use the bathroom sink due to a backup of water and could not read due to inadequate lighting in the room. The resident revealed he/she liked to wash in the sink on a daily basis and wash his/her hands after toileting. However, the resident revealed he/she could not complete either and was afraid of getting an infection from his/her hands not being clean. The findings include: Review of the facility's policy, Quality of Life - Accommodation of Needs, revised August 2009, revealed the resident's individual needs and preferences would be accommodated to the extent possible, except when the health and safety of the individual or other resident would be endangered. The policy revealed in order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. The policy revealed staff's attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes. Review of the facility's policy Quality of Life - Homelike Environment, revised May 2017, revealed the facility's staff and management would maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included: a clean, sanitary and orderly environment; and comfortable (minimum glare) yet adequate (suitable to the task) lighting. The policy revealed comfortable and adequate lighting was provided in all areas of the facility to promote a safe, comfortable, and homelike environment. The lighting design emphasizes: sufficient general lighting in resident-use areas; Task lighting as needed; Reduction in glare; even light levels; Maximum use of daylight; Night lighting to promote safety and independence; and dimming switches, where feasible. 1. Review of the clinical record revealed the facility admitted Resident #14, on 10/20/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #14 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) and determined he/she was interviewable. The facility assessed the resident's locomotion with use of a wheelchair (w/c). Review of the facility's notification letter, undated, revealed the facility planned to change the C Unit private rooms to semi-private rooms and would assist with transfer to another unit to continue use of a single room if desired. In addition, the facility would accommodate residents' needs as possible. The administrator signed the notification letter. Review of the bed status revealed the facility transferred Resident #14's, on 02/12/2021, from the C Unit room nine (C-9) to the B Unit room seven (B-7). Observations, on 03/12/2021 at 11:08 AM, revealed the facility room placement for Resident #14 was B-7. Observations revealed the resident transferred independently from the chair to an extra wide w/c, he/she went to the bathroom door, and attempted unsuccessfully to enter the bathroom because the width of the w/c. Observations revealed the bathroom door opened against the wall, therefore it only opened at a forty-five (45) degree angle. The bedside commode laid against the wall at the window and toilet paper sat on the windowsill. Interview with Resident #14, on 03/12/2021 at 11:08 AM, revealed the facility moved him/her to B-7 on 02/12/2021. The resident revealed the C-wing contained all single rooms. The resident stated the facility notified families of the intent to transition the C Unit rooms into double occupancy rooms. Resident #14 stated because of the size of his/her w/c it could not fit through a regular rest room door and the facility placed him/her in C-9 to allow him/her to maintain independence with toileting. Furthermore, the resident revealed his/her Power of Attorney (POA) notified the facility's administrator not to move the resident without consent or involvement. However, the resident revealed the administrator and upper management 'badgered him/her to move to another unit whereas he/she could remain in a single room and feared the facility would discharge him/her for continued refusal. The resident revealed he/she looked at the room prior to the move. However, the resident stated the facility did not ensure his/her w/c would fit in the rest room. The resident revealed he/she figured the facility reviewed the rest room door to accommodate the width of the w/c. Furthermore, the resident stated once in the room, he/she discovered the door to the rest room could not fit the w/c. Resident #14 stated he/she notified the administrator and POA with the request to return to C-9 until other arrangements could be made. The resident stated the facility did not respond on 03/12/2021 and he/she had to toilet in the brief from 02/12/2021 early afternoon to 02/13/2021 late morning when staff brought the BSC. Resident #14 revealed when staff brought the BSC on 03/13/2021 they remarked the resident would have to toilet in the BSC or use his/her brief. The resident stated he/she felt bad to be forced to use a brief or BSC. In addition, the resident remarked he/she felt like the facility did not care about what he/she needed to remain independent to the best of his/her ability and he/she felt invisible to the facility. Interview with Family Member (FM) #6, on, 03/13/2021 at 1:35 PM, revealed Resident #14 stated that he/she could not get into the bathroom to toilet or to wash his/her hands. The FM revealed the resident revealed he/she used a warm cloth or used bacterial gel for hand hygiene. The FM revealed the resident stated the w/c could not get through the rest room door. The FM revealed the other room had a wide entrance to the rest room and the door fully opened. The FM revealed Resident #14's POA requested the facility not to move the resident. The FM revealed the resident expressed anger because the facility would move him/her to a room that could accommodate the size of the w/c. Interview with FM #7, on 03/13/2021 at 1:59 PM, revealed they represented Resident #14 as his/her POA. The FM revealed they informed the administrator through phone conversations and mail that as the POA for Resident #14, the facility may not move Resident #14 without consent or input. The FM revealed Resident #14 informed the family after the move when the resident called and reported he/she could not get into the bathroom in the new room. The FM revealed they notified the administrator the facility moved the resident without the POA's consent and requested the resident either return the original room or a room which could accommodate the w/c. The FM revealed the administrator stated Resident #14 was cognitively intact and could make his/her own decisions and the resident gave consent after looking at the room and determined it accommodated his/her needs. The FM revealed the resident's therapist informed the facility the rest room could not accommodate the w/c and risked the resident's safety. The FM further revealed because the facility would not move the resident to accommodate the w/c, the facility provided a BSC in the open room for toileting. The FM revealed the facility did not accommodate the resident's toileting needs after numerous requests to remain independent to his/her ability. Review of FM #7's letter to the facility's Administrator, dated 02/03/2021, revealed as the representative for Resident #14, the FM requested the facility not move the resident to a new room without consent or input,. Review of Progress Notes, dated 02/12/2021 at 12: 08 PM, revealed the facility moved the resident to room B-7 around 11:00 AM. The facility failed to provide documentation of notification to the POA of the resident's room change. Observations with the Maintenance Director (MD), on 03/15/2021 at 11:00 AM, revealed the Director of Maintenance used the facility's tape to measure B-7 rest room door with the open angle of the door reported by the MD as less than ninety (90) degrees and the entry measured twenty-nine (29) inches. Further observation revealed the MD measurement for C-9's rest room included the door opened to one-hundred and eighty (180) degrees and the rest room door entry measured thirty-six (36) inches. In addition, the MD measured Resident #14's w/c width as 29 inches. Interview with the MD, on 03/15/2021 at 11:00 AM, revealed the facility did not request him to measure the rest room entry to B-7 before the facility moved Resident #14. He revealed plain visual sight could reveal the entry to B-7 could not accommodate the width of the w/c. He further revealed the facility knew the resident could not enter the rest room in B-7 when the administrator asked him to look at the entry the next day of the move. He revealed he notified the administrator even after he attempted to move the furniture around the room the resident still could not get into the rest room. He revealed facility administrator revealed she attempted to accommodate the resident with the move to a single room, the resident gave approval of the move, and therefore the resident decided the room worked for his/her needs with toileting. Furthermore, he revealed he felt the facility should move the resident to accommodate the resident to toilet in a restroom and not a BSC. Interview with the Occupational Therapist, on 03/15/2021 at 3:41 PM, revealed they assessed the resident's room for safety and accommodation for use of the rest room with the resident's w/c. He revealed the w/c could not fit through the rest room door. He revealed the resident's goal included to remain as independent as possible. He revealed he reported the use of the bathroom would be a risk to the resident's safety to the administrator. The OT stated the resident required a room with a larger entry to the rest room. However, the OT revealed the administrator remarked the resident made the decision to accept the room and the next time the OT went to complete therapy the room contained a BSC. The OT revealed Resident #14 expressed anger and dismay to be made to use a BSC and seemed more depressed after he/she was transferred to the new room. Furthermore, the OT revealed the facility provided a normal sized BSC and the equipment remained a safety concern for the resident's weight with the ability to sit and stand as the BSC caught the resident's hips. Interview with the Admission Director (AD), on 03/20/2021 at 10:59 AM, revealed the facility's administration made the decision to move Resident #14 to the B Unit because the resident wanted to remain in a single room. The AD stated the facility did not inquire if the room could accommodate a large w/c. He stated the facility knew how upset Resident #14 was since he/she moved to the room and would not move the resident to a new room. Continued interview revealed the facility approached him on 3/19/2021 to locate a room which could a rest room could accommodate Resident #14's w/c. He revealed the facility responsibility included to ensure the rights of the residents, make the residents comfortable and live in a homelike environment to accommodate the resident to maintain independence. The AD revealed the use of a BSC could make Resident #14 depressed as it would anyone. Interview with CNA #1, on 03/17/2021 at 1:16 PM, revealed Resident #14 could self-transfer and toilet when he/she resided in C-9. However, the aide revealed the resident required moderate assistance now that the facility provided the resident with a BSC. The aide revealed the resident reported to staff he/she wanted to use the rest room and requested many time to move to a room which could accommodate the size of his/her w/c. The aide revealed the resident told the administrator he/she didn't like to use the BSC and needed different accommodations. However, the administrator would not move the resident. Furthermore, the aide revealed the resident appeared emotional upset and at times angry when he/she could use a bathroom and was made to use the BSC. Furthermore, the aide revealed the resident's risk of falls increased because the resident could not use the grab bars to steady or pull up off the BSC which further increased the dependency for staff. The aide further revealed the resident did not have any accommodations to ensure he/she lived in a homelike environment and the facility's responsibilities included to provide a place like the resident lived in at home. Interview with CNA #18, on 03/14/2021 at 11:20 AM, revealed the aide cared for Resident #14 on Unit A/B and previously on Unit C/D. The CNA revealed when Resident #14 could transfer from the wheel chair, toilet independently, and take care cleansing after use of the toilet with occasional minimal assistance. However, the resident required assistance with toileting in B-7. CNA #18 revealed the resident could not reach to clean himslf/herself and required assistance on and off the BSC. The CNA revealed Resident #14 wanted to remain independent. CNA #18 revealed the resident's rights included to have the facility accommodate needs of the residents. The CNA further revealed because the resident could not get into the rest room, the resident could not wash their hands. The aide further revealed the resident feared losing his/her independence. Interview with Medical Records Coordinator/LPN, on 03/14/2021 at 9:40 AM, revealed she took care of Resident #14 when she filled in as a nurse on the unit for staff. She revealed the resident's abilities while he/she resided in C-9 included to transfer independently, able to toilet with minor assist and fiercely independent. The LPN revealed the resident could enter and exit the rest room in C-9 and he/she could not in B-7. The LPN revealed the facility provided the resident a BSC in B-7. The LPN stated Resident #14 complained frequently to staff about the required use of a BSC when he/she could use the rest room in C-9. Interview with Licensed Practical Nurse (LPN) #2, on 03/20/2021 at 7:45 AM, revealed the facility knew the resident could not enter the rest room in B-7. He stated instead of moving the resident the facility accommodated his/her toileting needs with a BSC. LPN #2 stated he considered the BSC disgraceful, and the facility's treatment to the resident was indignant, and the resident voiced to the facility provider that it was undignified utilities for toileting. Interview with Social Services, on 03/19/2021 at 10:12 AM, revealed the any resident who could use a rest room and was made to use a BSC would be upset and uncomfortable with the situation. The SS stated if the situation occurred to him he would demand to know why this happened and demand a room change to use the rest room. Interview with the DNS, on 03/20/2021 at 12:51 PM, revealed the facility should provide accommodations in the facility to meet a resident's request or need to maintain his/her level of care. the DNS revealed the facility moved Resident #14 while out of the building. The DNS revealed the rest room in Resident #14's room was small and the resident could not use the rest room. The DNS further stated the focus of the facility should always be about what the resident needs, not what the facility decided the resident needed. Furthermore, he expected the facility to provide and accommodate resident's needs to remain at the level physically and mentally to the best of the facility and staff's ability. Interview with the Executive Director (ED), on 04/03/ 1 at 2:00 PM, revealed the facility moved Resident #14 after the resident decided the room on the B Unit could accommodate his/her needs, including toileting. The ED revealed communications with the POA included only to not move the resident into a double occupancy room. The ED stated the facility moved the resident because the facility applied for the ability to increase census with double rooms. However, the ED revealed to date, the facility had not been notified of approval from the State. The ED revealed the facility utilized a program called magical moments where staff routinely met with the residents and document complaints or needs and as the ED, she signed off on the forms. The ED revealed staff notified her of Resident #14's concerns of the inability to access the rest room. She stated she spoke to the resident and discussed his/her desire to have a private room and the facility provided the private room as requested. She stated that in order to stay in a private room she would see if renovations could be done by maintenance to the door to allow access.The ED further revealed the facility's responsibilities included to provide residents with a quality of life which accommodated the resident's needs at all times. The ED revealed the failure to accommodate the resident's needs could cause an adverse effect to the resident. 2. Review of the facility's Quality of Life-Accommodation of Needs Policy, revised 08/2009, revealed the facility's goal was to provide an environment to maintain dignity and achieve the highest level of function and well-being for the residents. The policy revealed the facility would provide assistive devices for the physical environment and staff would communicate with the residents achieving the highest level of functioning while maintaining dignity. The facility did not provide a requested policy regarding translation for Residents with a language barrier or spoke a foreign language. Review of the clinical record revealed the facility admitted Resident #54 on 05/12/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of three (3) and resident usually comprehended and was understood by others. Review of Resident #54's care plan, initiated on 05/15/2020 with revisions on 02/10/2021, revealed interventions included difficulty with communication due to English as a second language and the goal to ensure communication of Resident #54's basic needs. The interventions included staff's anticipation of resident's needs, communication without distractions, use of simple words, and alternative tools as needed. Further care plan review revealed the provision of a communication board and therapy to screen quarterly and as needed. Review of the Social Services Progress Review for MDS Documentation, dated 01/29/2021, revealed Resident #54's speech was clear, was usually understood by staff, and understood communication provided by facility staff. Review of Speech Language Pathology Discharge Summary, dated 11/30/2020, revealed speech therapy identified Resident #54 had a moderate/expressive communication disorder and had difficulty understanding English, as his/her primary language was Russian. The speech therapy discharge summary revealed Resident #54 still required maximum cueing for communication with the use of simple yes/no questions, use of visual aides, and speaking slowly to increase understanding. Review of Psychiatry Progress Notes, dated 12/2020 through 02/2021, revealed Resident #54 had a mild comprehension impairment, was oriented to person, and English was not his/her primary language which affected communication with the resident. Observation of Resident #54, on 03/09/2021 at 11:28 AM, revealed Resident #54 lying in bed and just smiled when spoken to. When asked resident to verify his/her name, he/she repeated his/her last name back. Additional observation, on 03/18/2021 at 11:55 AM, revealed resident well groomed, dressed appropriately, and sitting in his/her wheelchair in the room. A communication board was not present. Interview with Certified Nurse Aide (CAN) #8, on 03/18/2021 at 10:58 AM, revealed she requested Resident #54 to speak English and the resident also had a communication board. Interview with CNA #21, on 03/13/2021 at 2:42 PM, revealed she used a translation application on her personal cellular phone to communicate with the residents with language barriers. Interview with CNA #17, on 03/13/2021 at 2:44 PM, revealed she used hand gestures to communicate with Resident #54 because the facility did not have translation services available. Interview with the Speech Language Pathologist (SLP), on 03/16/2021 at 2:14 PM, revealed assessments for residents with language barriers were completed on admission and quarterly. She stated she used a cellular phone translator application to communicate with non-English speaking residents. The SLP stated she communicated with facility staff to determine if the resident was having any difficulty with communication for the quarterly assessment. Interview with the Director of Social Services (SSD), on 03/17/2021 at 8:14 AM, revealed he did not use any tools to evaluate Resident #54 for a BIMS assessment for the MDS assessment. He stated he used video conference by telephone or utilized family members to translate for the residents with English as a second language with communication difficulties. He stated the facility did not have translation services available for staff to communicate with residents. The SSD stated Resident #54 did not have a communication board in his/her room. Interview with the Advanced Practice Nurse Practitioner (APRN), on 03/20/2021 at 3:40 PM, revealed her communication with non-English speaking residents and those with communication barriers was to motion to him/her what she was going to assess. She stated facility staff were also used to translate for non-English speaking residents. The APRN stated the facility did not have translation services available for staff use and therefore, she used her cellular phone at times to translate from English to another language. Interview with the Director of Nursing Services (DNS), on 03/21/2021 at 03/20/2021 4:17 PM, revealed the facility did not have any translation services available to staff to utilize. He stated there could be an inaccurate translation with the use of a translation application via cellular phone, which was not his preference. The DNS stated the facility was attempting to arrange for translation services for the facility. Interview with the Executive Director (ED), on 04/02/2021 at 2:30 PM, revealed the facility utilized visual translation boards, facility staff, and family members to translate for the residents who spoke a foreign language. She stated the facility had translation services via a telephone service, which was available to the ED, DNS, and SSD. She stated the contact information was not available to other facility staff members. She stated it could be frustrating for the residents not being able to communicate his/her needs. The ED stated the lack of awareness for translation services was an education opportunity. 3. Review of the clinical record revealed the facility admitted Resident #56, on 11/25/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Orders, dated 01/2021-03/2021, revealed no SLP services ordered. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a BIMS score of fourteen (14), resident was sometimes understood by others and sometimes understood communication with others. The MDS revealed Resident #56 required one (1) person staff support for transfers, walking in room/hall, dressing, eating, toilet use, personal hygiene, locomotion on/off unit. The assessment revealed resident had impaired range of motion for upper and lower extremities and required the use of a wheelchair and walker for mobility. Bed mobility required the assistance of two (2) staff members. The MDS revealed Resident #56 was always incontinent of bowel and bladder. Review of Resident #56's care plan, initiated on 02/23/2020 and last revised on 02/13/2021, revealed difficulty with communication due to Russian being primary language with English as a second language. The goal was to ensure Resident #56 was able to make basic needs known on a daily basis. The care plan revealed interventions including for staff to anticipate and meet needs; speaking to resident slowly, without distractions, and using simple words; and provide translation from resident's daughter as necessary to communicate with the resident. The facility failed to provide the requested policies for language barriers and interpretation services. Observation of Resident #56, on 03/15/2021 at 3:06 PM, revealed the resident sitting in a wheelchair by the window, well groomed, and appropriately dressed. Interview with Resident #56, on 03/15/2021 at 3:06 PM, revealed he/she did not speak English but spoke Russian. Attempted to interview the resident, but did not get a response. Interview with CNA #21, on 03/13/2021 at 2:42 PM, revealed the facility did not provide translation services and she used her cellular phone's translation application to communicate with the non-English speaking residents. Interview with CNA #17, on 03/13/2021 at 2:44 PM, revealed she did the best she could to communicate with the non-English speaking residents, using hand gestures to communicate. Interview with the Speech Language Pathologist (SLP), on 03/16/2021 at 2:14 PM, revealed she completed assessments for residents with language barriers upon admission and quarterly. She stated she utilized a translator application on her cellular phone to communicate with non-English speaking residents. The SLP stated for the quarterly assessment she asked staff and the resident if he/she was having any difficulty communicating. She stated she had provided Resident #54 with a Russian communication board but Resident#54 did not want to use it. The SLP stated she utilized family members to translate as needed. Upon further interview, the SLP stated the facility did not have any translation services available for staff use. Interview with the Director of Social Services (SSD), on 03/17/2021 at 8:14 AM, revealed he utilized family members to translate via telephone or video and staff members to communicate with non-English speaking residents. Interview with the Director of Nursing Services (DNS), on 03/21/2021 at 03/20/2021 at 4:17 PM, revealed he preferred not to use cellular phone translation applications or family members as translators which could result in a misinterpretation during communication. He stated the facility did not currently possess translation services for non-English speaking residents and the facility was in the process of obtaining a translation service. Interview with the Advanced Practice Nurse Practitioner (APRN), on 03/20/2021 at 3:40 PM, revealed she used a cellular phone translation application or hand gestures to communicate to the resident as to what she was assessing at the time. She stated she has also utilized facility staff to translate communication to the non-English speaking residents. Interview with the Executive Director (ED), on 04/02/2021 at 2:30 PM, revealed the facility utilized visual translation boards, facility staff, and family members to translate for the residents who spoke a foreign language. She stated the facility had translation services via telephone, which was available to the ED, DNS, and SSD. Further interview revealed the translation contact information was not readily available to staff. She stated it could be frustrating for the resident not being able to communicate his/her needs. The ED stated she was unsure if translation services was a topic presented during orientation; therefore, it was an educational opportunity for the facility. 4. Review of Resident #445's clinical chart revealed the facility admitted the resident, on 03/01/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS, completed on 12/19/2020, revealed the facility-completed assessment for Resident #445 identified his/her preferred language to be Spanish. The facility completed a Brief Interview for Mental Status (BIMS) and assessed the resident to have a score of fourteen (14) out of fifteen (15). Review of the Baseline Care Plan, revised 03/17/2021, revealed staff assessed the resident to have difficulty with communication due to a language barrier. Interventions were to anticipate needs and provide translator as necessary to communicate with resident. The translator was to be Spanish-speaking staff. Observation on 03/11/2021 at 6:00 AM and 03/18/2021 at 2:00 PM revealed Resident #445 approached the nursing desk to ask for assistance. When the resident would have a non-Spanish speaking nurse, the resident would come out and say, what seemed to be the same thing many times. It looked as if the resident did not understand the nurses answer to the question. Interview with CNA #21, on 03/13/2021 at 2:42 PM, revealed she used an application on her phone, to communicate with Resident 445. Interview with CNA #17, on 03/13/2021 at 2:42 PM, revealed that she just does the best she can to communicate with Resident #445. The CNA stated she usually got the point that they were trying to get across to her by gestering or pointing at things. Interview with CNA #8, on 03/18/2021 at 10:57AM, revealed she communicated with Resident #445 by using hand gestures. She stated some people used an application on their phone to communicate with her but she did not. Interview with Speech Language Pathologist, on 03/16/2021 at 2:20 PM, revealed she used a translator application on her phone with residents who did not speak English. She stated she did supply Communication Boards to residents who do not speak English when they were requested. As far as she knows, the facility did not have any translation services or any translator phones. She said she had not assessed Resident #445. She said there was usually a Spanish speaking staff in the facility to communicate with Resident #445. Interview with the Nurse Practitioner, on 03/20/2021 at 3:47 PM, revealed she used Google translate on her phone to speak with the residents. She also had used nurses who spoke the resident's language and resident's family to communicate with residents. Interview with the Director of Nursing (DON), on 03/20/2021 at 4:18 PM, revealed the facility had communication boards and Spanish speaking staff. He stated the facility was in talks with a Translation Company. He did not like translation applications being used. He stated if he

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Nurse Practitioner (NP) Care Services provided timely orders for one (1) of sixty nine (69) sampled residents (Resident #85). The facility received a critical lab value of a Blood Urea Nitrogen (BUN) level of 111 (above 20 is high) mg/dl (deciLiter) on 03/09/2021 at 1:00 AM. The facility notified the NP immediately. However, there was no documented evidence the NP addressed the critical lab until 4:14 PM (03/09/2021), roughly fifteen (15) hours later. In addition, the facility failed to provide adequate fluids per dietary recommendations after the NP ordered a reduction of fluid intake per Enteral Feeding. Furthermore, the NP failed to follow-up with pharmacy regarding insulin orders which were not initiated. The findings include: The State Survey Agency requested the facility's policy related to Reporting Critical Lab values. The facility presented its Change in Condition policy. Review of the Change in Condition policy dated October 2019 revealed an acute change in condition would be communicated to the physician and the responsible party. Review of the contract titled, Health Care Services Agreement (Medical Director Services), undated, revealed the agreement included services with a company owned and operated by an Advanced Practice Nurse Practitioner. The agreement revealed midlevel NP's provided services to the facility and residents for sudden needs of a resident. Further review revealed in an emergency the contractor availability on call included to advise the facility with resident concerns when the facility identified the medical provider as unavailable. However, the contracted NP failed to provide immediate services for Resident #85's critical lab and then provided services to the resident without documented consultation with the Pulmonary Medical Director (PMD). 1. Record review revealed Resident #85 was transferred to an acute care facility on 03/10/2021 and was not in the facility during the investigation. Review of Resident #85 clinical record revealed the facility initially admitted the resident on 04/10/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of four (4). Review of Resident #85's Comprehensive Care Plan, initiated 05/01/2020, revealed a potential for nutritional risk related to reliance on therapeutic enteral feeding for nutrition, significant weight loss, altered skin integrity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal stated the resident would not exhibit unplanned significant weight change thought the next review and the resident would receive adequate nutrition and hydration with a target date of 04/29/2021. Interventions included lab/diagnostic tests as ordered, report results to MD and follow up as indicated; provide tube feeding as ordered. Interview with Licensed Practical Nurse (LPN) #11 on 03/18/2021 at 3:18 PM revealed critical labs could be threatening to the resident. She indicated the lab would call to the floor and report the critical lab to a nurse. Per protocol, the nurse would then call the doctor/NP and the doctor/NP would give orders to intervene. LPN #11 further stated the outcome of untreated critical labs could be system failures. Review of the Lab Results Report for Resident #85, revealed the normal range for Blood Urea Nitrogen (BUN) was 7 mg/dL to 25 mg/dL. On 02/15/2021 Resident #85's BUN was 47 mg/dL. On 02/22/2021, Resident #85's BUN was 68 mg/dL. On 03/05/2021, Resident #85's BUN was 95 mg/dL. On 03/08/2021, Resident #85's BUN reached a critical level of 111 mg/dL. On 03/10/2021 Resident #85's BUN was again critical at 122 mg/dL. Interview with Certified Medication Technician (CMT), on 03/20/2021 at 11:11 AM, revealed she was new to the facility and assigned to the G Hall on 03/09/2021, the evening the critical lab value for Resident #85 was called into the facility. CMT indicated she always answered the phone, however the nurse on her hall was in a resident's room providing treatment, so she took the critical lab for Resident #85's BUN of 111 mg/dL. CMT further stated she immediately reported the critical lab to the nurse on the A- Hall, LPN #12. She revealed she did not remember time. However, indicated it was after midnight. Interview with LPN #12 on 03/20/2021 at 10:47 AM, revealed she was responsible for the A/B Unit and the C/D Unit on the night the critical lab for Resident #85 was reported. She stated she took over the C/D Unit at 11:00 PM. LPN #12 explained an unnamed staff member on the G-hall took the critical lab value. She stated she did not recall the time, but it was the middle of the night. She additionally stated she immediately notified the NP by phone of Resident #85's BUN of 111. The NP indicated she would address the critical lab when she made her morning rounds. Review of Physician/ Prescriber orders in Point Click Care (PCC) reflected the orders were placed into the system by Licensed Practical Nurse (LPN) #11, on 03/09/2021 at 4:14 PM, approximately 15 hours after the critical lab was called to the facility. Review of the Physician/ Prescriber Order written by the Nurse Practitioner, dated 03/09/2021 untimed, revealed orders were written to administer D5W (intravenous sugar solution to rehydrate) at 100 cc/hour continuous; Basic Metabolic Panel (BMP) in AM (morning). Review of Resident #85's Hospital records, revealed the resident was admitted to the hospital on 03/10/2021 at 12:35 PM with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital labs, dated 03/10/2021 at 12:56 PM, revealed a Blood Urea Nitrogen (BUN) lab value of 123 mg/dL (reference range 7-20 mg/deciliter (dL)), (The BUN test measures the level of nitrogen in the blood to assess the functions of the kidneys and liver) and Sodium of 155 mmol/L (reference range 137-145 mmol/L. Interview with the Medical Records Coordinator, on 03/18/2021 at 3:47 PM, revealed after the facility received a critical lab, the doctor or NP should be notified for guidance. She further stated, critical labs should be acted on immediately because the resident's condition could get worse. Interview with the Director of Nursing Services (DNS) on 03/19/2021 at 11:40 AM, revealed he did not know the official policy for reporting critical labs. He stated the nurse should immediately notify the doctor/ NP of the critical labs by phone call. The nurse should then document the call in the progress notes along with any orders. An additional interview with DNS on 03/21/2021 at 12:25 PM revealed Physician Services were to oversee care of the residents. He stated he was unaware of the fifteen (15) hour delay after the facility notified the NP of the critical labs. The DNS further stated, the provider should deal with critical labs immediately and indicated it would not be practical to wait. Additionally, the DNS stated there could be adverse outcome with a delay in treatment. Interview with the NP on 03/18/2021 at 10:50 AM revealed the cause of an elevated BUN was Chronic Kidney Disease, dehydration, and/or kidney failure. The NP further stated potential complication of BUN of 111 could be kidney failure and dysfunction. Further interview with NP on 03/20/2021 at 3:40 PM, revealed she did not remember when the first critical lab for Resident #85's BUN of 111 mg/dL was reported to her. She indicated she rounded in the facility and wrote orders for Resident #85 midmorning or early afternoon and added she could not remember the date. She explained sometimes the facility called or texted with critical labs at night, adding, they had the option to call other providers. However, if it was a critical lab they usually called her. However, she explained she would have given orders when notified of a critical lab BUN of 111 mg/dL. She added, usually she would see the critical labs before they were reported to facility. 2. Review of Physician/ Prescriber physical order sheet written by the NP, dated 02/22/2021 untimed, revealed a written order to increase free water to one thousand and five-hundred (1500) cc every twenty-four (24) hours or sixty-two (62) cc per hour. Review revealed the previous order included 300 cc of water every 4 hours. This resulted in a decrease of free water by 300 cc in a 24 hour period. Review of the Progress Notes- Nutrition/Dietary Notes written by the RD effective 01/19/2021 at 10:57 AM and on 02/24/2021 at 10:04 AM revealed the Nutrition at Risk (NAR) review. Review revealed the recommendations for free water/flushes of 300 cc every four (4) hours for a total of 1800 cc every day. However, the recommendation was not ordered after the NAR review on 02/24/2021. Review of Resident #85's Medication Administration Record (MAR) dated 01/01/2021- 03/01/2021, revealed the facility did not include on the MAR or Treatment Administration Record (TAR) an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #85's clinical record revealed the facility documented evidence did not include that staff provided the resident free water/flushes or monitored for hydration from 12/28/2020-03/10/2021. The facility sent Resident #85 to an acute facility for an evaluation on 03/10/2021 after review of lab results drawn on 03/10/2021 at 4:28 AM. Review of Resident #85's Lab Result, dated 03/10/2021 at 4:28 AM, revealed the resident's BUN was 122 mg/dL (reference range 7-25 mg/dL) and a sodium level of 158 mEq/L (reference range 135-145 mEq/L). The result of 122mg/dL was noted as a critical level. Review of admission hospital records, dated 03/10/2021, revealed the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #6 on 03/17/2021 at 10:57 AM revealed Resident #85 was ordered 1500 cc of free water every 24 hours. However, she was unsure if it appeared on the MAR to chart. She also stated the potential outcome for a resident not receiving enough fluids would be dehydration. Interview with LPN #11 on 03/18/2021 at 2:27 PM revealed there were no free water no orders on the MAR to administer free water to Resident #85. She stated she flushed with 60 cc of water when she changed Resident #85's feeding bag. However, did not give any additional water free to Resident #85. Interview with Registered Dietician (RD) on 03/18/2021 at 2:42 PM revealed she calculated tube feeds and free water needs and would give suggested orders. She stated sometimes the Advanced Practice Registered Nurse (APRN) would also give orders for free water. The RD additionally stated feeding pumps were discussed in clinical meeting. Dual pumps had pre-programmed amounts to ensure residents received free water to potentially prevent elevated labs or dehydration. She also indicated Resident #85 was last assessed as a Nutrition at Risk (NAR) resident on 02/24/2021 and was suggested him/her to receive 300 ml of free water every four (4) hours. RD assessed MAR/Treatment Administration Record (TAR) record on PCC during the interview and replied she did not see free water flushes on the MAR/TAR. However, stated free water flushes were ordered for February and March. She indicated she did not know how to ensure free water was given if it did not show up on the MAR/TAR and stated, That would be a DNS question. RD additionally stated the potential outcome for not receiving free water flushes could be elevated labs or dehydration. Interview with DNS on 03/19/2021 at 11:40 AM revealed free water was given via G-tube and calculated by dietician. He explained the RD made recommendations. However, the orders for free water would need to come from the doctor. He indicated the order for free water should show on the MAR and explained, if it's not on the MAR the nurse would not know to do give free water. In addition, he stated the potential outcome for not receiving hydration would be a clogged G -tube and potential for dehydration. Interview with NP on 03/20/2021 at 1:40 PM revealed free water is the extra water given to residents to accommodate their needs. NP was asked to clarify the free water order written by NP on 02/22/2021 increase free water to 1500 cc per 24 hours or 62 cc per hour. The previous free water order was 300 cc every 4 hours. The NP explained she could not give you definitive answer as to why free water was decreased. However, stated Resident #85 did have a history of Heart Failure or there were multiple orders for free water/flushes and may have been over looked. 3. Review of Physician order, dated 03/01/2021, revealed the NP ordered on, 03/01/202, to start [MEDICATION(S)] 10 units subcutaneous twice a day. Review revealed this was an increase from the previous order which was to administer [MEDICATION(S)] 10 units subcutaneous once a day. Review of Resident #85's March 2021 MAR/TAR revealed Pending Confirmation an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The provider ordered the [MEDICATION(S)] 10 unit one time a day, the previous order, to be discontinued on 03/14/2021. However, record review revealed the [MEDICATION(S)] [MEDICATION(S)] 10 units subcutaneous two times a day was not imitated as ordered. However, review revealed Resident #85 continued to receive the discontinued dose of [MEDICATION(S)] 10 units once a day. Record review of Resident #85's Lab Result, dated 03/10/2021 at 4:28 AM, revealed a blood glucose level of four hundred and eighty-three (483) mg/dL. The normal range for glucose included 65-125 mg/dL. Further review of Resident #85 Weight and Vitals Summary, dated 03/10/2021, revealed documented blood sugars of three hundred and eighty-seven (387) mg/dL at 7:48 AM and three hundred and eighty-nine (389) mg/dL at 10:11 AM prior to Resident #85 being sent to the hospital. Record review of Resident #85's hospital admission records, dated 03/10/202, revealed the resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Lead Pharmacist, on 03/20/2021 at 12:23 PM, revealed the facility entered an electronic order entered, on 03/01/2021 at 1:16 PM, for [MEDICATION(S)] [MEDICATION(S)] 10 units subcutaneous to be given twice a day. However, the order remained pending confirmation until discontinued on 03/14/2021 when Resident #85 was sent to the hospital. The Lead Pharmacist stated pending confirmation meant the doctor or NP would need to sign off on the order. He also stated pharmacy could not see PCC and explained they used a different system. He stated when the doctor/NP signed the order, it would be electronically submitted and the order would appear for staff on the MAR. He stated a new electronic order was received on 03/19/2021 for [MEDICATION(S)] 10 units once a day instead of twice a day. Further interview with the NP, on 03/20/2021 at 3:40 PM, revealed she worked independently, without oversite from the Medical Directors or a Physician because after four (4) years of work as a NP, the state of Kentucky did not require someone to oversee her. She revealed she had seen orders with pending confirmation. However, she stated she was not sure what pending confirmation meant and was never instructed that she needed to make any changes to orders with pending confirmation. the NP stated she thought the nursing staff addressed those orders. She stated she could not verify every order she wrote was imitated and did not follow-up to ensure orders were entered into PCC. She stated the potential outcome for not receiving the updated order for insulin included uncontrolled blood sugar, a higher risk of infections, long-term eye nerve damage, kidney issues, heart issues, or stroke. Interview with the Pulmonary Medical Director (PMD), on 03/20/2021 at 9:30 AM, revealed the facility Nurse Practitioner (NP) rarely worked with the PMD. The PMD revealed he only worked with two NP's employed by his practice. Furthermore, the PMD revealed he did not provide supervision because the NP was contracted for services by the facility and not under his practice. Further interview on 04/02/2021 at 11:15 AM, revealed the contracted NP did not take call for emergency, on call services, or notifications for the PMD residents. The PMD revealed he expected the facility to call him or his NP's for all care needs related to residents under his services. However, the contracted NP should directly notified the PMD for any concerns with resident's which he may need to address. The PMD revealed the contracted NP notified him of resident needs because staff addressed issues with the contracted NP who made daily rounds while he made rounds twice a week. Interview with the Medical Director (MD), on 03/20/2021 at 12:01 PM, revealed he oversaw the medical aspect for the facility and the second medical director oversaw the residents with pulmonary diagnoses. The MD revealed the facility held an independent contract with the facility NP and he did not provide oversite or supervision. Further interview, on 04/02/2021 at 10:01 AM, revealed when the MD first became the director the contracted NP made changes to resident care without notification. The MD revealed he met with the contracted NP with specific instructions to consult him for resident needs which may require significant order changes. The MD revealed the contracted NP addressed care needs in the facility for low level management for urgent care response needs (I.E. a urinary tract infection). Otherwise, the MD revealed he expected the contracted NP to call and discuss any changes in care. Furthermore, the MD revealed the contracted NP worked for the facility and the facility was a single entity business and therefore not the supervisor for the contracted NP. The MD further revealed the PMD followed Resident #85 for care.

Based on interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of nineteen (19) sampled residents (Resident #6). The facility care planned Resident #6 for pain and Registered Nurse (RN) #1 failed to complete a prompt assessment and administer pain medication as care planned for Resident #6 after sustaining an injury and pain from a fall. The findings include: Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the facility did not have a policy on care plans; however, utilized the Resident Assessment Instrument (RAI) as their policy. Review of the RAI, Minimum Data Set (MDS) Manual, Chapter 4.7, page 4-1, #12 revealed the Interdisciplinary Team (IDT) identifies specific, individualized steps or approaches that will be taken to help the resident achieve his or her goals. These approaches serve as instructions for resident care and provide for the continuity of care by all staff. Precise and concise instructions help staff understand and implement interventions. Review of the clinical record for Resident #6 revealed the facility admitted the resident on 08/26/15 with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment, completed on 09/02/15, revealed the facility assessed the resident as requiring one (1) person extensive assist to walk and one (1) person limited assist to complete activities of daily living (ADLs). The facility conducted a Brief Interview for Mental Status (BIMS) exam during the MDS assessment with a score of nine (9) out of fifteen (15) on the BIMS exam indicating the resident was moderately impaired. Review of Resident #6's care plan related to pain, dated 09/04/15, revealed the resident experienced the frequent presence of pain in his/her back due to a lumbar compression fracture after a fall at home prior to admission to the facility. Interventions included staff evaluating the location and intensity of the resident's pain. Staff was to administer pain medication as ordered, report any uncontrolled pain to the physician, and evaluate vital signs as needed. The staff was to observe for both verbal and nonverbal indicators of pain. Review of the Physician Orders, dated October 2015, revealed the physician ordered [MEDICATION NAME] 5-325 milligram (mg) tablet by mouth every six (6) hours as needed (PRN) for pain. The order also stated the facility must document pain level on a scale of one (1) to ten (10). Review of the Incident Log, printed 11/27/15 at 8:35 AM, revealed Resident #6 sustained a fall on the night of 10/28/15 or early morning of 10/29/15. The fall occurred in the resident's room at an unknown time. The report stated the resident sustained [REDACTED]. Interview with RN #1, on 11/24/15 at 6:10 PM, revealed Resident #6 complained of pain and had difficulty moving on the morning of 10/29/15. The RN stated she did not give the resident pain medication at the time and decided to monitor the resident for continued pain instead. She could not state why she did not give pain medication at that time as directed by the care plan and policy. Further interview with RN #1, on 11/25/15 at 2:58 PM, revealed RN #1 did not complete all assessments after Resident #6 reported a fall on 10/29/15. The nurse stated she did not remember if she assessed the resident's pain on 10/29/15 and did not document any pain assessment as directed by the care plan. Review of the Departmental Notes completed by RN #1, on 10/31/15 at 8:53 AM, revealed the RN completed a late entry pertaining to Resident #6's fall on 10/29/15. The note stated Resident #6 complained on Thursday morning, 10/29/15, of some difficulty moving his/her left leg, was grimacing, and complaining of pain. The note did not contain information indicating the resident's pain rating on the pain scale nor any interventions used to assist the resident to control pain, as directed by the plan of care. Review of the narcotic sheet for Resident #6's [MEDICATION NAME], dated 10/09/15, revealed the nursing staff signed as removing the medication from the narcotic drawer on 10/30/15 at 7:00 PM and on 10/31/15 at 1:00 AM. However, review of the Medication Administration Record [REDACTED]. Review of the facility's Departmental Notes, dated 10/27/15 through 10/31/15, revealed no documented evidence of pain assessments completed after Resident #6's reported fall as directed by the care plan. Interview with the Assistant Director of Nursing (ADON), on 11/25/15 at 11:10 AM, revealed that by not identifying and documenting Resident #6's injury as directed by the care plan, the resident's pain may have been prolonged and he/she was at increased risk of injury and pain. Further interview with the Director of Nursing (DON), on 11/25/15 at 9:00 AM, revealed the nurse should have completed and documented pain assessment per the care plan. Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the staff did not manage Resident #6's pain per the care plan and resulted in a delay in identifying the resident's fracture. Record review revealed the resident was diagnosed with [REDACTED].

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure staff provided care and services to meet the clinical needs for one (1) of nineteen (19) sampled residents (Resident #6). The staff failed to assess, monitor, and manage pain after Resident #6 sustained a fall and delayed the identification of an injury after Resident #6 experienced significant pain from the fall. The resident was diagnosed with [REDACTED]. The findings include: Review of the facility's Residents' Rights, not dated, revealed the residents had the right to receive adequate and appropriate care and services. Review of the facility's Care System Guideline for Pain Management, not dated, revealed the facility would complete a pain assessment upon admission, change of condition, and quarterly using a numeric rating scale or verbal descriptor scale. The facility would conduct a pain assessment after a resident fall or any acute change of condition where pain was suspected. The facility would then record the findings of the pain assessment in the clinical records including the evidence based rating or descriptor scale. Additionally, nursing would note ongoing monitoring and effectiveness of interventions in the medical record and progress notes. After a resident experienced a fall or other acute change, the Interdisciplinary Team (IDT) would then review the completed pain assessment and evaluate the effectiveness of the resident's pain management interventions. Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the facility used the Perry Potter Clinical Nursing Skills and Techniques, Eighth (8th) Edition, as the facility's policy for assessing range of motion and for conducting musculoskeletal and neurologic assessments. Review of the Perry Potter Clinical Nursing Skills and Techniques, 8th Edition, revealed the facility would conduct a neurological assessment and musculoskeletal assessment when a resident reported pain or impairment. The facility would complete the assessments to determine the nature, extent, location, duration, and severity of the resident's reported pain. The assessments would include asking the resident to describe recent falls and to describe the type, location, and severity of the pain. The assessments also would include observing the resident for a change in Range of Motion (ROM) and other functioning. The steps for implementing the assessments included observing the resident's body for alignment while the resident was sitting, laying down, and in several other positions, inspecting gait as the resident walked, and asking the resident to move the major joints. Review of the facility's Care System Guideline for Falls, not dated, revealed the facility would physically assess a resident for injuries and render medical attention as needed after a resident fall. The facility would then notify the physician and resident's responsible party. Review of the facility's Incident Report Checklist, dated 12/24/13, revealed the information the facility would include in the nurse's note pertaining to a resident fall and the steps nursing staff would taken to complete an incident investigation. The form stated what information the nurse's note must entail which included: injury description; pain level; neuro checks for any head injury or unwitnessed fall; and range of motion. The checklist would include places for staff to document they completed a head to toe assessment and if they initiated neuro checks. Interview with the Director of Nursing (DON), on 11/25/15 at 9:00 AM, revealed nursing staff was required to use the Incident Report Checklist with each resident fall. Interview with Resident #6, on 11/23/15 at 4:30 PM, revealed the resident had fallen in his/her room a couple of weeks prior and that he/she needed increased assistance with transfers in and out of the bed since that fall. The resident stated he/she had first come to the facility after suffering a fall in the home that resulted in a broken backbone. However, the resident fell again while at the facility and suffered a broken hip. Resident #6 stated he/she got out of the bed in the night and tripped on a chair in the room. He/she bumped his/her head on the chair on the way to the floor and landed on his/her knee on the floor. Resident #6 stated he/she was unclear on the amount of time that passed between the fall and going to the hospital. The resident was unclear about any details regarding reporting the fall to the staff or any assessments or treatments following the fall. Review of the clinical record for Resident #6 revealed the facility admitted the resident on 08/26/15 with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment, completed on 09/02/15, revealed the facility assessed the resident as requiring one (1) person extensive assist to walk and one (1) person limited assist to complete activities of daily living (ADLs). The facility conducted a Brief Interview for Mental Status (BIMS) exam during the MDS assessment with a score of nine (9) out of fifteen (15) on the BIMS exam indicating the resident was moderately impaired. Review of Resident #6's care plan related to pain, dated 09/04/15, revealed the resident experienced the frequent presence of pain in his/her back due to a lumbar compression fracture after a fall at home prior to admission to the facility. Interventions included the staff was to evaluate the location and intensity of the resident's pain. The staff was to administer pain medication as ordered, report any uncontrolled pain to the physician, and evaluate vital signs as needed. The staff was to observe for both verbal and nonverbal indicators of pain. Review of the Physician Orders, dated October 2015, revealed on 08/26/15 the physician ordered [MEDICATION NAME] 5-325 milligram (mg) tablet by mouth every six (6) hours as needed (PRN) for pain. The order also stated the facility must document the pain level on a scale of one (1) to ten (10). Review of the Incident Log, printed 11/27/15 at 8:35 AM, revealed Resident #6 sustained a fall on the night of 10/28/15 or early morning of 10/29/15. The fall occurred in the resident's room at an unknown time. The report stated the resident sustained [REDACTED]. Review of the Resident Incident Report, dated 10/30/15 at 12:11 AM, revealed Registered Nurse (RN) #1 created an incident report in the facility's medical records. The narrative explained the resident reported he/she had gotten out of bed, tripped on something, and fell forward hitting his/her head on a chair in the room. The resident then reported he/she went back to bed. The narrative continued to state the resident had a bruise on the top of his/her head, bruises on his/her left rib cage, and an abrasion on his/her left leg. The RN documented she placed steri strips on the resident's open areas. The incident report did not contain vital signs or report of pain assessment or if nursing completed any range of motion assessments as stated in their policy. Interview with Certified Nursing Assistant (CNA) #2, on 11/25/15 at 10:55 AM, revealed the resident reported pain and difficulty moving his/her left leg on the morning of 10/29/15. CNA #2 stated she was providing morning care to Resident #6 and asked the resident to straighten his/her leg. The resident stated he/she was unable to put the leg down due to pain in the leg and rubbed the inside of his/her leg. The CNA stated she noticed bruising on the inside of the leg. Resident #6 then told the CNA that he/she had gotten up in the night and fell over the chair in the room. CNA #2 stated because of the resident's increased confusion at that time, she was unsure at that time if the resident had really fallen or if he/she had dreamed they had fallen. However, the CNA stated she did report the possible fall to the nurse, RN #1. The CNA witnessed RN #1 asking the resident what had happened and the resident stated he/she had fallen. Interview with RN #1, on 11/24/15 at 6:10 PM, revealed Resident #6 complained of pain and acted as though he/she had difficulty moving on the morning of 10/29/15. RN #1 stated Resident #6 had been experiencing a lot of confusion since his/her return from the hospital on [DATE]. On the morning of 10/29/15, the resident reported pain and difficulty moving. Resident #6 reported he/she had fallen in the room and hit the chair. The RN stated she did not give the resident pain medication at the time and decided to monitor the resident for continued pain. She could not state why she did not give pain medication at that time. The nurse stated she looked at the resident and did not see any bruising on the resident nor see abnormalities with the resident's leg at that time. RN #1 did not take vitals after learning of the fall. She stated she did not feel they were necessary because the resident had fallen on a prior shift. She stated later in the afternoon the resident denied any pain. She stated she was off for a couple days following the incident and she made a note of the incident in the Departmental Notes a few days later when she returned to work. Further interview with RN #1, on 11/25/15 at 2:58 PM, revealed RN #1 did not initiate neurological checks on the resident because the fall happened prior to her shift. She stated she was unsure of how long before her shift the fall had taken place, but that she felt it was unnecessary to conduct neurological checks on the resident when the fall had taken place on a previous shift and some time had already passed. The nurse stated she did not remember if she assessed the resident's pain on 10/29/15, and that she did not know if she documented any pain assessment as directed by the policy. RN #1 stated she completed a head to toe assessment of the resident, but was not sure if she touched the resident during the assessment. She stated the head to toe assessment revealed the resident had some scratches on his/her rib cage. RN #1 stated the scratches on the resident's rib cage were not unusual. Review of the Departmental Notes completed by Licensed Practical Nurse (LPN) #1, on 10/29/15 at 12:19 AM, revealed Resident #6 was in bed with periodic wakefulness. LPN #1 documented she did not observe Resident #6 attempting to get out of bed. Review of the Departmental Notes completed by RN #1, on 10/31/15 at 8:53 AM, revealed the RN completed a late entry. RN #1 documented Resident #6 complained on Thursday morning, 10/29/15, of some difficulty moving his/her left leg and was grimacing and complaining of pain. The note stated the nurse asked the resident about his/her pain through the day. The resident reported pain one additional time that morning and then reported no pain to the nurse the remainder of the day. However, review of the Medication Administration Record [REDACTED]. Review of Departmental Notes completed by LPN #1, on 10/30/15 at 10:16 PM, revealed Resident #6 complained of pain to left leg and was unable to lay leg flat. The LPN documented she called the Nurse Practitioner and obtained an order for [REDACTED]. Review of the MAR indicated [REDACTED]. However, there was no documented evidence LPN #1 assessed resident's level of pain or effectiveness of the PRN pain medication she administered per the MAR. Interview with LPN #1, on 11/24/15 at 4:55 PM, revealed Resident #6 reported pain to the nursing staff on 10/30/15. LPN #1 stated Resident #6 experienced a lot of confusion at the time he/she reported pain to her on 10/30/15. She stated the resident also had a UTI at the time and had increased confusion. LPN #1 stated she was assisting with getting the resident ready for bed when he/she reported having leg pain. The LPN conducted a pain assessment and visually inspected the resident's leg. She stated the resident's leg had some outward rotation and she called for an order for [REDACTED]. Review of the Departmental Notes completed by LPN #1, on 10/31/15 at 12:52 AM, revealed the LPN received the x-ray results. The x-ray results were positive for a fracture involving the femoral neck with a lateral displacement two (2) days after the incident. LPN updated the POA and called the ambulance service to transport the resident to the emergency room . Review of the MAR indicated [REDACTED]. However, there was no documented evidence LPN #1 assessed the resident's level of pain or effectiveness of the PRN pain medication she administered per the MAR. Review of the Medication Administration Record [REDACTED]. Further review of the Departmental Notes, 10/27/15 through 10/31/15, revealed no evidence of post fall neurological checks, no recorded pain assessment rating scale, and no evidence of a ROM assessment completed after Resident #6's reported fall as directed by the policy. Interview with the DON, on 11/24/15 at 5:45 PM, revealed the DON kept a copy of notes she made during the investigation into Resident #6's fall and fracture. The investigation notes stated the fall took place after Tuesday, 10/27/15, as evidenced by staff interviews who reported no abrasions, bruises, or complaints of pain on that day (10/27/15). Interview with the Assistant Director of Nursing (ADON), on 11/25/15 at 11:10 AM, revealed the standard of care the nurses should have done after discovering a resident fall included a head to toe assessment, skin check, and neurological checks. The purpose of completing these assessments and checks was to determine if the resident sustained [REDACTED]. The nurse should have then documented the results of the assessments, along with vital signs, on the incident report. The DON then reviewed the incident reports. The ADON further stated that by not identifying Resident #6's fracture, the resident was at increased risk of injury and pain. Interview with the DON, on 11/24/15 at 5:45 PM, revealed the nursing staff did not inform her of the fall until she received a call from the nurse about the resident's confirmed fracture on 10/31/15. Further interview with the DON, on 11/25/15 at 9:00 AM, revealed the nurse should have completed and documented vitals, a ROM assessment, and a pain assessment. The DON reviewed the incident report and stated based on the report it did not appear the nurse complete a pain assessment, vitals, range of motion check, or initiate neurological checks. The Incident Report Checklist directs staff to complete a head to toe assessment. Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the staff did not follow facility policy which resulted in a delay in identifying the resident's fracture. Nursing staff did not conduct the appropriate assessments after the resident fell and the nurse's notes were sketchy. The lack of assessments was concerning and indicated a lackadaisical approach to nursing care. This could have put the resident in pain for longer than necessary. Interview with the Director of Clinical Operations, on 11/25/15 at 9:00 AM with the DON, revealed per the documentation after Resident #6 fell , the nurse did not complete vitals, conduct neuro checks, and complete a range of motion assessment. The staff did not report the incident to the DON. As a result, the DON, Administrator, and Director of Clinical Operations were unaware of the resident's fall until after LPN #1 was notified of the fracture on 10/31/15. Review of the Weekly Event Report Summary, dated 11/05/15, revealed the Director of Clinical Services recorded the resident had increased pain to his/her left hip on 10/30/15 and was assessed by the nurse. The nurse noted the hip was bruised and obtained an order for [REDACTED]. The resident had reported he/she fell earlier in the week. The facility discharged the resident to the hospital for surgical repair of the fracture. Review of the hospital discharge packet, dated 11/03/15 at 9:01 AM, revealed the hospital admitted the resident on 10/31/15 and he/she underwent left hip replacement for his/her displaced, fractured left hip. The report further stated the resident developed severe left hip pain, limited range of motion, and an inability to bear weight after falling out of bed two (2) days prior to the date of admission, 10/31/15. The hospital reported the findings of the x-rays included a fracture through the femoral neck with a fifty percent (50%) displacement of the femoral shaft relative to the head.

Based on interview, record review and facility policy review, it was determined the facility failed to complete a full Fall investigation for one (1) of nineteen (19) sampled residents (Resident #6). Resident #6 fell on [DATE]; however, Registered Nurse (RN) #1 failed to complete the fall assessment which would have included a head to toe assessment and assessing the resident's pain level. On 10/29/15 and 10/30/15 Resident #6 complained of pain to the left leg and was unable to lay leg flat. The resident was diagnosed with [REDACTED]. The findings include: Review of the facility's Care System Guideline, Falls, not dated, revealed the facility would conduct a fall huddle to investigate the circumstances around the resident's fall. Next, the facility would complete a Post Fall Investigation and include information to assist in choosing interventions to prevent future falls. The facility would then place the fall event and intervention on the twenty-four (24) hour report. Interview with the Director of Nursing (DON), on 11/25/15 at 9:00 AM, revealed nursing staff was required to use the Incident Report Checklist with each resident fall. Review of the facility's tool, Incident Report Checklist, dated 12/24/13, revealed the information the facility would include in the nurse's note pertaining to a resident fall and the steps nursing staff would take to complete an incident investigation. The form stated the nurse's note must include the following information: date and time; type of incident; location; title of individual reporting the incident; appearance or position of the resident when staff discovered the incident; injury description; treatment order; if staff used a lift; pain level; neuro checks for any head injury or unwitnessed fall; range of motion; notification of healthcare provider; notification of Power of Attorney (POA); notification of DON or Assistant Director of Nursing (ADON); and, any immediate interventions. The checklist also included places for staff to document they completed a head to toe assessment and if they initiated neuro checks. Review of the clinical record for Resident #6 revealed the facility admitted the resident on 08/26/15 with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment, completed on 09/02/15, revealed the facility assessed the resident as requiring a one (1) person extensive assist to walk and one (1) person limited assist to complete activities of daily living (ADL). The facility conducted a Brief Interview for Mental Status (BIMS) exam during the MDS assessment. The resident scored a nine (9) out of fifteen (15) on the BIMS exam which meant the resident had a moderate cognition impairment. Review of the care plan related to falls, dated 09/04/15, revealed Resident #6 was at risk of falls due to a history of falls, decreased cognition, and impaired mobility. The facility included several interventions to prevent falls. The staff was to monitor Resident #6 for changes in condition that may have warranted increased supervision or assistance. The staff was to assist the resident with transfers and ambulation with the use of a walker. Additional interventions included staff reminding the resident to use the call light and ensuring the resident's bed was at the appropriate height, the call light was within the resident's reach, and the resident was to wear non-skid socks. Review of the Incident Log, printed 11/27/15 at 8:35 AM, revealed Resident #6 sustained a fall on the night of 10/28/15 or early morning of 10/29/15. The fall occurred in the resident's room at an unknown time. The report stated the resident sustained [REDACTED]. No in-house treatment or other disposition was recorded on this form. Review of the Resident Incident Report, dated 10/30/15 at 12:11 AM, revealed Registered Nurse (RN) #1 created an Incident Report in the facility's medical records. The narrative explained the resident reported he/she had gotten out of bed, tripped on something, and fell forward hitting his/her head on a chair in the room. The resident then reported he/she went back to bed. The narrative continued to state the resident had a bruise on the top of his/her head, a bruises on his/her left rib cage, and an abrasion on his/her left leg. The RN recorded she placed steri strips on the resident's open areas. However, record review revealed the Incident Report was not completed per the facility's policy and procedures. The incident report did not contain vital signs or report of pain assessment. Nursing did not place the date and time of the incident on the form. In the narrative of the Resident Incident Report, the nurse failed to include information about who first discovered the incident, if nursing staff initiated neuro checks related to the resident reporting hitting his/her head, or if nursing completed any range of motion assessments. Additionally, the nurse did not include information pertaining to notification of the DON or ADON of the incident. Interview with Resident #6, on 11/23/15 at 4:30 PM, revealed the resident stated he had fallen in his/her room a couple of weeks prior and that he/she needed increased assistance with transfers in and out of the bed since that fall. Resident #6 stated he/she got out of the bed in the night and tripped on a chair in the room. He/she bumped his/her head on the chair on the way to the floor and landed on his/her knee on the floor. Interview with the DON, on 11/24/15 at 5:45 PM, revealed the DON kept a copy of notes she made during the investigation into Resident #6's fall. Review of the DON's investigation notes, not dated, revealed Certified Nursing Assistant (CNA) #2 reported on Thursday, 10/29/15, Resident #6 told her he/she fell . The CNA reported this to Registered Nurse (RN) #1 on Thursday morning, 10/29/15. The notes further stated the resident was not able to state what day the fall took place. RN #1 reported the fall to the MDS Coordinator. The investigation notes further revealed the fall took place after Tuesday, 10/27/15, as evidenced by staff report of no abrasions, bruises, or complaints of pain on that day. Interview with Certified Nursing Assistant (CNA) #2, on 11/25/15 at 10:55 AM, revealed she was providing morning care to Resident #6 on 10/29/15 and asked the resident to straighten his/her leg. The resident stated he/she was unable to put the leg down due to pain in the leg and rubbed the inside of his/her leg. The CNA stated she noticed bruising on the inside of the leg. Resident #6 then told the CNA that he/she had gotten up in the night and fell over the chair in the room. CNA #2 stated because of the resident's increased confusion at that time, she was unsure at that time if the resident had really fallen or if he/she had dreamed they had fallen. However, the CNA stated she did report the possible fall to the nurse, RN #1. CNA #2 stated per the policy, if a CNA sees or suspects a fall, the CNA was to report the incident to the floor nurse. The CNA witnessed RN #1 asking the resident what had happened and the resident stated he/she had fallen. Interview with RN #1, on 11/24/15 at 6:10 PM, revealed Resident #6 complained of pain and appeared to have some difficulty his/her leg on the morning of 10/29/15. Resident #6 reported he/she had fallen in the room and hit the chair. The nurse further stated the fall had happened prior to her coming on shift that day, and other staff did not appear aware of the fall. RN #1 did not take vitals after learning of the fall. She stated she did not feel they were necessary because the resident had fallen on a prior shift. RN #1 stated she initiated an incident report later that day. She stated she was off for a couple days following the incident and she made a note of the incident in the Departmental Notes a few days later when she returned to work. Further interview with RN #1, on 11/25/15 at 2:58 PM, revealed RN #1 did not initiate neurological checks on the resident because the fall happened prior to her shift. She stated she was unsure of how long before her shift the fall had taken place but that she felt it was unnecessary to conduct neurological checks on the resident when the fall had taken place on a previous shift and some time had already passed. The nurse stated she did not remember if she assessed the resident's pain on 10/29/15, and that she did not know if she documented any pain assessment. RN #1 stated she completed a head to toe assessment of the resident but was not sure if she touched the resident during the assessment. She stated the head to toe assessment revealed the resident had some scratches on his/her rib cage. RN #1 further stated she informed the MDS Coordinator of the fall. She stated the MDS Coordinator used to be the acting DON and when he was acting DON, nursing staff reported falls to him. RN #1 further stated nurses were supposed to report falls to the DON; however, she believed the DON was already aware of the fall and so she told the MDS Coordinator to get instruction. RN #1 was unable to state what led her to believe the DON knew of the fall. Interview with MDS Coordinator, on 11/25/15 at 10:32 AM, revealed on the morning of 10/29/15 RN #1 reported Resident #6 had fallen. She told the MDS Coordinator about the fall and asked what she should do since the nurse who worked third (3rd) shift had not put an incident report in the system. The MDS Coordinator advised the RN to generate an incident report. The MDS Coordinator also revealed the nurse should have informed the DON of the fall. He stated prior to the DON's employment, nursing staff did report falls to the MDS Coordinator. He stated he did not follow-up to ensure the nurse reported the fall to the DON and that he did not report the fall to the DON. After reviewing the Resident Incident Report, the MDS Coordinator stated the report was not completed per the facility's policy. Interview with the Staff Development Coordinator, on 11/24/15 at 5:15 PM, revealed the first employee to witness or discover an incident, such as a fall or injury of unknown origin, was responsible to report the incident to the floor nurse. The nurse should have then initiated the incident report as soon as they learned of the situation after ensuring the resident's safety. The nurse should have then notified the POA, physician, and the DON. The IDT should also have known about the incident. The Staff Development Coordinator also stated he was not employed at this facility at the time of the incident and could not speak to the incident itself. However, after reviewing the Resident Incident Report, he did state the report appeared incomplete. Interview with the ADON, on 11/25/15 at 11:10 AM, revealed nursing staff did not inform her of Resident #6's fall. The ADON stated the nursing staff should have reported the fall to the DON. She also the nurses should have completed a head to toe assessment, skin check, and neurological checks and documented the results of the assessments, along with vital signs, on the incident report. Per interview, the DON reviews the incident reports. Interview with the DON, on 11/24/15 at 5:45 PM, revealed the nursing staff did not inform the DON of the fall until 10/31/15. The DON stated she was off work ill on 10/29/15 when nursing discovered the resident had fallen. The resident reported the fall to CNA #2 on the morning of 10/29/15. The CNA reported the fall to the RN #1. RN #1 entered an incident report stating she had notified the physician and the POA on 10/29/15. RN #1 made a note in the medical record about the incident on 10/31/15. Further interview with the DON, on 11/25/15 at 9:00 AM, revealed the nursing staff did not complete and document the investigation per the facility's policy to ensure the resident's safety. The nurse should have completed and documented vitals, a ROM assessment, and a pain assessment. The DON reviewed the incident report and stated based on the report it did not appear the nurse complete a pain assessment, vitals, range of motion check, or initiate neurological checks. After the incident report was completed, the staff should have initiated an Incident Report Checklist and a huddle. The Incident Report Checklist instructs staff on what information to include in the documentation, such as date and time, type of incident, location, who reported it, appearance when found, injury description, treatment order, pain level, neuro checks, range of motion, notifications, and immediate interventions. The Incident Report Checklist directs staff to complete a head to toe assessment. The checklist further instructs staff to conduct a huddle to discuss the fall and interventions and includes a Resident Fall Analysis worksheet. The DON stated she was unable to find an Incident Report Checklist for Resident #6's fall reported on 10/29/15. Interview with the Director of Clinical Operations, on 11/25/15 at 9:00 AM with the DON, revealed the staff did not conduct the investigation and ensure the safety of the resident per the facility's standard. Per the documentation, after Resident #6 fell , the nurse did not complete vitals, conduct neuro checks, and complete a range of motion assessment. RN #1 reported the fall to the MDS Coordinator verbally and the MDS Coordinator informed the therapy department of Resident #6's fall verbally. Staff did not document this communication. Per interview, the RN notified the physician and the POA and documented this communication on the incident form. However, staff did not report the incident to the DON. As a result, the DON, Administrator, and Director of Clinical Operations were unaware of the resident's fall until 10/31/15. Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the staff did not manage Resident #6's fall per policy and resulted in a delay in identifying the resident's fracture. Nursing staff did not conduct the appropriate assessments after the resident fell . The lack of assessments were concerning and indicated a lackadaisical approach to nursing care.

Based on interview, record review and facility policy review, it was determined the facility failed to maintain an accurate clinical record for one (1) of nineteen (19) sampled residents (Resident #6). Resident #6 fell on [DATE]; however, Registered Nurse (RN) #1 failed to complete the fall assessment which would have included a head to toe assessment and assessing the resident's pain level. On 10/29/15 and 10/30/15 Resident #6 complained of pain to the left leg and was unable to lay leg flat. The resident was diagnosed with [REDACTED]. (Refer to F309 and F323) The findings include: Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the facility did not have a policy regarding documentation or accuracy of the clinical record. Review of the facility's Care System Guideline for Pain Management, not dated, revealed the facility would complete a pain assessment after each resident's fall. The facility would then record the findings of the pain assessment in the clinical records including evidence based pain scales. Additionally, the facility would note the ongoing monitoring and effectiveness of pain interventions in the electronic medical record system and progress notes. After the pain assessment, the Interdisciplinary Team (IDT) would then evaluate the effectiveness of the resident's pain management after a fall or other acute change. Review of the facility's guideline for Falls, not dated, revealed the facility would physically assess a resident for injuries and render medical attention as needed after any resident experienced a fall. The facility would then notify the physician and responsible party. Review of the facility's Incident Report Checklist, dated 12/24/13, revealed the facility would include in the nurse's note the steps nursing staff would take when completing an incident investigation. The form stated the nurse's note must include the following information: date and time; type of incident; location; title of the individual reporting the incident; appearance or position of the resident when staff discovered the incident; injury description; treatment order; if staff used a lift; pain level; neuro checks for any head injury or unwitnessed fall; range of motion; notification of healthcare provider; notification of Power of Attorney (POA); notification of the Director of Nursing (DON) or Assistant Director of Nursing (ADON); and, any immediate intervention. The checklist also included places for staff to document they completed a head to toe assessment and if they initiated neuro checks and would become part of the medical record. Review of the Resident Incident Report, dated 10/30/15 at 12:11 AM, revealed Registered Nurse (RN) #1 created an incident report in Resident #6's medical record. The narrative explained the resident reported he/she had gotten out of bed, tripped on something, and fell forward hitting his/her head on the chair in the room. However, continued review of the Resident Incident Report revealed RN #1 did not record vital signs or pain level in the incident report. RN #1 did not place the date and time of the incident on the form and did not include who first discovered the incident had taken place. RN #1 also did not document if she initiated neuro checks related to the resident reporting he/she hit his/her head. RN #1 did not include if she completed any range of motion assessments. Additionally, the nurse did not note if she did or did not notify the DON or ADON of the incident as directed by policy. Interview with RN #1, on 11/24/15 at 6:10 PM, revealed it was her responsibility; however, she did not document the resident's level of pain using a pain scale. RN #1 stated she initiated an incident report later that day, but did not document vitals or neuro checks because she did not do them. She stated she did not make a note in the Departmental Notes until she returned to work a few days later. Interview with the Director of Nursing (DON), on 11/24/15 at 5:45 PM, revealed RN #1 entered an incident report after midnight on 10/30/15. RN #1 did not create a note in the medical record about the incident until 10/31/15. Review of the Departmental Notes completed by RN #1, on 10/31/15 at 8:53 AM, revealed the RN completed a late entry and documented Resident #6 complained on Thursday morning, 10/29/15, of some difficulty moving his/her left leg and was grimacing and complaining of pain. RN #1 did not record the resident's pain rating on the pain scale nor any interventions used to assist the resident to control the pain. Further interview with RN #1, on 11/25/15 at 2:58 PM, revealed she did not document the resident's pain level on 10/29/15 and did not remember if she assessed the resident's pain at that time. Review of Departmental Notes completed by Licensed Practical Nurse (LPN) #1, on 10/30/15, revealed Resident #6 complained of pain to the left leg and was unable to lay the leg flat. The nurse did not document in the Departmental Note the resident's pain scale rating, the intervention used to control the pain, nor the effectiveness of the pain medication administered. Review of the narcotic sheet for Resident #6's [MEDICATION NAME], dated 10/09/15, revealed the nursing staff signed as removing the medication from the narcotic drawer on 10/30/15 at 7:00 PM and on 10/31/15 at 1:00 AM. However, review of the Medication Administration Record [REDACTED]. Interview with LPN #1, on 11/24/15 at 4:55 PM, revealed Resident #6 reported having leg pain and stated the resident had reported pain to the nursing staff on 10/30/15. LPN #1 stated she had no knowledge of the resident having reported a fall the previous morning. She stated she did review the departmental notes and saw no notes pertaining to a fall. Interview with MDS Coordinator, on 11/25/15 at 10:32 AM, revealed on the morning of 10/29/15 RN #1 told the MDS Coordinator Resident #6 had fallen. She stated the nurse that work third (3rd) shift had not put an incident report into the system. The MDS Coordinator stated the RN should have completed the Resident Incident Report in the medical record per policy. Interview with the Assistant Director of Nursing (ADON), on 11/25/15 at 11:10 AM, revealed the standard of care the nurses should have done after discovering a resident fall included the completion and documentation of a head to toe assessment, Range of Motion (ROM) check, skin assessment, and neurological checks. The nurse should have then documented the results of the assessments, along with vital signs, on the incident report. The ADON reviewed the incident report and stated it was not completed. Further interview with the DON, on 11/25/15 at 9:00 AM, revealed the nursing staff did not complete the investigation and document to ensure the resident's safety per the facility's standard. The nurse should have completed and documented vitals, a skin assessment, a pain assessment, a range of motion check, and neurological checks. However, there was no documented evidence these assessments were completed. Additionally, after the incident report was completed, nursing should have initiated the Incident Report Checklist. The checklist instructed the nurse on what information to include in the documentation, such as date and time, type of incident, location, who reported it, appearance when found, injury description, treatment order, pain level, neuro checks, range of motion, notifications, and immediate interventions. However, the facility was unable to locate an Incident Report Checklist in the medical record for this resident's fall. She stated the nurse should have initiated a checklist to ensure all assessments were completed and documented in the medical record according to policy. Interview with the Director of Clinical Operations, on 11/25/15 at 9:00 AM with the DON, revealed the staff did not complete the required documentation in the medical record. After Resident #6 fell , the nurse did not complete vitals, conduct neuro checks, or complete a range of motion assessment. As a result, the DON, Administrator, and Director of Clinical Operations were unaware of the resident's fall until after LPN #1 discovered the fracture on 10/31/15. Interview with the Administrator, on 11/25/15 at 3:20 PM, revealed the nursing staff did not conduct or document the appropriate assessments after the resident fell and the nurse's notes were sketchy. The Administrator stated the lack of assessments were concerning.

Based on interview, record review, review of the facility's investigation and Abuse policy, it was determined the facility failed to have an effective system in place to ensure development and implementation of written policies and procedures which prohibited mistreatment, neglect and abuse of residents for one (1) of thirty-one (31) sampled residents (Resident #20). During the annual survey, Resident #20 reported an allegation of abuse to the State Survey Agency on 08/13/13 at 3:00 PM. Per the interview, on 08/10/13 Resident #20 reported to Licensed Practical Nurse (LPN) #6 that State Registered Nurse Aide (SRNA) #6 had jerked his/her leg and hurt the resident. The resident stated he/she was scared of SRNA #6 and had requested to LPN #6 the SRNA not care for the resident anymore. However, per the resident's interview and record review, SRNA #6 continued to care for Resident #20 on 08/10/13; providing care to the resident during the day and evening shift, and also worked a double shift on 08/11/13 on another unit. Resident #20 also reported to the SSA that on 08/12/13 Social Worker #3 told the resident that LPN #6 was aware of the incident and "would take care of it". Interview with LPN #6 revealed he did not report the allegation of abuse by Resident #20 on 08/10/13 as he denied Resident #20 told him about the abuse. In addition, interview with LPN #2 revealed Resident #20 had also reported the allegation to her the morning of 08/12/13 and she had informed Social Worker #3 that the allegation could be abuse. Interview with Social Worker #3 revealed she was made aware of the allegation on 08/12/13; however, she did not take the necessary steps to protect all residents in the facility, report and investigate the incident, because she thought Resident #20 was "simple-minded" and complained a lot. In addition, Social Worker #3 stated she did not follow the facility's abuse policy and could not state why she did not report the allegation of abuse by Resident #20 as per the policy. There was no documented evidence an investigation was initiated for Resident #20's allegation of abuse until 08/13/13 at 8:45 PM, after surveyor intervention. The facility's failure to develop and implement policy and procedures related to abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. During the annual survey, the State Survey Agency (SSA) notified the facility of Resident #20's abuse allegation on 08/13/13. The facility immediately initiated an investigation and initiated corrective actions based on their findings. After further investigation, the SSA determined Immediate Jeopardy existed related to abuse and the facility was notified on 08/15/13 and determined to exist on 08/10/13. The facility provided an acceptable Allegation of Compliance (AOC) on 08/20/13 alleging the removal of Immediate Jeopardy on 08/15/13. The facility initiated corrective action on 08/13/13 upon being informed of an allegation of unreported abuse. The Immediate Jeopardy was determined to be removed as alleged on 08/15/13, prior to exit on 08/22/13. The scope and severity of F226 was lowered to a "D" while the facility continues to implement and monitor quality assurance measures. The findings include: Review of the facility's policy titled Policy for Prevention and Detection of Abuse and Neglect, revised 09/13/12, revealed the facility would report all alleged violations to the appropriate agencies and would then initiate an investigation and take corrective action as required. The facility would investigate alleged violations of abuse and neglect to determine if abuse or neglect had occurred, the extent of abuse/neglect, any causative factors, and appropriate interventions to prevent further injury. A resident assessment to determine whether injury occurred from the alleged abuse would be conducted and the results of the investigation would be documented in the medical record. If a report of suspected abuse or neglect was reported the staff was to complete the "Abuse Checklist" and take the following corrective action: immediately take measures to protect the resident; assess the resident for mental or physical harm; contact the Administrator, DON, Supervisor or Charge Nurse on Duty and the Social Worker and inform him/her of the incident; Call the alleged incident to the appropriate agencies; and alleged incidents would also be reported to the State Agency. The policy identified the facility would take measures to protect residents from further abuse and neglect and during the course of an investigation the alleged perpetrator would not be allowed to work. Upon conclusion of the investigation, the facility would make a determination as to whether there was sufficient evidence to substantiate the allegation of abuse. Review of the facility's investigation, dated 08/13/13, of the allegation of abuse revealed an abuse/neglect investigation checklist was completed, on 08/13/13 at 8:45 PM, by the Director of Nursing (DON) after surveyor intervention. Further review of the facility investigation revealed SRNA #6 was notified of immediate suspension from work by the DON per telephone on 08/13/13 (no time noted) and Social Worker #3 was notified of immediate suspension in person by the Administrator, on 08/13/13 at 5:00 PM. Interview with Social Worker #3, on 08/13/13 at 3:20 PM, revealed Resident #20 reported SRNA #6 had jerked his/her right leg on 08/10/12 and was rough and hurt him/her. Social Worker #3 also stated LPN #2 called her on 08/12/13 (unsure of time) to report Resident #20 had alleged SRNA #6 had hurt him/her on 08/10/13. However, Social Worker #3 stated she did not report the allegation and no investigation was initiated because Resident #20 was "simple-minded" and complained a lot. Per interview, Social Worker #3 revealed the facility's abuse policy was not followed in regards to the completion of the abuse/neglect investigation checklist, suspension of the alleged perpetrator to protect all residents, and appropriate reporting of the alleged abuse with initiation of an investigation into the allegation. Social Worker #3 could not specify the reason for not reporting the allegation of abuse by Resident #20 as directed by the policy. Interview with the DON and the Administrator, on 08/13/13 at 5:30 PM, revealed athe Administrator was not made aware of the allegation of abuse by Resident #20 and no investigation had been initiated prior to surveyor intervention. The Administrator revealed the abuse policy in effect at the time of the incident with Resident #20 was the previous administration's policy (Diversicare was the new owner/administration) and she felt the policy did not give clear guidance to the nursing staff. She stated the Social Worker should have reported the incident immediately and due to this an investigation was not initiated timely and residents were not protected. Further interview with the DON, on 08/14/13 at 9:59 AM, revealed if staff had received an allegation of abuse they should have reported it to her. The DON revealed she was responsible to initiate investigations for allegations of abuse which would include protection of all facility residents, reporting to appropriate agencies and initiation of an investigation. The facility provided an acceptable Allegation of Compliance (AOC) on 08/20/13 alleging the Immediate Jeopardy was removed on 08/15/13. The facility took the following immediate steps to remove the Immediate Jeopardy: 1. The facility suspended SRNA #6 on 08/13/13. 2. The Director of Nursing initiated an investigation into the allegation of abuse on 08/13/13. 3. The Director of Nursing reported the incident to the appropriate agencies on 08/13/13. 4. The Director of Nursing completed a head-to-toe physical assessment of Resident #20 on 08/13/13. 5. The Regional Continous Quality Improvement (CQI) Director, RN reviewed the prior six months of facility concerns/complaints to ensure all were reported per policy. 6. The Director of Nursing, CQI Director, Assistant Director Nursing, Wound Care Nurse assessed the entire resident population of 92 residents either physically or by interview on 08/14/13. 7. The facility held an emergency QA meeting on 08/13/13, attended by Corporate and Administrative staff. 8. Diversicare abuse policy approved and implemented by the QA team on 08/13/13. 9. The ADON notified the Medical Director on 08/13/13 of approval and implementation of the Diversicare Abuse Policy. 10. The Administrative staff trained all facility staff in the building on the Diversicare Abuse Policy with a post test administered to the employees. A no-one-shall-work mandate was initiated by the Administrator on 08/13/13 until they were trained on the Diversicare Abuse Policy prior to working with a post test administered to employees on 08/14/13. 11. The Administrator, Admission/Social Services Coordinator or the Activity Director will conduct meetings on a weekly basis with residents for four (4) weeks to determine if residents feel safe in the facility and that they are permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family member or visitors. The first meeting will take place on 08/21/13. The State Agency validated the acceptable Allegation of Compliance AOC) as follows: 1. Review of SRNA #6 employee file revealed a notice of suspension effective 08/13/13. Interview with SRNA #6, on 08/13/13 at 12:43 PM, confirmed the suspension and she stated she was not allowed to return pending results of the investigation. 2. Review of the facility's investigation, dated 08/13/13, revealed it was initiated by the Director of Nursing. Review of the Abuse/Neglect Investigation Checklist, revealed the facility initiated an investigation of the allegation of abuse regarding Resident #20 on 08/13/13. 3. Review of the investigation report revealed the DON reported the allegation to the appropriate agencies at 9:40 PM on 08/13/13. The report was completed by the DON. 4. Review of the investigation attachment revealed the DON conducted a head to toe assessment with no acute injury found on 08/13/13. 5. Interview with the CQI Director, Staff #4, on 08/22/13 at 2:45 PM, revealed she had reviewed all concerns and complaints for the past six (6) months and no concerns had been identified. 6. Review of a skin assessments on 08/22/13, revealed forty-seven (47) skin assessments were completed for residents who were identified as non-interviewable. Review of documented interviews were completed with forty-five (45) residents identified as interviewable to determine if they were being cared for appropriately and felt safe. The total of ninety-two (92) residents were assessed with [REDACTED]. 7. Review of the minutes on 08/22/13 for the Emergency Quality Assurance Interdisciplinary Team Meeting, revealed the meeting was conducted on 08/13/13 and the team approved and implemented the new abuse policy. 8. Review of the facility policy Resident Abuse with an effective date of 07/01/09, revealed it was the replacement policy for the new ownership of the facility. The abuse policy contained all components as required; screening, training, prevention, identification, investigations, protection, and reporting. The policy also included the procedure for prevention of misappropriation of resident property. 9. Review of the QA minutes revealed the Medical Director was notified of the Immediate Jeopardy, the allegation and the change in the Abuse policy on 08/13/13. 10. Review of the sign in sheets and completed post tests for the training on the abuse policy on 08/22/13, revealed one hundred and twenty-eight (128) staff had signed in for the abuse training and had completed the post test by 08/15/13. A "No One Shall Work" mandate was implemented by the Administrator on 08/13/13 for all staff to be educated on the Abuse Policy prior to returning to work. Interviews with fourteen (14) random staff revealed they had been trained on the new facility abuse policy to include; how to identify abuse, protection of the resident, how to report, when to report any and all suspicions/allegations of abuse. Interview with LPN #7, on 08/22/13 at 3:23 PM, revealed she had been retrained last week on the new abuse policy. LPN #7 identified the types of abuse and included the protection of the resident. She stated she would report any suspicion of/or an allegation of abuse to her supervisor. She stated they were told, failure to report would lead to disciplinary action. She stated she had taken a post test after the completion of the training. Interview with Registered Nurse (RN) #4, on 08/22/13 at 3:34 PM, revealed she had been trained on the new abuse policy and had completed a post test sometime last week. Interview with Staff Development Director #5, on 08/22/13 at 3:40 PM, revealed she was trained by the DON on the new abuse policy and then she did the training for the staff. She identified abuse policy and requirements to include the disciplinary process and stated she had completed a post test. Interview with MDS Nurse #6, on 08/22/13 at 3:41 PM, revealed she had been trained on the abuse policy and identified the process. She stated she had also completed a post test upon completion of the training. Interview with Housekeeping Staff #11, on 08/22/13 at 3:43 PM, revealed she was trained last week on abuse and neglect and had completed a post test. She stated they could lose their jobs for failing to report an allegation of abuse. Interview with Maintenance Staff #7, on 08/22/13 at 3:46 PM, revealed he had been trained on abuse and neglect last week and had completed a post test. Interview with Dietary Aide #12, on 08/22/13 at 3:49 PM, revealed he had been trained last week on the abuse/neglect policy and had completed a post test. Interview with the Dietary Supervisor #13, on 08/22/13 at 3:53 PM, revealed he had been trained last week on abuse/neglect policy and had completed a post test. Interview with RN #5, on 08/22/13 at 3:59 PM, revealed she had been trained upon hire and last week for the abuse/neglect policy. She stated she was to report any allegation of abuse to the nursing supervisor on the weekends and during the week she was to report to the DON and/or the Administrator. She stated she had completed a post test after the training. Interview with SRNA #7, on 08/22/13 at 4:00 PM, revealed she had been trained last week on the abuse policy and had completed a post test. Interview with the Admissions Coordinator, SW #14, on 08/22/13 at 4:03 PM, revealed she had been trained last week on the abuse policy and had completed a post test. Interview with Activity Assistant #15, on 08/22/13 at 4:06 PM, revealed he had been trained last week on the abuse policy and completed a post test. Interview with SRNA #8, on 08/22/13 at 4:10 PM, revealed she had been trained last week on the abuse and neglect policy and had completed a post test. Interview with DON, on 08/22/13 at 4:15 PM, revealed she was trained on the new abuse policy by the administrator, last week. 11. Review of the minutes for the first scheduled meeting with the residents regarding concerns, dated 08/21/13 at 11:00 AM, confirmed the staff met with the residents to obtain any concerns the residents may have had. There were no concerns expressed by the residents. Interviews on 08/21/13 with Resident #22 at 3:10 PM, Resident #23 at 3:20 PM, Resident #24 at 3:28 PM revealed the meeting took place and the residents were encouraged to express any concerns.

Based on interview, record review, review of the facility's investigation and Abuse policy, it was determined the facility failed to have an effective system in place to ensure all allegations of abuse were reported to the appropriate agencies, that all residents were protected from further potential abuse and that an investigation was initiated timely for one (1) of thirty-one (31) sampled residents (Resident #20). During the annual survey, Resident #20 reported an allegation of abuse to the State Survey Agency on 08/13/13 at 3:00 PM. Per the interview, on 08/10/13 Resident #20 reported to Licensed Practical Nurse (LPN) #6 that State Registered Nurse Aide (SRNA) #6 had jerked his/her leg and hurt the resident. The resident stated he/she was scared of SRNA #6 and had requested to LPN #6 the SRNA not care for the resident anymore. However, per the resident's interview and record review, SRNA #6 continued to care for Resident #20 on 08/10/13; providing care to the resident during the day and evening shift, and also worked a double shift on 08/11/13 on another unit. Resident #20 also reported to the SSA that on 08/12/13 Social Worker #3 told the resident that LPN #6 was aware of the incident and "would take care of it". Interview with LPN #6 revealed he did not report the allegation of abuse by Resident #20 on 08/10/13 as he denied Resident #20 told him about the abuse. In addition, interview with LPN #2 revealed Resident #20 had also reported the allegation to her the morning of 08/12/13 and she had informed Social Worker #3 that the allegation could be abuse. Interview with Social Worker #3 revealed she was made aware of the allegation on 08/12/13; however, she did not take the necessary steps to protect all residents in the facility, report and investigate the incident, because she thought Resident #20 was "simple-minded" and complained a lot. There was no documented evidence an investigation was initiated for Resident #20's allegation of abuse until 08/13/13 at 8:45 PM, after surveyor intervention. The facility's failure to have an effective system in place to ensure residents were protected from abuse, that allegations of abuse were reported timely and an investigation was initiated has caused or is likely to cause serious injury, harm, impairment or death to a resident. During the annual survey, the State Survey Agency (SSA) notified the facility of Resident #20's abuse allegation on 08/13/13. The facility immediately initiated an investigation and initiated corrective actions based on their findings. After further investigation, the SSA determined Immediate Jeopardy and Substandard Quality of Care (SQC) was identified on 08/15/13 and determined to exist on 08/10/13 at 42 CFR 483.13 Resident Behavior & Facility Practice (F225) at a scope and severity of a "J". The facility was notified on 08/15/13 of the Immediate Jeopardy. The facility provided an acceptable Allegation of Compliance (AOC) on 08/20/13 alleging the removal of Immediate Jeopardy on 08/15/13. The facility initiated corrective action on 08/13/13 upon being informed of an allegation of unreported abuse. The Immediate Jeopardy was determined to be removed as alleged on 08/15/13, prior to exit on 08/22/13. The scope and severity of F225 was lowered to a "D" while the facility continues to implement and monitor quality assurance measures. The findings include: Review of the facility's policy titled Policy for Prevention and Detection of Abuse and Neglect, revised 09/13/12, revealed the facility would report all alleged violations to the appropriate agencies and would then initiate an investigation and take corrective action as required. The facility would investigate alleged violations of abuse and neglect to determine if abuse or neglect had occurred, the extent of abuse/neglect, any causative factors, and appropriate interventions to prevent further injury. A resident assessment to determine whether injury occurred from the alleged abuse would be conducted and the results of the investigation would be documented in the medical record. If a report of suspected abuse or neglect was reported the staff was to complete the "Abuse Checklist" and take the following corrective action: immediately take measures to protect the resident; assess the resident for mental or physical harm; contact the Administrator, DON, Supervisor or Charge Nurse on Duty and the Social Worker and inform him/her of the incident; Call the alleged incident into appropriate agencies; and alleged incidents would also be reported to the State Agency. The policy identified the facility would take measures to protect residents from further abuse and neglect and during the course of an investigation the alleged perpetrator would not be allowed to work. Upon conclusion of the investigation, the facility would make a determination as to whether there was sufficient evidence to substantiate the allegation of abuse. Interview with Resident #20, on 08/13/13 at 3:00 PM, revealed the resident was having trouble with the right leg. During a shower on 08/10/13 a SRNA moved the leg and picked it up and jerked it a little and it hurt. The resident stated he/she had reported this to LPN #6 on 08/10/13 when he/she yelled for the LPN while in the shower room. The resident further stated he/she told LPN #6 they did not want the aide to take care of him/her anymore because the resident was afraid of the aide and did not want the aide fooling with him/her. Per interview, LPN #6 told the resident to "leave it alone" and the resident stated he/she trusted LPN #6. However, the SRNA came back the rest of the day. The resident further stated he/she told Social Worker #3 of the incident on 08/12/13 and the Social Worker told the resident that LPN #6 had taken care of it. Per the resident, Social Worker #3 told the resident to "just forget about it". Review of Resident #20's record revealed the facility admitted the resident on 09/26/10 with [DIAGNOSES REDACTED]. Record review further revealed the facility assessed Resident #20 as having a cognition score of twelve (12) on the Minimum Data Set (MDS), dated [DATE], utilizing the Brief Interview for Mental Status (BIMS) indicating the resident was interviewable. The MDS further revealed the resident had no physical or behavioral symptoms or rejection of care and was assessed by the facility as having pain, but only occasionally. Review of the comprehensive plan of care, dated 07/06/13, for Resident #20 indicated he/she did have pain relieved by prescribed pain medications and topical [MEDICATION NAME]. Interview with Social Worker #3, on 08/13/13 at 3:20 PM, revealed Resident #20 had told her on the morning of 08/12/13 (unsure of time) that SRNA #6 had jerked his/her right leg on 08/10/12, she was rough and had hurt him/her. Social Worker #3 indicated it was her understanding that the resident told LPN #6 about the aide hurting him/her on 08/10/12 and LPN #6 had talked with SRNA #6. Interview with LPN #6, on 08/14/13 at 11:33 AM, revealed Resident #20 had reported having pain in his/her leg to him, but Resident #20 had not reported abuse to him on 08/10/13. He stated he saw the resident during medication pass as SRNA #6 was taking the resident into the shower room and no complaint was alleged. He stated on 08/10/13 Resident #20 told him that he/she did not like SRNA #6, but he/she did not specify why. LPN #6 stated he did not hear an allegation of abuse from Resident #20 on 08/10/13. Further interview with Social Worker #3, on 08/13/13 at 3:20 PM, revealed LPN #2 called her on 08/12/13 (unsure of time) to report Resident #20 had alleged SRNA #6 had hurt her on 08/10/13. Per interview, Social Worker #3 acknowledged LPN #2 had reported an allegation of abuse to her on 08/12/13 (unsure of time); however, she stated she did not report the allegation and no investigation was initiated because Resident #20 was "simple-minded and complained a lot". However, review of the resident's comprehensive plan of care, dated 07/06/13, revealed there was no care plan for any concern with untoward behaviors or frequent complaining. Review of a Behavior/Intervention Monthly Flow Record, dated August 2013, for Resident #20 revealed consistent zeroes for numbers of behavior episodes that had occurred from 08/01/13 through 08/15/13. Interview with LPN #2, on 08/14/13 at 10:34 AM, revealed on 08/12/13 during first shift, Resident #20 told her a big, fat girl grabbed his/her right leg and hurt it and the resident yelled out that it hurt and then the aide told him/her to shut up. She further stated the resident reported that it hurt really bad. LPN #2 stated she called Social Worker #3 on 08/12/13 and told her of the allegation stating to Social Worker #3 this could be an abuse situation. She stated she asked if she needed to report the allegation to the DON and the Social Worker told her she would handle it. Review of the Social Service Progress notes, dated 08/12/13, revealed Social Worker #3 charted LPN #2 called and stated that Resident #20 was saying that some SRNA had hurt him/her. The progress note indicated she told LPN #2 she would be there and talk with the resident. However, there was no documentation the resident had reported an incident to the Social Worker or that the Social Worker was aware of LPN #6's knowledge of the incident. Interview with SRNA #6, on 08/14/13 at 12:43 PM, revealed she had provided care for Resident #20 on 08/10/13 and had showered the resident that morning before breakfast. She further stated the resident complained of right leg pain when she rolled the resident to the edge of the bed to assist him/her with undressing for a shower and the resident would yell out sometimes when he/she was rolled. SRNA #6 did state Resident #20 complained he/she had hurt him/her when he/she was pushed in the wheelchair over the hump into the shower room. She indicated she never grabbed or jerked the resident's leg and did not tell the resident to shut up. Review of the facility's investigation of the allegation of abuse revealed an abuse/neglect checklist was not completed until 08/13/13 at 8:45 PM by the Director of Nursing (DON) after surveyor intervention. Further review of the facility's investigation revealed SRNA #6 was not suspended from work until 08/13/13 (no time noted) per telephone by the DON. Social Worker #3 was notified of the suspension in person by the Administrator, on 08/13/13 at 5:00 PM. Interview with the DON and the Administrator, on 08/13/13 at 5:30 PM, revealed the Administrator was not made aware of the allegation of abuse by Resident #20 and no investigation had been initiated prior to surveyor intervention. Further interview with the DON, on 08/14/13 at 9:59 AM, revealed Social Worker #3 had reported to her that sometime on the morning of 08/12/13 an "issue" with Resident #20 had occured over the weekend. Social Worker #3 stated the resident's leg was hurting and LPN #6 had taken care of it. She stated there was no allegation of abuse presented to her. The DON stated she had followed up and read the nursing notes revealing the resident had issues regarding pain and the nurse had assessed the resident's pain and given him/her medications ordered by the physician. Further interview with the Administrator, on 08/13/13 at 5:30 PM, revealed the Social Worker should have reported the incident immediately. The Administrator further revealed the facility did not report the allegation of abuse to the appropriate agencies, ensure the protection of all of the facility residents or initiate an investigation timely. The facility provided an acceptable Allegation of Compliance (AOC) on 08/20/13 alleging the Immediate Jeopardy was removed on 08/15/13. The facility took the following immediate steps to remove the Immediate Jeopardy: 1. The facility suspended SRNA #6 on 08/13/13. 2. The Director of Nursing initiated an investigation into the allegation of abuse on 08/13/13. 3. The Director of Nursing reported the incident to the appropriate agencies on 08/13/13. 4. The Director of Nursing completed a head-to-toe physical assessment of Resident #20 on 08/13/13. 5. The Regional Continous Quality Improvement (CQI) Director, RN reviewed the prior six months of facility concerns/complaints to ensure all were reported per policy. 6. The Director of Nursing, CQI Director, Assistant Director Nursing, Wound Care Nurse assessed the entire resident population of 92 residents either physically or by interview on 08/14/13. 7. The facility held an emergency QA meeting on 08/13/13, attended by Corporate and Administrative staff. 8. Diversicare abuse policy approved and implemented by the QA team on 08/13/13. 9. The ADON notified the Medical Director on 08/13/13 of approval and implementation of the Diversicare Abuse Policy. 10. The Administrative staff trained all facility staff in the building on the Diversicare Abuse Policy with a post test administered to the employees. A no-one-shall-work mandate was initiated by the Administrator on 08/13/13 until they were trained on the Diversicare Abuse Policy prior to working with a post test administered to employees on 08/14/13. 11. The Administrator, Admission/Social Services Coordinator or the Activity Director will conduct meetings on a weekly basis with residents for four (4) weeks to determine if residents feel safe in the facility and that they are permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family member or visitors. The first meeting will take place on 08/21/13. The State Agency validated the acceptable Allegation of Compliance AOC) as follows: 1. Review of SRNA #6 employee file revealed a notice of suspension effective 08/13/13. Interview with SRNA #6, on 08/13/13 at 12:43 PM, confirmed the suspension and she stated she was not allowed to return pending results of the investigation. 2. Review of the facility's investigation, dated 08/13/13, revealed it was initiated by the Director of Nursing. Review of the Abuse/Neglect Investigation Checklist, revealed the facility initiated an investigation of the allegation of abuse regarding Resident #20 on 08/13/13. 3. Review of the investigation report revealed the DON reported the allegation to the appropriate agencies at 9:40 PM on 08/13/13. The report was completed by the DON. 4. Review of the investigation attachment revealed the DON conducted a head to toe assessment with no acute injury found on 08/13/13. 5. Interview with the CQI Director, Staff #4, on 08/22/13 at 2:45 PM, revealed she had reviewed all concerns and complaints for the past six (6) months and no concerns had been identified. 6. Review of a skin assessments on 08/22/13, revealed forty-seven (47) skin assessments were completed for residents who were identified as non-interviewable. Review of documented interviews were completed with forty-five (45) residents identified as interviewable to determine if they were being cared for appropriately and felt safe. The total of ninety-two (92) residents were assessed with [REDACTED]. 7. Review of the minutes on 08/22/13 for the Emergency Quality Assurance Interdisciplinary Team Meeting, revealed the meeting was conducted on 08/13/13 and the team approved and implemented the new abuse policy. 8. Review of the facility policy Resident Abuse with an effective date of 07/01/09, revealed it was the replacement policy for the new ownership of the facility. The abuse policy contained all components as required; screening, training, prevention, identification, investigations, protection, and reporting. The policy also included the procedure for prevention of misappropriation of resident property. 9. Review of the QA minutes revealed the Medical Director was notified of the Immediate Jeopardy, the allegation and the change in the Abuse policy on 08/13/13. 10. Review of the sign in sheets and completed post tests for the training on the abuse policy on 08/22/13, revealed one hundred and twenty-eight (128) staff had signed in for the abuse training and had completed the post test by 08/15/13. A "No One Shall Work" mandate was implemented by the Administrator on 08/13/13 for all staff to be educated on the Abuse Policy prior to returning to work. Interviews with fourteen (14) random staff revealed they had been trained on the new facility abuse policy to include; how to identify abuse, protection of the resident, how to report, when to report any and all suspicions/allegations of abuse. Interview with LPN #7, on 08/22/13 at 3:23 PM, revealed she had been retrained last week on the new abuse policy. LPN #7 identified the types of abuse and included the protection of the resident. She stated she would report any suspicion of/or an allegation of abuse to her supervisor. She stated they were told, failure to report would lead to disciplinary action. She stated she had taken a post test after the completion of the training. Interview with Registered Nurse (RN) #4, on 08/22/13 at 3:34 PM, revealed she had been trained on the new abuse policy and had completed a post test sometime last week. Interview with Staff Development Director #5, on 08/22/13 at 3:40 PM, revealed she was trained by the DON on the new abuse policy and then she did the training for the staff. She identified abuse policy and requirements to include the disciplinary process and stated she had completed a post test. Interview with MDS Nurse #6, on 08/22/13 at 3:41 PM, revealed she had been trained on the abuse policy and identified the process. She stated she had also completed a post test upon completion of the training. Interview with Housekeeping Staff #11, on 08/22/13 at 3:43 PM, revealed she was trained last week on abuse and neglect and had completed a post test. She stated they could lose their jobs for failing to report an allegation of abuse. Interview with Maintenance Staff #7, on 08/22/13 at 3:46 PM, revealed he had been trained on abuse and neglect last week and had completed a post test. Interview with Dietary Aide #12, on 08/22/13 at 3:49 PM, revealed he had been trained last week on the abuse/neglect policy and had completed a post test. Interview with the Dietary Supervisor #13, on 08/22/13 at 3:53 PM, revealed he had been trained last week on abuse/neglect policy and had completed a post test. Interview with RN #5, on 08/22/13 at 3:59 PM, revealed she had been trained upon hire and last week for the abuse/neglect policy. She stated she was to report any allegation of abuse to the nursing supervisor on the weekends and during the week she was to report to the DON and/or the Administrator. She stated she had completed a post test after the training. Interview with SRNA #7, on 08/22/13 at 4:00 PM, revealed she had been trained last week on the abuse policy and had completed a post test. Interview with the Admissions Coordinator, SW #14, on 08/22/13 at 4:03 PM, revealed she had been trained last week on the abuse policy and had completed a post test. Interview with Activity Assistant #15, on 08/22/13 at 4:06 PM, revealed he had been trained last week on the abuse policy and completed a post test. Interview with SRNA #8, on 08/22/13 at 4:10 PM, revealed she had been trained last week on the abuse and neglect policy and had completed a post test. Interview with DON, on 08/22/13 at 4:15 PM, revealed she was trained on the new abuse policy by the administrator, last week. 11. Review of the minutes for the first scheduled meeting with the residents regarding concerns, dated 08/21/13 at 11:00 AM, confirmed the staff met with the residents to obtain any concerns the residents may have had. There were no concerns expressed by the residents. Interviews on 08/21/13 with Resident #22 at 3:10 PM, Resident #23 at 3:20 PM, Resident #24 at 3:28 PM revealed the meeting took place and the residents were encouraged to express any concerns.