Every finding on record at Signature Healthcare at Colonial Rehab & Wellness

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure residents were assessed to determine their capacity to consent or were free from sexual abuse for three of 24 sampled (Residents (R) 2, R33, and R34). Review of facility documentation of multiple incidents and sexual abuse allegations involving R63 revealed the following: 1. On 02/22/2022, staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident. The facility failed to assess the residents for their ability to consent and failed to update R63's care plan related to the monitoring that occurred after the event. 2. On 08/14/2022, R63 kissed R2 after R2 allegedly asked for a kiss and the facility considered the incident mutual, however, when interviewed during the facility's investigation, R2 could not recall the incident. The facility failed to assess the residents' ability to consent and failed to update R63's care plan related to his sexual behaviors after the incident. 3. On 02/16/2023, another resident reported R63 appeared to be fondling R34's breast and the facility unsubstantiated the inappropriate behavior by R63, although an order for daily medication doses for behavior was initiated for R63. The facility failed to assess the residents for their ability to consent and failed to update R63's care plan related to sexual behaviors after the incident. 4. On 05/17/2023, R33 yelled and staff discovered R63 in her room. R33 reported to staff that R63 exposed himself to her and the facility unsubstantiated the allegation. The facility failed to update R63's care plan related to the sexual behaviors after the incident. 5. On 08/09/2023, R63 admitted exposing himself to R34 but stated he did not know why he had done that. The facility unsubstantiated the incident and again failed to update R63's care plan related to his sexual behaviors after the incident. Therefore, on 09/04/2023 at approximately 10:30 AM, the Activities Director witnessed R63 with his hand in the blouse of R34's blouse, appearing to fondle the breast of R34. R34 was heard to yell out and the AD immediately separated the two residents. R63 admitted touching R34's breast, was placed on one-to-one (1:1) supervision, local law enforcement was notified and the resident was subsequently arrested and charged with a misdemeanor. Refer to 656 The facility's failure to have an effective system to ensure residents were protected from sexual abuse was likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 08/14/2022 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a K. The facility was notified of the IJ on 07/03/2024. An acceptable Immediate Jeopardy Removal Plan was received on 07/08/2024, which alleged removal of the IJ on 07/09/2023 and the State Survey Agency (SSA) validated IJ was removed on 07/09/2024, prior to exit on 07/11/2024. Non-compliance remained in the area of 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F600) at a Scope and Severity (S/S) of a E; while the facility monitored the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property dated 10/17/2022, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The State Survey Agency (SSA) requested a policy regarding determining a resident's ability to consent; however, the facility did not provide such policy. Review of the Long-Term Care Facility Self-Reported Incident Form Initial Report (IR), received on 08/09/2023, revealed a staff member passing by R63's room observed R63 exposing himself to the female resident who also alleged R63 touched her left breast. The Long-Term Care Facility Self-Reported Incident Form 5-Day Follow-Up Report (5Day) revealed R63 admitted exposing himself but could not recall why. R63 was accepted into an area facility for evaluation and treatment. Additionally, the facility unsubstantiated the incident while acknowledging the incident occurred. The 5Day reveals no indication regarding assessment of the residents' capacity to consent to sexual activity. Review of the facility's Initial Report dated 09/04/2023 and Final Report/5 Day Follow-Up investigation documentation, revealed R63 and R34 had been in an activity when the Activities Director (AD) witnessed R63's hand down the front of R34's shirt, appearing to touch her breast. Per review, the AD separated the residents, reported the incident to the Director of Nursing (DON), and the facility placed R63 on 1:1 observation. Continued review revealed when R63 was interviewed he stated he had (touched R34's breast) but could not recall why. Further review revealed the facility's Administrator substantiated the allegation of sexual abuse which had been witnessed by a staff member. In addition, review of the investigation information revealed local law enforcement was immediately notified and R63 was escorted out of the facility, taken to the local law enforcement agency and charged with sexual abuse. 1. Review of R34's clinical record revealed the facility admitted the resident on 06/17/2021, with diagnoses to include encephalopathy unspecified, unspecified convulsions, and epileptic seizures related to external causes, with status epilepticus (prolonged seizure, seizure lasting more than 5 minutes or when seizures occur very close together). Review of R34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/2021 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Continued MDS review revealed on 09/04/2023, the facility also assessed R34's BIMS score to be six (6) out of fifteen (15) indicating severe cognitive impairment. Continued review of R34's clinical record revealed no indication of an assessment conducted regarding the resident's capacity to consent to sexual relations. Review of R34's clinical record progress note 09/04/2023, revealed the facility assessed the resident to have no injury following the encounter with R63. Per review of the note, R34 was assessed by psychiatry to have no mental distress noted, with no mention of inappropriate sexual behaviors. During an interview on 05/16/2024 at 4:37 PM, with the Activities Director, she stated she witnessed R63 putting his hand down R34's shirt touching her right breast (on 09/04/2023). She stated R34 yelled out and R63 took his hand out of R34's shirt, and the two residents were immediately separated. The Activities Director further stated R63 was placed on 1:1 observation. 2. Review of R63's clinical record revealed the facility admitted the resident on 09/07/2018, with diagnoses to include: vascular dementia, without behavioral disturbance; psychotic disturbance; mood disturbance; and anxiety. Review of R63's MDS with an ARD of 09/07/2018, revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Continued MDS review revealed the facility assessed R63 on 08/30/2023, on an unscheduled BIMS assessment, with a score of eleven (11) out of fifteen (15) also indicating moderate impairment. Review of R63's care plan, undated, revealed on 02/20/2023, the facility care planned R63 for behaviors with the problem/focus of the resident demonstrating inappropriate behaviors with other residents. Per review, the interventions dated 02/20/2023, included to assist resident away from other residents as needed; determine the cause for the inappropriate behavior and refer to a physician/psychiatrist for intervention; encourage participation in structured activities as he would attend; and observe for triggers of inappropriate behaviors. Continued review of R63's clinical record progress note revealed previous allegations/incidents of sexual abuse beginning on 02/24/2022 when R63 and R2, while sitting at a dining room table lightly kissed each other on the lips. Review revealed on 08/14/2022, R63 and R2 kissed each other while attending an activity; and on 05/17/2023, R63 allegedly exposed himself to R33. Per record review, on 08/09/2023 staff responded to R24 yelling from her room and upon entering the room R24 told them R63 entered her room exposed himself. Further review revealed the facility unsubstantiated all those incidents/allegations. Review of R63's clinical progress notes revealed assessments by psychiatry on 08/17/2022, 02/17/2023, 05/19/2023, and 05/26/2023, after inappropriate behaviors with no psychosocial concerns noted. Review of progress notes for R63, on 07/18/2023, revealed R63 requested condoms and staff supplied them. Additional review of R63's care plan revealed the facility did not address the resident's continued acts of inappropriate behavior (exposing himself or unwanted sexual touching) in his care plan after each unsubstantiated allegation. Further review revealed no documentation noting the facility specifically addressed the behaviors of R63 to alert staff of his potential sexual behaviors. Interview with State Registered Nursing Assistant (SRNA) 7 on 05/16/2024 at 1:56 PM, revealed she provided 1:1 observation of R63 in February or March, 2023 because the resident had kissed another resident. During an interview with Licensed Practical Nurse (LPN) 1 on 05/15/2024 at 9:15 AM, she stated she believed R63 was not a danger to female residents, but believed there might have been opportunities for R63 to interact independently and without supervision with female residents and inappropriately touch those residents. Interview with the SDC on 07/11/2024 at 1:26 PM, revealed the facility recently adopted an assessment tool to determine a resident's capacity to consent to sexual relationships and education had been provided to staff regarding this assessment over the past few days. During an interview on 07/03/2024 at 3:34 PM with the psychiatric nurse practitioner, she stated there were many factors that went into determining consent. She stated the BIMS score was used, the resident's Power of Attorney (POA) was contacted, and if the resident was in charge of their own health care. She stated it was a composite of many different evaluations. Further, she stated other factors that were taken into account were if the resident was on pain medication or psychotropic medication, whether the resident had an infection. She stated many factors were involved in making a consent determination. The psychiatric nurse practioner stated as a nurse practitioner, evaluating someone for consent to engage in sexual activitiy was beyond her scope of practice to determine consent. She stated the term consent was actually a legal term and two physicians were required to determine capacity. She stated the facility had not asked her to be involved with determining a resident's capacity for consent. During an interview on 07/03/2024 at 1:37 PM, with the MDS Nurse Coordinator, she stated R63 had a potential for reoccurrence of inappropriate behaviors. She stated R63's care plan was discussed in the facility's morning meetings, and his behaviors escalated after his stroke. The MDS Nurse Coordinator stated she knew R63 before and after his stroke and the resident had definitely changed after the stroke. She stated however, R63 had not had enough of a significant change to discuss doing a change in condition assessment. The MDS Nurse Coordinator further stated R63 was being discussed in the facility's Interdisciplinary Team (IDT) meetings to determine his ability to be involved in relationships. During an interview on 07/02/2023 at 11:42 AM, the Medical Director stated R63's care was reviewed in the facility's morning meetings and Quality Assurance Performance Improvement (QAPI) meetings. She stated a psychiatric provider evaluated R63 after each allegation of inappropriate sexual behaviors. The Medical Director stated the Psychiatric Nurse Practitioner started R63 on medication to control some of his sexual impulsivity, had increased the medication after another incident of sexually inappropriate behavior, but the resident had continued to have the inappropriate sexual behaviors. During interview with the Director of Nursing (DON) on 05/16/2024 at 2:50 PM, she stated previous allegations of inappropriate sexual behaviors by R63 had been unsubstantiated. She stated, even though the allegations were unsubstantiated or lacked enough evidence to confirm, the facility implemented actions to prevent further episodes of R63's inappropriate sexual behavior. Per the DON in interview, the incident that occurred on 09/04/2023, was witnessed by a staff member and was substantiated by the facility. The DON stated all of the alleged incidents involving R63 were reported to the State Survey Agency (SSA) and investigated, but found to be unsubstantiated due to lack of sufficient evidence. In continued interview with the DON on 05/16/2024 at 2:50 PM, she stated the facility educated staff on all allegations of abuse. She stated she ensured all residents were safe by informing staff of the incident/allegations during morning meetings. According to the DON in interview, residents' care plans were updated when the allegation of (abuse) was brought to staffs' attention. She stated education related to residents' rights was provided to all residents. She stated all dining and group activities were monitored by staff to decrease the chance of inappropriate resident-to-resident interaction. The DON stated three of the four previous incidents involving R63 occurred in the dining room which also served as the activities area. She said the other incidents occurred when R63 was going to his room and allegedly went into a female resident's room and exposed himself to that resident. The DON stated however, that incident was unsubstantiated. She stated residents who wandered had staff that kept eyes on them and those residents were redirected when necessary. The DON further stated she and other members of management were involved in monitoring of residents during activities and during dining times. In additional interview with the DON on 07/03/2024 at 12:13 PM, she stated the facility assessed residents who were cognitively intact to determine their ability to make rational and informed decisions, and one of those determinants was the BIMS score assessment. Further, she stated the residents' physical and mental health were evaluated. The DON stated the residents were educated on the risk of sexually transmitted infections, risk of having a relationship and possible poor outcomes. Lastley, the DON stated condoms were provided to the residents with education provided to the residents on what type of affection is appropriate while in public. During an interview with the Administrator on 05/24/2024 at 2:19 PM, he stated it was his expectation residents would be safe from sexual abuse or any other type of abuse. The Administrator stated he expected residents' care plans to be updated any time there was a change in the resident. He stated if any resident was found to be adversely affected from an incident, they were to have a physical assessment and if necessary, to be seen by psychiatry.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its staff developed and implemented the resident's care plan with interventions to address inappropriate sexual behavior and failed to ensure the residents were assessed and care planned for the ability to consent to sexual activity for four of 24 sampled residents (Residents (R) 63, R2, R33, and R34). On 02/22/2022, Resident (R) 63 was observed by staff to have kissed R2. The facility failed to develop R63's comprehensive care plan to address the inappropriate behavior. Then approximately 6 months later, on 08/14/2022, R63 kissed R2 again, after R2 asked for a kiss. The facility considered this incident mutual, however, when the facility interviewed R2 after the incident, she could not recall the incident. There was no evidence the facility had assessed or developed/implemented R63's care plan to identify the potential risks to other residents related to the behaviors; and there was no evidence R2 could consent to the inappropriate kissing with the other resident. On 02/16/2023, a fell ow resident stated R63 appeared to be fondling R34 on her [R34's] breast. R63's care plan was developed approximately four days after the incident, on 02/20/2023 with the problem identified as: Behavioral - resident demonstrated inappropriate behaviors with other resident. The interventions dated 02/20/2023 included to assist resident away from other residents as needed; determine the cause for inappropriate behavior and refer to a physician for intervention; encourage participation in structured activities as he will attend; and, observe for triggers of inappropriate behaviors. Further review, however, revealed the facility failed to assess the resident and include interventions to monitor the resident's whereabouts to identify potential risks to other residents. Additionally, there was no evidence the resident could consent to sexual activity with another resident. On 05/17/2023, R63 allegedly exposed himself to R33 while he was in her room. One day after this incident, R63's care plan was developed to include 1:1 staff supervision. As a result of the facility's failure to develop R63's care plan and implement interventions necessary to address the resident's sexually inappropriate behaviors, R63 was allowed to sexually assault R34 on 09/04/2023. Because this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that a reasonable person in these residents' position would have experienced severe psychosocial harm, dehumanization, and humiliation, as a result of the sexual abuse. Refer to F600. The facility's failure to have an effective system to ensure residents' care plans were developed and implemented with interventions necessary to prevent abuse is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 08/14/2022 at 42 CFR 483.21, Develop/Implement Comprehensive Care Plan (F656) at the highest Scope and Severity (S/S) of a K. The facility was notified of the IJ on 07/03/2024. An acceptable Immediate Jeopardy Removal Plan was received on 07/11/2024, which alleged removal of the IJ on 07/09/2024 and the State Survey Agency (SSA) validated IJ was removed on 07/09/2024, prior to exit on 07/11/2024. Non-compliance remained in the area of 42 CFR 483.21, Develop/Implement Comprehensive Care Plan, (F656) at a Scope and Severity (S/S) of a E; while the facility monitors the effectiveness of systemic changes and quality assurances activities. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 02/09/2024, revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and was to be revised as necessary with changes. Review of facility policy Abuse, Neglect, and Misappropriation of Property, revised 05/08/19, revealed upon admission and periodically thereafter the facility assessed residents for potential vulnerabilities/concerns. Additionally, the resident's plan of care would address these vulnerabilities or concerns. Continued review of the policy revealed as part of the facility's investigation into an incident, the facility Inter-Disciplinary Care Planning Team initiated or reviewed a care plan for affected resident(s) to address the resident(s) condition with measures implemented to prevent recurrence. Further review revealed no language regarding assessing a resident's ability for the capacity to consent to sexual activity. 1. Review of facility record progress notes, dated 02/22/2022, revealed staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident. Additionally, on 08/14/2022, approximately 6 months after the first incident between the two residents (R63 and R2), R63 kissed R2 after R2 reportedly asked for a kiss and the facility considered the incident mutual. However, when interviewed during the facility's investigation, R2 could not recall the incident. a). Review of the clinical record for R63 revealed the facility admitted him on 09/07/2018, with diagnoses that included: anxiety, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Review of R63's Comprehensive Care Plan, dated 02/12/2022, revealed the facility referred R63 to the physician for interventions related to inappropriate behaviors. Continued review of the care plan revealed staff were to observe R63 for triggers to inappropriate behaviors; however, review revealed no triggers were defined for this intervention. Additional interventions included to provide one to one (1:1) supervision until psych (Psychiatrist) could see the resident. Review additionally revealed no documented evidence of interventions implemented for R63's sexual tendencies. The goal listed for R63's behavioral care plan was his behaviors would not result in disruption of others environment and had a goal date of 08/24/2023. Review of R63's Comprehensive Care Plan revealed on 08/15/2022, the Problem was noted that R63 was affectionate towards other resident that was not able to consent consistently and interventions which included the facility provided the resident with supervision by staff as needed; psychosocial evaluation as needed; and every 15 minute checks. Continued review revealed however, lack of interventions necessary to address R63's inappropriate sexual behaviors towards female residents. Review of R63's psychiatrist/psychologist notes, dated 02/17/2023, revealed to begin Sertraline (a medication used to treat depression, obsessive compulsive disorder, panic attacks, post-traumatic stress disorder, and social anxiety disorder) 50 milligrams (mg) daily for anxiety and possible sexually inappropriate behaviors. The note also indicated no psychosocial concerns and to monitor for changes in mood or behavior. b). Review of R2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 revealed the facility assessed the resident as having a BIMS of 3, which indicated severe cognitive impairment. Review of the Quarterly MDS with an ARD of 02/11/2022 revealed a BIMS score of 6, indicating severe cognitive impairment. Review of R2's care plan, revealed documentation to suggest the facility assessed the resident to have the capacity to consent to being kissed by other residents. Additionally, there was no evidence to suggest the resident's care plan was developed to include interventions to prevent or protect the resident from abuse. 2. Review of facility record investigation notes, dated 02/16/2023, a fell ow resident stated R63 appeared to be fondling R34's breast and the facility unsubstantiated the allegations of inappropriate sexual behavior although an order for daily medication doses for the resident's behaviors began for R63. The facility failed to ensure the resident's care plan was implemented to provide supervision of the resident's behaviors and to monitor for his triggers. Review of R63's care plan revealed a Problem/focus dated 02/20/2023 that the resident demonstrated inappropriate behaviors with other residents. The interventions listed for this problem included to assist resident away from other residents as needed, to determine the cause for inappropriate behavior and refer to a physician for intervention, to encourage participation in structured activities as he will attend, and to observe for triggers of inappropriate behaviors. 3. Review of facility clinical notes, dated 05/17/2023, revealed R33 reported to staff that R63 exposed himself to her. a). Review of R63's care plan revealed on 05/18/2023, the resident's care plan was revised to include interventions for: 1:1 staff supervision; assist R63 away from other residents as needed; determine the cause for his inappropriate behaviors; observe for triggers for his inappropriate behaviors. Further review revealed no description of sexual behaviors or triggers staff to observe for to address the resident's inappropriate behaviors. b). Review of the Quarterly MDS with an ARD of 03/16/2023 revealed a BIMS score of 12, indicating moderate cognitive impairment. Review of R33's care plan revealed no documentation to support the resident was assessed for the capacity to consent to sexual activity. 4. Review of the facility records, dated 08/09/2023, revealed R63 admitted he exposed his penis to R34 but stated he did not know why. Approximately, less than a month later, R63 was witnessed to have his hand down the front of R34's shirt touching her breast. The facility failed to implement the resident's care plan to include observing for triggers for the resident's inappropriate behaviors and to move the resident away from other resident's. a). Review of R63's care plan review, on 08/09/2023, revealed the facility placed R63 on 1:1 supervision; however the facility did not provide documentation such supervision occurred from 08/19/2024 midnight through 11:00 AM on 09/04/2024. On 09/04/2023 at approximately 10:30 AM, the Activities Director witnessed R63, in the hallway, with his hand down the front of R34's shirt touching her right breast. The staff failed to implement the resident's care plan by providing 1:1 supervision for the resident. b.) Review of the clinical record for R34 revealed the facility admitted the resident on 06/17/2021, with diagnoses that included epileptic seizures related to external causes with status epilepticus; encephalopathy unspecified; and unspecified convulsions. Review of the Quarterly MDS with an ARD of 07/06/2023 , revealed the facility assessed R34 to have a BIMS score of six out of 15 on 07/06/2023, which indicated severe cognitive impairment. Review of a Progress Note for R34 dated 09/04/2023, revealed the facility assessed the resident to have no injury following the incident of R63 touching her breast. Review further revealed no documentation to support the facility assessed R34 for the capacity to consent to sexual activity. In interview on 05/16/2024 at 4:37 PM, the Activities Director stated she witnessed R63 putting his hand down the front of R34's shirt touching her right breast. She stated R34 yelled out when R63 did that, and R63 then took his hand out of R34's shirt. The Activities Director further stated the two residents were immediately separated and R63 was placed on 1:1 supervision. In interview on 05/16/2024 at 2:50 PM, the Director of Nursing (DON) stated previous allegations of (sexual)behaviors by R63 had been unsubstantiated, but the incidents had became more frequent. She stated, even though those allegations had been unsubstantiated or lacked enough evidence to confirm, the facility implemented actions to prevent further episodes, to include observing for the resident's behaviors, triggers, and one-on-one supervision. The DON said the event on 09/04/2023, had been witnessed by staff and the facility substantiated abuse. She stated, Everyone knew R63 and knew to be aware of his movements when he was out in the facility. The DON stated residents' care plans were developed/updated when an allegation of (abuse) was brought to staffs' attention. Interview with the DON on 07/03/2024 at 9:22 AM revealed the IDT team discussed and determined a resident's ability to be involved in a relationship. The IDT team utilized the BIMS score, along with other observations such as how the resident managed their daily activities as the worked to determine the resident's ability. In interview on 05/24/2024 at 2:19 PM, the Administrator stated it was his expectation for residents to be safe from sexual abuse or any type of abuse. He stated he also expected residents' care plans to be updated any time there was a change in a resident. Per the Administrator, he stated it was his expectation that the facility's policies would be followed.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of any significant medication errors for one of seven sampled residents (Residents (R)58). On 05/03/2022, R58 developed increased altered mental status and was sent to the emergency room (ER) for evaluation. During assessment of R58 at the ER, the ER nurse discovered a 75 microgram (mcg) fentanyl patch (narcotic medication used to treat severe pain) on the resident's left upper arm/shoulder. However, review of the facility's information for R58 revealed no documentation noting fentanyl as one of R58's medications. Review of R2's (R58's roommate) orders revealed that resident had an active order for a 75 mcg fentanyl patch. The Director of Nursing (DON) assessed R2 and did not find the resident's prescribed fentanyl patch. The facility's failure to have an effective system to ensure residents were free from significant medication (med) errors is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 05/03/2022 at 42 CFR 483.45, Residents are Free of Significant Med Errors, (F760) at the highest Scope and Severity (S/S) of a J. The facility was notified of the IJ on 07/03/2024. An acceptable Immediate Jeopardy Removal Plan was received on 07/08/2024, which alleged removal of the IJ on 07/09/2024 and the State Survey Agency (SSA) validated IJ was removed on 07/09/2024, prior to exit on 07/11/2024. Non-compliance remained in the area of 42 CFR 483.45, Residents are Free of Significant Med Errors (F760) at a Scope and Severity (S/S) of a D while the facility monitors the effectiveness of systemic changes and quality assurances activities. The findings include: Review of the facility's policy titled, Medication Administration, dated 09/2018, revealed two resident identifiers and triple medication verifications were required prior to medication administration. Continued policy review revealed the resident identifier methods to use might include: checking residents' identification bands; checking residents' photographs attached to the medical record; or verifying a resident's identification with other nursing care personnel. Further review revealed medications supplied for one resident should never be administered to another resident. Review of the facility's policy titled, Notification of Change of Condition dated 07/07/2022, and last revised 09/15/2023, revealed the facility must inform the resident, consult with the physician, and notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status, or a decision to transfer or discharge a resident from the facility was made. Further review of the policy revealed the medical provider was to provide guidance related to the resident's change in condition. Review of the facility's policy titled, Controlled Medication dated 11/13/2023, and last reviewed 05/30/2024, revealed the facility was to ensure controlled medications recordkeeping was in place in accordance with federal, state, and other applicable laws and regulations. Review of the fentanyl patch package insert revealed the following common adverse effects which included: nausea, vomiting, insomnia, dizziness, constipation, hyperhidrosis (excessive sweating), fatigue, feeling cold, anorexia, diarrhea, somnolence (excessive sleepiness), and headache. 1. Review of R58's closed medical record Face Sheet revealed the facility admitted the resident on 04/21/2022, with diagnoses of pneumonia, parkinson's disease, and need for assistance with personal care. Review of R58's 5-Day Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of R58's Physician Order Report dated 04/03/2022 through 05/03/2022 revealed no documented evidence of an order in place for a 75 microgram (mcg) fentanyl patch. Review of R58's, Medication Administration Record (MAR) dated 05/01/2022 through 05/03/2022 revealed no documentation noting administration of a fentanyl patch. Further review revealed R58 had an order for Tylenol 325 milligrams (mg), two tablets every four hours as needed for mild pain. Review of R58's progress note dated 05/03/2022 at 10:11 AM, revealed the resident felt unwell and documentation noting a decline in mental status. Continued review revealed documentation noting R58 experienced arousal difficulty and failed to swallow her medications. Per review of the progress note, staff notified the physician and received orders to draw blood for laboratory (lab) values; obtain an x-ray; and an electrocardiogram (EKG). Further review revealed R58's family decided later to have the resident sent to the hospital for evaluation. Review of the facility's Event Report dated 05/03/2022, for this incident involving R58 revealed the resident had been lethargic and drowsy, but oriented to person, place, time, and situation. Continued review revealed R58 received an incorrect medication, and the facility transferred the resident to the hospital. Review of the facility's document titled, Investigation undated, revealed the facility determined R58's roommate had a fentanyl patch ordered which was documented as changed on 05/02/2022 and placed on the resident's roommate's left shoulder by an agency Kentucky Medication Aide (KMA). Further review revealed the facility made multiple unsuccessful attempts to contact the KMA. In addition, review revealed the facility determined a medication error had occurred after ER staff called the facility to clarify orders upon discovering the fentanyl patch on R58. Review of the Emergency Medical Services (EMS) run sheet dated 05/03/2022 for R58 revealed the following information at 9:42 AM-call received for person with altered mental status and lethargy for two days, onset on 05/02/2022 at 8:00 AM. Per review of the EMS run sheet at 9:51 AM, EMS made contact with R58, and the assessment of the resident revealed she was sitting up in wheelchair, confused, only oriented to her name, and was found to have a pulse oximetry (ox) reading of 81% on room air (oxygenation status significant for hypoxia). Review revealed R58 was placed on two liters of oxygen per nasal cannula and the resident's oxygenation status improved to 97%. Further review of the EMS run sheet revealed at 10:01 AM, EMS left facility with R58 to transfer to hospital and at 10:51 AM, EMS arrived at the hospital with the resident and gave report to the triage nurse. Review of R58's hospital records dated 05/03/2022 revealed the resident presented to the emergency room (ER) with confusion, nausea, vomiting, and lethargy. Per review, during the assessment of R58, the ER Registered Nurse (RN) discovered a 75 microgram (mcg) fentanyl patch with no initials, date, or time located on the resident's left upper chest/shoulder area. Continued review of the hospital records, revealed the ER RN contacted the nursing facility and informed the facility's Director of Nursing (DON) that R58 had the fentanyl patch in place. Review of the hospital records also revealed the Assistant DON (past not current) called the ER and reported to the ER nurse a medication error occurred regarding the fentanyl patch which had been placed on R58 on 05/02/2022 at 9:00 AM. Further review revealed the ER nurse informed R58's family of the medication error made at facility. Additional review revealed R58 remained as an inpatient at the hospital for five days and upon discharge the resident was discharged to another facility. Review of R58's, Discharge Summary, dated 05/10/2024 revealed a discharge diagnosis of encephalopathy secondary to fentanyl side effect. 2. Review of R2's medical record Face Sheet revealed the facility admitted the resident on 08/22/2020, with diagnoses of dementia, chronic lymphocytic leukemia, and chronic pain syndrome. Review of R2's Annual MDS with an ARD of 06/16/2024, revealed the facility assessed the resident to have a BIMS score of one out of 14, indicating severely impaired cognition. Review of R2's, Physician Order Report dated 04/03/2022 through 05/03/2022, revealed the resident had an active order for a fentanyl patch 75 mcg to be changed every three days. Review of R2's MAR dated 05/02/2022, revealed KMA 1 documented a fentanyl patch was applied to R2's left shoulder between 6:15 AM and 10:00 AM on that date. Review of R2's Controlled Drug Record revealed fentanyl patch 75 mcg documented as applied to the left shoulder of the resident on 05/02/2022, by KMA 1. The State Survey Agency (SSA) Surveyor attempted interview with R2 on 05/16/2024 at 9:37 AM; however, the resident was not interviewable. In interview with KMA 1 on 05/15/2024 at 10:48 AM and on 07/03/2024 at 10:53 AM, she stated she was employed by an agency, and worked per diem (by the day) at the facility during 2022. She stated she had been a KMA since 2015. KMA 1 stated she did not recall R58, had never placed a fentanyl patch on a resident and did not recall any incident at the facility of putting a fentanyl patch on the wrong resident. She stated she did not recall ever being asked about a medication error at the facility. In interview with the Staff Development Coordinator (SDC) on 05/16/2024 at 9:39 AM, she stated she was the nurse working with the agency KMA who passed medications in R58's room on 05/02/2022. The SDC also indicated she was the 2nd signature when the KMA signed out the fentanyl patch; however, the SDC did not recall observing the KMA place the patch on a resident. The SDC stated later on 05/02/2022 the resident appeared sleepier than usual on that date but answered questions without difficulty. The SDC stated nursing continued to monitor R58 and notified the physician and the following day the resident displayed increased drowsiness and was sent out to the hospital. She further stated the facility's policy required two patient identifiers to be confirmed prior to administration of medications. Additionally, the SDC stated she was unaware of any education provided to the KMA. On 05/23/2024 at 12:23 PM, the SSA Surveyor requested contact information for the previous DON; however, the facility was unable to locate or provide that information. The SSA Surveyor attempted telephonic (phone) interview with R58's family; however, no return call was received. In an interview with the Pharmacist on 07/03/2024, he stated there had been no obvious interactions with R58's medications and the concern with a fentanyl patch was giving someone a sudden dose of that medication at that strength. The Pharmacist stated the symptoms experienced by R58 were consistent with fentanyl side effects in someone who was opioid naive, meaning that person was not prescribed the medication or had only recently used opioid drugs. During an interview with the DON on 05/23/2024 at 12:48 PM and at 1:34 PM, she stated the medication error involving R58 was reported to the state and an event form was completed. The DON stated notifications were made to both the physician and to R58's family. She stated identifiers used for medication administration at the facility included: pictures of residents on the MAR; residents' names on their doors; residents' name and birthdate; and verification of the resident with other staff. The DON stated if medication errors occurred, staff received education in-services on the rights of medication administration and reporting responsibilities. She further stated the rights of administration helped prevent medication errors and adverse effects to residents. Interview with the DON, on 07/03/2024 at 12:13 PM, revealed medication administration now includes a down-time system including a printable medication administrtion record that includes the resident's room number and a picture of the resident. During an interview with the Administrator on 05/23/2024 at 1:49 PM, he stated it was his expectation for staff to properly identify residents prior to medication administration. The Administrator stated medication errors were reviewed during the facility's monthly Quality Assurance Performance Improvement (QAPI) meetings.

Based on observation, interview, record review, and review of the facility's policies, 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 and control the development and transmission of communicable diseases and to implement interventions to protect one (1) out of ten (10) sampled Residents (R), R43. Observation revealed R43's room door had a sign posted noting the resident was on Enhanced Barrier Precautions (EBP). However, further observation revealed Certified Nurse Aide (CNA) 3 entered R43's room without donning Personal Protective Equipment (PPE) as required. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions revised 03/25/2024, revealed the facility's infection control policies and practices were intended to maintain a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infections. Continued policy review revealed Enhanced Barrier Precautions (EBP) were additional measures to attempt to decrease transmission of Multidrug-Resistant Organisms (MDRO). Per review of the policy, when a resident was placed on EBP, appropriate signage was to be placed at the resident's room entrance, for staff to know the instructions for the use of Personal Protective Equipment (PPE), and to ensure personnel were aware of the need and the type of precautions to be used. Further review revealed EBP were indicated when contact precautions did not apply and when a resident had chronic wounds and or indwelling medical devices regardless of MDRO status. Review of the facility policy titled, Infection Control dated 01/23/2024, revealed the policies and practices were intended to help prevent and manage transmission of diseases and infections. Additional review revealed guidelines for implementing isolation precautions, including standard and transmission-based precautions. Review of the facility's policy titled, Infection Prevention and Control Policies revised 10/2018, revealed programs were established to help prevent development and transmission of communicable diseases and infections. Continued review revealed prevention of infection included educating and ensuring staff adhered to proper techniques and procedures, implemented appropriate isolation precautions, and followed guidelines such as from the Centers for Disease Control and Prevention (CDC). Review of the facility's signage for Enhanced Barrier Precautions (procedure to be used) revealed providers and staff must wear gloves and a gown for high contact resident care activities including changing briefs or assisting a resident with toileting. Review of R43's face sheet revealed the facility admitted the resident on 02/13/2024 with diagnoses to include acute osteomyelitis (bone infection); diabetes; and peripheral vascular disease (decreased blood flow by narrowed vessels to limbs). Review of R43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Review of R43's order set dated 04/08/2024, revealed an order for EBP related to the resident's pressure wound. Review of R43's Comprehensive Care Plan (CCP) dated 04/08/2024, with revision date of 5/22/2024, revealed the facility identified a problem for the resident of infection control related to pressure wound. Continued review of the care plan revealed interventions for staff to use PPE as indicated. Review of R43's progress note dated 05/23/2024 at 4:14 PM, revealed the resident had a wound to the right lateral ankle measuring 0.6 centimeters (cm) x 0.7 cm x 0.2 cm with light serous (clear to yellow fluid) drainage. Review of the weekly skin assessment for R43 documented on the Medication Administration Record (MAR) dated 05/21/2024, revealed a notation of 2, which indicated the resident had existing skin impairment. Further review revealed however, no indication of the location. On 05/22/2024 at 1:15 PM, observation revealed EBP signage for R43's on the resident's door. Review of the EBP signage posted revealed staff were to don PPE, including gloves and a gown when providing high contact resident care activities which included changing briefs or assisting in toileting. Continued observation revealed an isolation cart that contained PPE available for use. Further observation revealed CNA 3 failed to don the required PPE prior to entering R43's room. During interview at the time of observation, CNA 3 stated she had only donned gloves to provide incontinent care for R43. In an additional interview with CNA 3 on 05/23/2024 at 12:30 PM, she stated she had gone in to answer R43's call light and once she was in the room, the resident asked her to provide incontinent care which was changing the resident's adult brief. She stated she started talking to R43 during care and simply forgot to don a gown, but had donned gloves. CNA 3 said as soon as she exited R43's room with the soiled brief to discard, and saw the (State Survey Agency) Surveyor, she remembered she should have donned a gown prior to changing R43's brief. She stated the facility provided training on donning PPE for EBP rooms and she knew better. When asked why it was important to don proper PPE for isolation rooms, she stated it was to prevent the spread of germs from staff to residents. The CNA further stated she reported herself to the Director of Nursing (DON) and was provided isolation training at that time. During an interview with the Staff Development Coordinator (SDC) on 05/23/2024 at 1:40 PM, she stated CNA 3 had self-reported the incident of not donning the PPE and additional isolation training had been provided for the CNA at that time. She stated all staff were trained when providing direct resident care/touch care, to don proper PPE for infection prevention. The SDC further stated it was her expectation that staff followed the training received for infection prevention. During an interview with the Infection Preventionist (IP)/DON on 05/23/2024 at 1:50 PM, she stated CNA 3 had reported the incident of not wearing the PPE immediately and training was provided for the CNA at that time. She stated transmission was a concern and staff should be following the facility's policy, signage, and trainings for isolation precautions. In an interview with the Administrator on 05/23/2024 at 12:40 PM, he stated his expectations were for staff to follow all the facility's infection control trainings and the signage posted on residents' doors when providing resident care as a prevention measure. He further stated staff had received infection control trainings including training on EBP.

Based on observation, interview and record review, it was determined the facility failed to ensure food was served at an appetizing temperature. Resident interviews and review of Resident Council Meeting minutes revealed resident complaints of cold food. Observation of the tray line on 05/11/2021 revealed the facility was not using the pellet warmer (part of the plate warming system to keep food warm). A test tray was obtained on 05/11/2021, and the mixed greens were cool and not at an appetizing temperature. The findings include: Review of facility policy titled Food Temperatures dated 3/19/2021 revealed foods should be served at proper temperatures to insure food safety and palatability. Review of the facility policy titled Maintenance Service dated January 2005 revealed maintenance should be provided to all areas of the building, grounds and equipment. It further stated maintenance should establish priorities in providing repair services. Observation in the kitchen during tray line on 05/11/2021 at 4:50 PM revealed the kitchen staff were not using the pellet warmer and interview with at the time of the observation with kitchen staff (Cook and Dietary Manager) revealed the pellet warmer was not working. Observation of test tray on 05/11/2021 at 4:50 PM revealed the chicken was 150.8 degrees, the mashed potatoes were 141.2 degrees and the greens were 118.2 degrees. A taste test of the greens revealed the greens tasted cool. Review of resident council meeting minutes for 02/25/2021 revealed the residents complained about the food being cold. Review of grievances related to cold food revealed a grievance had been documented on 02/25/2021 and and a follow-up documented on 02/26/2021. Continued review revealed documentation the pellet warmer was not working and maintenance was notified. Interview with Residents #12, Resident #13 and Resident #36, on 05/11/21 at 2:23 PM and 3:30 PM, revealed at times their food would be cold and sometimes staff would get another tray if needed due to the temperature of the food. Interview with the Dietary Manager, on 05/12/2021 at 9:55 AM, revealed the pellet warmer had not worked for weeks and maintenance had been notified. The Dietary Manager further stated maintenance had been working on the pellet warmer but the pellet warmer had not been repaired. The Dietary Manager stated she was aware residents had complained about cold food and had educated staff on quicker tray pass and to recheck temperatures on food trays. Interview with Director of Plant Operations on 05/12/2021 at 10:14 AM and 05/13/2021 at 10:15 AM and 2:24 PM, revealed he provided maintenance in the facility. He stated he was aware the pellet warmer was not working and was working on fixing it but had not fixed the pellet warmer yet. The Director of Plant Operations further stated he had ordered parts and had been troubleshooting the problem. Per the Director, he had been working in other areas of facility and that had delayed him from working on the warmer. Interview with the Administrator, on 05/13/2021 at 10:45 AM, revealed she was aware the pellet warmer was not working, and of resident grievances related to cold food. In addition, she stated maintenance staff were working to repair the pellet warmer. The Administrator further stated it was her expectation for repairs to done as quickly as possible.

Base on observation, interview and record review the facility failed to keep food stored under sanitary condition. A dented can of apples was stored on a shelf in the kitchen available for use. The findings include: Review of facility policy Food Storage dated 03/09/2020, revealed upon delivery all food items should be inspected for safe transport and quality upon receipt and food items should be stored thawed and prepared in accordance with good sanitary practice. It further stated under area titled Canned Fruits, dented of bulging cans should be placed on the damaged goods shelf and returned for credit. Observation on 05/11/2021 at 8:15 AM, 05/12/2021 at 10:13 AM and 05/13/2021 at 10:08 AM revealed a dented can of apples present in the dry storage canned food area. Interview with Dietary Aide, on 05/13/2021 at 10:09 AM, revealed damaged cans should be placed on the damaged food shelf. The Dietary Aide stated the dented can left on the shelf with other the undamaged cans was just missed. Interview with Dietary Manager, on 05/11/2021 at 8:15 AM, revealed it was the facility policy to not use dented cans and that staff was educated by word of mouth to not use dented cans. The Dietary Manager further stated all staff are responsible for unloading and storing new inventory and to monitor for damaged items. The Dietary Manager stated all dietary staff were expected to remove damaged cans and place them where they can be disposed of or returned.

Based on interview, record review, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed, for two (2) of seven (7) sampled residents (Resident #4 and #5), to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment. This program would help to prevent the development and transmission of communicable disease and prevent infection from and/or contain the COVID-19 virus. Observations, on 07/28/2020, revealed State Registered Nurses Aide (SRNA) #1 and #2 did not follow Infection Control protocol when entering and exiting Residents' (both on Droplet Precautions) rooms. SRNA #1 entered and exited Resident #4's room without wearing or changing required Personal Protective Equipment (PPE) and did not perform required hand hygiene and disinfection of eye goggles. SRNA #2 entered and exited Resident #5's room and did not perform required hand hygiene and disinfection of eye goggles. Observations, on 07/29/2020, revealed Housekeeper #3 and #4 were cleaning areas, including residents' rooms, and in hallways not wearing masks as required by Infection Control protocol; the masks did not cover their noses. The findings include: Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection; arrived for admission with symptoms of an infection; or had a laboratory confirmed infection and was at risk for transmitting the infection to other residents. Additionally, standard precautions were used when caring for residents at all times regardless of their suspected or confirmed infection status. Per policy, TBP were additional measures that protected staff, visitors, and other residents from becoming infected, and were determined by how specific pathogens spread from person to person. Continued review revealed when a resident was placed on TBP, appropriate notification was placed on the room entrance and on the front of the chart so personnel and visitors were aware of the need for and the type of precaution. The signage informed the staff of the type of CDC precautions, instructions for use of PPE, and/or instructions to see the nurse before entering the room. Further, when TBP were in effect, if resident-care equipment items required re-use and could not be dedicated to a single resident, the item would be cleaned and disinfected according to current guidelines before use with another resident. Continued review of the policy revealed Droplet Precautions would be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that could be generated by the individual coughing, sneezing, talking, or by the performance of procedures. Additionally, a mask, gloves, gown, and goggles should be worn when entering a resident's room with Droplet Precautions. Review of a procedure door signage, Droplet Precautions; in Addition to Standard Precautions, Washington State Hospital Association, dated 04/16/2009, revealed families and visitors should follow instructions on the information sheet and go to the Nurse's Station with any questions. The information sheet was taped to the resident's doorframe. Additionally, the sheet stated everyone must clean hands when entering and leaving the room and wear a mask. Further, the information sheet listed that Doctors and Staff must use gowns, gloves and eye covers when in the room. Review of the facility's Education and Training records, dated 04/01/2020, revealed nursing staff received ongoing training and education regarding Donning and Doffing PPE, COVID-19 Infection Control, and Handwashing. This training and education included when to wear PPE, handwashing and sanitizing requirements, respiratory hygiene, and strategies for minimizing the spread of COVID-19. 1. Review of Resident #4's medical record revealed the facility admitted him/her on 06/26/2020 with [DIAGNOSES REDACTED]. Review of Resident #4's Progress Note, dated 06/27/2020, revealed the resident was admitted to the facility after a rehabilitation hospital stay related to a motor vehicle accident, placement of a [MEDICAL CONDITION], and treatment of [REDACTED]. Review of Resident #4's Admission Minimum Data Set (MDS) Assessment, dated 07/03/2020, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of thirteen (13) indicating cognition was intact. Additional review revealed the facility assessed the resident as requiring extensive to total assistance with Activities of Daily Living (ADL's). Further review revealed the facility assessed the resident as having Acute and Chronic [MEDICAL CONDITION]. Review of Resident #4's Comprehensive Care Plan (CCP), dated 07/13/2020, revealed the resident was at risk for active infection related to potential exposure to COVID-19. The goal was for the resident not to demonstrate signs and symptoms of an active COVID-19 infectious process through the next review. Interventions included placing the resident on Droplet Isolation related to appointments and educating the resident on hand washing, social distancing, the reason(s) for possible future isolation, and visitor limitation. Further review revealed staff were to maintain appropriate PPE use according to state requirements and availability and were to report any changes of condition to the Physician, i.e. new/worse cough, fever (100.4 degrees Fahrenheit or greater), shortness of breath, and sore throat. Observation, on 07/28/2020 at 5:00 PM, revealed Resident #4's hallway door had Droplet Precautions and Standard Precautions information sheets taped to the resident's door. An additional observation showed a PPE [MEDICATION NAME] beside the door in the hallway which included gowns, gloves, and masks. A further observation revealed the hallway door was closed. Observation of SRNA #1, on 07/28/2020 at 5:00 PM, revealed SRNA #1 knocked on Resident #4's door, opened the door while standing in the hallway, and asked the resident why the call light was on; SRNA # 1 was wearing a dedicated mask and goggles. Resident #4 stated he/she needed to be changed. SRNA #1 then donned gown and gloves; however, she did not perform hand hygiene prior to donning the PPE and entering Resident #4's room. Continued observation of SRNA #1, on 07/28/2020 at 5:05 PM, revealed SRNA #1 exited Resident #4's room wearing a mask and goggles; she walked down the hallway and into a supply room without changing her mask or disinfecting her goggles. Further observation of SRNA #1, on 07/28/2020 at 5:08 PM, revealed SRNA #1 entered Resident #4's room again without performing hand hygiene prior to donning gloves and a gown. An additional observation also revealed SRNA #1 exited Resident #4's room, on 07/28/2020 at 5:13 PM; however, she did not change her mask or disinfect her goggles before she walked to the staff restroom to wash her hands and then down the hallway into other residents' rooms. Interview with SRNA #1, on 07/28/2020 at 5:20 PM, revealed she had worked at the facility for two (2) years. Additionally, the facility had provided recent and ongoing training and education related to COVID-19, TBP, PPE, and Infection Control procedures. Per interview, she was trained by the facility on how to don and doff PPE correctly according to CDC guidelines. Per interview, she stated first she should have removed her dedicated mask outside Resident #4's room, performed hand hygiene, and donned a new mask with PPE before entering the room. SRNA #1 continued, each time she exited the isolation room she should have doffed the mask worn in the isolation room, disinfected the eye goggles, performed hand hygiene, and donned a new mask to wear in the hallway. She stated she knew what to do correctly but did not do so because she was nervous. SRNA #1 stated it was important to maintain CDC guidelines related to donning and doffing PPE and hand hygiene to ensure staff did not bring germs into the hallway and contaminate other residents or staff. 2. Review of Resident #5's medical record revealed the facility admitted him/her on 06/18/2020 with [DIAGNOSES REDACTED]. Review of Resident #5's Progress Note, dated 07/07/2020, revealed the resident was readmitted to the facility after a hospital stay related to a pacemaker infection and abnormal laboratory values. Additionally, the note revealed the resident's respirations were eighteen (18) breaths per minute and oxygen saturation was ninety-two (92) percent. Further, per note, the resident had complaints of shortness of air and required the use of oxygen. Review of Resident #5's MDS Assessment, dated 07/13/2020, revealed the facility assessed the resident as having a BIMS score of fifteen (15) indicating cognition was intact. Additional review revealed the facility assessed the resident as requiring supervision to limited assistance with ADL's. Further review revealed the facility assessed the resident as having [MEDICAL CONDITION] with [MEDICAL CONDITION]. Review of Resident #5's CCP, dated 07/21/2020, revealed the resident was at risk for active infection related to potential exposure to COVID-19. The goal was for the resident not to demonstrate signs and symptoms of an active COVID-19 infectious process through the next review. Interventions included educating the resident on hand washing, social distancing, the reason(s) for possible future isolation, and visitor limitation. Further review revealed staff were to maintain appropriate PPE use according to state requirements and availability and were to report any changes of condition to the Physician, i.e. new/worse cough, fever (100.4 degrees Fahrenheit or greater), shortness of breath, and sore throat. Observation, on 07/28/2020 at 5:00 PM, revealed Resident #5's hallway door had Droplet Precautions and Standard Precautions information sheets taped to the resident's door. An additional observation showed a PPE [MEDICATION NAME] beside the door in the hallway which included gowns, gloves, and masks. A further observation revealed the hallway door was closed. Observation of SRNA #2, on 07/28/2020 at 5:02 PM, revealed SRNA #2 approached Resident #5's room wearing a mask and goggles; SRNA #2 donned gloves and a gown, knocked on the resident's door, and entered to deliver a meal tray. Further, the observation revealed she did not perform hand hygiene before donning PPE and entering Resident #5's room. Further observation of SRNA #2, on 07/28/2020 at 5:05 PM, revealed SRNA #2 opened Resident #5's door; doffed her gloves, gown, and mask in the doorway; stepped into the hallway wearing goggles; and donned a new mask. This observation showed she did not perform hand hygiene before donning a new mask. An additional observation revealed SRNA #2 then walked down to the next doorway, sanitized her hands, and walked down the hallway into other residents' rooms; however, she did not disinfect her goggles when she exited Resident #5's room. Interview with SRNA #2, on 07/28/2020 at 5:30 PM, revealed she had worked at the facility for one (1) year. Additionally, the facility had provided her with training related to COVID-19, TBP, PPE and Infection Control procedures. Per interview, she was trained by the facility on how to correctly don and doff PPE according to CDC guidelines, and PPE and disinfectant were always available as needed. Continued interview revealed masks and goggles were worn in the facility at all times. She stated for residents who were on Droplet Precautions, staff were supposed to take off their extended use regular masks and hang them on the doorway outside the residents' rooms and put on a new mask, a new gown, and new gloves before entering an isolation room. SRNA #2 stated when exiting an isolation room, PPE worn in the room should be removed and placed in the receptacles in the room before going into the hallway. Further, she stated the next step was to enter the hallway, put on a fresh mask, disinfect the goggles, and then perform hand hygiene. However, SRNA #2 did not verbalize she knew to perform hand hygiene before donning a clean mask. SRNA #2 stated she knew what to do per guidelines, but she missed the hand hygiene steps because she was nervous. Additionally, she stated she should have cleaned her goggles before walking in the hallways and into other rooms. Further, SRNA #2 stated it was important to follow infection control guidelines to reduce the spread of pathogens. 3. Observation, on 07/29/2020 at 11:00 AM, revealed Housekeeper #3 on the Bourbon Street Unit, in and out of a resident's room and the therapy gym wearing a mask under her nose. Interview with Housekeeper #3, on 07/29/2020 at 11:05 AM, revealed she had received training on COVID-19 and how to properly wear a face mask, but wearing a mask over her nose at all times made her glasses fog up. Further, she stated it was important to wear PPE to decrease the risk of passing illness along to people. 4. Observation, on 07/29/2020 at 11:10 AM, on the Makers Mark Unit, revealed Housekeeper #4 in and out of residents' rooms and in the hallway wearing a mask under her nose. Interview with Housekeeper #4, on 07/29/2020 at 11:15 AM, revealed she had received training on COVID-19 and how to properly wear a face mask, but wearing a mask over her nose at all times made it hard for her to breathe. Further, she stated it was important to wear PPE to decrease the risk of passing illness along to people. Interview with Licensed Practical Nurse (LPN) #1, on 07/28/2020 at 5:40 PM, revealed she had worked at the facility for three (3) years and was assigned to the hallway where Resident #4 and #5 resided. Per interview, the facility had provided training/education on COVID-19, TBP, PPE and Infection Control procedures. Additionally, she revealed she had been the facility Staff Development Coordinator and Infection Preventionist for a while. Further, she stated she was constantly watching all staff to ensure compliance with Infection Control practices and would provide re-education as necessary; however, she had not identified any concerns with SRNA #1 and #2's infection control practices. Continued interview revealed anytime a staff member entered an isolation room, hand hygiene should be performed and new PPE should be donned. She stated she expected SRNA #1 and #2 to perform hand hygiene before donning PPE; each time they entered a resident's room; each time they exited a resident's room; before donning a new dedicated mask; and after cleaning eye protection. LPN #1 stated not maintaining guidelines for infection control increased the risks and sources of cross contamination to other residents and staff. Interview with the Director of Nursing (DON), on 07/30/2020 at 12:15 PM, revealed she expected staff should don and doff PPE per facility policy and CDC guidelines each time they entered and exited an isolation room, including washing their hands prior to donning and after doffing PPE. Additional interview revealed eye protection should be disinfected each time staff exited an isolation room. Further, she stated it was important to maintain Infection Control policy and procedure to prevent transmission of disease. Continued interview revealed her surveillance and audit process did not identify problems/concerns with staff performing hand hygiene, disinfecting eye protection, or wearing masks per CDC guidelines. Interview with the Administrator, on 07/30/2020 at 12:45 PM, revealed he had worked at the facility for six (6) weeks. Additionally, he stated he expected staff to maintain facility policies and regulations related to infection control practices. Specifically, he mentioned hand hygiene before donning and after doffing PPE; wearing PPE (masks) correctly; and disinfecting eye protection after being in an isolation room. Further, the Administrator stated it was important to maintain infection control practices to ensure residents' safety and decrease the risk of infection.

Based on observation, interview, record review, review of facility policies, and review of the Kentucky Board of Nursing (KBN), Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure services provided by the facility meet professional standards of quality for two (2) of four (4) sampled residents (Residents #3 and #4). Resident #3 had current physician's orders [REDACTED]. Interview with Resident #3, on 01/13/2020, revealed he/she had requested the narcotic pain pill on the evening of 01/12/2020 and again during the morning of 01/13/2020, but the nurse on duty said it was not available, and offered him/her [MED] ([MEDICATION NAME]), instead. Interview, on [DATE]20 with Licensed Practical Nurse (LPN) #2, revealed [MEDICATION NAME] 7.5/325 mg was not available for Resident #3 the evening of 01/12/2020 and the morning of 01/13/2020. In addition, Resident #3 and Resident #4 did not get their scheduled [MEDICATION NAME] Subcutaneous (SQ) Injection medication (anticoagulant medication) on 01/13/2020 as staff could not locate the medication which had been placed in the Medication Cart instead of the Treatment Cart used to store injectable medications. Nursing staff was unaware the medication was available in the facility Emergency Drug Kit (EDK). The findings include: Review of the facility Medication Administration 7.1 General Guidelines, dated 09/2018, revealed medications are administered in accordance with the written orders of the prescriber. Review of the facility physician's orders [REDACTED]. All medication administration errors or omissions identified in the Electronic Medication Administration Record [REDACTED]. Review of the KBN, AOS #14, revised October 2015, Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statutes (KRS) 314.021 (2), nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (ARNP). This includes preparing and administering medications in the prescribed dosage, route, and frequency. 1. Review, of Resident #3's clinical record revealed the facility admitted the resident on 12/24/19 with [DIAGNOSES REDACTED]. Review of Resident #3's physician's orders [REDACTED]. ([MEDICATION NAME]-[MEDICATION NAME] is a narcotic pain medication) Further review of Resident #3's Physician order [REDACTED]. ([MEDICATION NAME] is an anticoagulant medication used to treat and prevent blood clots) Interview, on 01/13/2020, 2:30 PM, with Resident #3, revealed the facility admitted him/her on 12/24/19 from an acute care hospital, and he/she anticipated discharge to home this week. Resident #3 further stated he had two (2) knee replacements at the acute care hospital in November 2019, but fell at the hospital one (1) day after the knee surgery and sustained another fracture. Further interview revealed he/she was receiving rehabilitation therapy at this facility prior to going back home. Additional interview with Resident #3, revealed the nurse on duty 0[DATE]20, told him/her that his/her injectable anti-coagulant and narcotic pain medication were both about to run out. Resident #3 stated he/she had requested the narcotic pain pill, [MEDICATION NAME] 7.5/325 mg on the evening of 01/12/2020 and again during the morning of 01/13/2020, but the nurse on duty said it was not available, and offered him/her [MED] ([MEDICATION NAME]), instead. He/she stated his/her pain was an eight (8) or a nine (9) on 01/12/2020 and 01/13/2020, if referring to a pain scale of one (1) to ten (10) with ten (10) being the worst pain. Additional interview revealed he/she had not received his/her ordered anticoagulant today (01/13/2020). Review of Resident #3's Medication Administration Record [REDACTED]. Further, the resident received [MEDICATION NAME] ER, 650 mg on 01/13/2020 at 8:00 AM. Additional review of the MAR, revealed the resident did not receive his/her subcutaneous dose of [MEDICATION NAME] on 01/13/2020. LPN #1 signed off on the MAR, noting she did not administer the [MEDICATION NAME]. Observation, on 01/14/2020 at 9:40 AM, of the Back Hall Medication Cart, with Certified Medication Technician (CMT) #4, revealed a package containing seven (7) [MEDICATION NAME] 30 mg/milliliter (ml) injections prescribed to Resident #3 was stored in the Medication Cart. In addition, there was a package of seven (7) doses of [MEDICATION NAME] 40 mg/0.4 ml prescribed to Resident #4. Interview with CMT #4, on 01/14/2020 at 9:40 AM, who was assigned to the Medication Cart, revealed the [MEDICATION NAME] subcutaneous injections were supposed to be stored in the licensed nurse's Treatment Cart. She stated only licensed nurses could administer injectable medications. She further stated the injections were probably stored in the CMT's Medication Cart by accident when pharmacy delivered them. CMT #4 then notified Registered Nurse (RN) # 1, that Resident #3 and Resident #4's [MEDICATION NAME] medication had been stored in the Medication Cart. Further observation on 01/14/2020 at 9:42 AM, revealed RN #1 gave Resident #3 his/her subcutaneous injection. Resident #3 stated, Has that been here all this time because I did not receive it yesterday. RN #1 responded she was unable to attest to that because she had been off duty and had just returned to work. Resident #3 then inquired about the status of the [MEDICATION NAME] 7.5/325 mg pain medication, and stated he/she had just returned from his/her Physical Therapy session. Shortly after the resident's request for pain medication, on 01/14/2020, at 9:44 AM, RN #1 returned to the room with medication, stating it was [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablet and administered the medication to Resident #3. Interview with RN #1, on 01/14/2020 at 9:45 AM, revealed the [MEDICATION NAME] 5-325 mg dose was available in the Narcotic Emergency Drug Kit (EDK), so she contacted the Physician and obtained an order for [REDACTED].#3 and further discuss the resident's needs for pain relief. Further interview with RN #1, revealed injectable medications should be stored in the licensed nurse's Treatment Cart and not in the Medication Cart used by the CMTs for oral medications, because only the nurses administered the injectable medications. RN #1 went to the nurse's Treatment Cart to store the [MEDICATION NAME], which had previously been stored in the CMT's Medication Cart. Resident #3's package now had six (6) doses of the medication because the nurse had just administered one (1) of the injections to the resident. The package had a label affixed that indicated the medication was filled by the pharmacy on 01/13/2020. Continued interview with RN #1, revealed Resident #3 should have received the 01/13/2020 dose of [MEDICATION NAME] 30 mg/0.3 ml because even if it was not available in the Treatment Cart, [MEDICATION NAME] 30 mg/0.3 ml was available in the facility's EDK. RN #1 further stated, if the medicine was not available in the EDK, the licensed nurse should have called the pharmacy and requested a STAT (immediate) delivery of the medication. Interview, on [DATE]20 at 7:18 PM with LPN #1, revealed on 01/13/2020, she observed that Resident #3's [MEDICATION NAME] injectable anticoagulant was not available in the Treatment Cart. She stated injectable medications were stored in the Treatment Cart because only the licensed nurses could administer injectable medications. LPN #1 stated she did document via the MAR indicated [REDACTED]. She stated she called the pharmacy to find out if the medication had been delivered, but pharmacy staff confirmed it had not been re-ordered and therefore not delivered. LPN #1 further stated she clicked the re-supply button in the computerized system, and re-ordered the medication. Continued interview with LPN #1, revealed Resident #3 was receiving [MEDICATION NAME] anticoagulant medication because he/she was status [REDACTED]. LPN #1 stated she was not aware the facility's EDK contained [MEDICATION NAME] 30 mg/0.3 ml injectable doses. LPN #1 stated the licensed nurses were responsible for re-ordering medication when low in stock, to ensure residents never missed doses of their medications. Interview, on [DATE]20 at 5:10 PM, with LPN #2, revealed she worked the night shift on 01/12/2020 and that night [MEDICATION NAME] 7.5/325 mg was not available for Resident #3 when he/she requested it. LPN #2 stated she offered the resident [MEDICATION NAME] because the resident stated his/her pain level was a three (3) out of a possible ten (10) on the pain scale, with (10) being the worst pain. Further, she checked with Resident #3 later in the shift and the resident informed her the [MEDICATION NAME] was effective for relieving his/her pain. LPN #2 stated she notified the Medical Provider to get an updated prescription for the [MEDICATION NAME] 7.5/325 mg tablets, and provided the pharmacy's fax number. LPN #2 further stated she called the pharmacy at approximately 4:00 AM to see if they had received the prescription. Per interview, the pharmacy staff told her they did not yet have an updated prescription for Resident #3's medication. LPN #2 stated when she gave report to the oncoming day shift staff, she asked them to follow up on the status of Resident #3's prescription for [MEDICATION NAME]. 2. Review of Resident #4's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's physician's orders [REDACTED]. Review of Resident #4's MAR, dated 01/01/2020-01/14/2020, revealed the resident did not receive his/her dose of [MEDICATION NAME] 40 mg/0.4 ml on 01/13/2020. LPN #1 documented the medication was not administered. Additional interview on [DATE]20 at 7:18 PM, with LPN #1, revealed Resident #4's doses of [MEDICATION NAME] 40 mg/0.4 ml were not in the Treatment Cart on 01/13/2020, and Resident #4 did not receive his/her dose of that medication on that date. LPN #1 stated she reordered Resident #4's [MEDICATION NAME] at the same time she reordered Resident #3's medication. She stated she made a mistake by not checking the facility's EDK for the doses of [MEDICATION NAME] for Residents #3 and #4, because both strengths of the medication were available in the EDK. Observation, on 01/14/2020 at 10:08 AM, revealed the facility's EDK contained [MEDICATION NAME] 30 mg/0.3 ml and [MEDICATION NAME] 40 mg/0.4 ml injectable preparations for use. Review of the Narcotic EDK, revealed [MEDICATION NAME] 7.5 Milligram (mg)/325 mg was not among the contents. However, [MEDICATION NAME] 5/325 mg tablets and [MEDICATION NAME] 10/325 mg tablets were stored in the Narcotic EDK. Interview, on 01/16/2020 at 1:03 PM, with the Director of Nursing (DON), revealed the facility's EDK included [MEDICATION NAME] 30 mg and 40 mg doses which were available for administration, if necessary. She stated the licensed nurse should have been aware that the injectable anticoagulant was included in the EDK stock. Per interview, the EDK should have been used to obtain the medication for Resident #3 and Resident #4 in order for them to receive the morning doses on 01/13/2020 and then the nurse could have reordered the medications through the routine reordering process. Further interview with the DON, revealed nurses were supposed to ask residents to describe their pain via a numerical pain scale, and if Resident #3 stated his/her pain level was a three (3) out of a possible ten (10), then it would seem acceptable to offer the [MEDICATION NAME] first before trying the [MEDICATION NAME]. However, she stated if the resident had an active order for [MEDICATION NAME] 7.5/325 mg, it should have been available in case [MEDICATION NAME] 650 mg did not relieve the resident's pain. Further interview with the DON, revealed she was to review the Medication Administration Report available through the Matrix Electronic Record Storage System, as per facility policy. However, she stated she did not review the Medication Administration Report for the weekend of 01/11/2020 and 01/12/2020, at the end of the day on 01/13/2020, or on the morning of 01/14/2020 due to the State Survey was initiated on 01/13/2020. The DON stated if she had reviewed the reports, she would have identified Residents #3 and #4 did not receive their 01/13/2020 doses of the anticoagulant. In addition, she would have completed an event report and notified the residents' Physicians and responsible parties. Per interview, the Report would have helped her identify the nurse who did not administer the medications, and she could have re-educated the nurse. She stated she did normally review the Reports on a routine basis, as the Reports were essential for tracking medication error rates and omissions. She stated it was important to review the Reports in order to identify medication errors, in order to keep the residents safe. Interview, on 01/16/2020 at 3:16 PM, with the Administrator, revealed Residents #3 and #4 should have received their anticoagulant medications, as ordered by the physician. She stated it did not shock her that the nurses was not aware the [MEDICATION NAME] doses were available in the facility's EDK. Per interview, there was a need for ongoing education with the nursing staff related to the EDK process. Further, it was her expectation that staff order narcotic pain medications prior to the stock running out for the residents to ensure pain was controlled Continued interview with the Administrator, revealed the data collected through the Medication Administration Reports was useful in discovering the root cause of medication errors and omissions. She stated she learned about medication errors and omissions during daily Clinical White Board meetings with the Interdisciplinary Team (IDT) Members. Per interview, the Clinical White Board meetings did not occur as usual during the present week, because the State Survey was occurring. Otherwise, she said the IDT would have caught those medication omissions. She stated going forward the DON and the Assistant Director of Nursing (ADON) would be responsible for conducting routine medication cart audits to ensure medications were available for administration.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to store, prepare, and serve food under sanitary conditions. Observation of the kitchen revealed a scoop in the brown sugar storage container. In addition, kitchen staff prepared food without wearing a beard restraint. The findings include: Review of the facility's policy, Food Storage, revised 09/14/18, revealed to label and date all stored containers or bins, and keep them free of scoops. Review of the facility's policy, Personal Hygiene/Safety, revised 03/05/19, revealed beards or any body hair that might be exposed (i.e., arms) must be covered. Uncovered, short (hairs no longer than 1/8 inch in length), and well-groomed mustaches would not pose a food safety hazard. Observation of the kitchen, on 05/21/19 at 10:44 AM, revealed a scoop in the brown sugar container located on the prep table and a male Cook with a beard that was not covered as he prepared food. Interview with the Dietitian, on 05/21/19 at 11:01 AM, revealed the facility was out of beard guards and she had instructed male staff to wear hairnets as beard guards until the next shipment of beard guards arrived. Interview with the Dietary Aide (DA), on 05/23/19 at 9:21 AM, revealed the scoop had been in the brown sugar for a while and she understood if a scoop was left in the container, it posed a contamination risk. She stated the Dietary Manager (DM) and the Nutritionist had trained her on cross-contamination. The DA stated the beard guard shipment had not arrived so staff had been wearing hairnets as beard guards. Interview with the Cook, on 05/23/19 at 9:31 AM, revealed he prepared breakfast and forgot to remove the scoop from the brown sugar. The Cook stated the facility did not have scoop holders so the scoops were removed after every use and washed. According to the Cook, beard guards should be worn at all times when prepping food; however, the facility was out of beard guards and hairnets were to be utilized until the shipment came in. The Cook stated beard guards were necessary to keep hair from falling into the food, which could cause cross-contamination and residents to become ill. Interview with the DM, on 05/23/19 at 10:10 AM, revealed she had no idea why the scoop was in the brown sugar and had been reminding staff about sanitation in the kitchen including removing the scoop from dry products. The DM stated she completed undocumented audits of the kitchen and had noticed sometimes staff rushed and forgot to remove the scoop from the brown sugar, which could cause cross-contamination and result in residents becoming sick. The DM revealed the facility had been out of beard guards for thirty (30) days but they came in yesterday. She stated the beard guards covered hair and protected the food. The DM further stated she was not aware the cook did not have one covering his beard on 05/21/19.

Based on observation, interview, record review, and review of the facility's glucometer reference manual, it was determined the facility failed to calibrate glucometers (used to check blood sugar levels) to ensure accuracy for six (6) of six (6) glucometers on three (3) of three (3) halls, East, West, and Back Halls. In addition, the control solutions to calibrate the glucometers were expired. The findings include: The facility did not provide a policy for calibration of glucometers. Review of the Assure Platinum Blood Glucose Monitoring System: Quality Assurance/Quality Control (QA/QC) Reference Manual, revised (MONTH) 2014, revealed the control solution should be used within 90 days (3 months) of first opening. Observation of the West Hall treatment cart, on [DATE] at 2:40 PM, revealed two (2) bottles of glucometer control solution (normal and high) labeled with an open date of [DATE] and two (2) bottles with no open date. Interview with Licensed Practical Nurse (LPN) #1 during the observation revealed control solution should be used within 90 days of opening. She stated there was a risk for incorrect glucose readings and insulin dosing if expired controls were used to calibrate the glucometers. The LPN revealed night shift nurses were responsible for calibrating the glucometers. Further observation on [DATE], revealed two (2) bottles of glucometer control solution on the East Hall and two (2) bottles on the Back Hall were not labeled with open dates. Review of the facility's Glucose Monitoring System: Quality Control Record, dated (MONTH) 2019, revealed the serial numbers for the glucometers were not listed on the log to determine which glucometer was calibrated and the glucometers were not calibrated daily for the East/West Halls. The facility did not provide a Quality Control Record for the Back Hall. Review of the Quality Control Records, dated (MONTH) 2019, revealed the serial numbers of the glucometers were not listed and the glucometers were not calibrated daily for the West and Back Halls. The facility did not provide a Control Record for the East Hall. The facility did not provide (MONTH) 2019 Quality Control Records for the East, West, or Back Halls. Interview with LPN #2, on [DATE] at 3:00 PM, revealed open bottles of glucose control solution expired on the date listed on the manufacturer label. According to the LPN, night shift nurses were responsible for calibrating the glucometers. Interview with Registered Nurse (RN) #2, on [DATE] at 1:18 PM, revealed she probably did not check for the open or expiration date on bottles of control solution. She further revealed she checked glucometer controls on night shift for the East and Back Halls; however, she did not know where to document the results. The RN stated she did not ask the Director of Nursing (DON) for direction on calibrating the glucometers or documenting the results because management was already gone for the day when she came to work. According to RN #2, a resident could potentially get the wrong dose of insulin if the glucometer was not calibrated or the control solution was expired. Interview with the DON, on [DATE] at 2:29 PM, revealed the night shift nurse was responsible for calibrating glucometers daily. The DON stated the nurse should list the serial number of each glucometer and document the calibration results daily for each the facility's six (6) glucometers. She revealed the DON was responsible for ensuring nurses calibrated the glucometers and documented the results in the log daily; however, she had not been monitoring glucometer calibrations. She further revealed there were no additional Quality Control Records available and it appeared the records were not retained. The DON stated there was a potential for incorrect blood glucose readings if a glucometer was not calibrated. Interview with the Interim Administrator, on [DATE] at 1:09 PM, revealed the DON was responsible for ensuring all glucometers were calibrated daily. The Administrator stated he was not aware of any issues related to glucometers prior to the survey.

Based on observation, interview, and record review, it was determined the facility failed to ensure temperatures were monitored for six (6) of six (6) resident refrigerators on one (1) of three (3) Halls, the West Hall. The findings include: Review of the facility's Housekeeping In-service Training, undated, revealed it was the responsibility of every housekeeper to check and log the temperature of every refrigerator during the housekeeping routine on any given day. All refrigerators had a thermometer inside and a log to record temperatures attached to the exterior. After checking the temperature, the housekeeper must record the temperature on the log attached to the refrigerator. The housekeeper should also clean both the inside and outside of the refrigerator the same as any other piece of furniture in the room (including all resident rooms and other locations a refrigerator might be located within a given housekeeping routine). Observation of the West Hall, on 05/21/19 beginning at 9:38 AM, revealed there were no temperatures documented on the logs attached to the refrigerators located in Rooms 1B, 3A, 8A, 10A, 13B, and 14A. The facility did not provide Refrigerator Temperature Logs for resident refrigerators. Interview with Certified Nursing Assistant (CNA) #4, on 05/23/19 at 2:03 PM, revealed she thought the third shift nurse was responsible for checking the temperatures of resident refrigerators. She stated it was important to monitor the temperatures because a resident could potentially get sick if he/she ate spoiled food. Interview with CNA #4, on 05/23/19 at 1:53 PM, revealed she was not sure who was responsible for checking the temperature of refrigerators in resident rooms. Interview with Registered Nurse (RN) #2, on 05/23/19 at 1:18 PM, revealed CNAs on night shift were responsible for checking the temperature of resident refrigerators. She stated it was important to monitor the refrigerators to ensure there was no spoiled food and prevent the risk of salmonella or other foodborne illness. Interview with the Director of Nursing (DON), on 05/23/19 at 2:29 PM, revealed she was not monitoring the resident refrigerators and was under the impression housekeeping staff was monitoring the temperatures. Interview with the Director of Housekeeping/Account Manager, on 05/23/19 at 3:10 PM, revealed housekeeping staff was responsible for checking and logging temperatures of resident refrigerators daily; however, temperatures were not logged because there were no thermometers in the refrigerators. He further revealed different processes were in place at different facilities to monitor refrigerators and he did not know who was responsible for monitoring the refrigerators for this facility. Interview with the Interim Administrator, on 05/24/19 at 1:09 PM, revealed the facility did not monitor the refrigerators located in resident rooms to ensure refrigerator temperatures were maintained. The Administrator revealed he was responsible for monitoring and oversight of the housekeeping department.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene during medication administration on one (1) of three (3) halls, the West Hall. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, revised (MONTH) (YEAR), revealed the facility considered hand hygiene the primary means to prevent the spread of infection. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. The policy further revealed alcohol-based hand rub containing at least 62% alcohol, or soap (antimicrobial or non-antimicrobial) and water, should be used before and after direct contact with residents. Observation of medication administration on the West Hall, on 05/21/19 at 2:59 PM, revealed Registered Nurse (RN) #1 assessed the lungs, checked the pulse oximetry (ox), added medication to the nebulizer machine, and adjusted the nebulizer tubing for the resident in room [ROOM NUMBER] Bed B. The nurse did not perform hand hygiene after contact with the resident, and assessed the blood pressure and pulse ox of the resident in Bed A. She discarded a cup of liquid and moved the over bed table with her bare hands. The nurse did not perform hand hygiene after contact with the resident in Bed A and the table, and returned to the resident in Bed B and discontinued the nebulizer and assessed the resident's lungs and pulse ox. Interview with RN #1, on 05/22/19 at 3:30 PM, revealed hand hygiene should be performed before and after contact with a resident to prevent the spread of infection. She stated she should have performed hand hygiene but there was no sanitizer or bathroom in the residents' room. Interview with RN #2, on 05/23/19 at 1:18 PM, revealed staff should perform hand hygiene before and after contact with a resident to prevent the spread of germs and potential infection to other residents. Interview with the Director of Nursing (DON), on 05/23/19 at 2:29 PM, revealed staff should perform hand hygiene before and after contact with a resident to prevent potential exposure and the spread of infection. She stated the Staff Development Coordinator audited medication administration annually and there were no issues identified with hand hygiene or infection control. According to the DON, it was important to perform hand hygiene because the elderly population was more susceptible to infection. Interview with the Interim Administrator, on 05/24/19 at 1:09 PM, revealed the facility was always educating staff on handwashing and infection control. The Administrator stated he was not aware of any concerns related to infection control.

Based on interview, record review, facility policy review, and facility investigation review it was determined that the facility failed to report an allegation of abuse within two (2) hours for one (1) of three (3) sampled residents (Resident #1). On 05/10/19, a facility hospitality aide allegedly observed State Registered Nurse Aide (SRNA) #2 smack Resident #1 on the lips while assisting the resident with a shower. However, the hospitality aide did not report the allegation to facility Administration until three (3) days later, on 05/13/19. The findings include: Review of facility policy titled Abuse, Neglect, and Misappropriation of Property, undated, revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment are to be reported immediately, but no later than two hours after the allegation is made. Review of Resident #1's medical record revealed the facility admitted the resident on 12/01/15 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/10/19, revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the assessment. Review of the facility's final investigation dated 05/17/19 revealed Hospitality Aide #1 was in the bathroom on 05/10/19 assisting SRNA #2 with giving Resident #1 a shower when she observed SRNA #2 smack Resident #1 on the lips. Interview with Hospitality Aide #1 on 05/19/19 at 1:20 PM revealed on 05/10/19 she had observed SRNA #2 hit Resident #1 on the mouth while she was assisting the resident with a shower. Further interview with Hospitality Aide #1 revealed she had been trained to report any allegations of abuse to facility Administration immediately. Hospitality Aide #1 reported that she procrastinated in reporting the allegation because she was concerned about retaliation from SRNA #2. Interview with the facility Director of Nursing (DON) on 05/19/19 at 1:35 PM revealed staff were trained upon hire and at least monthly thereafter to report any allegation of abuse immediately to facility Administration. Continued interview with the DON revealed it was not acceptable to wait three (3) days to report an allegation of abuse. Interview with the facility Administrator on 05/19/19 at 1:56 PM revealed all facility staff were trained to report any allegations of abuse immediately. Continued interview with the Administrator revealed Hospitality Aide #1 should have immediately reported the allegation involving SRNA #2 and Resident #1 that occurred on 05/10/19.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the comprehensive care plan for one (1) of six (6) sampled residents, Resident #3. Resident #3 exited the facility, unwitnessed, and staff found the resident in a neighboring yard. The findings include: Review of the facility's policy, Comprehensive Care Plans, undated, revealed a person-centered comprehensive care plan, developed for each resident, included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. In addition, the care plan included how the facility would assist the resident to meet their needs, goals, and preferences. Further review revealed the facility implemented care plan interventions after consideration of the resident's problem areas and causes. Review of the clinical record for Resident #3 revealed the facility admitted him/her on 04/10/17, with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility completed the Staff Assessment for Mental Status and determined the resident had severely impaired cognition. The facility assessed the resident wandered one (1) to three (3) days and required extensive assistance of one (1) staff for locomotion off the unit. Review of the Comprehensive Care Plan for Resident #3, dated 04/20/17, revealed the resident was at risk for elopement with a goal that the resident would not elope from the facility and the resident's whereabouts monitored on an on-going basis. Interventions included monitoring the resident for tailgating when visitors were in the building, use diversional activities when exit-seeking behaviors occurred, use of an audible monitoring system to alert staff to exit seeking behaviors, and take the resident for a walk when trying to exit. Review of a facility Investigation, dated 07/06/18, revealed Resident #3 exited the facility on 07/02/18, unsupervised, and staff found and returned the resident in less than two (2) minutes, with no injuries noted. Interview with Certified Nursing Assistant (CNA) #1, on 07/25/18 at 3:50 PM, revealed she worked on 07/02/18 when Resident #3 exited the facility. She stated the resident's family came to visit and told staff he could not find the resident. A search began and the resident was found outside in the neighbor's yard. Interview with CNA #2, on 07/26/18 at 10:15 AM, revealed she worked on 07/02/18, and earlier in the evening before Resident #3 eloped, CNA #2 twice observed Resident #3 approach an exit door and push on the exit door. CNA #2 stated both times she approached Resident #3 and successfully re-directed the resident. CNA #2 stated at approximately 7:30 PM, she observed Resident #3 ambulating in the hall and the resident turned a corner towards the back of the facility, out of sight. She stated since Resident #3 liked to walk around the facility, and since CNA #2 was tending to the needs of another resident, she did not follow Resident #3. Interview with CNA #1, on 07/26/18 at 3:40 PM, revealed she was aware Resident #3 often wandered around the facility but could not specify what interventions to employ in order to re-direct Resident #3, or how to supervise Resident #3. Interview with the Director of Nurses (DON), on 07/26/18 at 11:25 AM, revealed staff was to supervise Resident #3 when the resident ambulated. The DON stated staff should retrieve a resident if the resident ambulated out of sight, around a corner, or should walk along with the resident. The DON did not know if staff followed the comprehensive care plan on 07/02/18, as she was unaware if any staff witnessed Resident #3 attempting to exit the facility.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision for one (1) of six (6) sampled residents, Resident #3. On 07/02/18, Resident #3 exited the facility without staff knowledge. The findings include: Review of the facility's policy, Elopement/Wandering, not dated, revealed the facility was to maintain resident safety by identifying residents at risk for wandering/elopement behavior. Review of the facility's policy, Secure (Wandering) Systems on Doors, dated (MONTH) 2005, revealed all exterior doors of the building would be in compliance with all state and local codes for paths of egress. The facility would have secured doors with proper means of egress. All the doors would alarm when opened without the proper steps followed, ensuring the safety of the residents and staff members. The doors were checked daily, Monday through Friday Review of Resident #3's clinical record revealed the facility admitted him/her on 04/10/17, with [DIAGNOSES REDACTED]. Review of the Physician Orders, dated 07/03/18, revealed an order for [REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility completed the Staff Assessment for Mental Status and determined the resident had severely impaired cognition. The facility assessed the resident wandered one (1) to three (3) days and required extensive assistance of one (1) staff for locomotion off the unit. Review of Resident #3's Care Plan, dated 04/20/17, revealed the resident was at risk for elopement with interventions to use diversional activities when exit seeking , take the resident for a walk when trying to exit, and use audible monitoring system to alert staff of exit seeking behavior. Review of a facility Investigation, dated 07/06/18, revealed on 07/02/18, staff found Resident #3 outside the facility. Staff interviews revealed around 8:00 PM, Resident #3's family could not find the resident, a search for the resident began, and the resident was found within two (2) minutes unharmed. Observation of the facility's exit doors, on 07/24/18 at 10:15 AM, revealed the entrance/exit door at the front main lobby was equipped with a Wanderguard alarm that locked the door when a resident wearing a Wanderguard came to close to the door. The remaining exits were egress exits, including the West Hall exit and the West Laundry exit. The egress doors had a fifteen (15) second delay for release and alarmed when opened. Interview with Certified Nursing Assistant (CNA) #1, on 07/25/18 at 3:50 PM, revealed she worked the night of 07/02/18, and the weather was stormy with lightning, thunder, and it was raining very hard. She stated she was assigned to the West Hall and the door alarms kept sounding and the panel indicated the West Hall exit and the West Laundry exit. The door alarms had been going off for about thirty (30) minutes and then Registered Nurse (RN) #1 called the maintenance man to report the sounding alarms and he said they normally did that when the weather was stormy. She stated Family #1 came to visit Resident #3 and said he could not find him/her so CNA #1 looked in the resident's room on the East Hall, notified the nurse on the East Hall that she could not find Resident #3, and notified the CNAs assigned to the resident, CNA #2 and #3, as they were in a room with another resident. She stated she looked for Resident #3 on the West Hall as Resident #3 had previously gone into other resident rooms. She stated Resident #3 was missing for about fifteen (15) to twenty (20) minutes and then staff found him/her in the neighbor's yard. Interview with RN #1, on 07/25/18 at 10:20 AM, revealed she worked the West Hall the evening of 07/02/18 and the exit doors were not functioning correctly, as a result of a storm. She stated the alarms had gone off about three (3) times, which the location box identified was the West Hall exit door that was near the nurses' station. She stated she personally checked the West Hall exit door and no residents were near the door. The alarm panel also indicated the West Courtyard Door alarmed and staff checked and verified there were no residents in that area. She stated when an alarm sounded, staff was to go and visualize the area and look for any residents inside or outside the door. Staff was to then enter a code, turn the alarm off, and clear the panel. She stated she called the Director of Maintenance (DOM) after the doors alarmed three (3) times, which was before Resident #3 exited the building. She stated the DOM said he would call the alarm company and inform them of what was going on and would be on his way into the facility. She stated the alarms sounding were the fire door alarms at the West Hall exit, which had a fifteen (15) second delay to open. She stated the West Laundry exit door the resident exited never alarmed. RN #1 stated when she was notified Resident #3 was missing from his/her room; all staff went room to room looking for him/her, as she was the lead and provided direction. She stated she and another staff split the perimeter of the exterior of the building, one going each way and she proceeded out the West Laundry exit and observed Resident #3 sitting on the grass at about 7:30 PM-7:40 PM. The RN stated she returned Resident #3 into the facility and completed a head to toe assessment and identified no injuries and notified Resident #3's family that the resident was okay. Review of the facility's Alarm Response Report, for the West Laundry Exit, dated 07/02/18, revealed the alarm sounded at 7:20 PM for 38 seconds, at 7:37 PM for 1 minute and 30 seconds, at 7:38 PM for 6 seconds, and at 7:52 PM for 6 seconds. The West Hall Exit alarmed on 07/02/18, at 6:15 PM, 6:17 PM, 6:18 PM, 6:20 PM, 6:23 PM, and at 6:28 PM. Interview with Family #1, on 07/25/18 at 12:45 PM, revealed he came to visit Resident #3 on 07/02/18 and the resident was not in his/her room. He stated Resident #3 frequently walked around and sometimes went in other residents' rooms. He stated he asked the nurse where the resident might be and stated staff moved quickly and it only took a couple of minutes to find Resident #3. Interview with the DOM, on 07/26/18 at 1:30 PM, revealed he received a call around 7:30 PM- 8:30 PM on 07/02/18, about issues with the doors and arrived at the facility around 9:00 PM. The DOM stated when he arrived; all the doors were working properly. He stated he checked the alarms daily for proper function. The DOM stated the facility had issues with the West Hall exit door one other time, and found that thunder jarred the door and caused the alarm to sound. He stated he was not aware of any issues with the West Laundry exit door or alarm. Interview with the Director of Nursing (DON), on 07/26/18 at 11:25 AM, revealed staff called her on 07/02/18 at 7:49 PM about the elopement. The DON stated she was not aware of any issues with exit doors or alarms that day. Interview with the Administrator, on 07/26/18 at 1:12 PM, revealed he was notified of the elopement and came in to the facility on [DATE]. He stated staff informed him the door alarms malfunctioned because of storms in the area and Resident #3 exited through the West Laundry exit door, where staff found him/her sitting on the ground.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement their policies and procedures related to an allegation of abuse for one (1) of four (4) sampled residents, Resident #4. Two (2) staff failed to report an allegation of abuse made by Resident #4 per the facility's policy. The findings include: Review of the facility's policy, Abuse, Neglect, and Misappropriation or Property, undated, revealed the facility defined mental abuse as including, but not limited to, humiliation, threats of punishment or deprivation, withholding of goods or services, or any other statements or behavior that a reasonable person would consider humiliating, demeaning, or threatening to a resident. The facility defined verbal abuse as including, but not limited to, the use of any oral, written, or gestured language that includes any threat, frightening, disparaging, or derogatory language to the resident. The facility policy further revealed every stakeholder would immediately report any allegation of abuse to the charge nurse on duty. The facility policy defined an allegation of abuse as a report, complaint, grievance, statement, or incident that occurred or plausibly might have occurred. Directly after assuring the resident's safety, the charge nurse was to inform the facility Administrator/Abuse Coordinator, the Director of Nursing (DON), the Physician, and the resident's representative of the allegation of abuse. The Administrator then investigated all allegations, reports, grievances, and incidents that potentially could constitute an allegation of abuse. Review of Resident #4's clinical record revealed the facility admitted the resident on 01/05/17, with [DIAGNOSES REDACTED]. After a hospitalization , the facility readmitted the resident on 02/05/17, with additional [DIAGNOSES REDACTED]. The facility discharged the resident on 02/10/17. Review of the five (5) day Minimum Data Set assessment for Resident #4, completed 02/10/17, revealed the facility assessed the resident required extensive one (1) person assistance to complete toileting, personal hygiene, and dressing. The resident also required extensive one (1) person assistance to walk in his/her room and to transfer between surfaces, including to or from the bed, wheelchair, or standing position. Further, the facility conducted a Brief Interview for Mental Status examination during the assessment and assessed the resident with a score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Telephone interview with Resident #4's family member, on 03/08/17 at 11:16 AM, revealed the resident reported a couple of nights prior to the 02/05/17 hospitalization , a female Certified Nursing Assistant (CNA) on the night shift put her finger in the resident's face when the resident called for assistance to use the bathroom. Interview with the Licensed Practical Nurse (LPN), on 03/08/17 at 2:40 PM, revealed a few nights prior to Resident #4's 02/05/17 discharge to the hospital, the resident told the LPN he/she had a problem with a CNA on night shift. The resident told her he/she wanted to speak with the Administrator about the situation. The LPN stated the resident then reported the CNA on night shift had told him/her she was in the facility to assist the resident, not to do for the resident. The LPN stated she talked with the night shift nurse who stated she had overheard the entire interaction and stated the CNA was appropriate with the resident. The LPN stated she told the Administrator the resident wanted to see him, but did not tell the Administrator what the resident reported to her. The LPN stated the resident complained a lot and she thought he/she was complaining, not making an allegation of abuse. The LPN stated when a resident made an allegation of abuse, the facility trained her to first ensure the safety of the resident, and then report it to the Administrator immediately. Interview with the Certified Occupational Therapy Assistant (COTA), on 03/08/17 at 3:41 PM, revealed Resident #4 reported to her a CNA on night shift had yelled at him/her. The COTA stated the resident told her when he/she needed to go to the bathroom; the CNA told the resident he/she could do it by himself/herself. The COTA further stated the Therapy department had not yet released the resident to complete transfers and toileting independently at that time. She stated the resident reported the CNA was yelling at him/her that he/she was supposed to do it independently. After the resident reported the incident to her, the COTA stated she reported it to the resident's nurse. The nurse told the COTA she had already talked to the nurse from third shift who reported the CNA talked to the resident calmly and encouraged the resident to increase independence appropriately. The COTA further stated she thought the nurse had taken care of the situation because the nurse knew about it and was already talking to others about it. The COTA stated she did not report the incident to the DON or Administrator because she believed the nurse had already done that. Further interview with the LPN, on 03/08/17 at 4:20 PM, revealed the COTA reported Resident #4 had told her a CNA on night shift was mean to him/her. The LPN stated by then, she had already discussed the situation with the night shift nurse who stated she had overheard the entire interaction and the CNA had not been inappropriate with the resident. Further, she stated she had already told the Administrator the resident asked to speak with him. She stated she felt she had taken care of the situation. Interview with the Director of Nursing (DON), on 03/08/17 at 3:58 PM, revealed the facility trained all staff to report allegations of abuse to the next higher up person. She stated the COTA should have reported the incident to the Administrator, as he was her direct supervisor. Additionally, she stated the Administrator was the facility's Abuse Coordinator, and the facility trained all employees to report abuse allegations to him. She stated she was the supervisor for the LPN who received the report from Resident #4. The LPN did not report to her that Resident #4 had an issue with a CNA on night shift. The DON stated the LPN should have reported the incident to her or to the Administrator. She stated it was not the nurse's responsibility to investigate; it was her responsibility to report. The DON stated there was a possible risk to residents due to a breakdown in the reporting procedure. Interview with the Administrator, on 03/08/17 at 1:50 PM, revealed staff did not report Resident #4's concerns about a CNA on night shift to him. He stated the LPN told him the resident wanted to speak to him. He stated he did go and speak with the resident; however, the resident discussed concerns with call light response times and issues with getting assistance. He stated the resident did not bring up issues concerning a CNA at that time. The Administrator stated he trained staff to report issues they did not know how to handle or instances of abuse to him. He stated staff could report abuse concerns to the nurse and the nurse could call him if he was not in the building. The Administrator stated anytime anything aggressive happened or anytime a resident stated they did not feel safe, staff needed to report it. A resident reporting a staff yelled at him/her would be aggressive.

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents were provided with a comfortable and home-like environment on three (3) of three (3) hallways. Residents' interior bathroom doors were scraped, gouged, chipped, and discolored. In addition, two (2) residents' bathroom door casings were rusted at the base, caulk sealing was missing around the base of two (2) residents' toilets, and one (1) resident's bathroom sink drained slowly. The findings include: The facility did not provide a policy regarding building maintenance. Observation of resident room 20, on 01/25/17 at 2:11 PM, revealed while checking the water temperature in the bathroom sink, the water did not drain. Observation of the facility, on 01/27/17 at 08:13 AM, revealed the bathroom doors in resident rooms 4, 8, 13, 14, 24, 26, 34, and 37 were cracked at the bottom. The bathroom doors in resident rooms 1, 4, 8, 11, 13, 14, 24, 26, 28, 30, 34, 37, and 39, were discolored and required painting. The shared bathroom for resident rooms 30 and 32 had a strong smell of urine, the toilet base had missing caulk sealing and rusted bolts, and both bathroom door casings were rusted and crumbling at the base. The bathroom sink in resident room 20 drained slowly; and resident rooms 26 and 28's shared bathroom had rusted door casings at the base and the caulk sealing was missing around the toilet base. Review of Unsampled Resident A's clinical record revealed the facility assessed the resident on 12/02/16, with a Brief Interview for Mental Status score of nine (9) out of fifteen (15) and determined the resident was interviewable. Interview with Unsampled Resident A, on 01/27/17 at 11:15 AM, revealed he/she thought the bathroom toilet base looked dirty and the bathroom door casing was rotting away. Unsampled Resident A stated maintenance was supposed to paint the bathroom over six (6) months ago. Interview with Certified Nursing Assistant (CNA) #3, on 01/27/17 at 11:45 AM, revealed the bathroom door casings looked dirty. She stated the toilets needed sealing immediately. She stated staff logged maintenance concerns into the Maintenance Book kept at the nurse's station. Staff could also verbally tell maintenance staff about their concerns and after maintenance staff fixed the issue, they checked it off as completed in the Maintenance Book. Review of Work Orders in the Maintenance Book, dated 10/31/16 to 1/20/17, revealed on 12/28/16, there was a work order for room 20's sink reporting it was stopped up and dirty. There was no indication the repair was completed. None of the other facility observations were logged in the Maintenance Book. Interview with the Plant Operations Director (POD), on 01/27/17 at 8:13 AM, revealed the corporate office gave him a color scheme in April 2016 to paint hallways and corridors, but the plan did not include resident rooms and bathrooms. Further interview with the POD, on 01/27/17 at 1:35 PM, revealed the residents' nicked the doors with their wheelchairs, which caused pieces of the door's wood to surface. He stated the scuffs and scrapes on the doors needed painting so they would look more homelike. The POD also stated the bathroom toilet bases in rooms 32 and 28 looked horrible, needed deep cleaning to rid the smell of urine, and need re-caulking. The POD stated the bathroom door casings in rooms 32 and 28 were rusted and crumbled when touched. The POD stated room 20's sink would overflow if the water consistently ran, he fixed it once, but it needed to be addressed before the sink was completely clogged. According to the POD, he walked through the facility to monitor maintenance issues. He would write concerns on a note pad and cross them off as maintenance completed the repairs. He stated he checked the maintenance logbook daily. The POD stated he saw faults in the system he utilized because several maintenance issues were not addressed and still needed fixing. Interview with the Administrator, on 01/27/17 at 1:45 PM, revealed he observed several areas of maintenance issues that needed to be addressed because they looked bad.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care in accordance with the Comprehensive Care Plan for one (1) of sixteen (16) sampled residents, Resident #4. Observation revealed Resident #4 was in contact isolation and staff failed to follow care plan isolation precaution interventions while providing care. In addition, a visitor was observed in Resident #4's room, not wearing Personal Protective Equipment (PPE). The findings Include: Review of the facility's policy, Isolation-Categories of Transmission Based Precautions, revised January 2012, revealed infections requiring Contact Precautions included diarrhea associated with [MEDICAL CONDITIONS]. Gloves and gowns were to be worn upon entering the room. After removing the gown, do not allow clothing to come in contact with potentially contaminated environmental surfaces. Gloves were to be changed if having contact with infective material and hand hygiene performed before leaving the room. The facility would implement a system to alert staff to the type of precautions the resident required. The facility would also ensure the resident's care plan indicated the type of precautions implemented for the resident's infection. Review of the facility's policy, [MEDICAL CONDITION], revised July 2014, revealed when caring for residents with diarrhea or fecal incontinence caused by [MEDICAL CONDITION], staff would maintain vigilant hand hygiene. Hand washing with soap and water was superior to antibiotic hand rubs (ABHR) for the mechanical removal of [MEDICAL CONDITION] spores from hands. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 11/17/16, with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set assessment, dated 11/24/16, revealed the facility assessed Resident #4 as not interviewable with a score of five (5) out of fifteen (15) on his/her Basic Interview for Mental Status. Further review of Resident #4's clinical record, revealed a lab report, dated 01/23/17, which gave a positive result for [MEDICAL CONDITION] infection. Review of a physician order, dated 01/24/17, revealed the physician ordered [MEDICATION NAME] (an antibiotic) to treat the [MEDICAL CONDITION] infection. Review of Resident #4's Care Plan for Active Infection, initiated 12/02/16, revealed the resident had a history of [REDACTED]. The care plan was updated/revised on 01/24/17, and revealed there was a physician's orders [REDACTED]. The interventions for care of the resident included good clean hygiene techniques to avoid cross contamination, especially hand washing before meals and after bowel movements, and use of Personal Protective Equipment (PPE), if indicated. Review of the Certified Nursing Assistant (CNA) Care Plan for Resident #4, not dated, did not reveal any instructions for care specific to the resident's new and active [MEDICAL CONDITION] infection. Observation of breakfast tray pass, on 01/26/17 at 7:15 AM, revealed Resident #4 had an isolation cart outside the room and CNA #1 gowned, gloved, and entered the room. CNA #1's gown strings touched and dragged across the resident's room floor as she had not tied the gown strings around her waist. CNA #1 removed one glove from her hand and touched Resident #4's bed rail with her bare hand. CNA #1 sanitized her hands with sanitizing solution from a bottle inside her pocket after she exited Resident #4's room. Observation, on 1/26/2017 at 11:36 AM, revealed Resident #4 had a visitor in his/her room who was not wearing PPE. The visitor adjusted Resident #4's pillow, touched Resident #4's bedside table, blanket, and bed remote control. A CNA entered the room to provide care to Resident #4 and the visitor left the room. The visitor did not perform hand hygiene prior to leaving the room and stood in the hallway touching the handrail on the right side of the hallway. Observation during lunch tray pass, on 1/26/2017 at 11:51 AM, revealed CNA #2 entered Resident #4's room with his/her lunch tray and did not don PPE. CNA #2 sat the tray on the resident's bedside table and touched the bedside table with her bare hands, pushing the table up to the resident. Interview with CNA #2, on 1/26/2017 at 1:12 PM, revealed the facility policy on contact isolation precautions was to don PPE before entering a resident's isolation room. She stated she should have put a gown and gloves on prior to entering the resident's room. She stated she could have placed other residents and employees at risk of acquiring [MEDICAL CONDITION] by not following contact precautions. Interview with CNA #1, on 01/27/17 at 1:35 PM, revealed before she entered Resident #4's contact precaution room, she should have tied her gown. She stated she could not remember if she touched Resident #4's bed rail without a glove, and she should have washed her hands before she exited the resident's room. CNA #1 stated she mainly worked with restorative nursing in the dining room, but she helped serve the residents' meal trays and she made mistakes. CNA #1 also stated the Staff Development Coordinator trained her on contact precautions, how to apply PPE, and infection control six (6) months ago, but she was nervous and forgot. According to CNA #1, she knew Resident #4 had [MEDICAL CONDITION] and she could have transferred the bacteria to other residents, staff, and visitors by not following the contact precautions policy and procedures because [MEDICAL CONDITION] was very contagious. Interview with Licensed Practical Nurse (LPN) #1, on 01/27/17 at 11:00 AM, revealed Resident #4 had an active infection ([MEDICAL CONDITION]) that required the use of PPE when providing care to the resident. LPN #1 stated the sign outside Resident #4's room, posted at the isolation supplies cart, was an alert to staff to follow protocol for isolation. If staff entered the resident's room for any reason, staff was to don a disposable gown and a pair of disposable gloves, and staff was to dispose of the worn PPE and wash their hands with soap and water before exiting the resident's room. LPN #1 stated she would use soap and water to cleanse her hands before leaving Resident #4's room, not hand sanitizer. LPN #1 stated PPE use was for any person who entered/spent time in Resident #4's room. Interview with the Assistant Director of Nursing (ADON), on 01/27/17 at 1:40 PM, revealed the component of Resident #4's Care Plan, Personal Protective Equipment, if indicated, meant the use of PPE would go into effect when caring for the resident when he/she had an active infection, such as [MEDICAL CONDITION]. The ADON stated Resident #4 currently had [MEDICAL CONDITION]; therefore, staff should don PPE when entering the resident's room. The ADON stated if staff did not observe the precautions for contact isolation, then they were not following the components in Resident #4's Active Infection Care Plan. The ADON further stated the care plan component that spoke to observing hand hygiene applied to Resident #4 and the staff who provided his/her care. Interview with the Director of Nursing (DON), on 01/27/17 at 2:53 PM, revealed PPE use was indicated for Resident #4 as he/she had been diagnosed with [REDACTED]. The DON stated the care instructions in the resident's Active Infection Care Plan were set up for the resident, but all direct care staff and visitors were educated to use PPE and perform hand hygiene when the resident was under Contact Precautions. The DON stated if staff touched bed rails in the resident's room with ungloved hands, did not wear PPE in the room, and did not wash their hands before leaving Resident #4's room, then they did not follow the care plan. The DON stated she conducted periodic, random observations of staff and conducted an on the spot in-service education to correct issues with staff non-compliance.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a Pneumococcal vaccination was administered to one (1) of sixteen (16) sampled residents, Resident #7, to minimize the risk of the resident acquiring, transmitting, or experiencing complications of Pneumonia. The findings include: Review of the facility's policy, Pneumococcal Vaccine, revised August 2016, revealed all residents would be offered Pneumococcal vaccines to aid in preventing Pneumonia/Pneumococcal infections. Pneumococcal vaccines would be administered to residents unless medically contraindicated, already given, or refused. Review of the facility's Informed Consent for Pneumococcal Vaccine, revised 04/24/15, revealed the Advisory Committee on Immunization Practice recommended two (2) Pneumococcal vaccines for adults 65 (sixty-five) years of age or older. If a resident had a pneumonia vaccine after the age of 65 (sixty-five), then the resident should receive a second vaccination. Review of the clinical record for Resident #7 revealed the facility admitted the resident on 10/06/15, with the [DIAGNOSES REDACTED]. Review of Resident #7's quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Review of Resident #7's Pneumococcal and Influenza Vaccination consent form, dated 10/16/15, revealed the resident stated he/she had a Pneumococcal vaccination in 2013. There was no documented evidence the resident had received the Pneumococcal vaccine in 2013. Review of Resident #7's Informed Consent for Pneumococcal Vaccine revealed the resident gave the facility permission to administer a Pneumococcal vaccination on 10/16/16. Review of Resident #7's Immunization Report revealed the facility administered a Pneumococcal vaccination on 01/25/17. Interview with Resident #7, on 01/27/17 at 8:17 AM, revealed the resident told the facility when admitted that he/she had received the Pneumonia vaccine from her primary care physician. Resident #7 stated the nurse asked him/her if he/she wanted a Pneumococcal vaccination approximately five (5) months ago and the resident said yes. Resident #7 stated the nurse forgot to give him/her the vaccine, but came to him/her yesterday and asked if he/she still wanted the Pneumococcal vaccination and administered it yesterday. The resident stated he/she had never had Pneumonia and wanted the vaccination so he/she would not get Pneumonia because he/she was sick enough. Interview with Centers for Disease Control (CDC) Operator, on 01/27/17 at 9:06 AM, revealed the CDC recommended adults sixty-five (65) years and older with certain diseases or immune deficiency, receive one (1) to three (3) doses of the Pneumococcal Vaccine and then another dose one (1) year later. Interview with Licensed Practical Nurse #3, on 01/27/17 at 9:30 AM, revealed Resident #7 signed the consent for the facility to administer the Pneumococcal vaccine on 10/16/16. The staff who had the resident sign the consent should have followed through with administering the vaccination or delegated the task to someone else. The facility administered the Pneumonia vaccine to residents to help prevent the residents from getting Pneumonia. Interview with the Assistant Director of Nursing (ADON), on 01/27/17 at 10:51 AM, revealed she administered Pneumonia vaccinations to the residents. She stated when the facility admitted Resident #7; the Pneumonia vaccination was not administered because the resident stated he/she had one in 2013. She stated she did not know if there was documentation of the 2013 vaccination. The ADON stated the Center for Disease (CDC) recommended one (1) dose of the vaccine for residents over sixty-five (65) unless the resident had Diabetes, [MEDICAL CONDITION], or an immune compromising condition. Resident #7 had Diabetes and was septic when admitted so he/she should have received a second Pneumonia vaccination. The ADON stated she administered Flu vaccinations facility wide in October 2016, and Resident #7 stated he/she also wanted the Pneumonia vaccination. She stated she gave Resident #7 a Flu vaccine and wanted to monitor the resident for signs and symptoms of a reaction for one (1) month, but after the month period she forgot to administer Resident #7's Pneumococcal vaccine. The ADON stated Resident #7 should have received the Pneumococcal vaccination after the resident signed the consent on 10/16/16, and she should have documented in the nursing notes why she did not administer the vaccine. The ADON also stated facility staff administered Pneumococcal vaccinations to prevent residents from getting Pneumonia.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure staff followed appropriate infection control practices for one (1) of sixteen (16) sampled residents, Resident #4. Resident #4 had a [DIAGNOSES REDACTED]. Observation revealed two (2) direct care staff not following contact isolation precautions when entering Resident #4's room. In addition, a visitor was in Resident #4's room not wearing Personal Protective Equipment (PPE). The findings include: Review of the facility's policy, Isolation-Categories of Transmission Based Precautions, revised January 2012, revealed infections requiring Contact Precautions included diarrhea associated with Clostridium difficile (C-diff). Glove use and handwashing was to be observed. Gloves were to be worn when entering the resident's room. While caring for the resident, gloves were to be changed if having contact with infective material. Gloves were to be removed and hand hygiene was to be performed before leaving the resident room. Disposable gowns were to be worn upon entering the room under Contact Precautions. After removing a disposable gown, do not allow clothing to come in contact with potentially contaminated environmental surfaces. Review of the facility's policy, Clostridium Difficile, revised July 2014, revealed[DIAGNOSES REDACTED] spores could persist on resident care items and surfaces for several months and frequent handwashing with soap and water by staff and residents was a necessary step toward prevention and early intervention. Vigilant hand hygiene and glove use when caring for residents with[DIAGNOSES REDACTED] was considered best practice. Observation of breakfast tray pass, on 01/26/17 at 7:15 AM, revealed Resident #4 had an isolation cart outside the room and CNA #1 gowned, gloved, and entered Resident #4's room. CNA #1 did not tie her gown strings around her waist and allowed them to touch and drag across the resident's room floor. CNA #1 removed one glove from her hand and touched Resident #4's bed rail with her bare hand. CNA #1 sanitized her hands with sanitizing solution from a bottle inside her pocket after she exited Resident #4's room. Observation, on 1/26/2017 at 11:36 AM, revealed Resident #4 had a visitor in his/her room not wearing PPE. The visitor adjusted the resident's pillow, touched the resident's bedside table, blanket, and bed remote control. When a Certified Nursing Assistant (CNA) entered the room to provide care to the resident, the visitor left the room without performing hand hygiene and stood in the hallway touching the handrail. Observation during lunch tray pass, on 1/26/2017 at 11:51 AM, revealed CNA #2 entered Resident #4's room with his/her lunch tray without donning PPE. CNA #2 sat the lunch tray on the resident's bedside table, touched the bedside table with her bare hands as she pushed the table up to the resident. Interview with CNA #2, on 1/26/2017 at 1:12 PM, revealed the facility policy on contact isolation precautions was to don PPE before entering a resident's isolation room. She stated she should have put a gown and gloves on prior to entering the resident's room. She stated she could have placed other residents and employees at risk of acquiring[DIAGNOSES REDACTED] by not following contact precautions. Interview with Licensed Practical Nurse (LPN) #1, on 1/27/2017 at 8:22 AM, revealed staff who witnessed a visitor in a Contact Isolation room not wearing PPE were supposed to educate the visitor on the risks and encourage the visitor to wear the proper PPE. She stated if a resident was on contact isolation precautions, all staff was required to wear the proper PPE. She stated staff should perform hand hygiene prior to entering a contact isolation room and don PPE. After providing care, staff should remove the PPE, and wash their hands with soap and water prior to leaving the resident's room. She stated other residents could become infected if proper precautions were not followed. Interview with CNA #1, on 01/27/17 at 1:35 PM, revealed before she entered Resident #4's contact precaution room, she should have tied her gown strings. She stated she could not remember if she touched Resident #4's bed rail without a glove, and she should have washed her hands before she exited the resident's room. CNA #1 also stated the facility's Staff Development Coordinator trained her on contact precautions, how to apply PPE, and infection control six (6) months ago, but she was nervous and forgot. According to CNA #1, she knew Resident #4 had[DIAGNOSES REDACTED] and she could have transferred the bacteria to other residents, staff, and visitors by not following the contact precautions policy and procedures. Interview with the Assistant Director of Nursing (ADON), on 1/27/2017 at 1:06 PM, revealed residents on isolation precautions had a sign on their door informing visitors to see the nurse before entering the room. She stated when family members spoke with staff nurses; the nurses informed them of the appropriate PPE and hand hygiene as well as the risks to the residents in the facility if the policy was not followed. She stated nurses who educated visitors on appropriate PPE were required to chart that the education was given. She stated if education was not charted, then it was not done. Interview with the Director of Nursing (DON), on 1/27/2017 at 1:51 PM, revealed all staff was required to don PPE prior to entering isolation precaution rooms. She stated the PPE rules were important because they kept staff from spreading the infection to others. Continued interview at 2:53 PM, revealed PPE use was indicated for Resident #4 as he/she had been diagnosed with [REDACTED]. The DON stated she had not given staff a directive to document any visitor education regarding use of PPE. The DON stated staff should cleanse their hands with soap and water before leaving a resident room when isolation precautions were in effect. The DON stated she conducted periodic, random observations of staff and took note of any observed breaks in proper isolation procedures and conducted an on the spot in-service education to correct the issues with staff non-compliance.

Based on interview, record review, and review of the facility's policy for Abuse Prohibition, it was determined the facility failed to identify and investigate an incident of resident neglect for one (1) of six (6) sampled residents (Resident #1). On 11/15/12 at 5:15 AM, Resident #1 fell face forward onto the hallway floor after staff assisted the resident to transfer in a wheelchair without foot rests to the shower room for toileting. Resident #1 sustained facial injuries and bleeding and was returned to bed per physician order. Resident #1 demonstrated both verbal and non-verbal signs and symptoms of pain; however, no documentation of a pain evaluation or evidence of pain treatment was documented by staff. Staff reported the fall and injuries sustained by Resident #1 to the Attending Physician, on 11/15/12 at 5:15 AM, and the resident was returned to bed per physician order. Staff failed to report Resident #1's injuries to the Administrator, Director of Nursing, and the Charge Nurse at the time of the incident. Resident #1 was transferred to a local hospital for evaluation and treatment of [REDACTED]. The facility's failure to identify and investigate an incident of neglect placed residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 11/29/12 and was found to exist on 11/15/12. The facility provided a Credible Allegation of Compliance (AOC) on 12/07/12 and the state agency verified Immediate Jeopardy was removed on 12/07/12 prior to exit on 12/07/12. The scope and severity was lowered to a D at 42 CFR 483.13 (F224) Prohibit Mistreatment, Neglect, Misappropriation while the facility develops and implements the Plan of Correction to establish an effective system to ensure incidents of neglect are identified and investigated. The findings include: Review of the facility's policy for Abuse Prohibition, dated 02/05/03, revealed the policy was developed to prohibit mistreatment, neglect or abuse of residents, and to provide a means for individuals to report acts, incidents, or events related to resident mistreatment, neglect, abuse, and misappropriation of resident property. The policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the clinical record for Resident #1 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A physician order, dated 06/27/12, revealed Resident #1 was an assist of two (2) staff for transfers with the use of the mechanical lift as needed. Review of the Falls Risk Screen for Resident #1, revealed no documented falls; however, review of the facility Falls log revealed Resident #1 fell in the shower due to weakness on 05/27/12, and on 08/22/12 the resident fell during an attempt to transfer unassisted by staff. Review of the annual Minimum Data Set for Resident #1, dated 06/12/12, revealed the functional status for transfer was total dependence with a two person physical assist and cited physical limitations as weakness due to recent hospitalization , limited range of motion, poor coordination, poor balance, visual impairment, and pain. Review of the CNA Care Tracker documentation revealed documentation by staff of Resident #1's transfers without the assist of two (2) staff members, on twenty (20) days in October, 2012 and six (6) days in November 2012. During the combined months of October and November, 2012, Resident #1 was transferred without the assist of two (2) staff members by CNA #1 on one (1) day, CNA #3 on two (2) days, CNA #9 on one (1) day, CNA #11 on two (2) days, CNA #12 on four (4) days, CNA #13 on eight (8) days, CNA #14 on three (3) days, CNA #15 on one (1) day, CNA #16 on one (1) day, and CNA #17 on three (3) days. Review of the facility's incident report, dated 11/15/12 which detailed the fall of Resident #1, was witnessed by one (1) staff member, CNA #1, and detailed the injuries: abrasion to the shoulder and right hip, laceration to the bridge of the nose and forehead, and left leg shorter than right. Review of the facility Post Fall Investigation Tool detailed that Resident #1 was pushed in the hall by CNA #1 without foot rests on the wheelchair and fell face forward out of the wheelchair, and the investigation revealed Resident #1 was wearing non-skid socks at the time of the fall. The facility evaluation of findings and documentation of conclusion was stated as "Resident did not have foot pedals on," and included an immediate facility response to reiterate the importance of foot rests. Interview, on 11/26/12 at 2:35 PM, with CNA #1 revealed on 11/15/12 at 5:15 AM she assisted Resident #1 to stand, pivot, and sit in a wheelchair without assistance and transported the resident to the shower room for toileting. CNA #1 said her shift ended at 6:00 AM and she was in a hurry to complete all of her job functions and did not think to put the foot rests on the wheelchair. CNA #1 stated as she pushed Resident #1 in the wheelchair, the resident lunged forward out of the wheelchair and landed face first on the floor. CNA #1 said Resident #1 was bleeding from her head and nose, and groaned in pain. CNA #1 said Resident #1 was returned to bed after the physician had been notified of the fall. CNA #1 stated she was not aware of a physician order [REDACTED].#1. Review of the Nurse's Notes, dated 11/15/12 at 5:15 AM, detailed Resident #1 had lacerations to the forehead and nose with abrasions to shoulder and throughout face, and was non-verbal but grimaced with movement. Nursing documentation revealed the status of Resident #1 was reported to the physician and an order was obtained to return the resident to bed and to clean lacerations and apply steri-strips. The nursing documentation included vital signs; however, there was no assessment of pain and no documentation of pain medication administration for Resident #1. Further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview by telephone, on 11/26/12 at 3:30 PM, with LPN #1, revealed she was not aware she did not provide a pain assessment for Resident #1, and stated she was more concerned with the physical injuries the resident sustained [REDACTED]. LPN #1 stated she was not aware that she could have called the Medical Director on the behalf of Resident #1 to request emergent treatment, and did not know she had the authority to contact EMS (Emergency Medical Systems) for transfer of the resident to an acute facility without an order from the physician in case of a resident emergency. Interview by telephone, on 11/26/12 at 4:03 PM, with RN #1 revealed she was working on 11/15/12 and was the designated Charge Nurse when Resident #1 fell . RN #1 stated she was not told by LPN #1 that Resident #1 fell , she overhead another staff member discussing the fall at 6:00 AM or 6:30 AM that morning. RN #1 said the shift had been very busy, but she went to take a look at Resident #1, and returned to the nurse's station and told LPN #1 the resident needed to "go out (to the hospital)." RN #1 stated a short time later, LPN #2 from day shift arrived and assisted LPN #1 to transfer Resident #1 to the hospital. RN #1 said she was a new nurse and stated she was "not always sure what to do" when she was assigned to the Charge Nurse role. Interview, on 11/27/12 at 7:10 AM, with CNA #3 revealed she was working on 11/15/12 at 5:15 AM when she heard a loud "thud," and what sounded like a wheelchair turned over. CNA #3 said she came out of a resident room and found Resident #1 lying face down on the hallway carpet with arms folded underneath the resident. CNA #3 said Resident #1 was bleeding from the face and noticed one leg appeared to be longer than the other. CNA #3 stated Resident #1 was in "obvious pain" and was returned to bed after physician notification. CNA #3 stated she stayed with Resident #1 in the resident's room from 5:30 AM until 7:30 AM, as the resident continued to bleed from the face and moan in pain. CNA #3 stated she reported the continued bleeding to the LPN #1 multiple times as she attempted to control the bleeding and told LPN #1 that Resident #1 was bleeding, in pain, and needed to go to the hospital. CNA #3 stated LPN #1 did not return to observe or assess Resident #1, from 5:30 AM until 7:30 AM. Interview, on 11/27/12 at 1:40 PM, with CNA #6 revealed on 11/15/12 she arrived to work at 6:00 AM and did walking rounds with CNA #1 and was told that Resident #1 had fallen face forward from the wheelchair without foot rests. CNA #6 said when she went into Resident #1's room she was shocked at what she saw; CNA #3 was holding wash cloths on the residents face, but the bleeding would not stop, the amount of blood was "awful", the resident groaned, and it was obvious the resident was in pain. CNA #6 said she did not finish rounds, she stayed with CNA #3 to try to stop the bleeding. CNA #6 said CNA #3 went several times to tell the nursing staff that Resident #1 continued to bleed, and CNA #6 said no nurses came to the resident's room, so at 7:00 AM, she went to speak with LPN #3 who had just clocked in to work and told her Resident #1 was bleeding badly. CNA #6 said LPN #3 told her, "Yes, I know, I have been told, just go to the room and apply pressure." CNA #6 said LPN #3 came into the room sometime later, just prior to the arrival of EMS. CNA #6 stated she did not believe the nursing staff responded appropriately to the concerns she and CNA #3 had reported and said Resident #1 should have not suffered like that, and stated the accident was avoidable if the foot rests had been placed on the wheelchair. Interview, on 11/27/12 at 2:37 PM, with LPN #3 revealed that she was working on 11/15/12 and received report from LPN #2 regarding the fall of Resident #1. LPN #3 stated Resident #1 was weak in both lower extremities and stated it would be dangerous to transport Resident #1 in the wheelchair without the foot rests on the wheelchair because the resident could not raise and hold his/her feet up for staff assisted wheelchair transfers. LPN #3 stated after obtaining report from LPN #2 at 7:00 AM, she went to observe Resident #1 and found the resident was bleeding from both nares, had multiple facial lacerations, and thought it was obvious the resident had a broken nose. Resident #1 told LPN #3 that he/she "hurt all over." Interview, on 11/30/12 at 2:30 PM, with the Vice President of Operations (VPO) revealed Resident #1's fall on 11/15/12 was an accident and should not have happened and was a result of the foot rests not being replaced on the wheelchair. The VPO stated as a result of the facility's investigation it was understood that Resident #1 did not have the strength or mobility to lunge from the wheelchair as reported by CNA #1, and it was determined by the facility investigation that the resident's feet became entangled under the wheelchair which caused the resident to be propelled from the wheelchair. The VPO stated CNA #1 and LPN #1 had been suspended pending the results of the facility investigation, and stated CNA #1 voluntarily terminated her employment with the facility. The VPO stated LPN #1 was terminated on 11/30/12 as a result of her failure to take emergent action to obtain emergency treatment, failure to follow the emergency procedure, and failure to document appropriate actions for Resident #1 on 11/15/12. Interview by telephone, on 12/02/12 at 10:50 PM, with LPN #6 revealed she was aware Resident #1 was a two (2) person assist and required foot rests on the wheelchair at all times because the resident was not able to self-propel in the the wheelchair due to limited mobility in the lower extremities. LPN #6 defined neglect as not taking care of a resident in the proper way, and stated when Resident #1 fell out of the wheelchair on 11/15/12, this was an incident of neglect because the foot rests were required to maintain the resident's safety. Interview, on 12/05/12 at 2:28 PM, with LPN #2 revealed when she arrived to begin her shift on 11/15/12 at 7:00 AM, she was told by CNA #6 that Resident #1 had fallen, was injured, and needed to go to the hospital for treatment. LPN #2 said she went to observe the extent of the injuries to Resident #1, and quickly determined the resident needed to be transferred to the hospital for treatment. LPN #2 stated due to the extent of Resident #1's injuries, she thought the resident was experiencing pain. LPN #2 said she noted the resident was doing a lot of swallowing and thought the resident may have been swallowing blood. LPN #2 stated her primary concern for Resident #1 was to get the resident to the hospital before the resident developed impaired respiratory function as a result of a non-apparent internal injury. LPN #2 stated neglect was defined as withholding care, food, treatment, or pain medication. LPN #2 stated Resident #1 should have been treated for [REDACTED]. Interview, on 12/05/12 at 1:43 PM, with the Medical Director revealed he participated in a Quality Assurance and Assessment meeting by phone during the prior week to determine facility interventions to prevent recurrence of falls, such as the fall sustained by Resident #1. The Medical Director stated he could not comment on what the appropriate nursing actions were when Resident #1 fell because he did not know what exactly happened and was not told of the extent of the injuries. The Medical Director stated when possible head trauma was suspected, it would be prudent to transfer the resident, even if the resident was a DNR (Do Not Resuscitate) status, to the hospital for an evaluation as soon as possible to ensure the best outcome, and said failure to take emergent action could be interpreted as neglect. Review of the acceptable Allegation of Compliance (AOC), on 12/07/12, revealed the facility took the following immediate actions: 1. The Medical Director was advised of the Immediate Jeopardy on 11/29/12. 2. The Corporate Consultant reviewed the Abuse Policy and Procedure with the facility Administrator, Director of Nursing, MDS Coordinator, Restorative Nurse, Nurse Supervisors, and Director of Staff Development on 12/04/12. 3. A mandatory in-service of the Abuse Policy and Procedure was provided to staff on 12/04/12, by the Director of Staff Development and no staff was permitted to work prior to completion of the mandatory education. 4. The Corporate Consultant and Administrator reviewed all reports of abuse completed over the prior six (6) months and it was determined there were no reports of abuse. In addition, the Corporate Consultant and Administrator reviewed all incident reports over the last thirty (30) days to ensure all appropriate investigations were completed by the facility to determine a conclusion or root cause. 5. All current residents were interviewed by the Master Social Services Worker (MSSW) to determine if any resident experienced or exhibited any signs of abuse or neglect. In the case of current residents who were identified not to be cognitively intact, the MSSW interviewed a responsible party for the resident to identify any signs or symptoms of abuse or neglect. The State Agency validated the AOC on 12/07/12 prior to exit as follows: 1. The State Agency validated by interview with the Medical Director, on 12/05/12 at 12:55 PM, revealed he was contacted by the facility Administrator and Corporate Consultant and advised of the Immediate Jeopardy, but was not certain of the date of notification. 2. The State Agency validated by review of the content of the Abuse Policy and Procedure, and review of the signed attendance sheet that the Administrator, DON, MDS Coordinator, Restorative Nurse, Nurse Supervisors, and Director of Staff Development received the training on 12/04/12. Validation was supported by Review of the POS [REDACTED]. 3. The State Agency validated by review of the content of the Abuse Policy and Procedure, and review of the signed attendance sheet that the staff received abuse and neglect training on 12/04/12 and no staff members were permitted to return to work prior to completion of the mandatory abuse training. Staff abuse interviews, on 12/01/12 at 12:45 PM with LPN #4, and on 12/06/12 at 6:30 AM with CNA #8, revealed both staff identified failure to provide necessary goods and services to a resident to meet their needs was neglect. Both LPN #4 and CNA #8 recognized failure to assess and treat resident pain constituted resident neglect. 4. The State Agency validated by record review and interview of the Administrator on 12/07/12 at 7:00 PM, there were no reports of abuse or neglect made within the facility in the last six (6) months. Further interview with the Administrator revealed all incident reports in the facility for the last thirty (30) days were reviewed and were initialed by the Administrator and the Corporate Consultant to validate the root cause of all incidents were determined after the facility completed a thorough investigation. 5. The State Agency validated by interview, on 12/07/12 at 6:45 PM, with the Director of Social Services that all cognitively intact residents were surveyed by the facility to determine if any residents had experienced or witnessed abuse or neglect in the facility. Review of the Resident Roster, used by the Director of Social Services for interview, revealed all cognitively intact residents were interviewed, and the responsible party was interviewed for residents who were not identified to be cognitively intact. It was determined that no residents or responsible parties of residents had experienced or witnessed abuse or neglect in the facility. 6. Attempts to further interview CNA #1, LPN #1, and RN #1 during the extended partial survey did not occur as multiple phone messages were not returned by the staff members. Interview, on 11/30/12 at 2:30 PM, with the VP of Operations revealed CNA #1 and RN #1 voluntarily terminated employment at the facility, and the employment of LPN #1 was terminated on behalf of the facility, on 11/30/12.

Based on observation, interview, record review, and review of the CMS Care Plan instructions provided by the facility, it was determined the facility failed to ensure the Nursing and CNA Care Plans for one (1) of six (6) sampled residents included interventions to ensure the use of foot rests on the wheelchair to maintain resident safety after it was determined the resident was dependent with use of the wheelchair and required foot rests at all times to maintain resident safety. On [DATE] at 5:15 AM, Resident #1 was transported in a wheelchair by staff without the use of foot rests on the wheelchair. Resident #1 fell from the wheelchair face forward onto the floor and sustained head injuries. Resident #1 was transferred to a local hospital for assessment and treatment on [DATE] at 8:30 AM and was diagnosed with [REDACTED]. On [DATE] at 2:00 PM, Resident #1 was transferred to the regional Level I Trauma Center for further treatment. The Resident expired on [DATE] at 3:20 PM. In addition, the facility failed to ensure the Nursing Care plans for three (3) of six (6) sampled residents (Residents #4, #5, and #6) were updated to reflect all necessary nursing interventions. The failure of the facility to ensure Nursing and CNA Care Plans were updated placed residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and was found to exist on [DATE]. The facility provided a Credible Allegation of Compliance (AOC) on [DATE] and the State Agency verified Immediate Jeopardy was removed on [DATE] prior to exit on [DATE]. The scope and severity was lowered to a D at 42 CFR 483.20 (F280) Revised Care Plan, while the facility develops and implements the Plan of Correction to establish an effective system to ensure care plans are revised appropriately and available to staff. The findings include: Review of the CMS 4.7 RAI (Resident Assessment Instrument) and Care Planning (copy) provided by the facility as the basis for the care plan function, determined the comprehensive care plan was an interdisciplinary communication tool that included measurable objectives, time frames, and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan was to be reviewed and revised periodically and the services provided or arranged should be consistent with each resident's written plan of care. 1. Review of the clinical record for Resident #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Falls Risk Screen for Resident #1, revealed no documented falls; however, review of the facility's Falls Log revealed Resident #1 fell in the shower due to weakness on [DATE], and on [DATE] the resident fell during an attempt to transfer unassisted by staff. Review of the annual Minimum Data Set for Resident #1, dated [DATE], revealed the functional status for transfer was total dependence with a two person physical assist and cited physical limitations of weakness due to recent hospitalization , limited range of motion, poor coordination, poor balance, visual impairment, and pain. Further review of the MDS revealed no documentation regarding Resident #1's prior falls on [DATE] or [DATE]. Review of the Care Area Assessment (CAA) Summary revealed Resident #1 triggered for Falls. The facility's 'Review of Indicators of Falls' detailed the facility's plan to develop a care plan for Resident #1 to address falls, based on risk factors related to the care area such as diuretic use with incontinence, arthritis, [MEDICAL CONDITION], and depression. Review of the facility's Care Plan for Resident #1, revealed the problem of falls was addressed by the facility as a result of diuretic use, glasses, and anti-depressant use with interventions developed to address the related problems identified. Resident #1's prior falls on [DATE] and [DATE] were not addressed by the care plan and no specific interventions were identified to address the falls risk such as required foot rests on the wheelchair. Review of the CNA (Certified Nursing Assistant) Care Plan, updated [DATE], revealed Resident #1 required assist of two (2) staff for transfers, with glasses, and oxygen as needed. The need for foot rests on the wheelchair for Resident #1 to maintain resident safety was not included on the CNA Care Plan. Review of the facility incident report, dated [DATE], which documented the fall of Resident #1 detailed the injuries as: abrasion to the shoulder and right hip, laceration to the bridge of the nose and forehead, and left leg shorter than right. Review of the facility Post Fall investigation tool detailed that Resident #1 was pushed in the hall by CNA #1 without foot rests on the wheelchair and fell face forward out of the wheelchair and the investigation revealed Resident #1 was wearing non-skid socks at the time of the fall. The facility evaluation of findings and documentation of conclusion was stated as "Resident did not have foot pedals on," and included an immediate facility response to reiterate the importance of foot rests. Interview by telephone with CNA #1, on [DATE] at 11:20 AM, revealed on [DATE] at 5:15 AM she transferred Resident #1 without assist of another staff member to a wheelchair. CNA #1 stated she did not remember to place the foot rests on the wheelchair before she transported Resident #1 to the shower room for toileting. CNA #1 stated as she pushed the wheelchair in the hallway, Resident #1 lunged forward from the wheelchair and fell face down on the floor and began to bleed from the head and nose. CNA #1 stated she was not aware Resident #1 required an assist of two (2) staff for transfers, however she was aware the resident required foot rests on the wheelchair at all times. Interview by telephone with LPN #1, on [DATE] at 3:30 PM, revealed when she assessed Resident #1 after the fall on [DATE] the resident did not respond to verbal stimulus and would only move to withdraw to painful stimulus. LPN #1 detailed the injuries to Resident #1 as lacerations to the left eyebrow, face, nose. LPN #1 said Resident #1 continued to bleed from the lacerations until the resident was transported via Emergency Medical Services that morning. Interview, on [DATE] at 12:29 PM, with the Director of Therapy (DOT) revealed that Resident #1 was last treated in June, 2012 and did not meet the Therapy Goals, as the resident still required an assist of two (2) staff with mechanical lift for transfers. The DOT recalled that Resident #1 had lots of pain, which was osteoarthritic (joint/bone pain as a result of aging) in nature. The DOT was not sure where in the chart staff would locate information related to whether a resident required foot rests on the wheelchair for staff assisted transfers. The DOT stated if a resident was evaluated by Physical Therapy to be dependent with the use of the wheelchair, she would assume the resident would also require foot rests on the wheelchair. The DOT stated the facility did not have a policy used to determine the need for a resident to have foot rests on the wheelchairs. The DOT stated that Physical Therapy did not evaluate all residents for the need of foot rests, because not all residents were referred for Physical Therapy Treatment at the facility. Interview, on [DATE] at 2:37 PM, with LPN #3 revealed that CNAs carry a copy of the CNA Care Plan with them during their shift, and said copies of the CNA Care Plans were maintained on each nursing station for staff to review. LPN #3 said the CNA Care Plan included individual resident care needs, to assist the CNA to provide appropriate care for each resident. LPN #3 said after review of the CNA Care Plan, updated [DATE], there was no documentation to ensure CNA staff were aware of the need for Resident #1 to maintain foot rests on the wheelchair at all times to maintain resident safety. LPN #3 stated if the information was not available on the CNA Care Plan, the staff would have no other way to determine the need for foot rests on the wheelchairs, and said the Director of Nursing (DON) was responsible for updating the CNA Care Plans. Interview, on [DATE] at 9:00 AM, with LPN #4 revealed that all CNAs should have been aware that Resident #1 required foot rests on the wheelchair at all times because it was documented on the CNA Care Plan. Upon review of the CNA Care Plan, last updated, [DATE], LPN #4 stated there was no documentation to state that Resident #1 required the foot rests and did not know why the information was not included on the CNA Care Plan. LPN #4 stated the CNAs relied on the information on the CNA Care Plan to provide the appropriate care to the residents. LPN #4 stated the Director of Nursing (DON) was responsible for updating the CNA Care Plans. Interview, on [DATE] at 1:25 PM, with CNA #2 revealed documentation of a resident need for foot rests on the wheelchair at all times should be documented on the CNA Care Plan. Upon review of the CNA Care Plan, last updated [DATE], CNA #2 found there was no documentation of the need for foot rests on the wheelchair for Resident #1. CNA #2 said staff understand when a resident was not able to lift and hold their feet for a staff assisted transfer in the wheelchair, the resident required the use of foot rests to maintain resident safety. Interview, on [DATE] at 6:01 AM, with CNA #8 revealed all CNAs use the CNA Care Plan as a guide to provide the appropriate care for residents. CNA #8 said if a resident required foot rests on the wheelchair at all times, it should be documented on the CNA Care Plan. Upon review of the CNA Care Plan, last updated [DATE], CNA #8 found there was no documentation of the need for Resident #1 to have the foot rests on the wheelchair. CNA #8 stated that some of the new CNA staff had complained a couple of months ago that the CNA Care Plans did not include the most current information, and said some necessary changes had been discussed before at a staff meeting. Interview, on [DATE] at 3:35 PM, with the Director of Nursing (DON) revealed that she was responsible for updating the CNA Care Plans and was aware there was no documentation of the need for the foot rests on the wheelchair at all times for Resident #1, but was not sure why the information was not current on the CNA Care Plan, last updated [DATE]. The DON stated she did not believe the facility's failure to ensure the foot rests were on the wheelchair for Resident #1 contributed to the fall on [DATE] because residents fall all of the time. However, the DON stated the failure to document the need for foot rests on the wheelchair on the CNA Care Plan could increase the risk of a fall for a resident. The DON stated no Falls Care Plan was initiated for Resident #1 because the resident never had any prior falls at the facility. Interview, on [DATE] at 12:13 PM, with the MDS Coordinator revealed she was responsible to develop care plans for residents who were triggered for a focused area and the care plan was reviewed with the Interdepartmental Team quarterly to determine effectiveness and necessary updates. The MDS Coordinator stated she was aware Resident #1 fell in the shower room and had another fall previously, but was not sure why the falls were not addressed on the Nursing Care Plan with appropriate interventions. The MDS Coordinator stated the Falls Care Plan was last reviewed for Resident #1 on [DATE]. 2. Review of the clinical record for Resident #4, revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#4, revealed in Section C the resident scored 04 on the Brief Interview for Mental Status (BIMS) testing, and the Care Area Assessment Summary triggered Cognitive Loss and the facility documented intention to Care Plan the Focus of Cognition to reduce further cognitive loss. Review of the Comprehensive Care Plan at the Nurse's Station, revealed no plan for Cognitive loss for Resident #4. Review of the clinical record for Resident #5, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], for Resident #5, revealed the Care Area Assessment (CAA) Summary identified Pressure Ulcer as a focus for the resident. The facility documented intention to address the focus of Pressure Ulcer for Resident #5 based on the resident taking anti-depressants, recent [MEDICAL CONDITION], and confinement to the bed or chair most of the time. Review of the Comprehensive Care Plan at the Nurse's Station revealed no plan for Pressure Ulcer for Resident #5. Review of the clinical record for Resident #6, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], for Resident #6, revealed the resident was on a toileting program and was occasionally incontinent of urine (less than seven episodes of incontinence in a week) and the Care Area Assessment (CAA) Summary identified Urinary Incontinence as a focus for Resident #6. The facility documented intention to care plan for Urinary Incontinence due to functional incontinence and [MEDICAL CONDITION] with the use of [MEDICATION NAME] for medical management. Review of the Comprehensive Care Plan at the Nurse's Station revealed no plan for Urinary Incontinence for Resident #6. Interview, on [DATE] at 2:55 PM, with the MDS Coordinator revealed she was not sure why the Comprehensive Care Plans stored in binders on the Nursing Unit was not complete for Resident #4, Resident #5, or Resident #6 and said the Care Plans could have been lost if a resident changed rooms, or maybe the Care Plan was developed, but failed to print and was not placed in the binder. The MDS Coordinator said the Nurse was responsible to ensure that the Comprehensive Care Plans in the binder were complete for each resident, and the Care Plan addressed the individual needs of each resident. The MDS Coordinator was able to provide a copy of the Care Plan for Resident #4 to address Impaired Cognition, dated [DATE], and a copy of the Care Plan for Resident #5 for Pressure Ulcers, dated [DATE], and stated the facility neglected to initiate a Care Plan for Resident #6 for Urinary Incontinence. Interview, on [DATE] at 12:30 PM, with the DON revealed the MDS Coordinator was responsible to initiate the care plan and staff were responsible to provide updates to the care plan as needed. The DON was not aware the care plans for Resident #4, #5, and #6 were not complete as posted in the Care Plan Books on the Nursing Station. The DON stated the failure to ensure the care plans posted were complete for each resident could impact the ability of staff to provide appropriate interventions and result in a failure to meet residents needs. Review of the acceptable Allegation of Compliance (AOC), on [DATE], revealed the facility took the following immediate actions: 1. The Medical Director was advised of Immediate Jeopardy on [DATE] by the Administrator and Corporate Consultant. 2. A multidisciplinary team, including the Director of Nursing (DON), Director of Physical Therapy, and others met on ,[DATE] and reviewed all resident care plans and CNA care plans on [DATE] to ensure completeness and inclusion of appropriate information to reflect the use of foot rests for residents determined to be in need of them on wheelchairs to maintain safety. 3. CNA care plans were updated on [DATE] by the DON to reflect the use of foot rests on wheelchairs based on reviews completed [DATE]. The Director of Staff Development was assigned to update the master CNA care plans weekly. CNA care plans were reviewed during the Resident Care Plan meeting to ensure the Nursing care plan and CNA care plan were consistent. 4. Staff in-services were provided by the Corporate Consultant on [DATE] to ensure staff were aware of the facility changes to the resident Care Plan regarding reviewing, revising, and the use of the care plan as a communication tool. All future hired staff would be educated about Care Plans by the Director of Staff Development during orientation. 5. The Care Plan Team was provided an in-service by the Corporate Consultant on [DATE] to detail the process and responsibilities of care plan revision The State Agency validated the AOC on [DATE] prior to exit as follows: 1. The State Agency validated by interview with the Medical Director on [DATE] at 12:55 PM revealed he was contacted by the facility Administrator and Corporate Consultant and advised of the Immediate Jeopardy, but was not certain of the date of notification. 2. The State Agency validated the facility actions to identify residents who required the use of foot rests on the wheelchair to maintain resident safety, by interview, on [DATE] at 6:30 PM, with the DON who also provided documentation of notes, which included discussions with the IDT to identify residents who required foot rests from the larger group of residents who used wheelchairs for mobility in the facility. Observations of residents in the facility who were determined to require the use of foot rests on the wheelchair were validated on [DATE] at 5:30 PM and at 5:45 PM in the facility hallways and dining areas. 3. The State Agency validated CNA Care Plans were updated by record review of the CNA Care Plans available at the East and West Nursing Stations, documented as last updated [DATE]. Interview with the Director of Staff Development on [DATE] at 6:00 PM, revealed she would be responsible to ensure the master CNA Care Plans were updated weekly, and that the CNA Care Plan was reviewed at the Resident Care Plan meeting to ensure both the Resident Care Plan and the CNA Care Plan included consistent information. 4. The State Agency validated an in-service was provided by the Corporate Consultant on [DATE] regarding Resident Care Plans by review of the content of the in-service and review of the attendance logs for the in-service. Interview, on [DATE] at 6:40 PM, with RN #3 revealed staff were trained to understand the responsibility to review and revise the Care Plan, and understood the Director of Staff Development was responsible to update the CNA Care Plan weekly. Interview, on [DATE] at 6:40 PM, with RN #3 regarding Care Plan in-service, revealed she did attend the in-service and verbalized understanding of the need for the CNA Care Plan to include resident care interventions that were consistent with the Nursing Care plan, and her responsibility to review the Resident and CNA Care Plan to ensure completeness. 5. The State Agency validated an in-service was provided by the Corporate Consultant on [DATE] by review of the facility documentation of the content of the in-service and the attendance log for the in-service. Interview, on [DATE] at 6:30 PM with the DON and on [DATE] at 7:00 PM with the Administrator revealed the Care Plan Team would be reviewing and revising the Resident Care Plan quarterly, and comparing the CNA Care Plan to determine both care plans contained consistent information with regard to individualized and safe resident care.

Based on observation, interview, record review, review of the facility's policy, and Nursing Job Descriptions, it was determined the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (1) of six (6) sampled residents, (Resident #1). Resident #1 fell from the wheelchair, on [DATE] at 5:15 AM, and sustained multiple injuries with bleeding from the head. At the time of the fall, Resident #1 demonstrated verbal and non-verbal signs of pain, which were identified by multiple staff members, but the facility failed to ensure the resident received a pain assessment and pain treatment. After the Attending Physician was notified of the fall, Resident #1 was returned to bed, continued to bleed from facial injuries, and exhibited verbal and non-verbal signs of pain, which was not addressed by the facility. The facility failed to ensure Resident #1 received necessary emergency treatment in a timely manner. Resident #1 was transferred to a local hospital, on [DATE] at 8:30 AM, which resulted in a three (3) hour delay in the treatment of [REDACTED]. The resident expired on [DATE] at 3:20 PM. The facility's failure to recognize the critical need for emergent treatment of [REDACTED]. Immediate Jeopardy was identified on [DATE] and was found to exist on [DATE]. The facility provided a Credible Allegation of compliance (AOC) on [DATE] and the state agency verified Immediate Jeopardy was removed on [DATE] prior to exit on [DATE]. The scope and severity was lowered to a D at 42 CFR 483.25 (F309) Provide Services for the Highest Well-Being, while the facility develops and implements the Plan of Correction to establish an effective system to ensure residents receive appropriate and timely interventions by staff to address emergent care needs. The findings include: Review of the facility's policy for Pain, dated [DATE], revealed the facility was to assess each resident for the presence of and potential for the occurrence of pain with a goal to recognize when a resident experienced pain to identify circumstances when pain could be anticipated. The facility adopted the Wong-Baker Pain Scale to aide in recognition of severity of pain, and included a reference list which included Non-verbal Indicators of Pain and Non-Pharmacological Interventions. The Pain policy stated caregivers were responsible to document pain each shift if the resident verbalized or demonstrated non-verbal signs of pain. Review of the clinical record for Resident #1 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set for Resident #1, dated [DATE], revealed the functional status for transfer was total dependence with a two person physical assist and cited physical limitations as weakness due to recent hospitalization , limited range of motion, poor coordination, poor balance, visual impairment, and pain. Review of the Nurse's Notes, dated [DATE] at 5:15 AM, detailed Resident #1 had lacerations to the forehead and nose with abrasions to shoulder and throughout face, and was non-verbal but grimaced with movement. Nursing documentation revealed the status of Resident #1 was reported to the physician and an order was obtained to return the resident to bed and to clean lacerations and apply steri-strips. The nursing documentation included vital signs; however, there was no assessment of pain and no documentation of pain medication administration for Resident #1. Further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview by telephone with CNA #1, on [DATE] at 11:20 AM, revealed on [DATE] at 5:15 AM she transferred Resident #1 without assist of another staff member to a wheelchair. CNA #1 stated she did not remember to place the foot rests on the wheelchair before she transported Resident #1 to the shower room for toileting. CNA #1 stated Resident #1 lunged forward from the wheelchair and fell face down on the floor in the hallway and began to bleed from the head and nose. CNA #1 stated her shift ended at 6:00 AM, and she was trying to complete her routine duties, and as a result she failed to place the foot rests on the wheelchair. CNA #1 said she was told the physician advised LPN #1 to return Resident #1 to bed. Interview by telephone with LPN #1, on [DATE] at 3:30 PM, revealed on [DATE] after Resident #1 fell she was not aware she did not document a pain assessment or treat the resident for pain as she was more concerned about the injuries and bleeding. Interview by telephone with RN #1, on [DATE] at 4:03 PM revealed she was the assigned Charge Nurse on [DATE]. RN #1 said she was not notified by LPN #1 that Resident #1 had fallen on [DATE], and overheard about the fall from another staff member. RN #1 said the third shift was very busy that night and she took one look at Resident #1, then went to the Nurse's Station and reported to the LPN #1 that the resident needed to go to the hospital. RN #1 stated she returned to her work, and she was aware that LPN #2 from dayshift arrived later, and assisted LPN #1 with the transfer of Resident #1 to the hospital. Interview, on [DATE] at 7:10 AM, with CNA #3 revealed she heard Resident #1 fall on [DATE], then saw the resident lying face forward on the floor bleeding from the face and nose in obvious pain as the resident was groaning. CNA #3 said she stayed with Resident #1 after the resident was returned to bed from 5:30 AM until 7:30 AM in an attempt to control the bleeding. CNA #3 stated that RN #1 (Charge Nurse) came into the room, looked at Resident #1 and said "Oh, My God," but never returned to the room. Interview, on [DATE] at 2:37 PM, with LPN #3 revealed she was working on [DATE] after Resident #1 had fallen from the wheelchair. LPN #3 stated after she obtained the shift report from LPN #2, and was told EMS (Emergency Medical Systems) was on the way, she went to see Resident #1. LPN #3 said Resident #1 was lying in the bed and thought it obvious the resident had a broken nose, had lacerations to the face, and was bleeding from both nares. LPN #3 said she talked to Resident #1, who responded and told her "I hurt all over." Interview, on [DATE] at 9:00 AM, with LPN #4 revealed she was working on [DATE] and was told that Resident #1 had fallen on third shift. LPN #4 said she had taken care of Resident #1 since the resident was admitted to the facility, and she went into the room of Resident #1 to say good-bye before the resident went to the hospital. LPN #4 said Resident #1 was bleeding from the nose and eyes, with multiple lacerations and it was apparent to her that the bleeding continued and the resident was experiencing pain, because of grimacing facial expressions. Interview, on [DATE] at 2:28 PM, with LPN #2 revealed that due to the extent of injuries to Resident #1 on [DATE], LPN #2 thought the resident was experiencing pain. LPN #2 stated because of the extent of Resident #1's injuries, she did not ask LPN #1 if the resident was assessed or treated for [REDACTED]. Interview, on [DATE] at 6:30 AM, with CNA #8 revealed when she saw Resident #1 after the fall on [DATE], the resident had an uncomfortable look on her face and she knew the resident was in pain. CNA #8 said the way Resident #1 looked, "that just had to hurt." Interview, on [DATE] at 12:30 PM, with the Director of Nursing (DON) revealed that she interviewed LPN #1 about Resident #1's fall on [DATE]. The DON stated that LPN #1 never mentioned that Resident #1 complained of pain; however, the DON did find that LPN #1 documented in the Nurse's Notes that the resident grimaced with movement. The DON stated grimacing would be considered a non-verbal sign of pain, and stated a pain assessment should have been completed and documented for Resident #1 and the resident should have been treated for [REDACTED]. Review of the acceptable Allegation of Compliance (AOC), on [DATE], revealed the facility took the following immediate actions: 1. The Medical Director was advised of Immediate jeopardy notification on [DATE] by the Administrator and Corporate Consultant. 2. The Director of Staff Development provided an in-service to all non-licensed nursing staff on [DATE] and completed on [DATE] regarding pain, which included identification of pain, reporting of pain, and update to the facility's Standard of Care. All future hired staff would receive this education during facility orientation. 3. The Corporate Consultant provided in-service to all licensed staff on [DATE] and was completed on [DATE] to educate staff on the facility Pain Management Policy to include verbal and non-verbal indicators of pain with focus on failure to assess and treat pain as an indication of resident neglect. 4. The Corporate Consultant reviewed the Pain Management Program with the Nurse Supervisor to ensure program implementation and effectiveness, on [DATE]. 5. All residents in the facility were individually assessed on [DATE] for pain by an Administrative Core Group to identify any residents who had experienced pain without treatment or ineffective treatment of [REDACTED]. The State Agency validated the AOC on [DATE] prior to exit as follows: 1. The State Agency validated by interview with the Medical Director, on [DATE] at 12:55 PM, revealed he was contacted by the facility Administrator and Corporate Consultant and advised of the Immediate Jeopardy, but was not certain of the date of notification. 2. The State Agency validated by review of the information provided to staff during the in-service on [DATE] which included hand-outs with non-verbal indicators of pain and an updated facility Standard of Care to include assessment and treatment of [REDACTED]. Interview, on [DATE] at 6:20 PM with CNA #9, and on [DATE] at 6:25 PM, with CNA #10 revealed both participated in the in-service and were able to correctly verbalize non-verbal signs of pain, and stated the responsibility of the CNA was to document pain on the Care Tracker system and advised the nurse. CNA #10 stated the CNA was further responsible to follow-up with the resident to ensure that the pain had been treated, and address the pain with the nurse again if necessary. 3. The State Agency validated by review of the information presented at the in-service on [DATE] with the licensed staff as well as the attendance log to ensure all licensed staff received the information. Interview, on [DATE] at 6:40 PM, with RN #1 verified that she did attend the Pain In-Service and understood the role and responsibility of the nurse in the assessment and treatment of [REDACTED]. 4. The State Agency validated the training of the Nursing Supervisor to ensure the implementation and effectiveness of the Pain Management Program with review of the educational material and discussions with review of the attendance log dated [DATE]. Interview, on [DATE] at 5:45 PM, with Nursing Supervisor #1 revealed she recently attended the Pain In-Service. Nursing Supervisor #1 stated CNAs were trained to document resident pain in the Care Tracker System, and to report the pain at once to the nurse, then at the end of the shift, the Care Tracker System reports would be reviewed by the manager to ensure CNA notifications of resident pain was addressed by nursing with a pain assessment and pain administration as necessary. 5. The State Agency validated that all residents in the facility were assessed on [DATE] to determine any resident who had not been assessed or treated for [REDACTED]. Interview, on [DATE] at 6:30 PM, with the DON revealed that by means of the complete facility resident audit for pain, only one (1) resident was identified to complain of pain that the resident felt had not been assessed or treated. The DON reviewed this resident and provided physician documentation of the nature of the resident's pain, as well as evidence that the resident had pain medication ordered, received the medication, and provided documentation of that the pain was reassessed after treatment, and it was documented the resident's pain was improved upon treatment.

Based on interview, record review, review of the facility's policy for Falls Management, and job descriptions for nursing staff, it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #1) was provided adequate supervision and assistive devices to ensure the resident was free from accident hazards. Resident #1 was identified by the facility to be dependent for transfers and wheelchair mobility, and required the assist of two (2) staff for transfers, with foot rests on the wheelchair at all times. On [DATE] at 5:15 AM, Resident #1 was transferred to a wheelchair without assistance of two (2) staff, and transported by staff in a wheelchair to the shower room for toileting without the use of foot rests. Resident #1 fell from the wheelchair face forward onto the floor and sustained head injuries. Resident #1 was transferred to a local hospital for assessment and treatment, on [DATE] at 8:30 AM, and was diagnosed with [REDACTED]. On [DATE] at 2:00 PM, Resident #1 was transferred to the regional Level I Trauma Center for further treatment. The resident expired on [DATE] at 3:20 PM. The facility's failure to provide adequate supervision and assistive devices to residents to ensure they were free from accident hazards placed residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and was found to exist on [DATE]. The facility provided a Credible Allegation of Compliance (AOC) on [DATE] and the state agency verified Immediate Jeopardy was removed on [DATE] prior to exit on [DATE]. The scope and severity was lowered to a D at 42 CFR 483.25 (F323) Residents Free of Accident Hazards while the facility develops and implements the Plan of Correction to establish an effective system to ensure residents receive adequate supervision and assistive devices to prevent accidents. The findings include: Review of the facility's policy for Falls Management, dated [DATE], revealed the facility screened all residents to identify possible risk factors for falls, evaluated the risks to residents, and implemented interventions to reduce risks and monitor interventions to be modified as necessary. The purpose of the facility's Falls Management policy was to identify residents with risk factors that may place the resident at risk for falls, and to manage those residents who experienced a fall to minimize the risk of the further falls, or to minimize the risk of injury related to a fall. Review of the clinical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the Falls Risk Screen for Resident #1, revealed no documented falls; however, review of the facility's Falls Log revealed Resident #1 fell in the shower due to weakness on [DATE], and on [DATE] the resident fell during an attempt to transfer unassisted by staff. Review of the annual Minimum Data Set for Resident #1, dated [DATE], revealed the functional status for transfer was total dependence with a two person physical assist and cited physical limitations of weakness due to recent hospitalization , limited range of motion, poor coordination, poor balance, visual impairment, and pain. Review of the Nursing Care Plan for Resident #1 revealed the facility developed a care plan to address falls as related to diuretic medications; however, no intervention was documented to direct staff to ensure foot rests were on the resident's wheelchair at all times to prevent falls. Review of the CNA Care Plan revealed no documentation to direct staff that Resident #1 required an assist of two (2) staff for transfers and foot rests on the wheelchair at all times. Review of the CNA Care Tracker documentation revealed documentation by staff of Resident #1's transfers without the assist of two (2) staff members, on twenty (20) days in October, 2012 and six (6) days in [DATE]. During the combined months of October and November, 2012, Resident #1 was transferred without the assist of two (2) staff members by CNA #1 on one (1) day, CNA #3 on two (2) days, CNA #9 on one (1) day, CNA #11 on two (2) days, CNA #12 on four (4) days, CNA #13 on eight (8) days, CNA #14 on three (3) days, CNA #15 on one (1) day, CNA #16 on one (1) day, and CNA #17 on three (3) days. Review of the nursing facility job description for Certified Nurse Aide stated the CNA was responsible to provide direct care to residents in accordance with facility policies and procedures and to report resident needs and concerns to a licensed nurse. Review of the facility job description for Licensed Practical Nurse (LPN) and Registered Nurse (RN) detailed the nurse was responsible to perform acts requiring knowledge, judgement, and nursing skills in accordance with the scope of practice, and was responsible to supervise unlicensed nursing staff as assigned. Both job descriptions for LPNs and RNs stated supervisory responsibilities were to provide supervision for other assigned licensed and unlicensed nursing personnel. The facility job description for LPNs and RNs also detailed the responsibility to provide supervision, direction, and monitoring of the performance of subordinate staff on an ongoing basis during each shift for completion of tasks and assignments in a manner consistent with the quality standards established by the facility. Review of the facility incident report, dated [DATE] which detailed the fall of Resident #1 was witnessed by one (1) staff member, CNA #1, and detailed the injuries, abrasion to the shoulder and right hip, laceration to the bridge of the nose and forehead, and left leg shorter than right. Review of the facility Post Fall investigation tool detailed that Resident #1 was pushed in the hall by CNA #1 without foot rests on the wheelchair and fell face forward out of the wheelchair, and the investigation revealed Resident #1 was wearing non-skid socks at the time of the fall. The facility evaluation of findings and documentation of conclusion was stated as "Resident did not have foot pedals on," and included an immediate facility response to reiterate the importance of foot rests. Interview by telephone with CNA #1, on [DATE] at 11:20 AM, revealed on [DATE] at 5:15 AM she transferred Resident #1 without assist of another staff member to a wheelchair. CNA #1 stated she did not remember to place the foot rests on the wheelchair before she transported Resident #1 to the shower room for toileting. CNA #1 stated Resident #1 lunged forward from the wheelchair and fell face down on the floor in the hallway and began to bleed from the head and nose. CNA #1 stated she was not aware Resident #1 required an assist of two (2) staff for transfers. CNA #1 stated her shift ended at 6:00 AM, and she was trying to complete her routine duties, and as a result she failed to place the foot rests on the wheelchair. CNA #1 was aware Resident #1 required the use of foot rests on the wheelchair for transportation; however, CNA #1 denied the resident fall was related to her failure to place the foot rests on the wheelchair for safety. CNA #1 stated if Resident #1 had feet on the floor, then she would have experienced resistance while pushing the wheelchair and stopped the forward movement of the chair to avoid a fall from the wheelchair. Interview, on [DATE] at 1:25 PM, with CNA #2 revealed she was aware Resident #1 was dependent with the use of the wheelchair and required foot rests on the wheelchair for staff assisted transportation, because the resident was not able to raise and hold his/her feet up. CNA #2 stated Resident #1 leaned back in the wheelchair with his/her feet outstretched on the floor and said she never witnessed the resident attempt to get up or lunge from the wheelchair. CNA #2 stated due to the prone position of Resident #1 in the wheelchair, it would be impossible to safely transport the resident in the wheelchair without the use of the foot rests. CNA #2 stated the fall sustained by Resident #1 on [DATE] from the wheelchair was avoidable if the foot rests were in place on the wheelchair. Interview, on [DATE] at 7:10 AM, with CNA #3 revealed she was working in a resident room across the hall from where Resident #1 fell out of the wheelchair. She heard a loud 'thud' and what sounded like a wheelchair turned over and found the resident was laying face down on the floor with the resident's arms folded under the body. CNA #3 said she asked CNA #1 why the foot rests were not on the wheelchair and CNA #1 replied, "I forgot." CNA #3 stated Resident #1 required the use of foot rests on the wheelchair at all times because the resident was not able to raise and hold the feet off of the floor for staff assisted wheelchair transportation. CNA #3 said Resident #1 did not have the strength to lunge forward out of the wheelchair, and she knew the only way the resident could have fallen from the wheelchair was as a result of the resident's feet becoming tangled under the wheelchair which cause the resident to fall face forward. CNA #3 also said Resident #1 kept his/her arms folded in their lap when sitting in the wheelchair, and that was the reason the arms were folded under the residents body. Interview, on [DATE] at 1:25 PM, with CNA #2, revealed she was aware Resident #1 required an assist of two (2) staff for transfers because the resident was dependent. Interview, on [DATE] at 1:40 PM, with CNA #6 revealed she was aware Resident #1 was totally dependent on staff for care and required the assist of two (2) staff for all transfers with the use of foot rests for staff assisted wheelchair mobility. Interview, on [DATE] at 2:37 PM, with LPN #3 revealed she often cared for Resident #1 and stated the resident required an assist of two (2) staff for transfers and foot rests on the wheelchair at all times to maintain safety of the resident. LPN #3 stated Resident #1's lower extremities were weak and the resident did not have the strength to hold his/her feet up for staff assisted wheelchair transportation. LPN #3 stated it would be dangerous to transport Resident #1 in the wheelchair without the use of foot rests, because the resident's feet could become entangled under the chair and cause the resident to fall from the chair. LPN #3 stated the incident on [DATE], when Resident #1 fell from the wheelchair, was avoidable if the foot rests were placed on the resident's wheelchair. Interview, on [DATE] at 5:45 AM, with CNA #5 revealed she was aware Resident #1 was dependent with the use of the wheelchair and required an assist of two (2) staff for all transfers. Interview, on [DATE] at 9:00 AM, with LPN #4 revealed that she had provided care for Resident #1 since the resident was admitted to the facility and was aware the resident required foot rests on the wheelchair at all times. LPN #4 stated she never observed Resident #1 attempt to lean forward or lunge from the wheelchair and said the resident maintained a backward leaning prone position with legs and feet locked and outstretched in the wheelchair. LPN #4 stated if Resident #1 did not have foot rests on the wheelchair, he/she would be at risk of a fall from the wheelchair, and stated the fall from the wheelchair on [DATE] was avoidable if the foot rests were in place on the wheelchair. Interview by telephone, on [DATE] at 8:30 AM, with the Attending Physician revealed Resident #1 was unstable in the wheelchair and was at risk for falls. The Attending Physician said he was told Resident #1 had fallen out of bed and was not aware the resident fell from a wheelchair without the use of foot rests on the wheelchair. The Attending Physician stated it was likely Resident #1 fell from the wheelchair as a result of the lack of foot rests. The Attending Physician stated he was advised by the facility of the death of Resident #1, but was not aware of the cause of death and he did not know if the fall from the wheelchair caused or hastened the resident's death, and said, "the fall did not help." Interview, on [DATE] at 2:30PM, with the Vice President of Operations (VPO) revealed Resident #1's fall on [DATE] was an accident and should not have happened and was a result of the foot rests not being replaced on the wheelchair. The VPO stated as a result of the facility's investigation, it was understood that Resident #1 did not have the strength or mobility to lunge from the wheelchair as reported by CNA #1, and it was determined the resident's feet became entangled under the wheelchair which caused the resident to be propelled from the wheelchair. Review of the acceptable Allegation of Compliance (AOC), on [DATE], revealed the facility took the following immediate actions: 1. The Medical Director was advised of Immediate Jeopardy notification on [DATE] by the Administrator and Corporate Consultant. 2. An Interdisciplinary Team (IDT) met on [DATE] to evaluate all residents who utilized a wheelchair for mobility to determine the need for foot rests, and to determine a policy for the use of foot rests on wheelchairs in the facility. The IDT re-evaluated all residents who used wheelchairs for mobility to identify any needed changes and two (2) residents previously determined to require the use of foot rests refused the foot rests, which were removed by the facility. On [DATE] the IDT met to develop an audit tool to ensure residents who required the use of foot rests for wheelchair mobility had foot rests in place on the wheelchair, then met on [DATE] and [DATE] to evaluate all residents again to determine any necessary changes. On [DATE] all newly admitted residents were reviewed for the need for foot rests on the wheelchairs for mobility. 3. Upon completion of the IDT meeting, the Physical Therapy Manager reviewed the wheelchairs of all residents who were determined to need the foot rests which was completed on [DATE]. 4. Facility Administration developed a quick reference tool for staff, on [DATE], located in the MARs binders, TARs binders, Resident Care Plan Binder, and CNA Care Plan Binders to provide staff information regarding specific residents transportation needs with regard to the use of foot rests on wheelchairs to maintain resident safety. 5. The Director of Staff Development provided an in-service on [DATE] and was completed on [DATE] to educate staff on the use of foot rests on wheelchairs, transporting resident in wheelchairs, and CNA care plans. Future hired staff were to be provided the information during facility orientation. 6. The Corporate Consultant provided an in-service to licensed staff on [DATE] and concluded on [DATE] to educate staff on the Notification of Change Policy, Falls Management, Pain Management, Emergency Procedures, and Care Plans. Future hired staff were to be provided the information during facility orientation. 7. The facility developed an audit process for Administration, on [DATE], to ensure residents who required foot rests for transportation had the devices in place on the wheelchairs at all times, with audits completed no less that two (2) times daily which began on [DATE]. Audits were reviewed by the Facility Administrator and necessary staff intervention provided. 8. The Quality Assurance and Assessment Meeting was held on [DATE], with the Medical Director in participation by teleconference, to discuss the facility findings and the root cause of the Immediate Jeopardy and to begin the process to develop facility interventions and an Allegation of Compliance. 9. The Facility Administration developed a specific Job Description for the 'Nurse in Charge' on [DATE], and licensed staff were educated on the Nurse in Charge responsibilities on [DATE], with a copy of the job description placed on the 24 Hour report for staff reference. Future hired staff were to be provided the information during facility orientation. The State Agency validated the AOC on [DATE] prior to exit as follows: 1. The State Agency validated by interview with the Medical Director, on [DATE] at 12:55 PM, which revealed he was contacted by the facility Administrator and Corporate Consultant and advised of the Immediate Jeopardy, but was not certain of the date of notification. 2. The State Agency validated by record review of the IDT meetings on [DATE], [DATE], [DATE], [DATE], and [DATE] to determine the facility reviewed all facility residents to determine the need for foot rests on wheelchairs to maintain resident safety during transportation. Interview, on [DATE] at 7:00 PM, with the Administrator determined there were two (2) residents with impaired mobility of the lower extremities that the facility identified would require foot rests for safety, but both residents, who were cognitively intact refused the foot rests. 3. The State Agency validated by review of the records provided by the Administrator to confirm the Physical Therapy Manager reviewed all facility residents on [DATE] for the need of foot rests on the wheelchair to maintain resident safety during wheelchair transportation. 4. The State Agency validated by record review of the MAR, and TAR binders, the Resident and CNA Care Plan binders which were determined to include an updated list of facility residents who required foot rests on wheelchairs to maintain resident safety. 5. The State Agency validated the in-service provided to staff on [DATE], which concluded on [DATE] to educate staff on the use of foot rests, and CNA Care Plans by review of the educational material discussed, and the attendance log for the in-service. Interview, on [DATE] at 6:30 PM, with CNA #10 revealed she participated in the in-service regarding the use of foot rests to maintain resident safety and was told the facility policy stated all residents were to have foot rests on the wheelchair upon admission, until it was determined by the facility that the resident no longer needed the foot rests to maintain safety. 6. The State Agency validated the in-service provided to staff by record review of the educational material provided and the attendance log from the in-service on [DATE]. Interview, on [DATE] at 6:30 PM, with CNA #10 revealed she recently attended the Pain In-Service and understood the responsibility of the CNA to report resident pain promptly to the nurse and to document the pain level in the Care Tracker system, as well as her responsibility to follow-up with the resident to ensure the pain was treated. CNA #10 stated she was told the failure to assess and treat resident pain constituted resident neglect. 7. The State Agency validated the audit process developed to ensure residents who required foot rests for safe wheelchair transportation, had the foot rests attached to the wheelchair. Observation, on [DATE] at 5:00 PM and 5:30 PM, in the facility halls and in the dining areas determined that residents identified to need the foot rests, did have them in place for safe transportation. Interview, on [DATE] at 7:00 PM, with the Administrator revealed she had indicated review of the audits by initial and the process warranted, and record review determined the audits of residents who required foot rests were done at least twice daily. 8. The State Agency validated the QAA meeting which was held on [DATE] with the Medical Director, who participated by teleconference by interview. Interview, on [DATE] at 12:55 PM, with the Medical Director revealed that he did participate in the meeting, but was not able to state the cause of the fall. Interview, on [DATE] at 6:30 PM, with the DON revealed that the Medical Director was told the root cause of Resident #1's fall on [DATE] was a result of foot rests not replaced on the wheelchair during staff assisted transportation. Interview, on [DATE] at 7:00 PM, with the Administrator revealed when the Medical Director was told on [DATE] of the root cause of Resident #1's fall and when staff asked the Medical Director at the end of the meeting if he had any suggestions to add, he stated he felt all issues had been adequately addressed. 9. The State Agency validated the new Job Description for the 'Nurse in Charge' by review of the statement, and validated by observation that copies of the job description were placed on the 24 Hour report binder for reference on both the East and West Nursing Stations.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide effective administration to ensure resources were effectively and efficiently managed to provide the highest practicable physical, mental, and psychosocial well-being of each resident. Resident #1 fell from the wheelchair, on 11/15/12 at 5:15 AM, after a staff member transferred the resident without assistance of two (2) staff and failed to replace the foot rests on the wheelchair. Resident #1 demonstrated verbal and non-verbal signs of pain on 11/15/12 after the fall from the wheelchair and did not receive a pain assessment or treatment for [REDACTED]. The facility failed to identify other residents at risk for injury without the use of foot rests on wheelchairs. The facility failed to ensure staff were adequately supervised and knowledgeable of safety interventions to ensure provision of safe resident care. The facility failed to ensure staff were trained to recognize and treat pain, and failed to implement a procedure to ensure all residents were assessed and treated for [REDACTED].#1 on 11/15/12. The facility's failure to provide effective administration to ensure resources were effectively and efficiently managed to provide the highest practicable physical, mental, and psychosocial well-being of each resident placed residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 11/29/12 and was found to exist on 11/15/12. The facility provided a Credible Allegation of Compliance (AOC) on 12/07/12 and the State Agency verified Immediate Jeopardy was removed on 12/07/12 prior to exit on 12/07/12. The scope and severity was lowered to a D at 42 CFR 483.75 (F490) Administration, while the facility's Quality Assurance monitors the effectiveness of implementation of action plans and training to achieve and maintain compliance. The findings include: Review of the facility's policy for Notification of Changes, dated 07/01/08 revealed staff would immediately inform the resident, consult with the resident's physician, and notify the resident's responsible party in the case of an accident with the potential to require physician intervention, a significant change in resident condition, need to alter treatment, or a decision to transfer or discharge the resident from the facility. Further review of the policy revealed no staff direction for circumstances to report a change in condition to the Facility Administration, or circumstances which may require staff consultation with the Medical Director. Observation during the survey on 11/28/12 of both East and West Nursing Stations, revealed the facility maintained a copy of the Lippincott Manual, Volume Five (5) for staff reference; however, staff were not able to identify a specific binder or manual that included the facility's adopted Policy and Procedures. Interview, on 11/26/12 at 2:35 PM, with CNA #1 revealed on 11/15/12 at 5:15 AM she assisted Resident #1 to stand, pivot, and sit in a wheelchair without assistance and transported the resident to the shower room for toileting. CNA #1 stated she was not aware of a physician order [REDACTED].#1; however, she was aware that the resident needed foot rests on the wheelchair for safety. Interview, on 11/26/12 at 3:30 PM, with LPN #1 revealed she was not aware that she could have consulted the Medical Director by telephone to discuss the care and treatment of [REDACTED]. LPN #1 was not aware of any emergency protocol or Policy and Procedure manual in the facility. Interview, on 11/26/12 at 4:03 PM, with RN #1 revealed she was the Charge Nurse on 11/15/12 during third shift when Resident #1 fell from the wheelchair and was injured. RN #1 stated she was not advised of the injury by LPN #1 and overheard other staff describe the incident involving the resident's fall. RN #1 stated she went to observe Resident #1, and advised LPN #1 the resident needed to "go out (to the hospital)," but took no further action to assist LPN #1 with the transfer of the resident. RN #1 stated she was not aware that she could consult the Medical Director by phone if staff deemed it necessary for the resident's well-being. Interview, on 11/27/12 at 11:00 AM, with the Director of Nursing (DON) revealed the facility did not have a policy for Emergency Protocols in case of a resident emergency. The DON stated staff were trained to call her anytime a resident sustained [REDACTED].#1 fell on [DATE], until 12:00 PM that afternoon. The DON stated that LPN #1, who was assigned to the care of Resident #1 on 11/15/12, knew she could call the Medical Director if she needed to do so, because LPN #1 had been advised by the DON to call the Medical Director in the past. The DON was not aware LPN #1 did not advise RN #1 (Charge Nurse) of Resident #1's fall on 11/15/12, and stated that staff were trained to notify the Charge Nurse and the DON when a fall occurred in the facility. The DON stated she was not sure if there was a Policy and Procedure manual in the facility, but stated the Standard of Practice was the Lippincott Manual. Interview, on 12/05/12 at 2:28 PM, with LPN #2 revealed there had previously been a Policy and Procedure manual in the facility which staff referred to as "The Bible," but it was removed because it was determined the manual contained many different and conflicting instructions. Interview, on 11/28/12 at 8:45 AM, with the Staff Development Coordinator (SDC) revealed the facility relied on critical thinking and nursing judgement to respond to emergency situations in the facility. The SDC reported there was no Emergency Policy and Procedure at the facility, and stated that staff were trained to use their critical thinking and nursing judgement to function independently. The SDC also stated staff was trained to notify the Administrator or Director of Nursing when a resident was injured or sent to the hospital. Interview, on 11/30/12 at 2:30 PM, with the Vice President of Operations (VPO) revealed the facility did have a Policy and Procedure Manual that was available in the DON's office and stated the DON most likely wasn't aware the manual was there because the previous DON did not share that information with the current DON. Further interview, on 12/07/12 at 12:30 PM, with the DON revealed she was aware there was a Policy and Procedure Manual for the facility that was located in her office. The DON stated her office was locked when she was out of the facility and said staff was aware that they could use the Lippincott Manual for reference after normal business hours. Interview, on 12/05/12 at 1:43 PM, with the Medical Director revealed he did not know what the facility's Standard of Practice was and did not know if he had been requested to review and authorize by signature the adoption of a Policy and Procedure Manual for the facility. The Medical Director was not aware the staff could not access the Nursing Policy and Procedure Manual and said that should be available to staff working all shifts. The Medical Director said he participated in a Quality Assurance and Assessment meeting by phone during the prior week to determine facility interventions to prevent recurrence of falls, such as the fall sustained by Resident #1. The Medical Director stated when possible head trauma was suspected, it would be prudent to transfer the resident to the hospital for an evaluation as soon as possible to ensure the best resident outcome. Interview, on 12/07/12 at 12:55 PM, with the Administrator revealed that she was aware the Policy and Procedure manuals at the nursing stations were not complete and stated a complete copy of the Policy and Procedure manual was maintained in the DON's office, which was locked at night. The Administrator was not sure why the staff did not have access to the entire Policy and Procedure manual, but said if staff had a question after hours, they could call the DON at home. The Administrator was not sure if the Medical Director reviewed and documented acceptance of the Policy and Procedure manual. Interview, on 12/07/12 at 4:15 PM, with the Senior Vice President (SVP) revealed he was not sure if the Standard of Practice was reviewed and acknowledged as adopted by the Medical Director, but thought that the facility Administrator would know if this was accomplished. The SVP was not aware that multiple nursing staff was not aware if the facility had a Policy and Procedure Manual available for staff to reference, and that some staff stated the Policy and Procedure Manual was kept locked in the DON office. The SVP stated, without question, all staff should have access to the Policy and Procedure Manual at all times. Review of the acceptable Allegation of Compliance (AOC), on 12/07/12, revealed the facility took the following immediate actions: 1. The Medical Director was advised of the Immediate Jeopardy notification on 11/29/12 by the Administrator and Corporate Consultant. 2. Facility Administration, on 12/04/12, developed a quick reference tool for staff, located in the MARs binders, TARs binders, Resident Care Plan Binder, and CNA Care Plan Binders to provide staff information regarding specific residents transpiration needs with regard to the use of foot rests on wheelchairs to maintain resident safety. 3. The facility Nursing Policy and Procedure Manuals with current policies were placed in binders at both the East and West Nursing Stations on 12/02/12. 4. The Director of Staff Development provided an in-service on 11/16/12 and was completed on 12/03/12 to educate staff on the use of foot rests on wheelchairs, transporting resident in wheelchairs, and CNA care plans. Future hired staff were to be provided the information during facility orientation. 5. The Corporate Consultant provided an in-service to licensed staff on 11/30/12 and concluded on 12/03/12 to educate staff on the Notification of Change Policy, Falls Management, Pain Management, Emergency Procedures, and Care Plans. Future hired staff were to be provided the information during facility orientation. 6. The facility developed an audit process for Administration to ensure residents who required foot rests for transportation had the devices in place on the wheelchairs at all times, with audits completed no less that two (2) times daily which began on 11/30/12. Audits were reviewed by the Facility Administrator and necessary staff intervention provided. Audits were completed by administrative staff, the DON, East and West House Supervisors, and the Nurse Supervisor. 7. The Quality Assurance and Assessment Meeting was held on 12/03/12, with the Medical Director in participation by teleconference, to discuss the facility findings and the root cause of the Immediate Jeopardy and to begin the process to develop facility interventions and an Allegation of Compliance. 8. The Facility Administration developed a specific Job Description for the 'Nurse in Charge' and licensed staff were educated on the Nurse in Charge responsibilities on 12/04/12, with a copy of the job description placed on the 24 Hour report for staff reference. Future hired staff were to be provided the information during facility orientation. 9. The Corporate Consultant provided an in-service for the Administrator, DON, MDS Coordinator, Restorative Nurse, Nurse Supervisors, and the Director of Staff Development on 12/04/12 to ensure the Administrative staff was able to identify and investigate allegations of reported or suspected abuse and neglect. 10. The Director of Staff Development provided an in-service on 12/04/12 for all staff regarding the facility Abuse Policy and Procedure. The staff was not permitted to return to work without completion of the in-service. The State Agency validated the AOC on 12/07/12 prior to exit as follows: 1. The State Agency validated by interview with the Medical Director on 12/05/12 at 12:55 PM, that he was contacted by the facility Administrator and Corporate Consultant and advised of the Immediate Jeopardy, but was not certain of the date of notification. 2. The State Agency validated the quick reference tool for staff by observation on 12/07/12 of the presence and accuracy of the tool on all MAR binders on the medication carts, TAR binders on the treatment carts, the Resident Care Plan Binders and the CNA Care Plan Binders in both the East and West Nursing Stations. Interview, on 12/07/12 at 6:40 PM, with RN #3 verified that if a staff member was not sure if a resident required foot rests on the wheelchair for safe transportation, staff could readily access this information on the MAR indicated [REDACTED]. 3. The State Agency validated the provision of Nursing Policy and Procedure Manuals with current policies, by observation on 12/07/12 which determined the presence of the Manuals on both the East and West Nursing Stations. Interview, on 12/07/12 at 6:40 PM, with RN #3 revealed that she was aware Policy and Procedure Manuals were located at both Nursing Stations for staff reference, and that information regarding Emergency procedures and notification were contained in the manuals. Interview, on 12/07/12 at 5:45, with RN #2 revealed that she was aware the Nursing Policy and Procedure Manuals were located in a black binder on both Nursing Stations. 4. The State Agency validated the in-service provided to staff by the Director of Staff Development on 11/16/12, which concluded on 12/03/12 to educate staff on the use of foot rests, and CNA Care Plans by review of the educational material discussed, and the attendance log for the in-service. Interview, on 12/07/12 at 6:30 PM, with CNA #10 revealed she participated in the in-service regarding the use of foot rests to maintain resident safety and was told the facility policy stated all residents were to have foot rests on the wheelchair upon admission, until it was determined by the facility that the resident no longer needed the foot rests to maintain safety. 5. The State Agency validated the in-service provided to staff by record review of the educational material provided and the attendance log from the in-service on 12/03/12. Interview, on 12/07/12 at 6:30 PM, with CNA #10 revealed she recently attended the Pain In-service and understood the responsibility of the CNA to report resident pain promptly to the nurse and to document the pain level in the Care Tracker system, as well as her responsibility to follow-up with the resident to ensure the pain was treated. CNA #10 stated she was told the failure to assess and treat resident pain constituted resident neglect. 6. The State Agency validated the audit process developed to ensure residents who required foot rests for safe wheelchair transportation, had the foot rests attached to the wheelchair. Observation, on 12/07/12 at 5:00 PM and 5:30 PM in the facility halls and in the dining areas determined that residents identified to need the foot rests, did have them in place for safe transportation. Interview, on 12/07/12 at 7:00 PM, with the Administrator revealed she had indicated review of the audits by initial and the process warranted, and record review determined the audits of residents who required foot rests were done at least twice daily. 7. The State Agency validated the QAA meeting was held on 12/03/12 with the Medical Director, who participated by teleconference by interview. Interview, on 12/05/12 at 12:55 PM, with the Medical Director revealed that he did participate in the meeting, but was not able to state the cause of the fall. Interview, on 12/07/12 at 6:30 PM, with the DON revealed that the Medical Director was told the root cause of Resident #1's fall on 11/15/12 was a result of foot rests not replaced on the wheelchair during staff assisted transportation. Interview, on 12/07/12 at 7:00 PM, with the Administrator revealed she was aware that the Medical Director was told on 12/03/12 of the root cause of Resident #1's fall and when staff asked the Medical Director at the end of the meeting if he had any suggestions to the add, he stated that he felt all issues had been adequately addressed. 8. The State Agency validated the new Job Description for the 'Nurse in Charge' by review of the statement, and validated by observation that copies of the job description were placed on the 24 Hour report binder for reference on both the East and West Nursing Stations on 12/04/12. 9. The State Agency validated the in-service that was provided to the Administrative staff of the facility on 12/04/12 by review of the results of the post-test provided by the Corporate Consultant and validated the understanding of all Administrative staff and their responsibility to identify and investigate all reported and suspected incidents of abuse and neglect. 10. The State Agency validated by review of the Abuse and Neglect Policy provided to staff at the in-service provided by the Director of Staff Development on 12/04/12, and by review of the attendance log to ensure all staff were required to attend the in-service prior to return to work and it was determined the facility had 100% compliance with the mandatory staff in-service. Interview, on 12/06/12 at 6:30 AM, with CNA #8 revealed she was aware that staff failure to provide the services needed to meet the needs of any resident could be determined to be neglect. CNA #8 stated she was aware the failure of staff to assess and treat pain was a form of resident neglect. Interview, on 12/06/12 at 10:00 AM, with CNA #11 revealed she recently attended an abuse and neglect in-service and verbalized understanding the failure to assess and treat pain constituted resident neglect.