Every finding on record at Signature Healthcare at Heritage Hall Rehab & Well

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. Observation of medication administration on 07/31/2025 at 8:00 AM, revealed 2 medication errors out of 33 medication observations to result in a 6.06 percent medication error rate.The findings include:Review of the facility's policy titled, Medication Administration, dated 01/2025, revealed, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the label. The policy also stated, Verify medication is correct three times before administering the medication. When pulling medication package from the med cart, when dose is prepared, and before dose is administered.Review of R16's Face Sheet revealed the facility admitted the resident on 07/10/2025 with a diagnosis of cellulitis of the left lower leg.Review of R16's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/17/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 10 out of 15, indicating R16 was moderately cognitively impaired.Review of R16's Physician's Orders, dated 07/15/2025, revealed an order for metformin (given to reduce blood sugar) 1000 milligrams (mg) to be given twice a day and an order for metoprolol (given to lower blood pressure) 25 mg once a day.Observation on 07/31/2025 at 8:00 AM revealed Registered Nurse (RN) 4 prepared Resident (R) 16's medications, which included only one metformin 500 mg tablet. Further observation revealed RN4 dropped R16's metoprolol tablet, causing it to break. RN4 then gathered up the pieces to administer to R16, leaving approximately 0.25-0.5 part of the tablet on her medication cart. An unknown amount was administered to R16.During an interview on 07/31/2025 at 11:00 AM with the Director of Nursing/Infection Prevention Nurse (DON/IP), she stated it was her expectation that the facility did not have any medication errors, and if they did, they were identified and addressed appropriately.During an interview on 07/31/2025 at 1:27 PM with the Administrator, she stated it was her expectation that when medication errors occurred, they were identified and addressed for patient safety.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 out of 23 sampled residents, Resident (R) 81.Record review of R81's Baseline Care Plan did not address R81's primary language of Tagalog.The findings include:Review of the facility's policy titled, Baseline Care Plan, dated 09/23/2022 and last reviewed on 01/31/2025, revealed, A Baseline Care Plan will be developed and implemented to promote continuity of care and communication among facility stakeholders to increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Review of R81 Face Sheet revealed the facility admitted R81 on 06/30/2025 with a diagnosis of a right femur fracture.Review of R81's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of date 07/03/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight out of 15, indicating R81 was moderately cognitive impaired. Review of R81's Provider's History and Physical, dated 05/13/2025, revealed the family history was unobtainable due to language barrier.Review of R81's 48-hour Baseline Care Plan, with a completed date of 06/30/2025, revealed R81's communication was understood. Review of R81's Nurse Progress Note, dated 06/30/2025, revealed Daughter at bedside to translate.Review of R81's Provider Progress Note, dated 07/01/2025, revealed family was being used as an interpreter to communicate with provider. During an interview on 07/30/2025 at 1:20 PM with State Registered Nurse Aide (SRNA) 9 and SRNA11, they stated they were made aware of residents with language barriers by report, their computer system, and the nurse. During an interview on 07/30/2025 at 1:25 PM with Registered Nurse (RN) 5, she stated the admitting nurse was responsible for completing the baseline care plan upon admission. She stated the baseline care plan should address language barriers that were present on admission.During an interview on 07/30/2025 at 1:30 PM with Licensed Practical Nurse (LPN) 5, she stated the admitting nurse was responsible for completing the baseline care plan upon admission. She stated the Minimum Data Set (MDS) Nurse was responsible to complete the comprehensive care plan. She stated she was the nurse who admitted R81, and he was able to understand some words. Therefore, she stated she marked R81 as able to communicate.During an interview on 07/31/2025 at 11:00 AM with the Director of Nursing/Infection Prevention Nurse (DON/IP), she stated the baseline care plan was completed by the admitting nurse. During an interview on 07/31/2025 at 1:27 PM with the Administrator, she stated it was her expectation that baseline care plans were completed upon admission so staff could communicate with residents.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage for Enhanced Barrier Precautions (EBP), and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of nine residents investigated for infection control, Resident (R) 55, R16, R40, and R30.The findings include:Review of the facility's policy titled, Infection Control, dated 01/31/2025, revealed the objective of the facility's infection control policies and practices was to maintain a safe, sanitary, and comfortable environment for personnel, residents, and the public and to help prevent and manage transmission of diseases and infections.Review of the CDC's signage for Enhanced Barrier Precautions [EBP], undated, which the facility used, revealed providers and staff must wear gloves and gown for high-contact resident activities.Review of the facility's policies revealed the facility did not have individual polices for EBP or the safe cleaning and reprocessing of reusable resident-care equipment.1. Review of R55's Face Sheet revealed the facility admitted the resident on 07/13/2025 with diagnoses including Parkinson's disease and left side paralysis following a stroke. Review of R55's, Comprehensive Care Plan, revealed the resident required EBP related to an indwelling foley catheter.Review of R55's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/21/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of three out of 15, indicating the resident was severely cognitively impaired.Review of R55's, Physician Order Report, dated 04/09/2024 to 07/31/2025, revealed an active order in place for EBP.Observation on 07/29/2025 at 8:20 AM revealed the Minimum Data Set (MDS) Nurse entered R55's room which had an Enhanced Barrier Precaution (EBP) sign posted on the door. Further observation revealed the MDS Nurse repositioned the resident in bed without the proper Personal Protective Equipment (PPE). In an immediate interview, the MDS Nurse stated she pulled R55 up in the bed and should have used the appropriate PPE before she assisted the resident. She further stated it was important staff used proper PPE when care was provided to residents on EBP to help prevent the spread of infection. The MDS Nurse stated when staff failed to wear PPE, residents were placed at risk for infection.In an interview with State Registered Nurse Aide (SRNA) 5 on 07/30/2025 at 6:25 PM, she stated EBP were for residents with some type of opening such as catheter or feeding tube. She further stated Personal Protective Equipment (PPE) was required when staff provided care to a resident on EBP.In an interview with SRNA7 on 07/30/2025 6:42 PM, she stated if a resident was on precautions of any type, signage that showed what to wear was posted on the door. SRNA7 stated if a resident was on EBP staff were required to wear the PPE listed on the signage when they provided care. SRNA7 further stated if she just delivered trays or passed water, she was not required to wear PPE. In an interview with Licensed Practical Nurse (LPN) 3 on 07/30/2025 at 6:50 PM, she stated EBP was used for residents that had an opening where infection could be introduced. She further stated, residents with catheters, feeding tubes, and wounds were placed on EBP, and staff were required to wear PPE when they provided any type of direct care. In an interview with the Director of Nursing (DON)/Infection Preventionist (IP) on 07/31/2025 at 3:32 PM, she stated staff received annual infection control training as well as computer modules and frequent in-services throughout the year. The DON stated any resident on Transmission Based Precautions (TBP) or EBP had appropriate signage on their door to alert staff. She further stated it was her expectation that staff followed that signage, and if they were providing direct care to a resident on EBP, a gown and gloves should be worn. When asked if staff should have on PPE when they pulled a resident on EBP up in bed, the DON stated they should. The DON stated it was important staff followed guidelines for donning (putting on) PPE, so residents were protected from potential infection. During an interview with the Administrator on 07/31/2025 at 4:03 PM, she stated she expected staff to put on PPE for any resident on EBP if they provided care to that resident. She further stated if staff pulled a resident up in bed that was on EBP, they should have on the proper PPE. The Administrator stated it was important staff used PPE when they cared for residents on EBP because of the potential for infection.2. Review of R16's Face Sheet revealed the facility admitted the resident on 07/10/2025 with a diagnosis of cellulitis of the left lower leg.Review of R40's Face Sheet revealed the facility admitted the resident on 07/19/2025 with a diagnosis of acute respiratory disease.Review of R30's Face Sheet, revealed the facility admitted the resident on 07/13/2025 with a diagnosis of a sacrum fracture.Observation on 07/31/2025 at 8:00 AM to 8:18 AM, during medication administration, revealed Registered Nurse (RN) 4 touched R16's, R40's, and R30's oral medications with her hands, without wearing gloves. Additional observation on 07/31/2025 at 8:00 AM, revealed RN4 dropped R16's metoprolol tablet (used to lower blood pressure) onto her medication cart, without a barrier in place, then picked up the pieces of the tablet and administered it to R16.Additional observation on 07/31/2025 at 8:10 AM, revealed RN4 used a blood pressure cuff on R16 then, accidentally dropped the blood pressure cuff into the trash can in R16's room. RN4 then retrieved the blood pressure cuff and used it on R40, without cleaning it. During an interview on 07/31/2025 at 8:18 AM with RN4, she stated that shared equipment should be cleaned with Clorox wipes between resident use, and she should have worn gloves to administer medication and used a barrier to prepare medications.During additional interview on 07/31/2025 at 11:00 AM with the DON/IP, she stated it was her expectation that infection control prevention be maintained to prevent infection from spreading.During additional interview on 07/31/2025 at 1:27 PM with the Administrator, she stated her expectation for staff was to do their best, not to touch resident medications with their ungloved hands, and if that happened, then the pill should be discarded and replaced for infection control.

Based on observation, interview, record review and review of the facility's policy, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. Observation on 07/29/2025 at 6:22 AM revealed 2 of 2 medication carts located on the short-term rehab unit were unlocked and no staff was in the area. Additional observation on 07/31/2025 at 8:00 AM-8:18 AM, during medication administration on the short-term rehab unit, Registered Nurse (RN) 4 walked away from the medication cart that was left at the nurses' station to administer medication inside resident rooms on three different occasions without locking the medication cart.The findings include:Review of the facility's policy titled, Storage of Medication, dated 01/2025, revealed the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review revealed only the above-mentioned persons had access to medication carts and medication rooms. Per the policy, cabinets and supplies should remain locked when not in use or attended by persons with authorized access. Observation on 07/29/2025 at 6:22 AM during performance of the initial facility walk-through on the Rehabilitation Unit, designated as Unit B and Unit C, revealed two medication carts were unattended, no staff were visible in the area, and both medication carts were unlocked. Further observation revealed the drawers were able to be opened, and medications were observed in drawers.In an interview with Licensed Practical Nurse (LPN) 1 on 07/29/2025 at 6:26 AM, she stated she was assigned to medication cart Peaceful and was aware the cart had been left unlocked and unattended on the unit. LPN1 stated staff became distracted when the State Survey Agency (SSA) Surveyors entered the facility, and she had forgotten to lock it. LPN1 stated the medication cart should have been secured before she walked away. She stated it was important to keep the medication cart locked at all times when unattended so that nobody could steal the drugs.During an interview on 07/29/2025 at 6:15 AM with RN1, she stated he usually kept her medication cart locked but had walked away from it for a second. She stated it should be locked when unsupervised to keep other people from getting into the medications. Observation on 07/31/2025 at 8:00 AM to 8:18 AM, during medication administration on the Rehabilitation Unit, Registered Nurse (RN) 4 walked away from the medication cart that was left at the nurses' station to administer medication inside resident rooms on three different occasions without locking the medication cart.During an interview on 07/31/2025 at 8:18 AM with RN4, she stated the medication cart should be locked when unattended.During an interview with the Director of Nursing (DON) on 07/31/2025 at 3:30 PM, she stated the expectation was that all medication carts be locked when not within visible sight of the nurse. In further interview, she stated it was important to keep medication carts locked to prevent drug diversion by staff, theft of medications by family, visitors and residents.During an interview on 07/31/2025 at 1:27 PM with the Administrator, she stated it was her expectation that medication carts were kept locked so the medications were secured and unauthorized persons could not access medications.

Based on interview, record review, review of the facility's investigation, review of the police report, and review of the facility's policies, and the Kentucky Incident Based Reporting System (KYIBRS) Report, it was determined the facility failed to ensure residents were free from misappropriation of property for four (4) of sixty-one (61) sampled residents (Residents #1, #2, #3, and 62). Three (3) residents, Resident #1, #2, and #3 had medication misappropriated. A facility employee acceptable ten thousand dollars ($10,000) from Resident #62. Licensed Practical Nurse (LPN) #4 reported to the Director of Nursing (DON) that Registered Nurse (RN) #1 was exhibiting suspicious behaviors of wearing a backpack at work; being in the bathroom for long periods of time, and acting weird. While the DON was in the facility, on 08/11/2023 at 3:00 AM, RN #1 stayed in the bathroom for extended periods and walked around with a backpack. However, the DON reported there were no concerns, and staff members' reports were just speculation. In an interview with LPN #3, she stated on 08/26/2023 she observed RN #1 take a bottle of Morphine out of her pocket and place it into the medication cart at approximately 11:30 PM. LPN #4, stated she observed RN #1 on 08/26/2023 at approximately 10:00 PM talking belligerently, slurring her words, and her pupils were pinpoint. LPN #4 stated at 10:46 PM, she observed RN #1 enter the bathroom, and she did not exit until 11:26 PM. LPN #4 stated she called the DON at 10:46 PM initially and told her that RN #1 was higher than a f .ing [NAME]. LPN #4 stated she informed the DON that she wanted to call the police because she thought RN #1 had taken the Morphine that was delivered from the pharmacy at approximately 10:00 PM for Resident #2. In an interview with the Administrator, he stated on 08/27/2023 at 7:30 AM, he was made aware by the DON that the police had been called on 08/26/2023. The Administrator stated staff had texted the DON on 08/26/2023. However, she was not aware of the text until the next morning on 08/27/2023. He stated he was told by the DON that RN #1 had been arrested, and Morphine was found in RN #1's backpack. Despite this, the facility's initial investigation unsubstantiated the allegation of misappropriation due to the ongoing investigation by local law enforcement as they awaited a pending liquid medication analysis and toxicology report. However, the facility's Administrator and DON failed to immediately take action to investigate and report, implement corrective action consistent with the investigation's findings, and failed to take steps to eliminate any ongoing danger to the resident(s) in a timely manner. (See F610 and F835). The facility's failure to ensure residents were protected from misappropriation of narcotics and to take immediate action and have a system in place to ensure the residents were protected is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 09/21/2023 and determined to exist on 08/26/2023 in the area of 42 CFR 483.12 Freedom from Abuse and Neglect, F602 and F610 with a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on 09/21/2023. The IJ is ongoing. In addition, on 06/27/2022, Housekeeper #1 accepted $10,000 as a gift from Resident #62. The money was to be used to provide dental work for Housekeeper #1's daughter. The findings include: Review of the facility's policy, Abuse, Neglect, or Misappropriation of Resident Property, revised 10/17/2022, revealed the facility's intention was to prevent the occurrences of misappropriation of resident property and to assure all alleged violations of federal or state laws which involved misappropriation of resident property were investigated and reported immediately to the Facility's Administrator, and the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. Per the policy, the organization would include screening, training, prevention, identification, investigation, protection, and reporting to provide protection for the health, welfare and rights of each resident residing in the facility. Further, the policy revealed the Administrator, or designee, would conduct a reasonable investigation of each alleged violation. In addition, the Administrator would make reasonable efforts to determine the root cause of the alleged violation and would implement corrective actions consistent with the investigation findings and take steps to eliminate any ongoing danger to the resident or residents. Continued review revealed the Administrator would identify, intervene, and correct situations in which reported abuse, neglect, exploitation, or misappropriation of resident property might recur. Further review of the policy revealed exploitation was defined as taking advantage of a resident for personal gain, through the use of manipulation, initiation, threats, or coercion; and, misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy stated, Under no circumstances shall any Stakeholder accept any money, property, inheritance or anything else of value from a resident or resident's family member, nor enter into any joint ownership of any property, bank account, business, or anything else of value, with a resident, unless the resident is a family member of the Stakeholder. Additionally, the policy stated the facility trained employees on hire and annual thereafter related to abuse, including misappropriation of resident property. Review of the facility's policy, Controlled Medication and Drug Diversion Policy, revised 07/07/2022, revealed the facility was to investigate and make every reasonable effort to reconcile reported narcotic discrepancies. Per the policy, if a major discrepancy or a pattern of discrepancies occurred or if there was apparent criminal activity, the Director of Nursing (DON) would notify the Chief Executive Officer (CEO), Nurse Care Consultant (NCC), Regional Vice-President (RVP), and pharmacy immediately. Review of the facility's policy, Elder Justice Act Policy and Procedure, revision 04/05/2016, revealed it was the intent of the facility to uphold The Elder Justice Act as established under the Social Security Act and Patient Protection and Affordable Care Act of 2010 which required covered individuals to report reasonable suspicion of a crime to their state regulatory agency and to local law enforcement within specific time frames. The guide of the Elder Justice Act was if a covered individual had a reasonable suspicion, that individual must report this directly to both local law enforcement and the state survey agency without fear of retaliation. Per the policy, the Administrator, Director of Nursing (DON) or Abuse Coordinator could report the suspicion on behalf of a covered individual if that was the desire of the individual. Review of Registered Nurse (RN) #1's Employee File revealed a hire date of 03/02/2023, with the most recently received abuse education Agency Orientation Guide/Checklist, dated March 2023. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 08/10/2021, with diagnoses that included Cerebral Palsy, Respiratory Failure with Hypoxia, Psychosis, and Severe Intellectual Disabilities. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 06/14/2023, revealed the facility could not assess the resident with a Brief Interview for Mental Status (BIMS) score due to Resident #1 being never or rarely understood. Review of Resident #1's care plan, initiated on 02/08/2021, revealed a problem for pain with a long-term goal target date of 12/12/2023, that Resident #1 would verbalize or demonstrate relief or reduction of pain within one (1) hour after receiving interventions. Interventions included to administer medications as ordered, monitor, record any complaints of pain, record any nonverbal signs of pain, and use pain relief measures as needed. Review of Resident #1's Physician's Orders revealed an order, dated 08/07/2023, for Morphine Sulfate (an opioid used to relieve moderate to severe pain) 100 milligrams (mg)/5 milliliters (ml) (20 mg/ml), amount five (5) mg (0.25 ml) oral concentration liquid. Resident #1 was to receive 0.25 ml orally every six (6) hours for pain. Review of Resident #1's Medication Administration Record (MAR), dated 08/25/2023 through 08/26/2023, revealed RN #1 administered Resident #1's scheduled Morphine Sulfate on 08/25/2023 at 12:00 AM, with documentation on the Narcotic Record of 0.25 ml of the dose dispensed and 16.25 ml dose present/remaining. Further review of Resident #1's MAR documentation, dated 08/26/2023, revealed no documented evidence of RN #1's administration of Morphine Sulfate to Resident #1 on 08/26/2023 and no assessed pain evaluation. 2. Review of Resident #2's closed medical record revealed the facility admitted the resident, on 08/19/2023, with diagnoses that included Down's Syndrome, Encephalopathy, and Anxiety. Review of Resident #2's Admission MDS Assessment, dated 08/26/2023, revealed the facility assessed the resident with a BIMS' score of zero (0) of fifteen (15), indicating severe cognitive impairment. Review of Resident #2's care plan, initiated on 08/21/2023, revealed a problem for chronic pain with a goal that the resident would verbalize or demonstrate relief or reduction of pain within one (1) hour after receiving interventions. Interventions included positioning, report uncontrolled pain to physician and/or hospice nurse and MD, evaluate effectiveness of pain management interventions, observe, and record any complaints of pain. Review of Resident #2's Physician's Orders revealed an order, dated 08/21/2023, to admit Resident #2 to Hospice Services with a diagnosis of Mild Protein-Calorie Malnutrition. Further review revealed an order, dated 08/26/2023, for Resident #2 to receive Morphine Sulfate 100 mg/5 ml (20 mg/ml), amount five (5) mg (0.25 ml) oral concentration liquid to administer 0.25 ml orally every four (4) hours as needed (PRN) for pain. Additional review revealed a new order, dated 08/26/2023, for Resident #2 to receive Morphine Sulfate 100 mg/5 ml (20 mg/ml), amount ten (10) mg (0.5 ml) oral concentration liquid, to administer 0.5 ml orally every four (4) hours as needed (PRN) for pain. Review of the facility's Controlled Drug Record revealed on 08/26/2023 at approximately 10:00 PM, pharmacy delivered a thirty (30) ml bottle of Morphine Sulfate 100 mg/5 ml oral concentration liquid for Resident #2. The order stated to administer 0.5 ml orally every four (4) hours as needed (PRN) for pain. Further review revealed Resident #2's Morphine narcotic medication was signed off as received by RN #1 and witnessed by Licensed Practical Nurse (LPN) #3. Review of Resident #2's MAR, dated 08/25/2023, revealed RN #1 administered Resident #2's PRN Morphine Sulfate at 10:17 PM with an assessed pain score of three (3) of ten (10), with no follow-up pain assessment documented. Further review revealed on 08/26/2023 at 5:34 AM, RN #1 administered Resident #2's PRN Morphine Sulfate with an assessed pain score of seven (7) of ten (10), with no follow-up pain assessment documented. In addition, review of Resident #2's Narcotic Record revealed on 08/26/2023 at 10:30 PM, RN #1 signed that she had administered PRN Morphine Sulfate 0.5 ml to Resident #2. However, according to Resident #2's MAR, there was no documented evidence of RN #1's administration of Morphine Sulfate 0.5 ml to Resident #2 on 08/26/2023 at 10:30 PM, and no assessed pain evaluation was documented. Review of Resident #2's Progress Note, dated 08/27/2023 at 4:13 AM, revealed LPN #2 contacted the on-call Nurse Practitioner (NP) to request a new prescription be sent to the pharmacy to replace Resident #2's Morphine that had been confiscated by the police. 3. Review of Resident #3's closed medical record revealed the facility admitted the resident on 11/07/2017, with diagnoses that included Dementia, Chronic Kidney Disease (CKD) III, and Congestive Heart Failure (CHF). Review of Resident #3's Quarterly MDS Assessment, dated 05/28/2023, revealed the facility assessed the resident to have a BIMS' score of five (5) of fifteen (15) which indicated severe cognitive impairment. Review of Resident #3's care plan, dated 02/20/2023, revealed a focus for Hospice/Palliative Care with a goal that the resident would be supported to promote comfort and dignity throughout the dying process. There was an intervention to notify the physician/hospice provider if pain or discomfort was not alleviated by current preventative measures, treatment regimen, or medications provided. Review of Resident #3's Physician's Orders, dated 06/27/2023, revealed an order to admit Resident #3 to Hospice Services with a diagnosis of Mild Protein-Calorie Malnutrition. Further review revealed an order, dated 08/09/2023, for Resident #3 to receive Morphine Sulfate 10 mg/5 ml, (2 mg/ml) oral concentration liquid, to administer one (1) ml orally every two (2) hours as needed (PRN) for pain. Review of Resident #3's MAR dated 08/26/2023, revealed no assessed pain evaluation or PRN pain medication of Morphine had been documented as administered by RN #1. Review of the Narcotic Record for 08/26/2023 revealed the Morphine had not been administered. Review of Resident #3's Progress Note, dated 08/27/2023 at 4:34 AM, revealed LPN #2 contacted the on-call NP to request a new prescription be sent to the pharmacy to replace Resident #3's bottle of suspected tampered Morphine. The bottle of Morphine had been confiscated by police as evidence to be sent to the Kentucky State Police (KSP) Central Lab for testing. Review of the Long-Term Care Facility-Self-Reported Incident Form/Initial Report, dated 08/27/2023, with no time documented and signed by the Director of Nursing (DON), revealed an Allegation of Misappropriation of resident property occurred on 08/27/2023, involving Residents #1, #2, and #3. Additional review revealed the DON was notified that Agency Nurse/RN #1, had been pulled over by police after her shift ended at 11:00 PM last night', with suspicion of impairment and was noted to have syringes, blue food coloring, and saline in her backpack. Afterwards, the report stated police came to the facility and took Morphine from the medication carts for testing. Review of the Kentucky Incident Based Reporting System (KYIBRS) Report of incident KY 23-212, dated 08/27/2023 at 12:35 AM, revealed police were contacted by the facility's staff, LPN #3, who reported an employee (RN #1) was possibly under the influence was reportedly leaving intoxicated. The report revealed the driver failed to signal when turning into a parking lot. Officer #1 conducted a traffic stop on the vehicle for failure to signal and to conduct a Driving Under the Influence (DUI) investigation at 12:37 AM. At that time, RN #1 advised Officer #1 that the seven (7) syringes with the blue liquid were Morphine, and she had taken them from the facility. Per the report, RN #1 also advised Officer #1 she had taken a dose of Morphine while on shift earlier tonight while caring for twenty-one (21) residents. Further review of the report revealed RN #1 said she had taken the Morphine because she wanted to kill herself, and then RN #1 started to have chest pains. Continued review revealed the Emergency Medical Services (EMS) was called for medical treatment. RN #1 was transported to the hospital by paramedics related to her stating she wanted to commit suicide. Review of the Kentucky Incident Based Reporting System (KYIBRS) Report, while enroute RN #1 informed EMS personnel she had been conducting this unlawful act since January 2023. Per the report, an arrest warrant was issued for RN #1 on 08/27/2023 at 2:36 AM. The report stated RN #1 was implicated on eight (8) counts for the charge of Theft of a Legend Drug (a drug approved by the Food and Drug Administration (FDA) that could be dispensed to the public only with a prescription); twenty-one (21) counts of Wanton Endangerment in the First Degree; seven (7) counts of Possession of Controlled Substance; seven (7) counts of Theft by Unlawful Taking or Disposition; three (3) counts of Knowingly Abuse or Neglect of an Adult by Stealing; three (3) counts of Tampering with Physical Evidence; and one (1) count of Drug Paraphernalia. Review of the Administrator's Witness Statement, dated 08/28/2023 and signed by the Administrator, revealed on 08/26/2023 at 11:30 PM, he was called by the DON and was informed staff members were saying RN #1 was acting weird, walking around the nurse's station, had been to the bathroom several times, and was wearing her backpack. Per the statement, the DON told the Administrator, It's not a big deal; RN #1 was being budgeted at 11:00 PM anyway; she had spoken with RN #1; and RN #1 was going to finish up some charting and go home. The Administrator stated he asked the DON about RN #1's backpack, and the DON responded that RN #1 usually had one with her and in the bathroom. The Administrator stated the DON told him she had worked with RN #1 and that RN #1 went to the bathroom with the backpack. Further review revealed the Administrator stated the DON informed him that RN #1 had gastrointestinal (GI) issues. Per the statement, the DON told the Administrator that it had just been a crazy evening, and she had instructed the staff to call her for any issues with the medication cart count or if they needed anything else. The Administrator stated he told the DON to let him know if she heard anything more; however, he did not hear from the DON again until 7:30 AM on 08/27/2023. Review of State Registered Nurse Aide (SRNA) #2's telephone Witness Statement, dated 08/31/2023, signed by the [NAME] President of Clinical Operations (VPCO), revealed during her shift on 08/26/2023, she observed RN #1 looking in the narcotic box for a long period of time. SRNA #2 stated it appeared that RN #1 was flipping through the narcotics. SRNA #2 stated she had seen other nurses get in the narcotic box, but they did not look for a long time like RN #1 did. SRNA #2 also stated, while RN #1 was looking through the narcotic box, she kept looking around and over her shoulder. SRNA #2 stated RN #1 saw her watching, and RN #1 then shut the narcotic box quickly, put her backpack on, and went to the bathroom. SRNA #2 stated she immediately informed Licensed Practical Nurse (LPN) #2, LPN #3, and LPN #4 of RN #1's suspicious behavior. Review of LPN #2's telephone Witness Statement, dated 08/31/2023, signed by Unit Manager UM/LPN #10, revealed on 08/26/2023 at approximately 8:00 PM, SRNA #2 alerted LPN #2 that RN #1 had been going through the narcotic drawer with her backpack on. The statement revealed RN #1 continued to go to the bathroom frequently with her backpack on and stayed in the bathroom for forty (40) minutes. LPN #2 stated when RN #1 came out of the bathroom, LPN #3 met RN #1 to count the carts with her, and RN #1 then took Morphine out of her pocket and returned it to the medication cart. Further, LPN #2 stated, while counting the medication, the new bottle of Morphine was marked exactly at thirty (30) ml in the bottle. Per the statement, RN #1's face was flushed, and she was talking slowly while counting with LPN #3. Review of LPN #1's telephone Witness Statement, signed by the DON, undated, revealed the DON and Administrator spoke with LPN #1 via telephone on 08/28/2023. LPN #1 stated that RN #1 was witnessed by LPN #3, after RN #1 returned from the bathroom, to remove a Morphine bottle from her pants pocket and return the bottle to the medication cart (no date or time given). LPN #1 stated that was when she called the DON. Per the statement, RN #1 counted the medication cart with LPN #3, walked down the hallway three (3) times, and then went into the bathroom with her backpack and came out with her backpack. After this occurred, LPN #1 stated RN #1 continued to finish her charting, swaying at the medication cart, and then left through the laundry room door with her backpack on. Per the statement, RN #1 then came back inside without her backpack on, stopped at the medication cart to sign herself out, and walked out of the facility without her backpack. Further, LPN #1 stated she directly went out the laundry room door and saw RN #1's backpack lying by the facility dumpster with needles and syringes inside. Per the statement, RN #1 was observed driving from the facility, and she almost hit a fence. At that time, LPN #1 stated the police were called at 12:45 AM (no date given), and police were in and out of the facility and retrieved Morphine bottles for evidence. Review of the DON's typed Witness Statement, dated 08/31/2023 and signed by the DON, revealed she received a call from LPN #1, an agency nurse, around 10:45 PM on 08/26/2023, stating that RN #1 was in the building, had not taken her backpack off the entire time, and was using the bathroom frequently. Per the statement, LPN #1 told the DON that RN #1 appeared like she was doing drugs because RN #1 was walking around the nurses station, going to the bathroom frequently, and would not take the backpack off. The DON stated, at that point, the decision was made to remove RN #1 from the schedule, and staff needed to arrange how to cover the assignments while she called RN #1 to tell her that her shift was ending. The DON stated she called RN #1 and informed her that she was being cut, and RN #1 explained to the DON that she needed to complete some charting before she went home. The DON stated that she had spoken to RN #1 twice on the phone during her shift, once when RN #1 called her about some items to follow-up on clinically on Monday, and the other was when the DON called RN #1 about the need to end her shift. The DON stated during her contact with RN #1 on 08/26/2023, there were no signs of impairment, slurred speech, or altered cognition. Continued review of the statement revealed the DON stated LPN #1 called her back and notified her that there was a medication bottle wrapper in the trash can. The DON stated LPN #1 told her that she needed to call the police department, but no behavior changes had been relayed to her at that time, and she did not call the police. The DON stated she notified the Administrator of LPN #1's statements, and then she called the facility and told staff to call her back if they noticed any changes of behaviors, signs of impairment, or if the narcotic count was incorrect. The DON stated, they never called me back. Further, the DON stated she woke up on 08/27/2023 to see text messages from LPN #1 stating staff had found RN #1's backpack out by the dumpster, and police had confiscated it. The DON stated she was informed that the backpack contained needles and syringes filled with a blue substance, and the police officers had taken the Morphine in the building for evidence, along with RN #1's backpack. The DON stated she received additional text messages that RN #1 had been arrested, and she notified the Administrator immediately. Review of the Long-Term Care Facility-Self-Reported Incident Form/Final Report, dated 09/01/2023, signed by the facility's Administrator, revealed an allegation of misappropriation of resident property occurred on 08/27/2023, which involved Residents #1, #2, and #3. Review of the Final Report revealed the facility's Determination of Findings as documented: After a thorough investigation and interviews with staff and residents, at this time we are unable to substantiate that the alleged (RN #1) took the resident's medication due to the ongoing investigation still in process with the Local Police Department. According to the investigating officer, the results of the medication testing could take up to thirty (30) days to complete. Once the finalized results were complete, the facility would follow up with an addendum. The facility does substantiate that RN #1 was observed to be impaired at the end of her shift, was wearing a backpack that was later found to have syringes filled with a blue liquid solution, and was detained and taken to the Emergency Department (ED) due to impairment and voicing suicidal ideations to the officer. Review of the facility's Addendum dated 08/31/2023, revealed after additional information was available that was not available at the time when the five (5) day report was due, the nurse in question, RN #1, confessed to the arresting police officers that she had stolen Morphine from the places she worked. The facility substantiated neglect against RN #1. Review of LPN #3's telephone Witness Statement, dated 09/07/2023, no witness signature documented, revealed on 08/26/2023, she witnessed RN #1 go into the bathroom for forty (40) minutes and heard two (2) other nurses call the DON for help. LPN #3 stated she then witnessed RN #1 take a bottle of Morphine out of her pocket and placed it back into the medication cart. LPN #3 stated she went into the bathroom and found the seal from the new Morphine bottle, took a picture, and provided it to the police. In addition, LPN #3 stated she counted the narcotics with RN #1 and noted the new Morphine bottle only had thirty (30) ml and not the thirty-four (34) ml as was in new bottles. LPN #3 stated she asked RN #1 about it, and RN #1 told LPN #3 that she did not know about the missing medication. During an interview on 09/13/2023 at 1:50 PM with SRNA #1, she stated she worked night shift and had worked with RN #1 about a month ago. She stated RN #1 appeared under the influence of something. She stated that on the night shift about a month ago, RN #1 was mean to her and was yelling at her. SRNA #1 stated that both RN #1 and another agency nurse that night looked intoxicated, but she did not remember the other nurse's name. SRNA #1 stated they were both running around and were very unfocused. The SRNA stated that she reported it first to LPN #2, and LPN #2 called the DON about the incident. SRNA #1 stated the other nurse left the building sometime around midnight and did not come back into the building until about 3:00 AM. During continued interview with SRNA #1, on 09/13/2023 at 1:50 PM, she stated the DON got to the facility around 3:30 AM, but before the DON got to the building the other nurse had already left due to personal issues. The SRNA stated, that on that night a few residents came to the nursing station with complaints of not getting their medications. SRNA #1 stated she was scheduled to work with RN #1 a week later. She stated RN #1 refused to work with her; RN #1 was moved to another hallway. Further, SRNA #1 stated, she thought RN #1 used that as an excuse to get onto another hallway. The SRNA stated on that night, RN #1 looked high and could not focus that night either, before she moved to another hallway. In addition, SRNA #1 stated she reported it to the other night shift nurses, and the DON had been notified on multiple occasions about RN #1. However, she stated the DON kept defending RN #1, and she and other staff did not know why. SRNA #1 stated RN #1 always kept a backpack on her, except when she was sitting down, she went to the bathroom about ten (10) times a shift, and she would stay in the bathroom for over forty (40) minutes at the most. During an interview with LPN #4 on 09/13/2023 at 8:17 PM, she stated she reported on 08/26/2023 at 7:30 PM that SRNA #2 went to LPN #3, and informed her that RN #1 was acting oddly and was going through the medication carts but not passing medications. LPN #4 stated around 10:00 PM, RN #1 was talking belligerently, slurring words, and her pupils were pinpoint. At approximately 10:46 PM, LPN #4 stated she called the DON and told her RN #1 was higher than an f-in [NAME]. LPN #4 also stated RN #1 went into the bathroom right after that and was in there for quite some time. The LPN stated that the pharmacy brought in a new vial of Morphine, and RN #1 signed it off and went into the bathroom afterwards with her backpack on and did not come out of the bathroom until 11:26 PM. In continued interview with LPN #4, on 09/13/2023 at 8;17 PM, she stated she called the DON again and informed her that she and other staff wanted to call the cops because they felt RN #1 had taken the Morphine. LPN #4 stated she also informed the DON when RN #1 came out of the bathroom, LPN #3 had witnessed RN #1 pull a Morphine bottle out of the side pocket of her pants and put the vial back in the medication cart on the Tulip Hall. In addition, she stated LPN #3 showed LPN #2 and LPN #4 a picture of RN #1 putting the Morphine bottle back into the medication cart. LPN #4 stated they wanted to call the cops, but the DON said not to call the cops that it was speculation. LPN #4 stated the DON told her that she wanted to call the Administrator, and the DON called them back in about five (5) minutes and said they would send RN #1 home, it was speculation, and they would deal with RN #1 at a later time. During the continued interview with LPN #4 on 09/13/2023 at 8:17 PM, LPN #4 stated SRNA #2 and LPN #3 went to the bathroom and obtained the seal for the Morphine bottle in the bathroom. LPN #4 stated RN #1 ditched her backpack out the service door and could not focus on clocking out. LPN #4 stated she walked RN #1 to the time clock after about an hour. Afterwards, LPN #4 stated she and other staff went to check on what happened to RN #1's backpack, and they found it next to the dumpsters. LPN #4 stated she observed seven (7) syringes filled with a blue liquid substance, Scopolamine transdermal patches (prevent nausea and vomiting), and needles in RN #1's backpack. LPN #4 stated she took a picture of the contents with her cell phone and sent it to the DON. LPN #4 stated, at that time, LPN #3 called 911 Police Department (PD) but waited until RN #1 was in the vehicle. LPN #4 stated the PD was just a few blocks down the road, and police stopped RN #1 down the street and came back to the facility and picked up the backpack. LPN #4 stated during interview, on 09/13/2023 at 8:17 PM, that all nurses performed visual pain assessments on all the residents and did pain assessments on the two (2) Hospice residents, Residents #2 and #3, as well as Resident #1 since he/she was on Morphine. LPN #4 stated the night of the incident with RN #1, after she exited the facility, Resident #1 started to demonstrate behaviors and did not sleep. LPN #4 stated Resident #1 was very vocal even though the resident did not talk, and this was not typical behavior when Resident #1 was on his/her Morphine. LPN #4 stated she did visual assessments on those twenty-one (21) residents that RN #1 took care of, and no pain was noted other than the two (2) Hospice residents (Residents #2 and #3), who were hollering out in pain, looked strained, and clinched fists. The LPN stated the staff tried to reposition them and talked to them, but LPN #4 stated she and other nurses were scared to do anything else, not knowing for sure what the residents had received or not. She stated the PD had confiscated the Morphine earlier when they came back to the facility. In addition, LPN #4 stated it took an hour and one-half (1.5) to get the Nurse Practitioner to send new prescriptions for the residents. She stated two (2) residents were sent to the ED for abdominal pain, and one (1) resident had a fall. During the interview, on 09/13/2023 at 1:50 PM, LPN #4 stated she and other staff made sure all the residents were alive, not out of it, and SRNAs were put on high alert. LPN #4 stated she called the DON twice and texted her the rest of the time. LPN #4 stated she called the DON again and informed her nursing did not feel comfortable taking over RN #1's medication cart keys. She stated the DON replied that the important thing was to get RN #1 out of the building, and since they were overstaffed to go ahead and send her home. LP [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for one (1) of sixty-one (61) sampled residents (Residents #66). The facility assessed Resident #66 as requiring a pureed, nectar thick diet and needing supervision with meals. The resident had a diagnosis of Dysphagia. Resident #66 had a Physician's Order for nectar thickened liquids, and a pureed diet with double portions at dinner. Review of Resident #66's CCP, dated [DATE], revealed the facility care planned the resident as at risk for dehydration related to his/her risk of aspiration, and a mechanically altered diet. However, record review revealed no documented evidence of specific interventions for assisting Resident #66 with performing safe swallowing techniques or monitoring the resident during meals. Therefore, Resident #66 was found with a partially eaten cheeseburger, unresponsive and slumped over the dining room table after lunch. Emergency Medical Services (EMS) arrived and it was determined Resident #66 was deceased upon EMS' arrival. Review of Resident #66's Comprehensive Care Plan (CCP) dated [DATE] and revised on [DATE], revealed the resident was at risk for aspiration and had a mechanically altered diet. However, there was no evidence of interventions to assist or monitor Resident #66 while eating. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656 and 42 CFR 483.25 Quality of Care, F684 at a S/S of a J. The facility was notified of the IJ on [DATE] and the IJ is ongoing. The findings include: Review of the facility's policy titled, Accidents and Incidents effective [DATE], revealed the facility's intent was to provide an environment free from accidents and incidents that were avoidable. Further policy review revealed the facility investigated occurrences with applicable documentation and appropriate reporting. Review of the facility's policy titled, Comprehensive Care Plans effective [DATE], revealed the CCP was based on a thorough assessment which included but not limited to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) assessments. Continued review revealed care plan interventions were implemented for residents' problem areas, and the causes. Further review revealed the CCPs were prepared by the Interdisciplinary Team (IDT), and were ongoing. In addition, the CCP's were to be revised as information about the resident and the resident's condition changed. 1. Review of Resident #66's medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Dementia; Dysphagia, Oropharyngeal Phase, and Anxiety. Review of Resident #66's Annual MDS assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Further review revealed the facility assessed Resident #66 to require setup help only, when eating. Review of the Physician's Order dated [DATE], revealed Resident #66 had orders for nectar thickened liquids and a pureed diet related to Dysphagia (swallowing problem). Further review revealed Resident #66 was to receive double portions with dinner. Review of Resident #66's CCP dated [DATE] and revised on [DATE], revealed the facility care planned the resident as at risk for aspiration and to have a mechanically altered diet. However, further review revealed no documented evidence of specific person-centered interventions for Resident #66 to have assistance with meals, or to monitor him/her related to the resident's swallowing problems. Review of the Speech Therapist (ST) Note dated [DATE], revealed Resident #66's impulsivity continued, and the resident required minimal to moderate verbal cues to slow the rate of eating, and consume appropriate bolus (bite) size. Review of the ST Note dated [DATE], revealed Resident #66 was able to verbalize safe swallowing techniques; however, the resident did not always carry out those techniques independently. Review of Resident #66's Medical Nutrition Therapy (MNT) Evaluation Form dated [DATE], revealed supervision of Resident #66 was needed for his/her eating ability; Dysphagia referenced under swallowing ability; and the need for a Speech Language Pathologist (SLP) was also referenced. During interview on [DATE] at 10:17 AM, State Registered Nurse Aide (SRNA) #6 stated Resident #66 choked once before when eating a pork chop. The SRNA further stated Resident #66 did not eat his/her cheeseburgers and hid them in his/her shirt to take to his/her room. In interview on [DATE] at 1:01 PM, Licensed Practical Nurse (LPN) #9 stated Resident #66 had a prior incident of choking on a pork chop. LPN #9 stated Resident #66's roommate, Resident #10 often ordered two (2) cheeseburgers as a substitute for lunch and dinner and sometimes kept cheeseburgers in the room, which Resident #66 had access to. The LPN further stated a partially eaten cheeseburger was found on the table beside Resident #66 when the resident was found unresponsive and slumped over the table. During an interview on [DATE] at 3:55 PM, the Regional Clinical Dietitian, stated as she was the Regional RD she did not know Resident #66. She stated after review of the MNT Evaluation Form dated [DATE], Resident #66 was to have supervision at all meals. During an interview on [DATE] at 8:20 AM, the MDS Coordinator stated it was her responsibility to ensure the CCP was developed and person-centered to meet the assessed needs of the residents. She stated Resident #66's Annual MDS dated [DATE], documented the resident was independent with set up and supervision for meals. The MDS Coordinator further stated, after she reviewed the ST Notes, Resident #66 required supervision at mealtime; however, that was not reflected on the resident's CCP. In addition, she stated Resident #66's need for supervision at mealtime was not discussed in the clinical meetings. During an interview on [DATE] at 8:30 AM, the Rehabilitation Therapy Director (RTD) stated therapy staff held a weekly meeting for review of residents' CCPs and then reported to the IDT to ensure the CCPs were resident specific. The RTD stated Resident #66's CCP did not reflect the resident's specific care needs for swallowing interventions and monitoring during meals. The RTD further stated she was not able to explain why she had not received the information regarding Resident #66's need for monitoring and swallowing interventions from the ST. During an interview on [DATE] at 5:06 PM, the Administrator stated he was not aware of Resident #66's need for supervision.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the residents received quality of care based on the facility's identified care and treatment needs, and failed to ensure professional standards of practice were provided that would meet the residents' physical, mental, and psychosocial needs for one (1) of sixty-one (61) sampled residents (Resident #66). The facility assessed Resident #66, on [DATE], as needing a pureed, nectar thick diet and supervision with meals. Resident #66 was found unresponsive, slumped over at the dining room table after lunch, with a partially eaten cheeseburger on the table. Staff called the Emergency Medical Services (EMS). Prior to EMS' arrival Resident #66 was moved to the floor. Upon arrival EMS found Resident #66 laying on his/back with a blanket underneath his/her head in the dinning hall area of the nursing home. Resident #66 had no pulse. The resident's face was pale with a bluish color, the resident was rolled over and had mottled skin on the back of his/her arms and back. Resident #66 was pronounced dead at 3:55 PM. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F 656 and 42 CFR 483.25 Quality of Care, F 684 at a S/S of a J. The facility was notified of the IJ on [DATE]. The IJ is ongoing. The findings include: Review of the facility's policy titled, Accidents and Incidents, effective [DATE], revealed it was the intent of the facility to provide an environment free from accidents and incidents that were avoidable, and to investigate occurrences with applicable documentation and appropriate reporting. 1. Review of Resident #66's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Anxiety, Dementia, Dysphagia, and Oropharyngeal Phase (feeding difficulties). Review of Resident #66's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Further review revealed the facility assessed Resident #66 to require setup help only, when eating. Review of Resident #66's, Medical Orders for Scope of Treatment (MOST), revealed Do Not Attempt Resuscitation (DNAR) orders, dated [DATE]. Review of the Physician's Order dated [DATE], revealed Resident #66 had orders for nectar thickened liquids (NTL) and Dysphagia (swallowing problem). Resident #66 was to receive a pureed diet with double portions with dinner. Review of Resident #66's Comprehensive Care Plan (CCP) dated [DATE] and revised on [DATE], revealed the resident was at risk for aspiration and had a mechanically altered diet. However, there was no evidence of interventions to assist or monitor Resident #66 while eating. Review of the Speech Therapist (ST) Notes dated [DATE], revealed Resident #66's impulsivity continued; he/she required minimal to moderate verbal cues to slow the rate while eating, and should consume appropriate bolus (bite) size. Review of the ST Note dated [DATE], revealed Resident #66 was able to verbalize safe swallowing. However, he/she did not always do this independently. Review of the ST Note dated [DATE], revealed after the swallowing evaluation, education was provided to Resident #66 and staff on general safe swallowing. Review of the Medical Nutrition Therapy (MNT) Evaluation Form for Resident #66 dated [DATE], revealed supervision was marked under eating ability; Dysphagia was marked under swallowing ability; under Speech Language Pathologist (SLP) for treatment. Review of the Swallow Consult Form for Resident #66 titled, Fiberoptic Endoscopic Evaluation of Swallowing Report dated [DATE], revealed a safe PO (by mouth) diet was not recommended for Resident #66 due to the penetration/aspiration of thin liquids and nectar thick liquids (NTL), and the inability for full clearance of puree solids with risk for penetration/aspiration. If the resident continued with PO intake despite the risks for aspiration, it was recommended to continue a puree diet with NTL and after swallowing bites of puree, followed with two (2) to three (3) teaspoons (tsp.) of NTL before the next puree bite. Further review revealed the recommendation for the need of a gastrointestinal (GI) consult for further evaluation of an esophageal component, affecting the pharyngeal swallow. Review of the Emergency Medical Services (EMS) Run Sheet dated [DATE], revealed EMS was dispatched to the facility on [DATE] at 3:23 PM, and arrived to the facility at 3:25 PM and made contact with Resident #66 at 3:26 PM. Further review revealed EMS was dispatched to the facility for a resident that was unresponsive and not breathing. The resident was found laying on his/her back with a blanket underneath his/her head in the dining hall area of the nursing home. Prior to EMS' arrival, staff stated Resident #66 was moved to the floor and was found to have a faint pulse;.after being placed on the floor, Resident #66 lost his/her pulse. Further review revealed Resident #66's face was pale and bluish in color, and the resident had mottled skin on the back of his/her arms and back when EMS rolled him/her over. Continue review revealed Resident #66 was not allowed to have solid food and only puree food, but a piece of a hamburger was sitting on the table in the dining area close to the resident. None of the staff knew what really had happened to Resident #66, but stated the resident looked like he/she was falling asleep before the incident happened. Resident #66 was pronounced dead upon EMS arrival to the facility. 2. Review of Resident #10's medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Diabetes Mellitus, Anxiety, Depression, and Post-Traumatic Stress Disorder (PTSD). Review of Resident #10's Annual MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), indicating he/she was cognitively intact. During an interview with Resident #10, roommate of Resident #66, on [DATE] at 7:49 AM, the resident stated he/she did not share a hamburger with Resident #66. Resident #10 stated he/she ordered two (2) hamburgers at lunch and supper every day. He/she further stated Resident #66 was on a processed diet and appeared to cough or choke a lot at lunch. Review of a Nursing Progress Note, dated [DATE] at 6:17 AM, revealed Registered Nurse (RN) #3 documented that Resident 66's roommate, Resident #10, gave Resident #66 a bag of goldfish crackers. Further review revealed RN #3 explained to both residents that Resident #66 could not have crackers, because it went against his/her diet order. During an interview with State Registered Nurse Aide (SRNA)//Restorative Aide #12 on [DATE] at 12:30 PM, she stated Resident #66's roommate (Resident #10) took cheeseburgers back to his/her room and she often had to remind Resident #10 not to give Resident #66 any food. During an interview with SRNA #6 on [DATE] at 10:17 AM, she stated Resident #66's roommate kept cheeseburgers wrapped up in the room. SRNA #6 stated during the same week (did not say which day prior to [DATE]) Resident #10 had given Resident #66 a cheeseburger and she had instructed Resident #10 not to give Resident #66 a cheeseburger. During an interview with ST #1, on [DATE] at 8:48 AM, she stated Resident #66's diet order was puree with NTL. She provided Resident #66 with strategies for a safe swallow, and even with cues. She stated the resident could not safely swallow and required supervision with a pureed diet. During an interview with the Dietary Manager, on [DATE] at 9:10 AM and 4:46 PM, and on [DATE] at 12:10 PM, he stated Resident #66 was not on the assisted at meals list. He stated Resident #66 often sat in the dining room after a meal and asked for a drink, and Resident #66 did not have supervision with thickened drinks. He further stated Resident #66 would ask for regular food, but he had to explain to the resident that he/she could not be offered regular food due to his/her diet. He stated Resident #66's roommate (Resident #10), ordered two (2) cheeseburgers at lunch and supper. He stated the resident took the cheeseburgers and other food back to his/her room often hidden in his/her jacket. During an interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 1:01 PM, she stated she went to the dining room with Registered Nurse (RN) #6 and found Resident #66 laying over the table. She stated she left RN #6 to find Resident #66's code status and called EMS. She stated she then returned to the dining room to find RN #6 had Resident #66 on the floor. She stated she observed a cheeseburger with three (3) to four (4) bites sitting on the table where Resident #66 was found. She further stated Resident #66's roommate liked to keep cheeseburgers in his/her room. However, she had not seen Resident #10 give Resident #66 a cheeseburger. During an interview with the Assistant Director of Nursing (ADON), on [DATE] at 9:13 AM, she stated she did not recall if it was discussed in the morning meeting or clinical meeting that Resident #66 had requested regular food. The ADON stated staff were not assigned to the dining room after mealtime. However, they passed through' the dining room to observe residents who gathered on their own to watch television and listen to music. During an interview with the Director of Nursing (DON), on [DATE] at 8:18 AM, she stated staff did not observe Resident #66 choke. She stated the staff's supervision in the dining room during mealtime was supposed to be two (2) State Registered Nursing Assistants (SRNA) and one (1) Nurse. She stated the Interdisciplinary Team (IDT) had not discussed the incident and the facility had not completed an investigation of the incident. During an interview with the Administrator, on [DATE] at 5:06 PM, he stated the incident was isolated with Resident #66 and the facility did not investigate it. During an interview with the Medical Director, on [DATE] at 12:26 PM, he stated he was not informed of Resident #66's death on [DATE] until he attended the Ad-Hoc meeting on [DATE]. He stated he should have been made aware of Resident #66's death and if the resident was eating regular food. The Medical Director stated if on a regular diet, Resident #66 could have choked, causing aspiration pneumonia and/or death.

Based on interview, record review, review of the facility's policy and the Administrator's job description it was determined, the facility failed to be administered in a manner which enabled its' effective use of resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to immediately conduct an investigation of an allegation of misappropriation residents' narcotic medications. Licensed Practical Nurse (LPN) #4 reported to the Director of Nursing (DON) that Registered Nurse (RN) #1 was exhibiting suspicious behaviors of wearing a backpack at work; being in the bathroom for long periods of time, and acting weird. While the DON was in the facility, on 08/11/2023 at 3:00 AM, RN #1 stayed in the bathroom for extended periods and walked around with a backpack. However, the DON reported there were no concerns, and staff members' reports were just speculation. In an interview with LPN #3, she stated on 08/26/2023 she observed Registered Nurse RN #1 take a bottle of Morphine out of her pocket and placed it into the medication cart at approximately 11:30 PM. LPN #4, stated she observed RN #1 on 08/26/2023 at approximately 10:00 PM talking belligerently, slurring her words, and her pupils were pinpoint. LPN #4 stated at 10:46 PM, she observed RN #1 enter the bathroom, and she did not exit until 11:26 PM. LPN #4 stated she called the DON at 10:46 PM initially and told her that RN #1 was higher than a f .ing [NAME]. LPN #4 stated she informed the DON that she wanted to call the police because she thought RN #1 had taken the Morphine that was delivered from the pharmacy at approximately 10:00 PM for Resident #2; however, the DON told her not to call the police. In an interview with the Administrator, he stated on 08/27/2023 at 7:30 AM, he was made aware by the DON that the police had been called on 08/26/2023. The Administrator stated staff had texted the DON on 08/26/2023. However, she was not aware of the text until the next morning on 08/27/2023. He stated he was told by the DON that RN #1 had been arrested, and Morphine was found in RN #1's backpack. The facility's Administrator and DON failed to immediately take action to investigate and report, implement corrective action consistent with the investigation's findings, and failed to take steps to eliminate any ongoing danger to the resident(s) in a timely manner. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 09/21/2023 and determined to exist on 08/26/2023 in the area of 42 CFR 483.12 Freedom from Abuse and Neglect, F602 and F610 with a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on 09/21/2023. The IJ is ongoing. The findings include: Review of the facility's policy, Facility Administration revised 09/05/2018, revealed the facility was operated under the direction of a Chief Executive Officer (CEO) in accordance with Federal and State laws and professional standards. Continued review revealed the CE0 or Administrator was to report unusual occurrences to appropriate agencies in accordance with specific state and/or federal guidelines. Per review, the facility had a governing body consisting of the CEO, Director of Nursing (DON) and Medical Director that was legally responsible for establishing and implementing policies regarding the management and operation of the facility. Further review revealed the facility's policies and procedures were maintained and updated periodically to reflect current professional standards and practice through annual review. Review of the job description for the Administrator dated 03/2021, revealed the Administrator reported to the Regional [NAME] President of Operations and was to lead and direct the overall operations of the facility in accordance with residents' needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Per review, the Administrator was to monitor Data Points and address issues that affected the performance of the facility. Continued review revealed the Administrator was also to monitor each department's activities; communicate policies; evaluate performance; provide feedback and assist, observe, coach, and discipline as needed. Further review revealed the Administrator was to oversee via regular rounds the monitoring of delivery of nursing care, operation of support departments, cleanliness and the appearance of the facility; morale of the staff, and ensure resident needs were being addressed. In addition, the Administrator was to utilize survey information to address areas of importance as defined by the residents and he/she was responsible for the facility's Quality Assurance (QA) program. Review of the job description for the Director or Nursing (DON) dated 03/2021, revealed the DON reported to the Administrator and was to manage the overall operations of the facility's Nursing Department in accordance with company policies and standards of nursing practices and governmental regulations, so as to maintain excellent care for all residents' needs. Continued review revealed in the role of the DON, he/she was to plan, develop, organize, implement, evaluate and direct the Nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines given the long-term care facility. Further review revealed the DON was responsible for informing the State of any reportable incidents within the appropriate time frames and complete the investigative analysis as required. In addition, the DON was to regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations. On 08/11/2023 at 3:00 AM, the DON was in the facility working due to the facility requiring staff coverage and to observe Registered Nurse (RN) #1's behaviors which had been reported as suspicious. While the DON was in the facility on 08/11/2023, RN #1 stayed in the bathroom for long periods and walked around with a backpack on as reported by staff. However, the DON reported the staff members' reports as just speculation and there were no concerns regarding RN #1. On 08/26/2023, Licensed Practical Nurse (LPN) #4 reported to the DON that Registered Nurse (RN) #1 had suspicious behaviors of acting weird, being in the bathroom for long periods of time, and wearing a backpack at work. During an interview with LPN #3, she stated on 08/26/2023, at approximately 11:30 PM she saw RN #1 remove a bottle of Morphine from her pocket and place it in the medication cart. During an interview with LPN #4 on 09/13/2023 at 8:17 PM, she stated on 08/26/2023 at approximately 10:00 PM, she saw RN #1 slurring her words, speaking belligerently, and observed the RN's pupils as pinpoint. LPN #4 stated she saw RN #1 at 10:46 PM, enter the bathroom, and not come out of the bathroom until 11:26 PM. LPN #4 stated she called the DON initially at 10:46 PM, to tell the DON that RN #1 was higher than a f .ing [NAME]. LPN #4 stated she told the DON she wanted to call the police because she thought RN #1 had taken Morphine meant for Resident #2 from the medication cart which had delivered from the pharmacy at approximately 10:00 PM. The Administrator stated in interview on 08/27/2023 at 7:30 AM, that the DON made him aware the police had been called on 08/26/2023. He stated staff had texted the DON on 08/26/2023. However, he was not aware of the text messages until the morning of 08/27/2023. He stated the DON told him RN #1 had been arrested, and Morphine was found in the RN's backpack. In interview on 09/15/2023 at 6:03 PM, the Administrator stated he and the DON decided to send RN #1 home. The Administrator stated he was made aware of the situation involving suspected narcotic diversion by RN #1 by the DON on 08/27/2023 at 7:30 AM. However, he stated he did not go to the facility until 08/28/2022, and an Ad-HOC meeting was not completed until 08/29/2023. The Administrator stated he was the designated person for completing the investigation as the Abuse Coordinator. In interview on 09/15/2023 at 2:20 PM, the DON stated her attorney wanted to be present during any interviews, therefore no interview was obtained from the DON. In an interview on 09/19/2023 at 3:31 PM, the Medical Director stated he had been the facility's Medical Director since 2019. He stated, when he was asked about the recent drug diversion in the facility, he stated he had not been notified immediately. The Medical Director stated he had talked with the Administrative Team, and they were currently working on a process so the diversion did not happen again. He stated the Administrator notified him of the unfortunate incident on Tuesday, 08/29/2023. The Medical Director stated no one had notified him about the incident prior to 08/29/2023, and he did not get any phone calls about residents being in pain. He stated he set up a Quality Assurance (QA) meeting to deal with the incident, and he attended an Ad- Hoc Quality Assurance over the phone but no full blown' Quality Assurance and Prevention Improvement (QAPI) meeting. The facility had a QAPI meeting scheduled 09/19/2023 to discuss the incident going forward. He stated he had not heard of anyone having increased pain in the facility. The Medical Director stated the facility was in the process of decreasing the Morphine dose for Resident #1 and the plan was to either discontinue it or switch to pill form. He stated we had several Ad Hoc meetings over the phone about the incident, and his recommendation had been for getting the resident a new supply of morphine. In continued interview on 09/19/2023 at 3:31 PM, the Medical Director stated he was not aware of how quickly medications were replaced at the facility; however, he thought it was within twenty-four (24) hours. He stated reporting needed to be immediately, was to go up the chain of command, and he should have been notified immediately for something that major. The Medical Director stated if he had been notified immediately after the incident, he would have switched the narcotic pain medication to a pill form from the liquid form. He stated he would have started brainstorming quicker with the facility's administration on how to prevent the incident from happening again. Per the Medical Director, Everyone here is my patient, he would have made sure the morphine was replaced quicker and a pain assessment completed on everyone. He stated for Something that big I would have thought they would have called me. The Medical Director stated, We were going to discuss what the plan in place was at today's QAPI meeting. He stated his expectation for the administration role going forward, after an incident like that one was for them to go into the facility, and he also stated, I was shocked, and I didn't ask why they didn't come into the building. when notified. The Medical Director stated he thought it would show leadership and help staff see things were being taken seriously and issues were being taken care of if administration had come into the building. He further stated the risk for residents not receiving their Morphine was they could have opiate withdrawal and it could potentially be fatal. The Medical Director stated for residents not receiving their Morphine would be they would have increased pain from the withdrawal. In addition, he further stated psychosocial harm would be a result of the pain incurred.

Based on interview, record review, review of the facility's investigation, and review of the facility's policies, and the Kentucky Incident Based Reporting System (KYIBRS) Report it was determined the facility failed to ensure an thorough investigation was conducted timely; and failed to protect the safety of the residents after they were informed of an allegation of misappropriation related to narcotic (Morphine) drug diversion for three (3) of sixty-one (61) sampled residents (Residents #1, #2, and #3). Residents #1, #2, and #3 were prescribed Morphine (an opioid given to relieve moderate to severe pain). The Administrator and the Director of Nursing (DON) became aware of an allegation of misappropriation that Registered Nurse (RN) #1 had diverted narcotic medications on 08/26/2023. However, an investigation was not initiated until 08/27/2023. In addition, the Administrator, who was the Abuse Coordinator, did not come to the facility until 08/28/2023. The facility's Ad Hoc meeting to address the diversion was not held until 08/29/2023. The facility's failure to take immediate action to prevent drug diversion and have a system in place to ensure the residents were protected is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified on 09/21/2023 and determined to exist on 08/26/2023 in the area of 42 CFR 483.12 Freedom from Abuse and Neglect, F602 and F610 with a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on 09/21/2023. The IJ is ongoing. The findings include: Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, revised 10/17/2022, revealed the Administrator would investigate all allegations and provide complete and thorough documentation of the investigation of abuse/misappropriation. The Administrator would also determine the root cause; take steps to eliminate the ongoing danger to residents; and notify the Medical Director. Review of the facility's policy,Controlled Medication and Drug Diversion Policy revision date 07/07/2022, revealed the facility was to investigate and make every reasonable effort to reconcile reported narcotic discrepancies. The policy stated if a major discrepancy or a pattern of discrepancies occurred or if there was apparent criminal activity, the DON would notify the Chief Executive Officer (CEO), Nurse Care Consultant (NCC), Regional Vice-President (RVP), and pharmacy immediately. 1. Review of Resident #1's admission record revealed the facility admitted Resident #1 on 08/10/2021 with diagnoses that included Cerebral Palsy, Scoliosis, and Severe Intellectual Disabilities. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 06/14/2023, revealed the facility could not assess the resident with a Brief Interview for Mental Status (BIMS) score due to Resident #1 being never or rarely understood. Review of Resident #1's Physician's Orders revealed an order, dated 08/07/2023, for Morphine Sulfate 100 milligrams (mg)/5 milliliters (ml) (20 mg/ml), amount five (5) mg (0.25 ml) oral concentration liquid to administer 0.25 ml orally every six (6) hours for pain. 2. Review of Resident #2's admission record revealed the facility admitted Resident #2 on 08/19/2023 with diagnoses of Down's Syndrome, Encephalopathy, and Anxiety. Further review revealed Resident #2 was a Hospice/Palliative care resident. Review of Resident #2's Admission MDS Assessment, dated 08/26/2023, revealed the facility could not assess the resident with a Brief Interview for Mental Status (BIMS) score due to Resident #2 being never or rarely understood. Review of Resident #2's Physician's Orders revealed an order, dated 08/26/2023, for Resident #2 to receive Morphine Sulfate 100 milligrams (mg)/5 milliliters (ml) (20 mg/ml), amount five (5) mg (0.25 ml) oral concentration liquid to administer 0.25 ml orally every four (4) hours as needed (PRN) for pain. Additional review revealed a new order, dated 08/26/2023, for Resident #2 to receive Morphine Sulfate 100 mg/5 ml (20 mg/ml), amount ten (10) mg (0.5 ml) oral concentration liquid, to administer 0.5 ml orally every four (4) hours as needed (PRN) for pain. Review of Resident #2's Medication Administration Record (MAR) revealed the resident received a dose of Morphine 5 mg on 08/26/2023 at 12:33 PM with effective results. No further documentation was noted on the MAR for 08/26/2023. Review of the facility's Controlled Drug Record revealed on 08/26/2023 at approximately 10:00 PM, pharmacy delivered a thirty (30) ml bottle of Morphine Sulfate 100 mg/5 ml oral concentration liquid for Resident #2, with an order to administer 0.5 ml orally every four (4) hours as needed (PRN) for pain. Further review revealed Resident #2's Morphine narcotic medication was signed off as received by Registered Nurse (RN) #1 and witnessed by Licensed Practical Nurse (LPN) #3. 3. Review of Resident #3's admission record revealed the facility admitted Resident #3 on 11/07/2017 with diagnoses of Down's Syndrome, Dementia, Epilepsy, and Anxiety. Further review revealed Resident #3 was a Hospice/Palliative care resident. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility could not assess the resident with a Brief Interview for Mental Status (BIMS) score due to Resident #3 being never or rarely understood. Review of Resident #3's Physician's Orders, dated 06/27/2023, revealed an order, dated 08/09/2023, for Resident#3 to receive Morphine Sulfate 10 mg/5 ml, (2 mg/ml) oral concentration liquid, to administer one (1) ml orally every two (2) hours as needed (PRN) for pain. Review of the Kentucky Incident Based Reporting System (KYIBRS) Report of incident KY 23-212, dated 08/27/2023 at 12:35 AM, revealed the police stopped RN #1 for her vehicle's failure to signal and to conduct a Driving Under the Influence (DUI) investigation at 12:37 AM. At that time, RN #1 advised Officer #1 that the seven (7) syringes with the blue liquid were Morphine, and she had taken them from the facility. Per the report, RN #1 also advised Officer #1 she had taken a dose of Morphine while on shift earlier tonight while caring for twenty-one (21) residents. Per the report, while enroute to the hospital, RN #1 informed Emergency Medical Services (EMS) personnel (called because RN #1 was expressing suicidal ideation) she had been conducting this unlawful act since January 2023. Per the report, a warrant of arrest was issued for RN #1 on 08/27/2023 at 2:36 AM, which included eight (8) counts for the charge of Theft of a Legend Drug (a drug approved by the Food and Drug Administration (FDA) that could be dispensed to the public only with a prescription); twenty-one (21) counts of Wanton Endangerment in the First Degree; seven (7) counts of Possession of Controlled Substance; seven (7) counts of Theft by Unlawful Taking or Disposition; three (3) counts of Knowingly Abuse or Neglect of an Adult by Stealing; three (3) counts of Tampering with Physical Evidence; and one (1) count of Drug Paraphernalia. Review of the Long-Term Care Facility-Self-Reported Incident Form/Initial Report, dated 08/27/2023, revealed the Director of Nursing (DON) was notified on 08/27/2023 at 7:30 AM that Registered Nurse (RN) #1 was pulled over by the police after her shift ended at 11:00 PM on 08/26/2023. The RN was pulled over for suspicion of impairment and was noted to have syringes, blue food coloring, and saline in her backpack. Further review revealed the police came to the facility and took Morphine from the medication carts for testing, and stated they would follow up. Per the investigation, Residents #1, #2, and #3's responsible parties, Hospice, and the Medical Director were notified; pain assessments were completed; pharmacy was notified and the medication (Morphine) was sent immediately (stat); all narcotic counts were completed and were accurate; and the investigation was started immediately. However, during an interview on 09/13/2023 at 8:17 PM with Licensed Practical Nurse (LPN) #4 she stated she had observed RN #1, on 08/26/2023 at approximately 10:00 PM, talking belligerently, with slurred speech and pinpoint pupils. LPN #4 stated she contacted the DON at approximately 10:46 PM and informed her that RN #1 was higher than a f**king [NAME]. LPN #4 stated the DON was made aware that LPN #3 had observed RN #1 take a Morphine bottle from her pocket and place it in the medication cart after RN #1 came out of the bathroom around 11:26 PM. LPN #4 stated she informed the DON that she felt the police should be contacted due to staff's suspicion that RN #1 had taken the Morphine that was delivered at approximately 10:00 PM for Resident #2. LPN #4 stated that she was informed not to call the police, but to let the DON contact the Administrator, and she would call her back. LPN #4 stated, on the return phone call from the DON around 11:30 PM, the DON instructed her to send RN #1 home, and they would deal with RN #1 later. LPN #4 stated she was informed by the DON that the Administrator stated that it was only speculation that RN #1 had misappropriated narcotics. LPN #4 stated she spoke with the DON two (2) different times and conversed by text message all the other times. Review of LPN #2's telephone Witness Statement, dated 08/31/2023, signed by the Unit Manager (UM/LPN) #10, revealed on 08/26/2023 at approximately 8:00 PM, State Registered Nurse Aide (SRNA) #2 alerted LPN #2 that RN #1 had been going through the narcotic drawer with her backpack on. The statement revealed RN #1 continued to go to the bathroom frequently with her backpack on and stayed in the bathroom for forty (40) minutes. LPN #2 stated when RN #1 came out of the bathroom, LPN #3 met RN #1 to count the carts with her, and RN #1 then took Morphine out of her pocket and returned it to the medication cart. Further, LPN #2 stated, while counting the medications, the new bottle of Morphine was marked exactly at thirty (30) ml in the bottle. Per the statement, RN #1's face was flushed, and she was talking slowly while counting with LPN #3. Review of the Long-Term Care Facility-Self-Reported Incident Form/Final Report, Addendum, dated 08/31/2023, revealed after additional information was available that was not available at the time when the five (5) day report was due, the nurse in question, RN #1, confessed to the arresting police officers that she had stolen Morphine from the places she worked, and the facility substantiated neglect against RN #1. Review of LPN #3's telephone Witness Statement, dated 09/07/2023, no witness signature documented, revealed on 08/26/2023, she witnessed RN #1 go into the bathroom for forty (40) minutes and heard two (2) other nurses call the DON for help. LPN #3 stated she then witnessed that RN #1 took a bottle of Morphine out of her pocket and placed it back into the medication cart. LPN #3 stated she went into the bathroom and found the seal from the new Morphine bottle, took a picture, and provided it to the police. In addition, LPN #3 stated she counted off the narcotics with RN #1 and noted the new Morphine bottle only had thirty (30) ml and not the thirty-four (34) ml as was in new bottles. LPN #3 stated she asked RN #1 about it, and RN #1 told LPN #3 that she did not know about the missing medication. During an interview on 09/19/2023 at 3:31 PM with the Medical Director (MD), he stated he had been the MD since 2019. He stated the Administrator made him aware of the unfortunate incident on Tuesday 08/29/2023. He stated he had been informed that RN #1 was arrested outside the building, and had been suspended. The Medical Director stated they had discussed how RN #1 had replaced Morphine with water and blue food coloring and ways to prevent this in the future. The MD stated that everybody was in crisis mode and trying to figure out how to deal with it. He further stated that nobody had notified him about the incident prior to 08/29/2023, and he did not get any phone calls about residents being in pain. The Medical Director stated he recommended switching residents from liquid form to tablet form of Morphine. He stated at the Ad-Hoc meeting participants were just brainstorming. He stated he was not sure if pharmacy had come up with anything yet to prevent this from happening again. The MD stated he should have been notified immediately for something that was this major. He said his expectation of administration would be for them to go to the facility immediately after being made aware of the situation. The Medical Director stated the risk with residents not receiving their ordered Morphine would be they could have opiate withdrawal, and it could potentially be fatal. During an interview on 09/15/2023 at 6:03 PM with the Administrator, he stated he was the designated person for completing the investigation as the Abuse Coordinator. He stated that he received a phone call on 08/26/2023 at approximately 11:30 PM from the DON reporting that she had been contacted by LPN #4. The DON stated LPN #4 informed her that RN #1 was acting weird, wearing a backpack, and going into the bathroom frequently. The Administrator stated he and the DON decided to send RN #1 home. He stated he was made aware of the situation involving suspected narcotic diversion involving RN #1 by the DON on 08/27/2023 at 7:30 AM. He further stated he did not come into the facility until 08/28/2022, and an Ad-HOC meeting was not completed until 08/29/2023. During an interview on 09/19/2023 at 2:07 PM with the [NAME] President of Clinical Operations (VPCO), she stated that she was informed by the Administrator and DON of an alleged incident of misappropriation of narcotics on 08/26/2023. She further stated that the Administrator and DON did not come into the facility until Monday morning, on 08/28/2023, but they should have come to the facility to address the situation on 08/26/2023.

Based on observation, interview, record review and review of the facility's abuse policy, it was determined the facility failed to ensure an environment that was free from abuse involving eight (8) of sixty-one (61) sampled residents (Residents #9, #35, #41, #50, #59, #66, #69 and #74). 1. On 01/11/2023, Resident #74 grabbed Resident #35's right arm causing a skin tear. 2. On 08/24/2022, Resident #41 was observed sitting on the side of Resident #69's bed holding Resident #69's arm and yelling at Resident #69, resulting in a bruise to the arm and a scratch to Resident #69's face. 3. On 03/11/2023, Resident #66 hit Resident #59 with his/her grabber device. 4. On 09/13/2023, State Registered Nursing Assistant (SRNA) #6 observed SRNA #5 when she made a comment in the presence of Resident #9 and his/her spouse. SRNA #5 stated, Why do I have to be the one to wipe the asses. 5. On 03/29/2023, Hospitality Aide #1 was observed telling Resident #50 to go to hell after the resident had made a comment to her. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, effective date 05/27/2016, revised on 07/06/2022, revealed it was the organizations's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of residents' property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal abuse was defined as the use of any oral, written or gestured language that include any threat, or any frightening, disparaging or derogatory language, to the residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability. 47711 1. Review of the facility' investigation dated 08/29/2022 revealed staff found Resident #41 setting on the side of his/her roommate's bed (Resident #69) screaming at him/her. Resident #41 had Resident #69's right arm in his/her hand. Resident #69 had bruising on his/her right arm and scratches on the right side of his/her face. Resident #41 and Resident #69 were separated. Resident #41 was placed on 1:1 monitoring. Resident #69 was moved to another room. Review of Resident #41's Admission Record revealed the facility admitted the resident on 04/13/2017 with diagnoses that included Alzheimer's Disease, Major Depressive Disorder, Anxiety Disorder, and Unspecified Dementia without Behavior. Review of Resident #41's Annual MDS Assessment, dated 07/22/2022, revealed the facility assessed the resident to have a BIMS' score of eight (8) out of fifteen (15) which indicated the resident had moderately impaired cognition. Review of Resident #69's Admission Record revealed the facility admitted the resident on 02/17/2021 with diagnoses that included Unspecified Dementia without Behavior Disturbance, Schizoaffective Disorder, Cognitive Communication Disorder. Review of Resident #69's Quarterly MDS Assessment, dated 06/30/2022, revealed the facility assessed the resident to have a BIMS' score of zero (0) out of fifteen (15) which indicated severe cognitive deficit. Review of the Nurse's Progress Note, dated 08/24/2022 at 4:35 PM entered by Licensed Practical Nurse (LPN) #13, revealed Resident #41 had been seen grabbing Resident #69's arm and Resident #69 had a small scratch to his/her face with visible blood coming from the scratch. Review of Resident #69's care plan, dated 04/21/2022, revealed the resident was at risk and/or had active behavior problems, was physically abusive, and resistant to care. During an interview, on 09/24/2023 at 8:47 PM, with Housekeeper #2, he stated that he had heard yelling coming from Resident #41's and Resident #69's room. Housekeeper #2 stated when he looked in, he saw Resident #41 with Resident #69's arm in his/her hand and it appeared that he/she was trying to pull Resident #69 up out of the bed. He further stated that Resident #41 was saying to Resident #69 this is my bed. 2. Review of Resident #74's Admission Record revealed the facility admitted the resident on 12/01/2015 with diagnoses that included Chronic Obstructive Pulmonary Disease, Dementia, Congestive Heart Failure, Major Depressive Disorder, Epilepsy, and Schizoaffective. Review of Resident #74's Quarterly MDS Assessment, dated 11/12/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) which indicated the resident had severe impaired cognition. Review of Resident #35's Admission Record revealed the facility admitted the resident on 05/27/2020 with diagnoses that included Unspecified Dementia, Dysphagia, generalized muscle weakness, and cognitive communication deficit. Review of Resident #35's Quarterly MDS Assessment, dated 12/20/2022, revealed the facility assessed the resident to have a BIMS' score of six (6) out of fifteen (15) which indicated the resident had severe impaired cognition. Review of the facility's investigation, dated 01/11/2023 revealed SRNA (State Registered Nurse Aide) #12/Restorative Aide heard verbal yelling. Upon entry to the room, SRNA #12/Restorative Aide witnessed Resident #74 grab his/her roommate's (Resident #35) right arm, which resulted in a skin tear. Per the investigation, Resident #74 was redirected to the nurses station for closer monitoring. Review of Resident #35's Physician Orders, dated 01/11/2023, revealed a new order to monitor Resident #35's right forearm for signs and symptoms of infection every shift until healed. Review of the Medication Administration Record (MAR) revealed starting on 01/11/2023 the staff documented monitoring of the injury, with no signs or symptoms of infection noted, until 01/31/2023, when the injury was healed. During an interview, on 09/24/2023 at 6:01 PM with SRNA #12/Restorative Aide, she stated she remembered the verbal yelling and Resident #74 grabbed Resident #35's arm causing a skin tear. She also stated she did not know of any other altercations between the two (2) residents. During interview with LPN (Licensed Practical Nurse)/Unit Manager #10, on 09/25/2023 at 9:24 AM, she stated this was the only incident between these two residents. 3. Review of the facility's investigation, dated 03/11/2023, revealed Resident #66 hit his/her roommate Resident #59 with his/her grabber (an assistive device used to pick up items). Resident #66 and Resident #59 were separated. Resident #66 was placed on 1:1 observation and moved to a private room. Further review of the investigation revealed a skin assessment was performed on Resident #59 with no injuries noted. Review of Resident #66's Admission Record revealed the facility admitted the resident on 12/27/2019 with diagnoses that included Unspecified Dementia, Unspecified Lack of Coordination, Paranoid Personality Disorder, Other Schizoaffective Disorders, Epileptic Seizures related to external causes, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #66's Quarterly MDS Assessment, dated 03/10/2023, revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15) which indicated the resident had intact cognition. Review of Resident #66's CCP revealed the facility care planned the resident on 12/13/2022 for at risk and/or active behavior problems including being physically and verbally abusive as evidenced by combative behavior with staff, threatening, cursing and yelling at staff and others, sexually inappropriate toward staff. Interventions included: intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention; remove from situation and take to another location as needed. Review of Resident #59's Admission Record revealed the facility admitted the resident on 12/01/2015 with diagnoses that included History of Traumatic Brain Injury, Heart Failure, Unspecified Intracranial Injury, Seizures, and Aphasia. Review of Resident #59's Quarterly MDS Assessment, dated 02/16/2023, revealed the facility assessed the resident to have a BIMS' score of zero (0) out of fifteen (15) which indicated the resident had severely impaired cognition. Review of the Nursing Progress Note, dated 03/11/2023 at 4:37 PM entered by LPN #6, revealed Resident #66 had been witnessed hitting his/her roommate with a grabber and was combative cursing at staff. Review of the Nursing Progress Note, dated 03/11/2023 at 4:44 PM entered by LPN #6 revealed Resident #59 had been smacked with a grabber by his/her roommate with no marks or bruising at that time. During an interview, on 09/24/2023 at 7:12 PM with SRNA #10, she stated as she was walking down the hall at approximately 3:00 PM on 03/11/2023, she observed Resident #66 in his/her room with a grabber in his/her right hand. Resident #66 was sitting in his/her wheelchair beside Resident #59's bed. SRNA #10 stated Resident #66 proceeded to lift the grabber up behind his/her head and came down on Resident #59's chest while he/she was in bed. SRNA #10 further stated Resident #59 attempted to stop the grabber from hitting him/her and grabbed it. 49360 4. Record review revealed the facility admitted Resident #9 on 08/06/2023 with diagnoses which included Parkinson's Disease, Vascular Dementia and Anxiety. Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/13/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), which indicated the resident was not interviewable. In an interview with State Registered Nursing Assistant (SRNA) #5, on 09/23/2023 at 4:42 PM, she stated she and SRNA #6 were providing incontinent care to Resident #9. While changing the resident, SRNA #5 jokingly said to SRNA #6, Why am I always wiping the asses? She stated she said this to her coworker in the presence of Resident #9 and the resident's spouse was at the bedside. In an interview with SRNA #6, on 09/23/2023 at 7:07 PM, she stated SRNA #5 made the comment about wiping the asses in front of the resident and his/her spouse. She said she felt this met the definition of abuse and reported the incident to Administration. A review of the facility's final investigation, dated 09/18/2023, revealed SRNA #5 was removed from the floor and suspended and the facility immediately initiated the investigation. Initial skin assessments and pain assessments were completed with no issues noted. Following the facility's investigation, SRNA #5 was terminated. In an interview with the Interim Director of Nursing (DON), on 09/18/2023 at 3:23 PM, she stated she expected staff to report any suspicion of abuse immediately. In an interview with the Interim Administrator, on 09/19/2023 at 2:34 PM, he stated all staff had been educated on abuse and the abuse policy. He also stated when abuse was reported, it was investigated. It was his expectation all staff would follow the facility's abuse policy. 5. Record review revealed the facility admitted Resident #50 on 06/07/2019 with diagnoses which included Cerebral Infarction, Flaccid Hemiplegia, Major Depressive Disorder, Anxiety, Impulse Disorder, Personality Disorders and Dementia with Behaviors. Review of the most recent Quarterly MDS Assessment, dated 06/07/2023, revealed the facility assessed Resident #50 to have a BIMS' score of fourteen (14) out of fifteen (15) which indicated the resident was interviewable. In an interview with Hospitality Aide (HA) #2, on 09/22/2023 at 7:57 PM, she stated HA #1 became upset when Resident #50 raised his/her voice saying the resident had made a racial comment using the N word. HA #1 told the resident to go to hell as she was leaving the room. During further interview HA #1 stated the resident had a history of making inappropriate comments to staff while they were providing care. She stated she reported the incident to the nurses. In a interview with Resident #50, on 09/22/2023 at 9:30 AM, he/she stated remembering the incident with Hospitality Aide #1, but not the details. According to the resident, he/she recalled HA #1 saying something ugly to him/her. The resident stated he/she heard the HA got fired that day. In an interview with HA #1, on 09/24/2023 at 1:34 PM, she stated Resident #50 said something about her being black, which she stated she was not black. Review of the facility's final investigation, dated 04/01/2022, revealed after a thorough investigation, it was determined Hospitality Aide (HA) #1, was verbally abusive to Resident #50. The facility terminated HA #1. During an interview, on 09/18/2023 at 3:23 PM with the Special Projects Director of Nursing (SPDON), she stated that she expected staff to report any suspicion of abuse immediately and for all staff to follow the facility's policies. During an interview on 09/19/2023 at 2:34 PM with the Interim Administrator, he stated that he expected all staff to follow the facility's abuse policy. 31383

Based on interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined the facility failed to protect residents' rights and dignity for one (1) of sixty-one (61) sampled residents (Resident #73). Review of the Facility's Investigation revealed on 10/31/2022, State Registered Nurse Aide (SRNA) #2 told Resident #73 to use the bathroom in his/her brief. The findings include: Review of the facility's policy titled, Resident Rights, dated 06/01/2015, revealed all residents should have the right to be treated with respect and dignity, and these rights would be promoted and protected by the facility. The policy stated all residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Per the policy, when providing care and services, the stakeholders would respect the residents' individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. Additionally, under Section Two (2), the policy stated the resident was entitled to exercise his/her rights and privileges as a resident of the facility and as a citizen or resident of the United States, to the fullest extent possible without interference, coercion, discrimination, or reprisal. Furthermore, under Section Three (3), the policy stated the facility would make every effort to support each resident in exercising his/her right to ensure that the resident was always treated with respect, kindness, and dignity. Review of Resident #73's Admission Record revealed the facility admitted the resident on 09/22/2022 with diagnoses of Age-Related Osteoporosis, Anxiety Disorder, and Other Abnormalities of Gait and Mobility. Review of Resident #73's Admission Minimum Data Set (MDS) Assessment, dated 09/21/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15), which indicated the resident had moderately impaired cognition. Review of Resident #73's Care Plan, initiated on 09/22/2022, revealed a focus that stated Resident #73 would have a reduced risk regarding complications related to decreased mobility. The care plan stated Resident #73 would be transferred with two (2) staff assistance and use the walker for toileting. In addition, a mechanical lift was care planned to be used if needed for transfers. Review of the facility's investigation, dated 10/31/2022, revealed SRNA #2 told the Administrator, on 11/02/2022, she did ask Resident #73 to use his/her brief for toileting as she felt that Resident #73 was not safe to transfer with a lift due to a recent fall. Furthermore, the investigation revealed SRNA #2 was suspended at the time pending completion of the investigation. Resident #73 was not available for interview because he/she had been discharged from the facility in November 2022. During an interview, on 09/23/2023 at 12:45 PM, with SRNA #2, she stated she did ask Resident #73 to use the bathroom in his/her brief as she felt that Resident #73 was not safe to transfer with a lift due to a recent fall. SRNA #2 stated there was an agency nurse, Licensed Practical Nurse (LPN) #13, working with her that was available for assistance with Resident #73's care. However, LPN #13 no longer worked at the facility. The State Survey Agency (SSA) Surveyor called LPN #13, on 09/23/2023 at 2:00 PM, 09/25/2023 at 10:14 AM, and 09/26/2023 at 5:24 PM. A voice message was left; with no call returned. During an interview on 09/25/2023 at 10:24 AM, with the Interim Director of Nursing (DON)/Regional Nurse, she stated asking a resident to use the bathroom in a brief was inappropriate. She stated that residents should be toileted based on how the resident was care planned. During an additional interview on 09/25/2023 at 4:50 PM, the Interim DON/Regional Nurse stated that asking a resident to use the brief was a dignity issue and her expectation was that staff followed the facility's policy. In an interview on 09/26/2023 at 4:39 PM with the Interim Administrator, he stated asking a resident to use the bathroom in a brief was inappropriate and was a dignity issue. Furthermore, he stated his expectation was that all staff members, regardless of their discipline, were expected to follow the facility's Resident Rights policy.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to notify the Medical Director (MD) of the change in the medical condition and the cause of death for one (1) of sixty-one (61) sampled residents (Resident #66). Interview with the MD revealed he was not notified that Resident #66 required supervision and monitoring during meals per the Speech Therapy (ST) evaluations. In addition, the MD was not informed that the resident's death was from choking on a cheeseburger on 06/24/2023. The findings include: Review of the facility's policy titled, Accidents and Incidents effective date 06/01/2015, revealed the intent was for the facility to provide an environment free from accidents and incidents that were avoidable. The facility investigates occurrences with applicable documentation and appropriate reporting. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall initiate and document investigation of the accident or incident. The time the resident's Physician was notified, as well as the time the physician responded and his or her instructions shall be documented. Review of the facility's policy titled, Charting and documentation, last reviewed on 04/14/2021, revealed incidents, accidents or changes in the resident's condition must be recorded. Documentation of the procedures and treatment shall include care-specific details and shall include at a minimum notification of the family, physician, or other staff. Record review revealed the facility admitted Resident #66 on 12/27/2019 with diagnoses that included Dementia, Anxiety, Dysphagia, and Oropharyngeal Phase. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact. Review of Resident #66's Physician Orders, dated 06/09/2023, revealed an order for the Speech Therapist to evaluate and treat the resident, as indicated. Review of Resident #66's Speech Therapy (ST) Notes, dated 06/11/2023, revealed the resident's impulsivity continued; he/she required minimal to moderate verbal cues to slow the rate while eating and should consume appropriate bolus (bite) size. The ST Note, dated 06/12/2023, revealed Resident #66 was able to verbalize safe swallowing; however, he/she did not always do this independently. The ST Note dated 06/15/2023, revealed after the swallowing evaluation, education was provided with the resident and staff on general safe swallowing precautions. During an interview with ST #1, on 09/20/2023 at 8:48 AM, she stated Resident #66's diet order was puree with NTL. She provided Resident #66 with strategies for a safe swallow, and even with cues, the resident could not safely swallow and required supervision with a puree diet. She stated the Therapy Director attended the Interdisciplinary Team (IDT) meeting and was supposed to report any new information related to therapies. During an interview with Registered Nurse (RN) #6, on 09/25/2023 at 9:10 AM, she stated on 06/24/2023 after the lunch meal, Resident #66 was found slumped over at the dining room table. RN #6 stated she was alerted to Resident #66 being slumped over the table in the dining room with a partially eaten cheeseburger on the table. The RN stated she attempted to clear Resident #66's mouth of food. She stated the resident remained unresponsive and Emergency Medical Services (EMS) was called. During an interview with Licensed Practical Nurse (LPN) #9, on 09/26/2023 at 1:01 PM, she stated she went to the dining room with Registered Nurse (RN) #6 and found Resident #66 laying over the table. LPN #9 stated she called EMS, then returned to the dining room to find RN #6 had Resident #66 on the floor. She stated she observed a cheeseburger with three (3) to four (4) bites sitting on the table where Resident #66 was found. Review of the EMS run sheet, dated 06/24/2023 at 3:23 PM revealed the resident was dead upon EMS' arrival. Review of the Progress Note, dated 06/24/2023 at 4:02 PM, revealed the Director of Nursing (DON) documented the Power of Attorney (POA) was notified; however, there was no documentation the Medical Director (MD) was notified. During an interview with the Medical Director, on 09/26/2023 at 12:26 PM, he stated he did not remember being notified of Resident #66 death. He stated he would remember an unusual death. The MD stated he was not aware of Resident #66 death until the Ad-hoc meeting on 06/29/2023. He stated he was not aware Resident #66 had eaten regular food. The MD stated he had not been made aware that Resident #66 required supervision and monitoring during meals. During an interview with the DON, on 09/28/2023 at 8:18 AM, she stated the MD was informed after the event. She stated the MD should be contacted immediately for death of a resident, reportable events, and medical errors. During interview with the Interim Administrator, on 09/28/2023 at 8:35 AM, he stated the Medical Director should be notified of any change in condition and should have been notified about Resident #66.

Based on observation, interview, and record review, it was determined the facility failed to accurately assess and reflect the resident's current status for one (1) of sixty-one (61) sampled residents (Resident #66). Review of Resident #66's Annual Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident as setup help only for functional status when eating. However, review of Resident #66's Speech Therapy (ST) Notes, dated 06/11/2023, revealed impulsivity continued, and the resident required minimal to moderate verbal cues to slow the food intake rate and consume appropriate bolus (bite) size. The findings include: Review of the facility's policy titled, Comprehensive Care Plans (CCP) effective 04/06/2015, revealed the CCP was based on a thorough assessment which included but was not limited to RAI (Resident Assessment Instrument) and MDS assessments. Continued review revealed care plan interventions were implemented for residents' problem areas, and the causes. Further review revealed the CCPs were prepared by the Interdisciplinary Team (IDT) and were ongoing, and the CCPs were to be revised as information about the resident and the resident's condition changed. Review of the MDS Registered Nurse (RN) Job Description dated 03/2021, revealed duties to oversee the coordination and participate in the completion of the Resident Assessment Instrument (RAI), MDS, Care Area Assessment (CAA) and Care Plan. Further review revealed duties to assist in completion of the RAI with the Interdisciplinary Team (IDT), and to complete the MDS using the medical record, bedside assessment, and staff, resident and/or family interviews. Review of Resident #66's medical record revealed the facility admitted the resident on 12/27/2019, with diagnoses that included Dysphagia, Oropharyngeal Phase, Dementia and Anxiety. Review of Resident #66's Annual MDS assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) which indicated he/she was cognitively intact. Further review revealed the facility assessed Resident #66 to require setup help only under functional status when eating. Review of the Physician's Order, dated 11/28/2022, revealed Resident #66 had orders for nectar thickened liquids and a pureed diet related to Dysphagia (swallowing problem). In addition, the resident was to receive double portions at supper. Review of Resident #66's CCP dated 07/15/2022 and revised on 04/27/2023, revealed the facility care planned the resident as at risk for aspiration and to have a mechanically altered diet. Further review revealed no documented evidence of specific person-centered interventions for Resident #66 to have assistance with meals, or to monitor the resident for swallowing problems. Review of the Speech Therapist (ST) Notes, dated 06/11/2023 and 06/12/2023, revealed Resident #66 was able to verbalize safe swallowing. However, the resident did not always carry this out independently and needed supervision due to continued impulsiveness. Review of the Medical Nutrition Therapy (MNT) Evaluation Form, dated 06/12/2023, revealed supervision was needed for Resident #66's eating ability; Dysphagia was referenced under swallowing ability; and the need of a Speech Language Pathologist (SLP) was also referenced. During an interview with the MDS Coordinator, on 09/27/2023 at 8:20 AM, she stated it was her responsibility to ensure the MDS and CCP were developed and person-centered to meet the assessed needs of residents. She stated Resident #66's Annual MDS dated [DATE], documented the resident was independent with set up instead of supervision for meals. She stated after review of the ST Notes, Resident #66 required supervision at mealtime and not set up only. She further stated that Resident #66's need for supervision at mealtime was not discussed in the clinical meetings. During an interview with the Assistant Director of Nursing (ADON), on 09/27/2023 at 9:13 AM, she stated that she along with the MDS Coordinator and Director of Nursing (DON) ensured the MDS and CCP were completed and updated. During an interview with the Regional Clinical Dietitian, on 09/27/2023 at 3:55 PM, she stated after review of the MNT Evaluation Form dated 06/12/2023, Resident #66 required supervision at meals. During an interview with the Administrator, on 09/27/2023 at 5:06 PM, he stated the MDS Coordinator and the IDT were responsible for the accuracy of the MDS and CCP.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to follow the comprehensive Person-Centered Resident Care Plan for one (1) of twenty (20) sampled residents, Resident #58. Resident #58's Comprehensive Care Plan (CCP) was not followed for correct application of the seat beat while he/she was in the wheelchair, which resulted in a fall with an injury for Resident #58. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 07/19/2021, revealed the Person-Centered Comprehensive Care Plan would include how the facility would assist the resident to meet their needs, goals, and preferences. Review of Resident #58 medical record revealed the facility admitted the resident initially, on 09/30/2020, and his/her latest readmission was on 02/26/2021. Patient #58's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 07/14/2021, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) for severe cognitive impairment. Continued review of the MDS Assessment, revealed, under section G, Functional Status, that Patient #58's transfers required a two (2) person assist. Section P, Restraints, revealed limb restraints for the seatbelt was required. Continued review of Resident #58's medical record revealed he/she sustained a fall, on 07/23/2021 at 10:15 AM, which resulted in bruising above the eye. Resident #58 was placed into the wheelchair by Licensed Practical Nurse (LPN) #4, per the record, and she applied the seatbelt. However, the record stated the seatbelt was not applied correctly, which resulted in a fall with an injury. The record stated LPN #4 did not follow Resident #58's CCP for placement of the seatbelt to Resident #58, while he/she was sitting in the wheelchair. The seatbelt was applied around the resident and attached to the cushion in the wheelchair. Review of Resident #58's CCP, under goals, dated 11/04/2020, revealed a restraint would be used when the resident was out of bed in a wheelchair, and the resident would be free of falls and/or would not sustain an injury related to falling through the next review date. Further review of the CCP, dated 11/19/2020, revealed a physical restraint was needed when the resident was in a wheel chair because of anxiety and decreased safety awareness, and the wheelchair seat belt could be used as the physical restraint. Continued review, under Approach, dated 12/02/2020, revealed an alarming seatbelt would be used, while the resident was in the wheelchair, for increased safety. Further review, under Approach, dated 07/23/2021, after the fall, revealed staff would receive a proper demonstration on how to utilize the wheelchair seatbelt. Interview with State Registered Nurse Aide (SRNA) #3, on 10/28/2021 at 3:15 PM, revealed Resident #58 required a two (2) person assist for transfers. She stated the resident had formerly used a wheelchair with a seat belt. She did not know about Resident #58's fall; however, she had access to the resident's CCP. The SRNA who assisted Resident #58 to the wheelchair with LPN #4, was not available for interview. Interview with Licensed Practical Nurse (LPN) #4, on 10/28/2021 at 3:58 PM, revealed Resident #58 asked the nurse to get up. She stated the resident had not been out of bed for months. LPN #4 stated, with the assistance of an aide, they placed the resident into the wheelchair. She stated she applied the seat belt around the resident sitting in the wheelchair. LPN #4 stated she thought the seat belt was in place; however, the resident slid out of the chair. She further stated the seat belt was applied wrong. She stated she did not realize the seatbelt was attached to the cushion in the wheelchair, which made the resident unsecured. LPN #4 stated she had not followed the resident's CCP. Interview with the Director of Nursing (DON) and the facility's Corporate Consultant, on 10/28/2021 at 4:15 PM, revealed the Interdisciplinary Team (IDT), which consisted of facility Department Managers, reviewed and revised care plans. She stated the IDT discussed falls and care plan interventions to see if revisions were needed. She also stated changes to the CCP were made by the MDS Coordinator, but staff nurses or the Regional Nurse Director also could make revisions. The DON stated Resident #58's care plan should have been followed, and anytime a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 10/28/2021 at 4:56 PM, revealed she expected the care plan to be followed to prevent falls and accidents.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to prevent a fall for one (1) of twenty (20) sampled residents, Resident #58. Resident #58 had a fall in the hallway due to the improper application of the seat beat to the residents wheel chair cushion which resulted in an injury. The findings include: Review of the facility's policy titled, Falls, dated 11/06/2019, revealed the intent of the facility was to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. Review of Resident #58's John Hopkins Fall Risk Assessment Tool, dated 07/14/2021, revealed the resident had a score of twenty-five (25), which made him/her a high fall risk. Review of the facility form Observation Detail List Report, dated 07/23/2021, revealed Resident #58's pre-restraining evaluation revealed the reason for the screening was to evaluate if a restraint was needed because medical symptoms warranted restraint use. Psychosocial considerations were Resident #58 was disoriented/confused and did not understand what was being said. Physical considerations were Resident #58's balance was unstable with transfers. The form stated a restraint alternative was a low bed and pillows. It also listed the facility was to continue using a seat belt for Resident #58 when up in the wheelchair to prevent falls. Observations of Resident #58, on 10/26/2021 at 10:30 AM, on 10/27/2021 at 12:00 PM, and on 10/28/2021 at 3:00 PM revealed the resident lying in bed with his/her eyes closed. Further observation revealed Resident #58 had a pressure mattress on the bed, bolsters to bilateral sides of the the bed, and fall mats bilateral to the sides of the bed. Review of Resident #58's medical record revealed the facility initially admitted the resident, on 09/30/2020, and he/she had a readmitted [DATE]. Patient #58's diagnosis were Abnormal Weight Loss, [CONDITION(S)], Anxiety Disorder, and Lack of Coordination. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 07/14/2021, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) for severely cognitively impaired. Continued review of the MDS Assessment revealed, under Section G, functional status, that transfers required a two (2) person assist. Review of Resident #58's Physician orders, dated 05/09/2021, revealed to use a seat belt for the wheelchair when the resident was up and to release the seat belt every two (2) hours to reposition the resident. Further review of the orders revealed, on 07/23/2021, after the fall, an order to initiate the falls prevention program for Resident #58. Review of Resident #58's fall investigation form, Event Report, dated 07/23/2021, revealed the resident fell forward in the wheelchair, hitting the left side of the face on the floor, on 07/23/2021 at 10:15 AM, outside of the resident's room in the hallway. The report stated the resident's current diagnoses included Dementia, Anxiety, and Depression. The report stated Resident #58 expressed no pain upon assessment; however, he/she was noted to have bruising and a bump on the left side of the face. In addition, per the report, the seat belt was in use with the wheelchair at the time of the fall. Review of Resident #58's Summary of the Fall, dated 07/23/2021 at 10:35 AM, revealed the resident got out of bed to sit in a wheelchair in the hallway. The seat belt was placed on the resident as ordered. Further, the Resident #58 moved forward in the wheelchair and fell forward hitting the left side of the face on the floor. Per the Summary, there was a hematoma to the left forehead above the left eye. Resident #58 was assisted to back to the wheelchair and then back to bed. Neurological (neuro) checks were started and ordered to be continued by the Nurse Practitioner. Resident #58's assessment with vital signs were unremarkable, and the resident had no complaints of pain at this time. At the completion time of the Summary, Resident #58 was resting in bed. The Summary stated staff continued to rouse the resident for neuro checks and assessments. Continued review of Resident #58's medical record revealed Licensed Practical Nurse (LPN) #4 documented the fall, on 07/23/2021 at 10:15 AM, with no pain, bruising, bump, seatbelt in place. Fall in the hallway. Further documentation, on 07/26/2021 at 10:31 AM, by the Interdisciplinary team (IDT), which had the facility's Department Managers as its members, revealed the IDT met this day to discuss the fall that occurred, on 07/23/2021, with Resident #58. The IDT stated Resident #58 was placed in the wheelchair by LPN #4, who fastened the seat belt. However, when LPN #4 went to clamp the seat belt, she improperly clamped it to the wheelchair cushion around the resident. The intervention deemed most appropriate by the IDT was staff would receive a proper demonstration on how to utilize the wheelchair with a seat belt. Interview with State Registered Nurse Aide (SRNA) #3, on 10/28/2021 at 3:15 PM, revealed Resident #58 required a two (2) person assist for transfers, and the information available for transfers was on the care plan or tablet. She stated the resident no longer used a wheelchair with a seat belt but uses a geri-chair when up. The SRNA who assisted LPN #4 was not available for interview. Interview with Licensed Practical Nurse (LPN) #4, on 10/28/2021 at 3:58 PM, revealed Resident #58 asked to get up out of the bed. The resident had not been out of the bed for months. LPN #4 stated, with the help of an aide, she assisted the resident to the wheelchair. LPN #4 stated she applied the seat belt and thought she had the seat belt correctly placed; however, the resident slid out of the wheelchair. LPN #4 stated the resident was assessed for injury; vitals signs were checked; and the Power-of-Attorney, physician, and the Administrator were notified. LPN #4 explained further she did not secure the seat belt properly. She further revealed she had previously, before and since the fall, received education on the correct use of the seat belt. Interview with the Director of Nursing (DON) and Corporate Consultant, on 10/28/2021 at 4:15 PM, revealed anytime a resident sustained a fall, he/she was assessed and new interventions were put in place. The DON stated staff was educated on using the seat belt correctly. Interview with the Administrator, on 10/28/2021 at 4:56 PM, revealed she expected staff to follow the care plan to prevent accidents.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to a system to accurately reconcile controlled medications using acceptable standard of practice and failed to have safguards and systems inplace to control, accountfor and periodically reconcile controled medications in order to prevent loss and diversion. This failure effected thirteen (13) of thirteen (13) sampled residents with ordered narcotic medications. The findings include: Review of the facility's policy, titled, Medication Administration: Controlled Substances, dated ,[DATE], revealed, Controlled Substance Medications were defined as Schedules II-V drugs under the United States Drug Enforcement Administration (DEA) classifications. Further policy review revealed controlled substances had the potential for physical and psychological dependence/abuse and were subject to special handling, storage, disposal and record keeping in accordance with Federal and State laws. Continued review of the facility policy revealed the Director of Nursing (DON), in collaboration with the consultant Pharmacist would establish/maintain an efficient system of receipt and disposition of all controlled substances with sufficient documented detail to allow for accurate reconciliation and to retain an account of all controlled substances within the facility. Review of the facility's policy, titled Medication Storage: Controlled Medication Storage, dated ,[DATE], revealed, medications that were included in the Drug Enforcement Administration (DEA) as controlled substances were subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with Federal, State and other applicable laws and regulations. Further review revealed the DON and consultant Pharmacist monitored facility for compliance with Federal and State regulations in the handling of controlled substance medications. The DON monitored staff to ensure the access system (keys) used to lock controlled medications and other medications subject to abuse were not the same as those used to access non-scheduled medications. The DON would ensure staff on duty maintained possession of access keys while he/she retained back up keys to all medication storage areas. Continued review of the controlled medication storage policy revealed, a controlled medication accountability record would be prepared upon receipt of inventory of controlled substance medications. Information required on the controlled medication accountability record would include the following: resident name; prescription number; name, strength (if designated), and dosage form of medication. Additional policy review revealed, at each change of shift, or when keys were surrendered, a physical inventory of all controlled substance medications, including refrigerated items, would be conducted by two (2) licensed nurses and documented on the controlled medication accountability record or verification of controlled substances count report. Continued review of the facility's policy revealed, current controlled medication accountability records shall be maintained in the Medication Administration Record [REDACTED]. Controlled medication accountability records shall be submitted to the DON and maintained on file upon completion of a controlled medication. Controlled substance medications remaining at the nursing care center after the Physician's Order (P.O.) has been discontinued or expired shall be retained at the facility in a securely double locked area with restricted access until destroyed as outlined by state regulation. Additionally, the consultant Pharmacist or Pharmacy designee, would routinely review a sampling audit of controlled medication storage, records and expiration dates to ensure compliance with State and Federal law and regulatory requirements. Review of the facility's policy, titled Controlled Medication and Drug Diversion, dated as revised on [DATE], revealed any discrepancies in controlled substance medication counts shall be reported to the DON immediately. The DON shall initiate an investigation and make every reasonable effort to reconcile all reported discrepancies while nurses remain on duty. The investigations would include, but were not limited to [NAME] Interviews. B. Record Reviews. C. Specific types and names of controlled substances missing or lost. D. Were the controlled substances associated with access by specific individuals? E. Are the losses random? F. Any potential impact on patient care? In a report to the Licensed Nursing Home Administrator (LNHA), the DON will document all irreconcilable discrepancies. If a major discrepancy or pattern of discrepancies was identified or criminal activity was apparent during the investigation, the DON would notify the LNHA, consultant Pharmacist and Pharmacy Manager immediately. If applicable, resident supply is replaced with the loss documented resident's prescriber and family notified if doses missed. Further policy review revealed timely notifications would be made to the appropriate agencies, such as local law enforcement, Drug Enforcement Administration, State Board of Nursing, State Board of Pharmacy, the State Medicaid Fraud Control Unit, and possibly the State Licensure Board for Nursing Home Administrators. Continued review of the facility's policy revealed, once diversion was substantiated, a determination would be made by the LNHA, consultant Pharmacist, Pharmacy Manager, and DON concerning possible notification of police or other enforcement agencies and any other actions to be taken. The Regional Vice President of Operations, Compliance Department and Legal Department shall be notified. 1. Review of Resident #1's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's (MONTH) 2019 Physician's Orders (P.O.) revealed an active order, with a start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 7.5 milligram (mg)-325 mg tablets (narcotic pain medication): Administer one (1) tablet by mouth every four (4) hours as needed (PRN) related to [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report for Resident #1 revealed, on [DATE], the Pharmacy dispensed a five (5) day supply of [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325 mg tablets. This was thirty (30) tablets. Further review of the Pharmacy's delivery manifest report revealed, on [DATE], the Pharmacy delivered another five (5) day supply of [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325 mg tablets, for Resident #1, an additional thirty (30) tablets. Continued review of the Pharmacy delivery report revealed the Pharmacy dispensed yet another thirty (30) tablets on [DATE] and an additional five (5) day supply or thirty (30) more tablets on [DATE], for Resident #1. Further review of the report revealed documented evidence of prescription numbers for each delivery with exception of [DATE] delivery. Review of manifest report details dated [DATE], revealed, no documented evidence of prescription number for [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets delivered to facility for Resident #1. Further review revealed [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablet prescription name was hand-written near bottom of delivery report next to Resident #1's name with amount of [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets delivered. Continued review revealed no documented evidence of facility or pharmacy staff signatures on manifest report. Review of Resident #1's (MONTH) 2019 Electronic Medication Administration Record [REDACTED]. Further review of EMAR for Resident #1 revealed no documented evidence [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325 mg tablets were administered from [DATE]-[DATE]. Resident #1's (MONTH) 2019 controlled medication accountability record was not provided for review and facility was unable to account for the remaining doses of Resident #1's medication. 2. Review of Resident #2's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's (MONTH) 2019 P.O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 5 mg tablets (narcotic pain medication): Administer one (1) tablet by mouth every six (6) hours prn pain for pain scale scoring of four (4) to six (6) for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed, the pharmacy dispensed thirty (30) [MEDICATION NAME] 5mg tablets, a seven (7) day supply, to the facility for Resident #2. Further review revealed the pharmacy dispensed an additional sixty (60) [MEDICATION NAME] 5mg tablets, or fourteen (14) day supply, to the facility on [DATE]. Continued review of the manifest report revealed documented evidence of prescription numbers for pharmacy deliveries on [DATE] and [DATE] for Resident #2. Review of Resident #2's (MONTH) 2019 EMAR revealed documented evidence the facility administered two (2) doses of [MEDICATION NAME] 5mg tablets from [DATE] through [DATE]. The facility was unable to account for the remaining doses of Resident #2's medication, which totaled twenty-eight (28) tablets. Resident #2's (MONTH) 2019 controlled medication accountability record was not provided for review and facility was unable to account for the missing doses of Resident #2's medication. 3. Review of Resident #3's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's (MONTH) 2019 P.O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets: Administer one (1) tablet by mouth three (3) times daily at 08:00 AM, 02:00 PM and 09:00 PM for [DIAGNOSES REDACTED].O. revealed an active order, with start date of [DATE], for [MEDICATION NAME] 0.5mg tablets: Administer one (1) tablet by mouth twice daily for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed the pharmacy dispensed sixty (60) [MEDICATION NAME] 0.5mg tablets, a thirty (30) day supply to the facility. Review of the delivery report dated [DATE], revealed, the pharmacy dispensed sixty (60) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets, a twenty (20) day supply, to the facility on [DATE], for Resident #3. Review of delivery manifest report dated [DATE], revealed documented evidence Resident #3 with twenty-seven (27) total doses of the [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets remaining in medication cart at time of delivery. Continued review of report, dated [DATE], revealed, the Pharmacy dispensed an additional one-hundred and eighty (180) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets, or an additional two (2) month supply to the facility, on [DATE], for Resident #3. Further review of the manifest reports revealed documented evidence of prescription numbers for each delivery of controlled substance medications dispensed to the facility for Resident #3 for (MONTH) 2019. Review of Resident #3's (MONTH) 2019 EMAR revealed documented evidence the facility administered eighty-four (84) doses of the resident's scheduled ninety-three (93) doses of [MEDICATION NAME]-[MEDICATION NAME] 5mg-325 mg tablets from [DATE] through [DATE] with no documented evidence the facility administered the medication on [DATE], [DATE] and [DATE] as ordered/scheduled at 1400. Further review of Resident #3's EMAR revealed documented evidence the facility held six (6) scheduled doses of [MEDICATION NAME]-[MEDICATION NAME] 5mg-325 mg tablets with rationale documented. Additional review of (MONTH) 2019 EMAR revealed the facility administered sixty-one (61) of the sixty-two (62) scheduled doses of [MEDICATION NAME] 0.5mg tablets from [DATE]-[DATE]. Continued review of the EMAR revealed no documented evidence of administration of scheduled morning dose of [MEDICATION NAME] 0.5mg tablet on [DATE]. Resident #3's (MONTH) 2019 controlled medication accountability records for [MEDICATION NAME] 0.5mg tablets were not provided for review and facility was unable to account for the remaining doses of each controlled medication for Resident #3. 4. Review of Resident #4's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS) Score conducted by facility Social Services Director on [DATE], revealed, Resident #4 was assessed as having a BIMS Score of eleven (11), which indicated the resident had some moderate impairment of cognition. Review of Resident #4's (MONTH) 2019 P.O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets: Administer one (1) tablet by mouth three (3) times daily for [DIAGNOSES REDACTED].O. revealed active order with start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets: Administer one (1) tablet by mouth twice daily as needed for [DIAGNOSES REDACTED].O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] ([MEDICATION NAME]) 100mg capsules: Administer one (1) capsule by mouth twice daily for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed the pharmacy dispensed ninety (90) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets, an eighteen (18) day supply, to the facility for Resident #4. Review of the delivery report dated, [DATE], revealed, pharmacy delivered an additional ninety (90) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets, an eighteen (18) day supply, for Resident #4. Review of the manifest report, dated [DATE], revealed, the pharmacy dispensed sixty (60) [MEDICATION NAME] ([MEDICATION NAME]) 100mg capsules, with fifty-seven (57) total doses/capsules remaining in medication cart at time of delivery. Review of documented evidence handwritten on identical copy of [DATE] manifest delivery report, revealed total doses remaining in medication cart this date, as twenty-seven (27) instead of fifty-seven (57) with notation documented below number twenty-seven (27), as, thirty (30) left, discontinued. Additional review of copy of manifest report, revealed facility staff nor pharmacy signature were provided. Review of delivery manifest dated [DATE], revealed the pharmacy dispensed another sixty (60) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets to the facility for Resident #4. Further review of each pharmacy manifest delivery report revealed documented evidence of prescription numbers for each of Resident #4's controlled substance medications dispensed to facility for (MONTH) 2019. Review of Resident #4's (MONTH) 2019 EMAR revealed documented evidence the facility administered eighty-seven (87) of ninety-three (93) scheduled doses of [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets from [DATE]-[DATE]. Further review revealed no documented evidence of administration of [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets on [DATE], [DATE] and [DATE] at 1400, [DATE] at 2100, and [DATE] and [DATE] at 0600. Continued review of (MONTH) 2019 EMAR revealed documented evidence of administration of only (1) dose of as needed [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets from [DATE]-[DATE] with one (1) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablet documented as administered on [DATE] at 11:53 PM. Additional review of Resident #4's (MONTH) 2019 EMAR revealed administration of nineteen (19) of scheduled twenty (20) doses of [MEDICATION NAME] ([MEDICATION NAME]) 100mg capsules from [DATE]-[DATE]. Further review of (MONTH) 2019 EMAR revealed documented evidence of rationale for Resident #4's missed dose of [MEDICATION NAME] 100mg capsule on [DATE]. Resident #4's (MONTH) 2019 controlled medication accountability records for [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets and [MEDICATION NAME] ([MEDICATION NAME]) 100mg capsules were not provided for review and facility was unable to account for the remaining doses of Resident #4's controlled medications. 5. Review of Resident #5's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's (MONTH) 2019 P.O. revealed an active order with a start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets: Administer one (1) tablet by mouth every four (4) hours as needed for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed, the pharmacy dispensed five (5) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets, or one (1) day supply to the facility for Resident #5. Review of the manifest report dated [DATE], revealed the pharmacy delivered another thirty (30) [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets, or a five (5) day supply to the facility for Resident #5. Review of delivery manifest reports revealed documented evidence of prescription numbers for each delivery of controlled substance medications dispensed to the facility for Resident #5 for (MONTH) 2019. Review of Resident #5's (MONTH) 2019 EMAR revealed no documented evidence the facility administered [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg tablets from [DATE]-[DATE]. Review of Resident #5's controlled medication accountability record dated [DATE] for [MEDICATION NAME]-[MEDICATION NAME] 5mg/325mg tablets delivered on [DATE], revealed five (5) doses of the controlled substance medication were signed out by Registered Nurse (RN) #1 with three (3) doses documented as administered on [DATE] at 01:30 AM, 06:30 AM and 08:15 PM. Further review of controlled medication accountability record for [MEDICATION NAME]-[MEDICATION NAME] 5mg/325mg tablets revealed two (2) additional doses were documented as administered by RN #1 on [DATE] at 01:00 AM and 05:50 AM. Controlled medication accountability record for pharmacy delivery for [MEDICATION NAME]-[MEDICATION NAME] 5mg/325mg tablets on [DATE] was not provided for review and the facility was unable to account for the remaining doses of Resident #5's medication. 6. Review of Resident #6's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's (MONTH) 2019 P.O. revealed an active order, with start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets: Administer one (1) tablet by mouth as needed for [DIAGNOSES REDACTED].O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets: Administer one (1) tablet by mouth one (1) time daily for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed the pharmacy delivered sixty (60) [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets, or a twelve (12) day supply, to the facility for Resident #6. Review of the manifest report, dated [DATE], revealed, the pharmacy dispensed an additional sixty (60) [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets, a twelve (12) day supply, to the facility for Resident #6. Further review of [DATE] delivery report, revealed documented evidence of prescription numbers for each delivery of controlled substance medications dispensed to the facility for Resident #6 for (MONTH) 2019. Review of Resident #6's (MONTH) 2019 EMAR revealed documented evidence the facility administered a total of thirty (30) doses of the scheduled thirty (30) doses of [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets from [DATE]-[DATE]. Further review of Resident #6's (MONTH) 2019 EMAR revealed no documented evidence the facility administered any as needed doses of [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets for Resident #6. Review of Resident #6's [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets controlled medication accountability record, dated [DATE], revealed, a total of twenty-six (26) tablets remaining in medication cart on [DATE]. However, controlled medication accountability record for [MEDICATION NAME]-[MEDICATION NAME] 7.5mg-325mg tablets for [DATE]-[DATE] was not provided for review. The facility was unable to account for Resident #6's missing doses of medication. 7. Review of Resident #7's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's (MONTH) 2019 P.O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 50mg tablets: Administer one-half (0.5) tablet by mouth one (1) time daily for [DIAGNOSES REDACTED]. Further review of (MONTH) 2019 P.O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 50mg tablets: Administer one-half (0.5) tablet by mouth twice daily as needed for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest reports, dated [DATE]-[DATE], revealed no documented evidence of pharmacy dispensing controlled substance medication to facility during that timeframe for Resident #7. Review of Resident #7's (MONTH) 2019 EMAR revealed documented evidence the facility administered thirty (30) doses of [MEDICATION NAME] 50mg tablets: Administer one-half (0.5) tablet by mouth one (1) time daily. Further review of Resident #7's (MONTH) 2019 EMAR revealed no documented evidence the facility administered [MEDICATION NAME] 50mg tablets: Administer one-half (0.5) tablet by mouth twice daily as needed for [DIAGNOSES REDACTED]. Review of Resident #7's [MEDICATION NAME] 50mg tablets controlled medication accountability record, dated [DATE], page three (3) of five (5), revealed, the pharmacy dispensed ninety and one-half (90.5) [MEDICATION NAME] 50mg tablets to the facility for Resident #7. Further review of controlled medication accountability record revealed documented evidence the facility signed out [MEDICATION NAME] 50mg one-half (0.5) tablet daily as administered from [DATE]-[DATE]. However, controlled medication accountability record for [DATE]-[DATE], page one (1), page two (2) and page three (3) were not provided for review. The facility was unable to account for resident's missing doses of [MEDICATION NAME]. 8. Review of Resident #8's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status Score (BIMS) of ten (10) which indicated the resident was moderately cognitively impaired. Review of Resident #8's (MONTH) 2019 P.O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 300 mg capsules: Administer one (1) capsule by mouth three (3) times daily for [DIAGNOSES REDACTED].O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 5mg tablets: Administer one (1) tablet by mouth three (3) times daily for [DIAGNOSES REDACTED].O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 5mg tablets: Administer one (1) tablet by mouth as needed twice daily for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed the pharmacy dispensed ninety (90) [MEDICATION NAME] 5mg tablets to the facility for Resident #8. Review of manifest report, dated [DATE], revealed the pharmacy delivered ninety (90) [MEDICATION NAME] 300 mg capsules, thirty (30) day supply, to the facility for Resident #8. Review of manifest report, dated [DATE], revealed the pharmacy delivered one-hundred twenty (120) [MEDICATION NAME] 5mg tablets, twenty-four (24) day supply, to the facility for Resident #8. Review of manifest report, dated [DATE], revealed the pharmacy delivered one-sixty (60) [MEDICATION NAME] 5mg tablets, twelve (12) day supply, to the facility for Resident #8. Further review of pharmacy manifest delivery reports, revealed documented evidence of prescription numbers for each delivery of controlled substance medications dispensed to the facility for Resident #8 for (MONTH) 2019. Review of Resident #8's (MONTH) 2019 EMAR revealed documented evidence of eighty-nine (89) of scheduled ninety (90) doses of [MEDICATION NAME] 300 mg capsules: Administer one (1) capsule by mouth three (3) times daily, were administered from [DATE]-[DATE] with documentation of resident refusal of scheduled morning dose on [DATE]. Further review of Resident #8's (MONTH) 2019 EMAR revealed documented evidence of eighty-six (86) of scheduled ninety (90) doses of [MEDICATION NAME] 5mg tablets: Administer one (1) tablet by mouth three (3) times daily, were administered from [DATE]-[DATE]. Continued review revealed no documented evidence for missed scheduled morning dose of [MEDICATION NAME] 5mg on [DATE]. Additional review revealed documented evidence of rationale for missed doses on [DATE] (midday & bedtime) and on [DATE] (midday). Continued (MONTH) 2019 EMAR review [REDACTED]. EMAR dated [DATE]-[DATE] was not provided for review. Review of Resident #8's [MEDICATION NAME] 5mg tablets controlled medication accountability record, dated [DATE], labeled page three (3) of four (4), revealed, a total of eleven (11) tablets remaining in medication cart on [DATE] with documented evidence of staff signature and notation on line item number eleven (11) as Error, wrong page. Review of [MEDICATION NAME] 5mg tablets controlled medication accountability record, dated [DATE], labeled page four (4) of four (4), revealed documented evidence of eleven (11) tablets remaining in medication cart on [DATE] with handwritten notation on line item number eleven (11) as wasted, hole in pack. Page one (1), page two (2) and page three (3) [MEDICATION NAME] 5mg controlled medication accountability records were not provided for review. The facility was unable to account for the remaining doses of Resident #8's controlled medications. Observation of medication administration performed by LPN #3, on [DATE] at 12:50 PM, for Resident #8, revealed accountability record for [MEDICATION NAME] ,[DATE]mg tablet with label containing information for scheduled and as needed dosing. Further observation of medication administration revealed LPN #3 with difficulty reading accountability record for Resident #8 while showing State Agency Representative controlled medication skid with pharmacy label so large, it wrapped around to the back of the skid/card of medication, which made it difficult for State Agency Representative to read. Continued observation revealed several irregularities noted on accountability record with signatures scratched through for several line items and notations as wrong page observed on numerous pages. Interview on [DATE] at 1:10 PM, with LPN #3, revealed the Pharmacy, up until approximately one month ago, delivered the resident's controlled scheduled medications individually labeled and contained within different skids that separated the resident's scheduled from as needed medications. Further interview with LPN #3 revealed now that both scheduled and as needed orders were typed on same prescription label on accountability record and on same skid/card, it was almost impossible to read and to keep a correct count of the controlled medications contained in the medication cart. 9. Review of Resident #9's clinical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's (MONTH) 2019 P.O. revealed active orders, with a start date of [DATE], for [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablets: Administer one (1) tablet by mouth three (3) times daily for [DIAGNOSES REDACTED]. Continued (MONTH) 2019 P.O. review revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 0.5mg tablets: Administer one-half (0.5) tablet to equal 0.25mg tablet by mouth twice daily for [DIAGNOSES REDACTED].O. revealed an active order, with a start date of [DATE], for [MEDICATION NAME] 100mg capsules: Administer one (1) capsule by mouth twice daily for [DIAGNOSES REDACTED]. Review of Pharmacy's delivery manifest report, dated [DATE], revealed the pharmacy dispensed thirty (30) [MEDICATION NAME] 0.5mg tablets to the facility for Resident #9. Review of pharmacy's delivery report, dated [DATE], revealed, the pharmacy delivered ninety (90) [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablets, to the facility for Resident #9. Review of the pharmacy delivery manifest, dated [DATE], revealed the pharmacy dispensed sixty (60) [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablets, to the facility for Resident #9. Review of each delivery manifest revealed documented evidence of prescription numbers for each delivery of controlled substance medications dispensed to the facility for Resident #9 for (MONTH) 2019. Review of Resident #9's (MONTH) 2019 EMAR revealed documented evidence of sixty (60) of sixty (60) scheduled doses of [MEDICATION NAME] 0.5mg tablets administered from [DATE]-[DATE]. Further review of (MONTH) 2019 EMAR revealed documented evidence of one-hundred fifty (150) of one-hundred fifty-five (155) scheduled doses of [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablets from [DATE]-[DATE]. Continued (MONTH) 2019 EMAR review [REDACTED]. Additional review of EMAR for (MONTH) 2019 revealed documented evidence of administration of sixty (60) of sixty (60) scheduled doses of [MEDICATION NAME] 100mg capsules from [DATE]-[DATE]. Review of Resident #9's [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablets controlled medication accountability record, dated [DATE], labeled as page two (2) of two (2), revealed, the pharmacy delivered sixty (60) tablets to facility for Resident #9. Further review of controlled accountability record, revealed twenty-seven (27) [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablets remaining in medication cart on [DATE]. [MEDICATION NAME]-[MEDICATION NAME] 7.5mg/325mg tablet accountability record, page one (1) of two (2) was not provided for review. The facility was unable to account for the remaining doses of Resident #9's medication. 10. Review of Resident #10's clinical record revealed the facility admitted the resident on

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for three (3) of twenty-two (22) sampled residents (Resident #54, #55, and #146). Although Resident #54 had a history of [REDACTED]. On 03/11/19, staff witnessed Resident #54 inappropriately touching Resident #13's chest area. (Refer to F-600) Resident #55 was admitted with contractures to his/her bilateral hand, wrists, and elbows. However, these contractures were not addressed in the (CCP). (Refer to F-641) In addition, Resident #146's physician's orders [REDACTED]. However, there was no documented evidence the CCP, dated 03/18/19 was developed to include the intervention for heel boots. Observation of Resident #146 on 03/18/19, 03/19/19 and 03/20/19 revealed the resident was in bed and was not wearing the heel boots. Also, Resident #146's CCP, dated 03/18/19, revealed an intervention to float heels when in bed. However, observation of Resident #146 on 03/18/19, 03/19/19 and 03/20/19, revealed the CCP was not implemented related to the intervention to float the resident's heels. The findings include: Review of the facility's Policy titled Comprehensive Care Plans, revised 07/19/18, revealed a person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs would be developed for each resident. Further review revealed the Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument. 1. Review of the facility Self Report Incident, dated 03/11/19, revealed on 03/11/19 at approximately 3:45 PM, it was reported to the Unit Manager by State Registered Nursing Assistant (SRNA) #1, Resident #54 was witnessed inappropriately touching Resident #13's chest area. Per the Report, SRNA #1 intervened, separated the residents, and placed Resident #54 on 1:1 (one on one) supervision. Nursing staff then skin assessments on both residents, and no injuries were found. Additional review revealed care plans were updated, and the physician and families were made aware of the incident. The Report was signed by the Administrator. Review of the facility's Investigation, completed 03/15/19, revealed the facility conducted skin assessments on all residents with a Brief Interview for Mental Status (BIMS) score of seven (7) or below and also interviewed all residents with BIMS scores of eight (8) or above. Further review of the Investigation, revealed the residents interviewed had no concerns related to abuse from another resident. Per the Investigation, Resident #54 was seen by the in house psychiatric provider on 03/12/19 who increased his/her [MEDICATION NAME] (Selective Serotonin Reuptake Inhibitor medication). Additional review of the Investigation, revealed the Social Service Director followed up with both Resident #54 and Resident #13 after the incident. Review of Resident #13's medical record revealed the facility admitted the resident on 12/13/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a BIMS Score of 99, indicating the resident had severe cognitive impairment. Review of Resident #13's CCP, initiated 03/11/19, revealed a problem of inappropriate touch. The goal revealed the resident would exhibit no signs or symptoms of increased emotional distress and would allow needs to be met daily. The interventions included: one (1) to one (1) visits by social service; all staff to provide support, encouragement, and reassurance; nursing and social services to observe daily for increased distress, withdrawal, and one (1) on one (1) supervision for twenty -four (24) hours, then fifteen (15) minute checks for seventy-two (72) hours. Review of Resident #54's medical record revealed the facility admitted the resident on 09/18/18 with [DIAGNOSES REDACTED]. Review of Resident #54's Quarterly MDS Assessment, dated 03/01/19, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15) indicating severe cognitive impairment. Additional review of the MDS Assessment, revealed the facility assessed the resident as having physical behavioral symptoms directed towards others, one (1) to three (3) days during the last seven (7) days. Review of Resident #54's Psychiatric Consult, dated 01/08/19, revealed this was an initial consult due to the resident's behavioral disturbances which included sexually inappropriate behavior towards staff. Further review of the Consult, revealed the resident had a history of [REDACTED]. Review of the CCP, dated 01/08/19, revealed Resident #54 had alteration in behavior, would become physically aggressive with other residents, and would hit, push, and strike out. The goal revealed the resident would have reduction or elimination of episodes of physical aggression towards other residents through use of behavior management techniques. The interventions included: immediately intervene with residents, decrease stimulation, remove the resident to a quiet area, and provide the resident with verbal reassurance. However, the CCP was not developed to address the resident's inappropriate sexual behaviors, nor did it include specific interventions to implement to prevent inappropriate sexual abuse towards other residents. Review of Resident #54's Psychiatric Consult, dated 01/30/19, revealed the resident had a [DIAGNOSES REDACTED]. The Consult revealed the resident had a history of [REDACTED]. Continued review of the Consult, revealed the resident was started on [MEDICATION NAME] (Selective Serotonin Reuptake Inhibitor medication), [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (antianxiety medication) for behavior. Continued review of Resident #54's CCP, revealed a problem of Resident-to-Resident altercation initiated 03/11/19. However, there was no goal noted. Also, the intervention for one (1) on one (1) for twenty-four (24) hours for safety was marked through with a line and a d/c beside the intervention. There were no other interventions added to the CCP. The Care Plan failed to address the 03/11/19 incident as sexual behavior towards another resident with appropriate goals or interventions to prevent recurrence. Review of the Psychiatric Consult, dated 03/12/19, revealed Resident #54 was identified as having the [DIAGNOSES REDACTED]. The section titled, History of Present illness, revealed the resident grabbed a female staff member, on 03/11/19. (However, review of the facility of the Facility Self-Reported Incident Form dated 3/11/19 revealed Resident #54 grabbed Resident #13's breast). Interview with State Registered Nursing Assistant (SRNA) #1, on 03/21/19 at 9:45 AM, revealed on 03/11/19 after lunch, while she was standing at the nurse's station reading the care plan book, she looked behind her and saw Resident #54 grabbing Resident #13's left breast. She stated both residents were in the hallway in their wheelchairs. Further interview revealed she immediately separated the residents and reported the incident to the Unit Manager. Per interview, in her mind Resident #54 knew what he/she was doing when he/she grabbed Resident #13's breast because he/she told SRNA #1, that he/she was trying to open it, referring to the Resident #13's shirt. Additional interview, revealed SRNA #1 was not sure if Resident #54 exhibited sexual behaviors towards other residents, but stated he/she would sometimes touch staff inappropriately and then laugh. SRNA #1 stated the facility was aware Resident #54 had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #3, on 03/21/19 at 4:03 PM, revealed Resident #54 had not exhibited any inappropriate behaviors since the increase in his/her medication by psychiatric services. However, she revealed the resident had a history of [REDACTED]. Further interview revealed the resident would laugh after grabbing the nurses on the bottom, every time. Interview with the Unit Manager (UM), on 03/21/19 at 4:14 PM, revealed staff had informed him of Resident #54's combative behaviors including pinching and hitting staff in the past, but he was unaware of the resident exhibiting sexual behaviors. He stated he had not reviewed Resident #54's Psychiatric Consults in which the resident's sexual behaviors toward staff were discussed prior to the incident with Resident #13. Further, if he had reviewed the Psychiatric Consults he would have identified the resident was exhibiting inappropriate sexual behaviors towards others and ensured the CCP included interventions to protect other residents as well as staff. Interview with the Director of Nursing (DON), on 03/21/19 at 4:30 PM, revealed Resident #54 did have a a history of pinching, patting, grabbing at staff's legs and chest, and was touchy feely with staff. She stated the resident also had a history of [REDACTED]. The DON stated the resident's sexual behavior had been addressed with outpatient psychiatric consultation and the resident was being treated for [REDACTED].#54 was trying to get Resident #13's shirt off, although he/she was witnessed grabbing Resident #13's left breast. Additional interview with the DON, revealed she ensured only male staff assisted Resident #54 with showers due to his/her sexual behaviors; however, the resident's CCP did not include this intervention. Per interview, Resident #54's Care Plan did not address the resident's sexual behaviors towards others, and did not include interventions for staff to implement to protect other residents from the resident's sexual behavior. Further interview revealed Resident #54's Care Plan should have been developed to address the resident's sexual behaviors and should have included interventions to be implemented in order to protect other residents from his/her sexual behaviors. Interview with the Administrator, on 03/21/19 at 4:45 PM, revealed the facility was aware of Resident #54's inappropriate sexual behavior prior to the incident with Resident #13. Further interview revealed Resident #54's CCP should have been developed to address these behaviors and included interventions to be implemented to protect other residents from Resident #54's sexual behaviors. 2. Review of Resident #146's medical record revealed the facility admitted the resident on 02/27/19 with [DIAGNOSES REDACTED]. Review of the Baseline Admission Care Plan, dated 02/28/19, revealed the resident had impaired skin integrity. The goal stated the resident would remain free from new areas of skin breakdown and wounds would show signs of healing and be free from infection. There were several interventions including weekly skin assessment and report changes, treatments as ordered; and heel boots as ordered. Review of physician's orders [REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/16/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers, and toileting. Additional review revealed the facility assessed the resident as having one (1) Stage II Pressure ulcer on admission, and one (1) unstageable Pressure ulcer on admission. Review of the Comprehensive Care Plan (CCP), dated 03/18/19, revealed the resident had unstageable pressure ulcers to the mid-back spine, right lateral ankle, right elbow, and right heel related to immobility, incontinence and Motor Vehicle Accident. The goal stated the pressure ulcers would exhibit signs of healing by 04/18/19. There were several interventions initiated on 03/18/19 including: report changes in skin status, observe effectiveness of response to treatments, weekly skin check, notify nurse immediately of any new areas of skin breakdown, consult Dietician as needed, assist PRN (as needed) to reposition, and float heels in bed. There was a new intervention dated 03/20/19 for heel boots when up in chair as elder will allow. However, there was no documented evidence of an intervention for heel boots when in bed as per the physician's orders [REDACTED]. Observation of Resident #146, on 03/18/19 at 7:30 PM, revealed the resident was lying on a pressure relief mattress with no heel boots noted on either foot, as per physician's orders [REDACTED]. Observation of Resident #146 on 03/19/19 at 1:30 PM, revealed the resident was lying on a pressure relief mattress with no heel boots on either foot, as per physician's orders [REDACTED]. State Registered Nurse Aide (SRNA) #1 was assigned to the resident during this observation. Review of physician's orders [REDACTED]. Observation of Resident #146, on 03/19/19 at 3:05 PM, revealed the resident was lying on an air mattress with his/her right foot floated on a pillow. However, the resident had no heel boots on bilateral feet, as per the physician's orders [REDACTED].#1 was assigned to the resident during this observation. Observation of Resident #146, on 03/20/19 at 9:00 AM, revealed the resident was lying on an air mattress with perimeter bolsters. No pressure heel boots were noted on either foot as per physician's orders [REDACTED]. SRNA #1 was assigned to the resident during this observation. Interview on 03/21/19 at 9:50 AM, with SRNA #1, revealed she had been assigned to Resident #146 the past few days. She stated she referred to the Kardex (Nurse Assistant Care Plan) for guidance on providing care. Further interview revealed Resident #146's Kardex had interventions for heel booties to both feet while in bed or in the wheelchair and therefore the resident should wear the heel boots and the resident's heels should not be directly on the mattress. Further interview revealed the resident had never refused heel boots or other measures to relieve pressure to the heels to her knowledge. Interview with Licensed Practical Nurse (LPN) #1/Wound Nurse, on 03/21/19 10:30 AM, revealed Resident #146 should have pressure relieving devices in place to include heel boots when in bed or when up in the wheelchair. Further interview revealed the floor nurses were responsible for ensuring the heel lift boots were in place as ordered. She stated Resident #146 often refused to wear the heel boots. Observation of Resident #146, on 03/21/19 at 1:15 PM, revealed the resident was lying on an alternating pressure air mattress. The heel boots were on top of the bedside chest of drawers. In addition, the resident's feet were not offloaded, as per the CCP. Interview with Resident #146, on 03/21/19 at 2:00 PM, revealed he/she was unable to apply heel boots or prop his/her heels without assistance. He/she stated he had never refused to wear the heel boots when staff offered to apply them, nor did he/she refuse other measures to relieve pressure to his/her lower extremities. Resident #146 verbalized the reason for the heel boots was to take pressure off his/her heels. Further interview revealed his/her right heel wound resulted from the heel lying directly on the mattress for an extended amount of time, and the possible consequence of a pressure wound to the foot was the loss of the foot. Interview on 03/21/19 at 3:30 PM, with MDS Nurse #2, revealed the CCP should be developed to include any applicable physician's orders [REDACTED]. Further interview revealed Resident #146's CCP should have been developed to include the intervention for heel boots since there was a physician's orders [REDACTED]. Further interview revealed staff should implement all Resident #146's CCP interventions to relieve pressure, which would include off loading the heels. Interview with the Director of Nursing (DON), on 03/21/19 at 3:00 PM, revealed once physician's orders [REDACTED]. Per interview, Resident #146's CCP should have been developed to include the orders for heel boots. Further interview revealed nursing interventions for the wounds on Resident #146's right heel included dressings as ordered, and off-loading to relieve further pressure on the heel. Per interview, Resident #146's CCP should be followed for all interventions including off loading the heels. Interview with the Administrator, on 03/21/19 at 3:30 PM, revealed the physician's orders [REDACTED]. 3. Review of Resident #55's clinical record revealed the facility admitted the resident on 01/23/19 with [DIAGNOSES REDACTED]. Observation of Resident #55 on 03/19/19 at 3:53 PM, revealed the resident was in bed, and contractures were noted to the resident's bilateral arms/hands. Review of Resident #55's physician's orders [REDACTED]. Review of the OT Evaluation and Plan of Treatment, dated 01/25/19, revealed Resident #55 was to receive OT for [DIAGNOSES REDACTED]. Continued review revealed the short-term goal was to safely wear the least restrictive splinting/orthotic device for two (2) hours on and two (2) hours off and improve Passive Range of Motion (PROM) for adequate hygiene. Further, the long-term goal was to safely wear the least restrictive splinting/orthotic device for four (4) hours on and four (4) hours off, as well as placing the resident on a Restorative Nursing Program (RNP) for PROM and splinting upon discharge from OT. Additional review revealed Resident #55 had contractures to his/her right and left elbows and hands. Review of Resident #55's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having both short-term and long-term memory problems as well as severe impairment in cognitive skills for daily decision making. Continued review revealed the facility assessed the resident as having no Functional Limitations in Range of Motion of his/her upper or lower extremities. Additional review revealed the facility assessed the resident as requiring total dependence of two (2) staff for bed mobility, transfers, dressing, and toileting; and as requiring extensive assistance from one (1) staff member for eating and personal hygiene. Further review of the MDS Assessment, revealed the facility did not assess the resident as having an Active [DIAGNOSES REDACTED]. Review of Resident #55's CCP, dated 02/06/19, revealed a problem area of Activities of Daily Living (ADL) Self-Care deficit. The goal associated with this problem area revealed the resident would not develop any complications related to decreased ADL self-performance. The interventions to help achieve the stated goal included: staff to provide all ADL care, refer to therapy services as needed, and 1/4 side rails to the top of Resident #55's bed on both sides. Review of physician's orders [REDACTED].#55 to be discontinued from OT due to his/her highest practical level being achieved. Review of Resident #55's OT Discharge Summary, dated 02/08/19, revealed it was determined that a splint/orthotic device was not appropriate for Resident #55 due to muscle tone. Continued review revealed Resident #55 was placed on a Functional Maintenance Program (FMP) for stretching to bilateral shoulder, elbows, wrists, and fingers to facilitate decreased tone/tightness. Further review of Resident #55's CCP, revealed no documented focus area, goal, or interventions related to his/her contractures and no interventions related to the Functional Maintenance Program. Review of the submitted FMP documentation, revealed Resident #55 was receiving Functional Maintenance Program (FMP), as prescribed for daily stretching to bilateral shoulders, elbows, wrists, and fingers, which started 02/09/19. Interview on 03/21/19 at 4:20 PM with Licensed Practical Nurse (LPN) #40 revealed she was assigned to Resident #55. She stated Resident #55 was on a Functional Maintenance Program as directed by Occupational Therapy. She further stated the resident received PROM daily as per OT instructions. Per interview, the nurses were responsible for providing the PROM. Interview on 03/21/19 at 4:24 PM, with MDS Coordinator #2, revealed Resident #55 did have contractures and therefore the Admission MDS Assessment, dated 01/30/19 should have reflected the resident had functional limitations in range of motion; and also the Assessment should have reflected the resident's active [DIAGNOSES REDACTED]. Continued interview revealed Resident #55's CCP should have been developed with interventions related to the resident's contractures and FMP. Interview on 03/21/19 at 4:33 PM, with the Director of Nursing (DON), revealed the purpose of the CCP was to identify the care needs and direct the care the resident receives. She stated it was her expectation the CCP be developed to include all care to be provided by staff . She further stated the MDS Coordinator was responsible for developing the CCP from the MDS Assessment. Continued interview, revealed Resident #55's contractures should have been addressed on the CCP. She stated it was important it was important for the CCP to be developed with interventions to help prevent further or worsening contractures, address and treat possible pain from the contractures, ensure no skin issues arise from the contractures, and address any other concerns related to the contractures. Interview on 03/21/19 at 4:47 PM, with the Administrator, revealed the purpose of the CCP was to ensure that staff were aware of the needs of the resident. She stated the MDS Coordinator was responsible for developing the CCP based on the resident's medical record, observations, and information on the MDS Assessment. Further interview revealed Resident #55's CCP should have been developed to address the resident's contractures in order for the resident to receive the proper care related to the contractures and proper assistance with his/her ADLs.

Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure that a resident's comprehensive assessment accurately reflects the resident's status for one (1) of twenty-two (22) sampled residents (Resident #55). Resident #55's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 01/25/19, revealed the resident had contractures to his/her right and left elbows and hands requiring a splinting/orthotic device. However, the Admission Minimum Data Set (MDS) assessment dated [DATE], did not reflect the resident's Functional Limitations in Range of Motion (ROM), nor was the MDS Assessment coded for an active [DIAGNOSES REDACTED]. The findings include: Review of the facility's Policy, titled Resident Assessment, reviewed 07/31/18, revealed the facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the Centers for Medicare and Medicaid, Resident Assessment Instrument (RAI) User Manual Version 3.0, Chapter 3, Section G0400, revealed the intent of the section was to determine whether functional limitation in ROM interferes with the resident's Activities of Daily Living or places the resident at risk for injury. This was a three (3) step which included: 1) testing the resident's upper and lower extremity ROM; 2) if the resident is noted to have limitation of upper and lower extremity ROM, review G0110 and /or directly observe the resident to determine if the limitation interferes with function or places the resident at risk for injury; and Code G0400 A/B as appropriate based on the above assessment. Further review revealed Section I, identified Active Diseases and Infections that drive the current Plan of Care. Medical Record sources for physician [DIAGNOSES REDACTED]. Review of Resident #55's medical record revealed the facility admitted the resident on 01/23/19 with [DIAGNOSES REDACTED]. Observation on 03/19/19 at 3:53 PM, revealed the resident was in bed, and contractures were noted to the resident's bilateral arms/hands. Review of Resident #55's physician's orders [REDACTED]. Review of Resident #55's OT Evaluation and Plan of Treatment, dated 01/25/19, revealed the resident was to receive OT for [DIAGNOSES REDACTED]. Further review revealed the short-term goal was to safely wear the least restrictive splinting/orthotic device for two (2) hours on and two (2) hours off and improve Passive Range of Motion (PROM) for adequate hygiene. The long-term goal was to safely wear the least restrictive splinting/orthotic device for four (4) hours on and four (4) hours off, as well as placing the resident on a Restorative Nursing Program (RNP) for PROM and splinting upon discharge from OT. Further review revealed Resident #55 had contractures to his/her right and left elbows and hands. Review of Resident #55's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having both short-term and long-term memory problems and having severe impairment in cognitive skills for daily decision making. Further review revealed the facility assessed the resident as having no Functional Limitations in Range of Motion of his/her upper or lower extremities. Additional review of the MDS Assessment, revealed the facility did not assess the resident as having an Active [DIAGNOSES REDACTED]. Interview on 03/21/19 at 4:24 PM, with MDS Coordinator #2, revealed she had been in the MDS role for approximately two (2) months. She stated the purpose of the MDS Assessment was to provide an accurate picture of the resident for billing purposes as well as for care purposes. She stated the Comprehensive Care Plan was generated from the MDS Assessment, and therefore the MDS Assessment must be accurate. Further interview revealed Resident #55 did have contractures and therefore the Admission MDS Assessment, dated 01/30/19 should have reflected the resident had functional limitations in range of motion; and also the Assessment should have reflected the resident's active [DIAGNOSES REDACTED]. Interview on 03/21/19 at 4:33 PM, with the Director of Nursing (DON), revealed the purpose of the MDS Assessment was to capture a picture of the resident and their current status and care needs. Per interview, the MDS Assessments were to be accurate in order to set the triggers for the care plan. Further interview revealed Resident #55's Admission MDS Assessment should have been coded to indicate functional limitations in range of motion and an active [DIAGNOSES REDACTED]. Interview on 03/21/19 at 4:47 PM, with the Administrator, revealed the purpose of the MDS was to send information to CMS regarding the care the facility was providing for each resident. Per interview, Resident #55's Admission MDS should have reflected the resident's contractures and limited ROM and [DIAGNOSES REDACTED]. The Administrator stated it was her expectation the MDS Assessments be completed accurately.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 1.16, it was determined the facility failed to submit Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for two (2) of twenty-three (23) sampled residents (Resident #1 and Resident #2). Resident #1's Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 01/23/19 was not submitted to CMS until 03/18/19. In addition, Resident #2's Quarterly MDS Assessment, with an ARD of 01/11/19, was not submitted to CMS until 03/18/19. The findings include: Review of the facility's Policy, titled MDS Assessment Completion, revised (MONTH) (YEAR), revealed the facility will conduct and submit resident assessments in accordance with the RAI Manual including federal and state submission timeframes. Review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). 1. 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 MDS Assessment, revealed the Assessment Reference Date (ARD) was 01/23/19. However, further review of the MDS Assessment, revealed the MDS Assessment was not submitted to CMS until 03/18/19. Additional review of the MDS Assessment, revealed Sections C, D, E, and Q were not completed until 03/18/19. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 07/29/17 with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS Assessment, revealed the ARD was 01/11/19; however, further review revealed the MDS Assessment was not submitted to CMS until 03/18/19. Additional review of the MDS Assessment, revealed Sections C, D, E, and Q were not completed until 03/18/19. Interview with MDS Coordinator #1, on 03/21/19 at 9:06 AM, revealed she had worked at the facility for ten (10) years as a Licensed Practical Nurse (LPN) and in (MONTH) (YEAR) she transitioned to MDS Coordinator. She stated she did not work for a period of time in (MONTH) 2019 due to health issues and during this time the Social Service Director resigned without completing the Social Services portion of the MDS Assessments. She stated she was unaware of these incomplete assessments until she was notified by CMS on 3/11/19, that they were late. Further interview revealed all sections of the MDS Assessment have to be completed and locked before it will transmit. She stated the Corporate MDS Coordinator came to the facility on [DATE] and helped complete an audit of all residents' assessments and found Resident #1 and Resident #2's MDS Assessments had not been transmitted during the fourteen (14) day window after completion of the assessment. She further stated these two (2) residents' MDS Assessments were a late submission and facility policy was not followed. Interview with MDS Coordinator #2, on 03/21/19 at 9:25 AM, revealed she was a Registered Nurse (RN) and had been in this position for two (2) months. She stated the completion and transmission of assessments for Resident #1 for the Quarterly MDS Assessment, with ARD date of 01/23/19; and Resident #2 for the Quarterly MDS Assessment, with ARD date of 01/11/19 was overlooked. She further stated when they realized these two (2) MDS Assessments had not been locked and transmitted, they were completed on 03/18/19 and submitted to CMS. Interview with the Director of Nursing (DON), on 03/21/19 at 1:42 PM, revealed if MDS Assessments were submitted late, it was likely due to the Social Service Director resigning and the MDS Coordinator being on leave. Further interview revealed MDS assessments should be accurate and timely. Interview with the Administrator, on 03/21/19 at 4:15 PM, revealed she was aware of the regulation related to MDS Assessments needing to be transmitted within fourteen (14) days once completed. Further, she was aware of the concern of Resident #1 and Resident #2's MDS Assessments not being transmitted in the allotted fourteen (14) days. Additional interview, revealed the Interdisciplinary Team conducted a Quality Assurance Meeting on 03/11/19, when the problem was identified and on 03/18/19, the Corporate MDS Coordinator came to the facility and conducted an audit of all residents' MDS Assessments. Continued interview revealed the audit revealed only Resident #1 and Resident #2's MDS Assessments were incomplete and the MDS Coordinator locked and transmitted the MDS Assessments that day. Additional interview revealed it was her expectation for the Assessments to be completed and submitted timely as per the RAI Manual.

Based on interview, record review and review of facility Policy, it was determined the facility failed to ensure residents are free from abuse for one (1) of twenty-two (22) sampled residents (Resident #13). Resident #54 had a history of [REDACTED]. The resident also had a history of [REDACTED]. However, the facility failed to have interventions in place to ensure residents were protected from Resident #54's sexual behaviors. On 03/11/19, State Registered Nursing Assistant (SRNA) #1 reported witnessing Resident #54 inappropriately touching Resident #13's chest area. The findings include: Review of the facility's Abuse, Neglect, and Misappropriation Policy, reviewed 11/16/17, revealed it is Signature's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of property. Abuse is defined as the willful inflicting of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish. Abuse includes physical abuse, mental abuse, verbal abuse and sexual abuse. Sexual abuse includes sexual harassment, sexual coercion, or sexual assault. Review of the facility Self Report Incident, dated 03/11/19 and signed by the Administrator, revealed on 3/11/19 at approximately 3:45 PM, it was reported to the Unit Manager by State Registered Nursing Assistant (SRNA) #1, Resident #54 was witnessed inappropriately touching Resident #13's chest area. SRNA #1 intervened, separated the residents, and placed Resident #54 on 1:1 (one on one) supervision. Nursing staff completed skin assessments on both residents, and no injuries were found. Further review revealed care plans were updated, and the physician and families were made aware of the incident. Review of the facility's Investigation, completed 3/15/19, revealed the facility conducted skin assessments on all residents with a Brief Interview for Mental Status (BIMS) score of seven (7) or below and interviewed all residents with BIMS scores of eight (8) or above. Per the Investigation, no residents interviewed had concerns related to abuse from another resident. Resident #54 was seen by the in house psychiatric provider on 03/12/19 who increased his/her [MEDICATION NAME] (Selective Serotonin Reuptake Inhibitor medication). Further review of the Investigation, revealed the Social Service Director followed up with both Resident #54 and Resident #13 after the incident. Review of Resident #13's medical record revealed the facility admitted the resident on 12/13/16 with [DIAGNOSES REDACTED]. Resident #13 was assessed by the facility per the Quarterly Minimum Data Set ((MDS) dated [DATE], as having a BIMS Score of 99, indicating the resident had severe cognitive impairment. Review of Resident #13's Comprehensive Care Plan, initiated 03/11/19 revealed a problem of reportable inappropriate touch. The goal stated the resident would exhibit no signs or symptoms of increased emotional distress and would allow needs to be met daily. The interventions included: one (1) to one (1) visits by social service; all staff to provide support, encouragement, and reassurance; nursing and social services to observe daily for increased distress, withdrawal, and one (1) on one (1) for twenty -four (24) hours, then fifteen (15) minute checks for seventy-two (72) hours. Review of Resident #54's medical record revealed the facility admitted the resident on 09/18/18 with [DIAGNOSES REDACTED]. Resident #54 was assessed by the facility per the Quarterly MDS Assessment, dated 03/01/19 as having a BIMS score of three (3) out of fifteen (15) indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as having physical behavioral symptoms directed towards others, one (1) to three (3) days during the last seven (7) days. Review of Resident #54's Psychiatric Consult, dated 01/08/19, revealed this was an initial consult for behavioral disturbances including sexually inappropriate behavior towards staff. Per the Consult, the resident had a history of [REDACTED]. Review of Resident #54's Comprehensive Care Plan, dated 1/08/19, revealed the resident had alteration in behavior, would become physically aggressive with other residents, and would hit, push, and strike out. The goal stated the resident would have reduction or elimination of episodes of physical aggression towards other residents through use of behavior management techniques. The interventions included: immediately intervene with residents, decrease stimulation, remove resident to a quiet area, and provide resident with verbal reassurance. However, the CCP did not address the resident's inappropriate sexual behaviors, nor did it include specific interventions to prevent inappropriate sexual abuse towards other residents. Review of Resident #54's Psychiatric Consult, dated 01/30/19, revealed the resident was identified to have a [DIAGNOSES REDACTED]. Per the Consult, the resident had a history of [REDACTED]. Further review of the Consult, revealed the resident was started on [MEDICATION NAME] (Selective Serotonin Reuptake Inhibitor medication), [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (antianxiety medication) for behavior. Further review of Resident #54's Comprehensive Care Plan, revealed a problem of Resident-to-Resident altercation initiated 03/11/19. However, there was no goal identified. In addition, the intervention for one (1) on one (1) for twenty-four (24) hours for safety was marked through with a line and a d/c beside the intervention. No other interventions were added to the Care Plan. The Care Plan failed to identify the 3/11/19 incident as sexual behavior towards another resident with appropriate goals or interventions to prevent recurrence. Review of Resident #54's Psychiatric Consult, dated 03/12/19, revealed the resident was identified as having the [DIAGNOSES REDACTED]. The section titled, History of Present illness, revealed the resident grabbed a female staff member on 3/11/19. (However, review of the facility of the Facility Self-Reported Incident Form dated 3/11/19 revealed Resident #54 grabbed Resident #13's breast not a female staff member). Interview with State Registered Nursing Assistant (SRNA) #1, on 03/21/19 at 9:45 AM, revealed on 03/11/19 after lunch, she was standing at the nurse's station reading the care plan book and looked behind her and saw Resident #54 grabbing Resident #13's left breast. Per interview, both residents were in the hallway in their wheelchairs. Continued interview revealed she immediately separated the residents and reported the incident to the Unit Manager. Per interview, in her mind Resident #54 knew what he/she was doing when he/she grabbed Resident #13's breast because he/she told SRNA #1, he/she was trying to open it, referring to the Resident #13's shirt. Per interview, SRNA #1 was not sure if Resident # 54 exhibited sexual behaviors towards other residents, but stated he/she would sometimes touch staff inappropriately and then laugh about it. Continued interview revealed the facility had trained the employees on types of abuse and abuse reporting, which is why she thought it was so important to report this incident on 03/11/19. Per interview, the facility was aware Resident #54 had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #3, on 03/21/19 at 4:03 PM, revealed Resident #54 had not exhibited any behaviors since the increase in his/her medication by psychiatric services. However, she stated, the resident had a history of [REDACTED]. Per interview, the resident would laugh after grabbing the nurses on the bottom, every time. Interview with the Unit Manager (UM), on 03/21/19 at 4:14 PM, revealed staff had informed him of Resident #54's combative behaviors including pinching and hitting staff, but he was unaware of the resident exhibiting sexual behaviors. Per interview, he had not reviewed Resident #54's Psychiatric Consults in which the resident's sexual behaviors toward staff were discussed prior to the incident with Resident #13. He stated if he had reviewed the Psychiatric Consults he would have identified the resident was exhibiting inappropriate sexual behaviors towards others and ensured the Care Plan included interventions to protect other residents as well as staff. Per interview, the facility trained staff on abuse prevention, and how to identify different types of abuse in order to implement interventions to protect residents from abuse. Interview with the Director of Nursing (DON), on 03/21/19 at 4:30 PM, revealed Resident #54 had a history of [REDACTED]. She stated the resident would also make sexual remarks towards staff; however, she had never known of the resident to exhibit sexual behaviors towards other residents until the incident on 03/11/19. Per interview, the resident's sexual behavior had been addressed with outpatient psychiatric consultation and the resident was being treated for [REDACTED].#54 was trying to get Resident #13's shirt off, although he/she was witnessed grabbing Resident #13's left breast. Continued interview with the DON, revealed she ensured only male staff assisted Resident #54 with showers due to his/her sexual behaviors; however, this was not addressed on the Care Plan. Further interview revealed Resident #54's Care Plan did not address the resident's sexual behaviors towards others, nor interventions to protect other residents from sexual abuse. Additional interview revealed Resident #54's Care Plan should have included interventions to prevent the resident's sexual behaviors towards others to the extent possible, and interventions to protect other residents from his/her sexual behaviors. Continued interview revealed the facility provided the staff with abuse training at orientation, annually and as needed and was her expectation residents were protected from abuse from staff as well as from other residents. Interview with the Administrator, on 03/21/19 at 4:45 PM, revealed the facility trained all staff on abuse and all aspects of the policy including identification of abuse and prevention of abuse during orientation, annually and as needed. Per interview, the facility attempted to protect all residents from abuse by ensuring staff followed the Abuse Policy. The Administrator stated the facility was aware of Resident #54's inappropriate sexual behavior and should have had interventions in place on the Care Plan to protect other residents.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the care plan related to staff assistance required during transfers was followed for one (1) of four (4) sampled residents (Resident #1). Resident #1's had a Comprehensive Care Plan which directed the resident be transferred by hoyer lift (mechanical lift) with two (2) person assist. However, on 08/19/16, at approximately 5:00 AM, State Registered Nurse Aide (SRNA) #10 attempted to transfer the resident from the bed to the wheelchair without use of the hoyer lift and without requesting assistance from other staff. During the transfer procedure, Resident #1 fell from the side of the bed onto the floor. SRNA #10 failed to inform the nurse of the fall and with the assistance of SRNA #7, transferred the resident from the floor to the wheelchair with a gait belt. Resident #1 sustained a Intertrochanteric Left Femoral Neck Fracture (hip). (Refer to F323) The facility's failure to ensure staff followed the Care Plan resulted in actual harm to Resident #1. The facility's written Quality Assurance (QA) Plan was received on 08/24/16. Based on validation of the QA Plan, the State Survey Agency determined the deficient practice represented past non-compliance, as it was identified and corrected regarding implementation of the Care Plan related to required staff assistance for transfers, prior to initiation of the investigation by the State Survey Agency. The findings include: Review of the policy titled Care Plans - Comprehensive, dated 06/01/15, revealed each resident was to have a plan of care based on a thorough assessment to incorporate risk factors associated with identified problems, reflect currently recognized standards of practice for problem areas and conditions, aide in preventing declines in the resident's functional status, and identify the professional services that are responsible for each element of care. Review of Resident #1's clinical record revealed the facility admitted the resident on 12/01/15 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 06/24/16, related to transfer needs, revealed the facility assessed Resident #1 as requiring extensive assistance and two person physical assist. Review of the Comprehensive Care Plan initiated April 2015, and updated March 2016, revealed a problem of At Risk for Falls, related to decreased mobility, impaired balance during transitions, incontinence, visual impairment, and a [DIAGNOSES REDACTED]. There were several interventions including transfers per hoyer lift with assist of two (2) staff. Review of the Final Incident Report Form dated 08/23/16, revealed SRNA #10 attempted to transfer Resident #1 from the bed to the wheelchair without use of the hoyer lift and without the assist of another staff member. Per the Report, the resident slid from the side of the bed onto the floor during the transfer. Further review of the Incident Report revealed interventions in place at the time of the fall included Assist x 2 with hoyer lift for transfers. Continued review revealed SRNA #10 did not report the fall to the Administrator or DON, and transferred Resident #1 from the floor to the wheelchair without being appropriately assessed first. Per the Incident Report, Resident #1 complained of pain during breakfast on the following shift and was given Tylenol (pain reliever and fever reducer) with relief Further review revealed Resident #1 again complained of pain after lunch, was assessed, and an X-Ray was ordered. Additionally the Incident Report revealed following X-Ray results, Resident #1 was sent to the local hospital emergency room for evaluation. Review of Nurse's Notes dated 08/19/16, recorded at 9:24 PM, revealed Resident #1 was up in the wheelchair at 8:00 AM, complained of pain in the right hand and left leg and was administered Tylenol six hundred fifty (650) milligrams (mg). Per the Notes, a reassessment at 10:00 AM revealed the resident was in the wheelchair smiling and nodded when asked if he/she felt better. Continued review revealed Resident #1 was returned to bed at 1:30 PM and was yelling out in pain and holding his/her left hip. According to the Notes, the nurse conducted an assessment at that time, noted swelling to the left hip area, administered Tylenol 500 mg, and notified the ARNP of the resident's pain and swelling. Further review revealed at 2:00 PM orders were received for X-Rays and at 4:30 PM the ARNP was in to see the resident and orders were received for stat [MEDICATION NAME] (narcotic pain medication) which was taken from the E-box (emergency box) and administered. Per the Note, the Mobile X-Ray arrived at 8:00 PM. Review of physician's orders [REDACTED]. [REDACTED]. Review of the Radiology Report dated 08/19/16 and read by the Radiologist at 10:01 PM, revealed Resident #1 had a Left Intertrochanteric Femur Fracture. Review of Nurse's Notes dated 08/20/16, recorded at 4:49 AM, revealed at 10:45 PM EMS was contacted for transport, and at 1:00 PM the hospital called to state the resident was being admitted . Review of the Diagnostic Imaging Report from the hospital Emergency Department dated 08/20/16, revealed a Intertrochanteric Left Femoral Neck [MEDICAL CONDITION] Hip. According to the Witness Statement by SRNA #10, dated 08/19/16, she attempted to transfer Resident #1 from the bed to the wheelchair without assistance and without use of the hoyer lift, and after Resident #1 fell , she failed to report the fall to the nurse. Review of the written interview conducted by the Administrator with SRNA #10 on 08/20/16, revealed SRNA #10 knew Resident #1 required two (2) person assist with the hoyer lift, and didn't know why she didn't follow the care plan. The State Survey Agency Representative attempted to contact SRNA #10 by telephone for an interview on 08/24/16 at 3:45 PM and 08/25/16 at 3:00 PM; however, the attempts were unsuccessful. Interview with SRNA #7, on 08/25/16 at 9:08 AM, revealed on 08/19/16 just after 5:00 AM, SRNA #10 asked for her help, stating Resident #1 was on the floor. SRNA #7 revealed she arrived at Resident #1's room and observed the resident was on the floor beside the bed on his/her left side. She stated, she assisted SRNA #10 in transferring Resident #1 to the wheelchair, with use of a gait belt, and no mechanical lift and the resident complained of leg pain. She stated she then asked SRNA #10 if she needed any further help, and went back to assisting the unsampled resident she had been with previously. Further interview revealed she assumed SRNA #10 had reported the fall and Resident #1 had been assessed by a nurse prior to SRNA #10 asking her for help. She stated she had not worked with Resident #1 and did not know Resident #1 required the assist of two (2) staff and the use of a hoyer lift for transfers. SRNA #7 stated when she came in later that same day at approximately 2:00 PM and asked about Resident #1, she realized the fall had not been reported. Interview with Registered Nurse (RN) #1, on 08/25/16 at 9:49 AM, revealed she was assigned to Resident #1 on 08/18/16 from 7:00 PM to 08/19/16 at 7:00 AM. She stated she passed medication to Resident #1 the morning of 08/19/16 and the resident did not express pain, did not appear to be in any pain, and no falls had been reported to her. Further interview revealed she was unaware Resident #1 had sustained a fall until she came in to work the evening of 08/19/16. Continued interview revealed it was her expectation for SRNA's to always follow resident care plans related to transfers and care provided. Interview with SRNA #2, on 08/24/16 at 1:17 PM, revealed she worked with Resident #1 in restorative dining on the morning of 08/19/16 and noticed when she turned the wheelchair around the resident grimaced as in pain. SRNA #2 stated she asked the resident if he/she was in pain and received no response, and when asked about pain a little later, stated his/her leg hurt. SRNA #2 revealed she informed RN #2 of the resident's complaints of pain and RN #2 questioned Resident #1, then administered medication to Resident #1 which was approximately 7:30 AM. Further interview revealed Resident #1's Nurse Aide Care Plan had an intervention for two (2) staff to assist with the hoyer lift for transfers. She stated the Nurse Aide Care Plans were located at the nursing stations, and she always made a copy to carry with her for reference for care. Interview with SRNA #3, on 08/25/16 at 1:28 PM, revealed she transferred Resident #1 with assistance of another SRNA using the hoyer lift after lunch on 08/19/16 at approximately 12:15 PM, as per the Nurse Aide Care Plan. She revealed the resident cried out in pain when they were attempting to provide incontinence care after lunch, and she informed RN #2, who assessed Resident #1. Further interview revealed SRNA #3 revealed she was unaware Resident #1 had sustained a fall during the previous shift when she was caring for the resident on 08/19/16. Further interview revealed care plans were located in a book at the nurse's station and staff was required to carry a copy with them to ensure they were aware of resident care needs. Interview with RN #2, on 08/25/16 at 10:09 AM, revealed the morning of 08/19/16, she was informed by SRNA #2, Resident #1 was complaining of leg pain and she administered Tylenol medication at 8:07 AM, which was prescribed for the resident's Arthritis pain. RN #2 further revealed when she followed up with Resident #1 approximately thirty (30) minutes later, the resident indicated the pain was gone. Continued interview revealed the SRNA's were attempting to provide incontinence care to Resident #1 on 08/19/16 after lunch, and she was again alerted Resident #1 was in pain, and completed a head to toe skin assessment, noting the resident's left hip was slightly larger than his/her/right hip, and he/she was grabbing at the hip in obvious pain. Further interview with RN #2, revealed she obtained physician's orders [REDACTED]. Continued interview revealed the X-Rays were completed at 8:10 PM, and the results of the X-Rays were received at 10:09 PM on 08/19/16, at which time Resident #1 was sent to the local hospital Emergency Department (ED) for evaluation. Interview with the Administrator and Director of Nursing (DON), on 08/25/16 at 2:50 PM, revealed based on the facility investigation and statements from SRNA #10 and SRNA #7, it was concluded SRNA #10 attempted to transfer Resident #1 without using the hoyer lift and without requesting assistance on 08/19/16, and the resident sustained [REDACTED].#10 nor SRNA #7 reported the resident sustained [REDACTED].#1 from the floor to the wheelchair without an assessment completed by the nurse. Continued interview revealed Resident #1's Care Plan was not followed related to transferring the resident with a hoyer lift and with the assistance of two (2) staff. Further interview revealed it was their expectation that SRNA's review resident care plans at the beginning of the shift and follow the care plans. The facility provided an acceptable QA Plan, which alleged correction of the deficient practice on 08/23/16. Review of the QA Plan revealed the facility implemented the following corrective actions: 1. An incident of potential neglect of Resident #1 was reported to the office of Inspector General on 08/22/16. The facility's investigation of the incident was initiated on 08/19/16 and included the following: Resident #1 was assessed by RN #2 for signs of abuse or injury related to pain on 08/19/16; the ARNP was notified of the assessment performed by RN #2 and an X-ray was ordered and obtained showing a [MEDICAL CONDITION] Hip; Resident #1 was sent to the ED for further evaluation on 08/19/16 at 10:45 PM and diagnosed with [REDACTED].#10 on 08/19/16, and a follow-up interview with SRNA #10 was conducted by the Administrator on 08/20/16; SRNA #10 was terminated by the facility on 08/22/16; and the Maintenance Director assessed all lifts on 08/20/16 to determine they were in proper working order and weekly assessments of the lifts were in place and up to date. 2. All residents with a BIMS greater than (>)7 were interviewed for abuse/neglect or any care concerns on 08/20/16 by the Quality of Life Director. Residents with a BIMS of less than eight (<8) were physically assessed beginning 08/19/16 and concluding on 08/20/16 by Unit Managers. All assessments, interviews and questionnaires were reviewed by the Administrator on 08/20/16 for any concerns. 3. All Incident/Accident Reports and Nurse's Progress Notes for the past thirty (30) days were reviewed by the Corporate Consultant with no concerns identified. 4. All personnel files of personnel involved in the care of Resident #1 were audited for any abuse concerns on 08/20/16 and all audit results were reviewed by the Administrator. 5. All resident Care Plans and SRNA Care Plans were reviewed and updated as needed, to include the use of mechanical lifts, bed mobility, and transfers on 08/20/16 by MDS Nurses. 6. All staff were re-educated by the DON on the facility's care plan policy, gait belt policy, resident lift policy, accidents and incidents policy, and falls policy beginning on 08/19/16 and concluding on 08/22/16. Staff was not allowed to return to work until completion of re-education, and all staff who was not re-educated by 08/22/16 was sent a certified letter explaining they would not be allowed to work until the training was complete. Training for all staff included a competency test on use of gait belts, transferring residents to wheelchair, and use of lifts. 7. Beginning on 08/21/16, the DON observed staff care delivery for five (5) different residents daily to include observation of transfers using the mechanical lift, and will continue to observe daily. All results will be reported at the weekly QA meeting, where the determination of the frequency of continued audits will be made. Any concerns identified during the audits will be addressed immediately and reported to the Administrator. 8. Beginning on 08/22/16, ten (10) charts were audited daily by the DON to ensure Comprehensive Care Plans reflected resident assessments and Nurse Aide Care Plan interventions matched Comprehensive Care Plans. All results will be reported at the weekly QA meeting, where the determination of the frequency of continued audits will be made. Any concerns identified during the audits will be addressed immediately and reported to the Administrator. 9. Beginning 08/21/16, five (5) skin assessments were conducted each day by the DON, and five (5) resident interviews were conducted by the Social Services Director. All results will be reported at the weekly QA meeting, where the determination of the frequency of continued audits will be made. Any identified concerns will be addressed immediately and reported to the Administrator. 10. A QA meeting was held on 08/20/16 to review the QA plan, and a second QA meeting was held on 08/22/16 to review the progress made on the QA plan. QA meetings will continue to be scheduled each week to monitor progress, and to determine the need for continuing frequency of ongoing audits. Per the Performance Improvement Plan, the Signature Clinical Consultant and/or the Regional Vice President will provide corporate oversight three (3) times a week. The State Survey Agency validated the implementation of the facility's Action Plan as follows: 1. Review of the State Agency Intake Form revealed the initial report was received from the facility on 08/22/16. Review of the Incident Report, dated 08/19/16 and signed by the Administrator, revealed a failure by SRNA #10 and SRNA #7 to report an event involving Resident #1. Further review revealed both SRNAs had been suspended immediately upon report of the incident. Review of the Final Report, dated 08/23/16 and signed by the Administrator, revealed SRNA #10 and SRNA #7 failed to report a fall witnessed by SRNA #10 on the morning of 08/19/16. Resident #1 indicated pain during the following shift, and was given pain medication and assessed for effectiveness, and X-Rays were ordered on [DATE] as a result of Resident #1's pain. The Radiology Report dated 08/19/16 revealed a Introchanteric Left Femoral Neck Fracture and the resident was transferred to the local hospital ED for further evaluation and admitted to the hospital. Review of a Witness Statement from SRNA #10, dated 08/19/16, revealed she attempted to transfer Resident #1 from the bed to the wheelchair without using a lift or getting assistance, and when Resident #1 fell , instead of alerting a nurse she asked for assistance from SRNA #7 in transferring Resident #1 from the floor to the wheelchair. Interview with SRNA #7, on 08/25/16 at 9:08 AM, revealed she had started her 5:00 AM rounds on the morning of 08/19/16 SRNA #10 came into the room where she was working and stated she needed assistance as Resident #1 was in the floor. SRNA #7 stated she assisted SRNA #10 in transferring Resident #1 from the floor to the wheelchair without a mechanical lift, at which point Resident #1 complained of leg pain. SRNA #7 revealed she did not normally provide care for Resident #1 and did not know what his/her care plan stated related to transfers. She further revealed she made the assumption SRNA #10 had already reported the fall and the nurse had assessed Resident #1 prior to asking for her assistance. She stated when she returned to the facility that afternoon at approximately 2:00 PM, and inquired as to how Resident #1 was feeling, she found out the fall had not been reported. She revealed she provided a statement at that time and was informed over the phone shortly thereafter, she was suspended. Interview with RN #2, on 08/25/16 at 10:09 AM, revealed Resident #1 had refused breakfast on the morning of 08/19/16 and stated he/she was in pain. RN #2 revealed she believed Resident #1 to be experiencing arthritic pain, as he/she had before, so gave him/her Tylenol, with a later reassessment revealing the pain was gone. RN #2 further stated when the SRNA's were assisting Resident #1 to lye down after lunch, Resident #1 complained of leg pain, at which point RN #2 assessed the resident, which revealed the resident was holding the left hip which was slightly larger than the right, but there was no redness or bruising. RN #2 revealed, based on her assessment she notified the ARNP and obtained orders for an X-Ray. Per interview, as the X-ray still had not been performed several hours later, she obtained an order for [REDACTED]. Interview with the DON, on 08/25/16 at 4:20 PM, revealed she was aware Resident #1 was experiencing leg pain and an X-Ray had been ordered prior to finding out on the afternoon of 08/19/16, the Resident #1 had suffered a fall that morning. She revealed she immediately had SRNA #7 who reported the fall, speak to the Administrator, and began educating staff and started auditing care shortly after. Review of the Stakeholder Termination Notice revealed the facility informed SRNA #10 of termination from employment on 08/22/16. Continued review revealed the reason for termination was violation of facility policy. The Termination Notice was signed by SRNA #10 on 08/22/16. Review of the Logbook for lift inspections revealed a routine inspection of all lifts was completed by the Maintenance Director on 08/20/16 with no concerns noted. 2. Review of the facility's QA Plan Binder revealed all residents with a BIMS >7 were interviewed for abuse/neglect or any care concerns on 08/20/16 by the Quality of Life Director. Questionnaires included questions regarding resident treatment by staff and questions regarding any concerns residents might express. Continued review of the binder revealed all residents with a BIMS < 8 received a skin assessment by 08/20/16 per the Unit Managers. No concerns were identified through questioning or assessments. 3. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed the Corporate Consultant reviewed all Incident/Accident Reports and Nursing Progress Notes for the past thirty (30) days and did not find anything that had gone unreported. 4. Five (5) personnel files were reviewed, with appropriate and timely background checks in place and evidence of training documented. 5. Four (4) resident care plans and nurse aide care plans were reviewed and interventions compared to the latest MDS Assessments, with all four (4) showing consistency related to required resident care and transfer assistance required. 6. Sign in sheets and copies of certified letters were reviewed and compared to employee listings, with all employees accounted for. Additionally, interviews with SRNA #1 on 08/24/16 at 1:03 PM, SRNA #2 on 08/24/16 at 1:17 PM, SRNA #3 on 08/24/16 at 1:28 PM, LPN #1 on 08/24/16 at 2:12 PM, LPN #2 on 08/25/16 at 7:43 AM, SRNA #5 on 08/25/16 at 8:13 AM, LPN #3 on 08/25/16 at 8:29 AM, SRNA #6 on 08/25/16 at 8:53 AM, SRNA #7 on 08/25/16 at 9:08 AM, RN #1 on 08/25/16 at 9:49 AM, RN #2 on 08/25/16 at 10:09 AM, SRNA #8 on 08/25/16 at 10:29 AM, SRNA #9 on 08/25/16 at 10:47 AM, LPN #4 on 08/25/16 at 1:14 PM, Quality of Life Director on 08/25/16 at 1:22 PM, Housekeeping #1 on 08/25/16 at 1:30 PM, LPN #5 on 08/25/16 at 1:34 PM, RN #3 on 08/25/16 at 1:41 PM, LPN #6 on 08/25/16 at 1:48 PM, Dietary #1 on 08/25/16 at 1:53 PM, and the Social Services Director on 08/25/16 at 2:01 PM revealed all had received the mandatory inservice training on following the care plan; incidents and accidents; falls and importance of reporting; the use of gait belts; mechanical lifts; and lift policy. Several SRNA's revealed they had been observed by the DON, sometimes daily, providing resident care according to the care plan and using gait belts and mechanical lifts. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed any staff who was not re-educated by 08/22/16 would not be allowed to return to work until they had received the required education. 7. On 08/25/16 the State Survey Agency Representative observed use of the hoyer lift by SRNAs with Resident #3 being transferred from bed to wheelchair at 9:35 AM; and use of the hoyer lift by two (2) different SRNA's with Resident #4 being transferred from wheelchair to bed at 10:54 AM. No concerns were noted during observations, and later review of resident Comprehensive Care Plans confirmed care was provided accordingly. Additionally, audit logs were reviewed from 08/21/16 through 08/25/16 of staff care delivery with no concerns identified. Competency checklists for use of the gait belt; transferring to wheelchair; and full body lift bed to wheelchair were reviewed for all SRNAs, dated 08/20/16 through 08/22/16. 8. Audit logs were reviewed of ten (10) charts audited daily by the DON from 08/22/16 through 08/25/16 to ensure care plans reflected resident assessments and Nurse Aide Care Plan interventions matched Care Plans. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed there had been no inconsistencies or concerns identified so far during chart audits. 9. Skin assessment results were reviewed, and five (5) skin assessments were conducted each day beginning 8/21/16, with no concerns identified. 10. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed a QA plan was presented and reviewed during a QA meeting on 08/20/16, and reviewed during a second QA meeting on 08/22/16. Interview revealed QA meetings would continue to be scheduled each week to monitor progress, and to determine the continuing frequency of ongoing audits. Continued interview with the Administrator, revealed corporate oversight would be provided three (3) times a week by the Signature Clinical Consultant and/or the Regional Vice President.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent a fall when one (1) staff member attempted to transfer the resident without assistance and without use of a mechanical lift as directed by the facility's policy and the resident's Comprehensive Care Plan. On 08/19/16, at approximately 5:00 AM, State Registered Nurse Aide (SRNA) #10 independently attempted to transfer Resident #1 from the bed to the wheelchair without requesting assistance and without utilizing a mechanical lift. Review of the facility's investigation findings, revealed Resident #1 slid off the side of the bed onto the floor during the transfer. After Resident #1 sustained the fall, SRNA #10 failed to report the fall to the nurse in order for the resident to be assessed for injuries, and instead transferred the resident to the wheelchair with a gait belt, with the assistance of SRNA #7. The resident was not assessed for injuries until 08/19/16 at approximately 1:30 PM. an order for [REDACTED]. On 08/19/16 at 10:45 PM Emergency Medical Services (EMS) was contacted to transfer the resident to the local hospital emergency room and the resident was admitted to the hospital. Review of the facility's policy revealed residents unable to transfer themselves independently or with minimum assistance were to be transferred using a lift with at least two (2) trained staff providing the transfer. In addition, review of the Comprehensive Care Plan for Resident #1, revealed instructions for the use of a hoyer lift (mechanical lift) and the assist of two (2) staff for transfers. The facility's failure to ensure it's policies and the Comprehensive Care Plan were followed resulted in actual harm to Resident #1. The facility's Quality Assurance (QA) Plan was received on 08/24/16. Based on validation of the QA Plan, the State Survey Agency determined the deficient practice represented past non-compliance, as it was identified and corrected related to implementation of the facility's policies regarding use of the mechanical lift, reporting falls, and implementation of the Comprehensive Care Plan, prior to initiation of the investigation by the State Survey Agency. The findings include: Review of the facility's Falls Policy, revised 06/01/15, revealed appropriate care plan interventions were to be implemented to minimize fall risk. Further review revealed a resident experiencing a fall was to have an assessment including neuro checks, range of motion, and vital signs, as well as pain evaluations. Per Policy, the physician and family was to be notified and an investigation was to begin. Review of the facility's policy titled Accidents and Incidents - Investigating and Report, undated, revealed accidents were to be investigated, including time and date and circumstances surrounding the accident, and reported to the Administrator and/or Director of Nursing (DON). Review of the facility's Resident Lift Policy, undated, revealed residents unable to transfer themselves independently or with minimum assistance were to be transferred using a lift with at least two (2) trained staff providing the transfer. Review of the 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 [DATE], revealed the facility assessed the resident as requiring extensive assistance and two (2) persons physical assist for transfers. Further review of the MDS revealed the facility assessed Resident #1 as unable to complete the Brief Interview for Mental Status (BIMS); as having both long and short term memory loss; and as severely impaired for decision-making ability. Review of the Comprehensive Care Plan related to falls revealed Resident #1 was assessed as At Risk for Falls on the care plan initiated April 2015 and updated March 2016, with the goal stating the resident would not have avoidable falls with injury. There were several interventions including two (2) persons to assist with a hoyer lift for transfers. Continued review of the Care Plan revealed the resident was dependent for all needs. Review of the Final Report Incident Form, dated 08/23/16, revealed SRNA #10 attempted to transfer Resident #1 from the bed to the wheelchair without assistance and without using the hoyer lift, when the resident slid from the side of the bed onto the floor. Continued review revealed interventions in place at the time included transferring the resident with a hoyer lift and the assist of two (2) persons. Further review revealed SRNA #10 did not report the fall to the Administrator or DON, and with assistance from SRNA #7, Resident #1 was transferred from the floor to the wheelchair without being appropriately assessed first. Per the Form, Resident #1 complained of pain during breakfast on the following shift and was given Tylenol (pain reliever and fever reducer) with good relief noted. Continued review revealed Resident #1 again complained of pain after lunch, was assessed, and an X-Ray was ordered. Additional review of the Form, revealed following X-Ray results, Resident #1 was sent to the local hospital emergency room for evaluation. Review of Nurse's Notes dated 08/19/16, recorded at 9:24 PM, revealed at 8:00 AM Resident #1 was up in the wheelchair and complained of pain in the right hand and left leg and was given Tylenol six hundred fifty (650) milligrams (mg). Per the Note, at 10:00 AM, Resident #1 was in the wheelchair smiling and nodded when asked if he/she felt better. Continued review revealed at 1:30 PM, Resident #1 was returned to bed and yelled out in pain holding the left hip. Per the Note, there was no redness or bruising noted but the left hip was somewhat swollen compared to the right hip, and there was no internal or external rotation. Tylenol 500 mg was repeated and the ARNP arrived and was notified of the resident's pain and swelling. At 2:00 PM orders were received for X-Rays. Further review of the Note, revealed at 4:30 PM the ARNP was in to see the resident and orders were received for stat Norco (narcotic pain medication) which was taken from the E-box (emergency box) and administered. At 6:00 PM the resident hurts when moving. At 7:00 PM the resident was quiet and smiling and X-Ray had not yet arrived, and physician's orders [REDACTED]. Further review of the Note, revealed X-Ray was there at 8:00 PM. Review of physician's orders [REDACTED]. Further review revealed physician's orders [REDACTED]. Continued review revealed physician's orders [REDACTED]. Review of the Radiology Report dated 08/19/16 at 10:01 PM, revealed a Left Intertrochanteric Femur Fracture. Review of Nurse's Notes dated 08/20/16, recorded at 4:49 AM, revealed at 10:45 PM EMS was contacted for transport, and at 11:00 PM report was called to the hospital. Per the Notes, at 1:00 PM the hospital called to state the resident was being admitted . Review of Resident #1's Diagnostic Imaging Report from the ED, dated 08/20/16, revealed a Intertrochanteric Left Femoral Neck Fracture of the Left Hip. Review of a Witness Statement by SRNA #10, dated 08/19/16, revealed she attempted to transfer Resident #1 from the bed to the wheelchair without assistance and without use of the hoyer lift, and after Resident #1 fell , she failed to report the fall to the nurse. Review of a Stakeholder Suspension Form, revealed SRNA #10 was suspended on 08/19/16. Review of a written interview conducted by the Administrator with SRNA #10 on 08/20/16, revealed SRNA #10 knew Resident #1 required two (2) person assist with the hoyer lift, and didn't know why she didn't follow the care plan. Review of a Stakeholder Termination Notice, revealed SRNA #10 was terminated from employment on 08/22/16 for failure to follow facility policy, which resulted in resident fall with injury. The State Survey Agency Representative attempted to reach SRNA #10 by telephone for an interview on 08/24/16 at 3:45 PM and 08/25/16 at 3:00 PM; however, the attempts were unsuccessful. Interview with SRNA #7, on 08/25/16 at 9:08 AM, revealed she was working with an unsampled resident on 08/19/16 just after 5:00 AM when SRNA #10 asked for her help, stating Resident #1 was on the floor. SRNA #7 revealed she ensured the unsampled resident's safety prior to going into Resident #1's room, where Resident #1 was on the floor beside the bed on his/her left side. SRNA #7 stated she asked the resident if he/she was in any pain, and did not receive an answer, which she described as normal behavior for the resident. She stated, she then assisted SRNA #10 in transferring Resident #1 to the wheelchair, with use of a gait belt, at which point Resident #1 did say his/her leg hurt. SRNA #7 stated she looked at Resident #7's leg, but could see no bruising, skin tears or redness. She then revealed she asked SRNA #10 if she needed any further help, and when SRNA #10 said no, she went back to assisting the unsampled resident she had been with previously. Further interview with SRNA #7 revealed she assumed SRNA #10 had reported the fall and Resident #1 had been assessed by a nurse prior to SRNA #10 asking for her help. She revealed she had not worked with Resident #1 and did not know Resident #1 required the assist of two (2) staff and the use of a hoyer lift for transfers. SRNA #7 stated she came in later that same day at approximately 2:00 PM to check on her schedule and asked about Resident #1, and realized at that time no fall had been reported. SRNA #7 revealed, following her report of the incident and giving a statement, she was contacted later that day and suspended over the phone. This was confirmed by review of a Stakeholder Suspension Form dated 08/19/16. Interview with Registered Nurse (RN) #1, on 08/25/16 at 9:49 AM, revealed she worked 08/18/16 from 7:00 PM to 08/19/16 at 7:00 AM and was assigned to Resident #1. She stated she passed medication to Resident #1 the morning of 08/19/16 and Resident #1 did not express any pain to her, did not appear to be in any pain, and no falls had been reported to her. She further stated she was unaware Resident #1 had sustained a fall until she came in to work the evening of 08/19/16. Interview with SRNA #2, on 08/24/16 at 1:17 PM, revealed she worked with Resident #1 in restorative dining the morning of 08/19/16. She revealed she went to get Resident #1 to take him/her to the dining room and Resident #1 grimaced like he/she was in pain when she turned the wheelchair around. SRNA #2 stated she asked Resident #1 if he/she was in any pain and the resident did not respond to the question. She further stated, once she sat down beside Resident #1 and attempted to cue him/her during breakfast, she realized the resident wasn't responding to cues, and when asked again about pain, stated his/her leg hurt. Per interview, SRNA #2 informed RN #2 of the resident's complaints of pain and RN #2 questioned Resident #1, then administered medication to Resident #1 at approximately 7:30 AM. Further interview with SRNA #2 revealed the only other time she saw Resident #1 that day was when staff brought him/her down for lunch; however, Resident #1 refused to eat and would not follow cues, and was taken out of the dining room. Continued interview revealed Resident #1's Nurse Aide Care Plan had an intervention for two (2) staff to assist with the hoyer lift for transfers. She stated the Nurse Aide Care Plans were located at the nursing stations, and she always made a copy to carry with her for reference. Interview with SRNA #3, on 08/25/16 at 1:28 PM, revealed she transferred Resident #1 with the assistance of another SRNA using the hoyer lift after lunch on 08/19/16 at approximately 12:15 PM, as per the Nurse Aide Care Plan. She stated the resident cried out in pain whenever they were attempting to provide incontinence care after lunch, and she informed RN #2, who assessed Resident #1 and ordered X-Rays. SRNA #3 revealed she was unaware Resident #1 had sustained a fall during the previous shift when she was caring for the resident on 08/19/16. Interview with RN #2, on 08/25/16 at 10:09 AM, revealed she worked with Resident #1 on the morning of 08/19/16, and was informed by SRNA #2, the resident complained his/her leg was hurting. RN #2 revealed she asked Resident #1 if he/she was in any pain, and the resident confirmed leg pain. RN #2 stated she administered Tylenol medication at 8:07 AM, which was prescribed for the resident's Arthritis pain. RN #2 revealed she followed up with Resident #1 approximately thirty (30) minutes later, and Resident #1 smiled and responded that his/her pain was gone. Further interview revealed when the SRNA's were attempting to provide incontinence care to Resident #1 and lye him/her down after lunch, she was again alerted Resident #1 was in pain, and went to assess him/her. RN #2 revealed she did a head to toe skin assessment, and did not see any redness or bruising, although Resident #1's left hip was slightly larger than his/her/right hip, and he/she was grabbing at the hip in obvious pain. Further interview with RN #2, revealed the ARNP was present in the facility at the time she assessed Resident #1, and she obtained orders from the ARNP for an X-ray at 2:00 PM; however, she stated at that point she had not been notified the resident had sustained a fall during the previous shift. She revealed she was notified by the Director of Nursing (DON) on the afternoon of 08/19/16, that Resident #1 had suffered a fall on 08/19/16 at approximately 5:00 AM. RN #2 revealed Resident #1's X-ray had not been obtained by 7:00 PM, so she obtained orders for a stat X-Ray. Continued interview with RN #2 revealed the X-Rays were completed at 8:10 PM, and the results of the X-Rays were received at 10:09 PM on 08/19/16, at which time Resident #1 was sent to the local hospital Emergency Department (ED) for evaluation. Interview with the Administrator and Director of Nursing (DON), on 08/25/16 at 2:50 PM, revealed based on the facility's investigation of the incident, including statements given by SRNA #10 and SRNA #7, it was concluded SRNA #10 attempted to transfer Resident #1 without using the hoyer lift and without requesting assistance on 08/19/16, and the resident suffered a fall. Further interview revealed neither SRNA #10 nor SRNA #7 reported the resident sustained [REDACTED].#1 from the floor to the wheelchair without an assessment completed by the nurse. Continued interview revealed SRNA #10 and SRNA #7 had been trained on proper performance of lift procedures and policies, but failed to follow facility's policy related to transfers. Per interview, SRNA #10 was terminated by the facility. The facility provided an acceptable QA Plan, which alleged correction of the deficient practice on 08/23/16. Review of the QA Plan revealed the facility implemented the following corrective actions: 1. An incident of potential neglect of Resident #1 was reported to the office of Inspector General on 08/22/16. The facility's investigation of the incident was initiated on 08/19/16 and included the following: Resident #1 was assessed by RN #2 for signs of abuse or injury related to pain on 08/19/16; the ARNP was notified of the assessment performed by RN #2 and an X-ray was ordered and obtained showing a fracture of the Left Hip; Resident #1 was sent to the ED for further evaluation on 08/19/16 at 10:45 PM and diagnosed with [REDACTED].#10 on 08/19/16, and a follow-up interview with SRNA #10 was conducted by the Administrator on 08/20/16; SRNA #10 was terminated by the facility on 08/22/16; and the Maintenance Director assessed all lifts on 08/20/16 to determine they were in proper working order and weekly assessments of the lifts were in place and up to date. 2. All residents with a BIMS greater than (>)7 were interviewed for abuse/neglect or any care concerns on 08/20/16 by the Quality of Life Director. Residents with a BIMS of less than eight (<8) were physically assessed beginning 08/19/16 and concluding on 08/20/16 by Unit Managers. All assessments, interviews and questionnaires were reviewed by the Administrator on 08/20/16 for any concerns. 3. All Incident/Accident Reports and Nurse's Progress Notes for the past thirty (30) days were reviewed by the Corporate Consultant with no concerns identified. 4. All personnel files of personnel involved in the care of Resident #1 were audited for any abuse concerns on 08/20/16 and all audit results were reviewed by the Administrator. 5. All resident Care Plans and SRNA Care Plans were reviewed and updated as needed, to include the use of mechanical lifts, bed mobility, and transfers on 08/20/16 by MDS Nurses. 6. All staff were re-educated by the DON on the facility's care plan policy, gait belt policy, resident lift policy, accidents and incidents policy, and falls policy beginning on 08/19/16 and concluding on 08/22/16. Staff was not allowed to return to work until completion of re-education, and all staff who was not re-educated by 08/22/16 was sent a certified letter explaining they would not be allowed to work until the training was complete. Training for all staff included a competency test on use of gait belts, transferring residents to wheelchair, and use of lifts. 7. Beginning on 08/21/16, the DON observed staff care delivery for five (5) different residents daily to include observation of transfers using the mechanical lift, and will continue to observe daily. All results will be reported at the weekly QA meeting, where the determination of the frequency of continued audits will be made. Any concerns identified during the audits will be addressed immediately and reported to the Administrator. 8. Beginning on 08/22/16, ten (10) charts were audited daily by the DON to ensure Comprehensive Care Plans reflected resident assessments and Nurse Aide Care Plan interventions matched Comprehensive Care Plans. All results will be reported at the weekly QA meeting, where the determination of the frequency of continued audits will be made. Any concerns identified during the audits will be addressed immediately and reported to the Administrator. 9. Beginning 08/21/16, five (5) skin assessments were conducted each day by the DON, and five (5) resident interviews were conducted by the Social Services Director. All results will be reported at the weekly QA meeting, where the determination of the frequency of continued audits will be made. Any identified concerns will be addressed immediately and reported to the Administrator. 10. A QA meeting was held on 08/20/16 to review the QA plan, and a second QA meeting was held on 08/22/16 to review the progress made on the QA plan. QA meetings will continue to be scheduled each week to monitor progress, and to determine the need for continuing frequency of ongoing audits. Per the Performance Improvement Plan, the Signature Clinical Consultant and/or the Regional Vice President will provide corporate oversight three (3) times a week. The State Survey Agency validated the implementation of the facility's Action Plan as follows: 1. Review of the State Agency Intake Form revealed the initial report was received from the facility on 08/22/16. Review of the Incident Report, dated 08/19/16 and signed by the Administrator, revealed a failure by SRNA #10 and SRNA #7 to report an event involving Resident #1. Further review revealed both SRNAs had been suspended immediately upon report of the incident. Review of the Final Report, dated 08/23/16 and signed by the Administrator, revealed SRNA #10 and SRNA #7 failed to report a fall witnessed by SRNA #10 on the morning of 08/19/16. Resident #1 indicated pain during the following shift, and was given pain medication and assessed for effectiveness, and X-Rays were ordered on [DATE] as a result of Resident #1's pain. The Radiology Report dated 08/19/16 revealed a Introchanteric Left Femoral Neck Fracture and the resident was transferred to the local hospital ED for further evaluation and admitted to the hospital. Review of a Witness Statement from SRNA #10, dated 08/19/16, revealed she attempted to transfer Resident #1 from the bed to the wheelchair without using a lift or getting assistance, and when Resident #1 fell , instead of alerting a nurse she asked for assistance from SRNA #7 in transferring Resident #1 from the floor to the wheelchair. Interview with SRNA #7, on 08/25/16 at 9:08 AM, revealed she had started her 5:00 AM rounds on the morning of 08/19/16 SRNA #10 came into the room where she was working and stated she needed assistance as Resident #1 was in the floor. SRNA #7 stated she assisted SRNA #10 in transferring Resident #1 from the floor to the wheelchair without a mechanical lift, at which point Resident #1 complained of leg pain. SRNA #7 revealed she did not normally provide care for Resident #1 and did not know what his/her care plan stated related to transfers. She further revealed she made the assumption SRNA #10 had already reported the fall and the nurse had assessed Resident #1 prior to asking for her assistance. She stated when she returned to the facility that afternoon at approximately 2:00 PM, and inquired as to how Resident #1 was feeling, she found out the fall had not been reported. She revealed she provided a statement at that time and was informed over the phone shortly thereafter, she was suspended. Interview with RN #2, on 08/25/16 at 10:09 AM, revealed Resident #1 had refused breakfast on the morning of 08/19/16 and stated he/she was in pain. RN #2 revealed she believed Resident #1 to be experiencing arthritic pain, as he/she had before, so gave him/her Tylenol, with a later reassessment revealing the pain was gone. RN #2 further stated when the SRNA's were assisting Resident #1 to lye down after lunch, Resident #1 complained of leg pain, at which point RN #2 assessed the resident, which revealed the resident was holding the left hip which was slightly larger than the right, but there was no redness or bruising. RN #2 revealed, based on her assessment she notified the ARNP and obtained orders for an X-Ray. Per interview, as the X-ray still had not been performed several hours later, she obtained an order for [REDACTED]. She revealed they received X-Ray results quickly, revealing a fracture, and an order was received for ED transfer at that time. Interview with the DON, on 08/25/16 at 4:20 PM, revealed she was aware Resident #1 was experiencing leg pain and an X-Ray had been ordered prior to finding out on the afternoon of 08/19/16, the Resident #1 had suffered a fall that morning. She revealed she immediately had SRNA #7 who reported the fall, speak to the Administrator, and began educating staff and started auditing care shortly after. Review of the Stakeholder Termination Notice revealed the facility informed SRNA #10 of termination from employment on 08/22/16. Continued review revealed the reason for termination was violation of facility policy. The Termination Notice was signed by SRNA #10 on 08/22/16. Review of the Logbook for lift inspections revealed a routine inspection of all lifts was completed by the Maintenance Director on 08/20/16 with no concerns noted. 2. Review of the facility's QA Plan Binder revealed all residents with a BIMS >7 were interviewed for abuse/neglect or any care concerns on 08/20/16 by the Quality of Life Director. Questionnaires included questions regarding resident treatment by staff and questions regarding any concerns residents might express. Continued review of the binder revealed all residents with a BIMS < 8 received a skin assessment by 08/20/16 per the Unit Managers. No concerns were identified through questioning or assessments. 3. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed the Corporate Consultant reviewed all Incident/Accident Reports and Nursing Progress Notes for the past thirty (30) days and did not find anything that had gone unreported. 4. Five (5) personnel files were reviewed, with appropriate and timely background checks in place and evidence of training documented. 5. Four (4) resident care plans and nurse aide care plans were reviewed and interventions compared to the latest MDS Assessments, with all four (4) showing consistency related to required resident care and transfer assistance required. 6. Sign in sheets and copies of certified letters were reviewed and compared to employee listings, with all employees accounted for. Additionally, interviews with SRNA #1 on 08/24/16 at 1:03 PM, SRNA #2 on 08/24/16 at 1:17 PM, SRNA #3 on 08/24/16 at 1:28 PM, LPN #1 on 08/24/16 at 2:12 PM, LPN #2 on 08/25/16 at 7:43 AM, SRNA #5 on 08/25/16 at 8:13 AM, LPN #3 on 08/25/16 at 8:29 AM, SRNA #6 on 08/25/16 at 8:53 AM, SRNA #7 on 08/25/16 at 9:08 AM, RN #1 on 08/25/16 at 9:49 AM, RN #2 on 08/25/16 at 10:09 AM, SRNA #8 on 08/25/16 at 10:29 AM, SRNA #9 on 08/25/16 at 10:47 AM, LPN #4 on 08/25/16 at 1:14 PM, Quality of Life Director on 08/25/16 at 1:22 PM, Housekeeping #1 on 08/25/16 at 1:30 PM, LPN #5 on 08/25/16 at 1:34 PM, RN #3 on 08/25/16 at 1:41 PM, LPN #6 on 08/25/16 at 1:48 PM, Dietary #1 on 08/25/16 at 1:53 PM, and the Social Services Director on 08/25/16 at 2:01 PM revealed all had received the mandatory inservice training on following the care plan; incidents and accidents; falls and importance of reporting; the use of gait belts; mechanical lifts; and lift policy. Several SRNA's revealed they had been observed by the DON, sometimes daily, providing resident care according to the care plan and using gait belts and mechanical lifts. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed any staff who was not re-educated by 08/22/16 would not be allowed to return to work until they had received the required education. 7. On 08/25/16 the State Survey Agency Representative observed use of the hoyer lift by SRNAs with Resident #3 being transferred from bed to wheelchair at 9:35 AM; and use of the hoyer lift by two (2) different SRNA's with Resident #4 being transferred from wheelchair to bed at 10:54 AM. No concerns were noted during observations, and later review of resident Comprehensive Care Plans confirmed care was provided accordingly. Additionally, audit logs were reviewed from 08/21/16 through 08/25/16 of staff care delivery with no concerns identified. Competency checklists for use of the gait belt; transferring to wheelchair; and full body lift bed to wheelchair were reviewed for all SRNAs, dated 08/20/16 through 08/22/16. 8. Audit logs were reviewed of ten (10) charts audited daily by the DON from 08/22/16 through 08/25/16 to ensure care plans reflected resident assessments and Nurse Aide Care Plan interventions matched Care Plans. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed there had been no inconsistencies or concerns identified so far during chart audits. 9. Skin assessment results were reviewed, and five (5) skin assessments were conducted each day beginning 8/21/16, with no concerns identified. 10. Interview with the Administrator, on 08/25/16 at 2:50 PM, revealed a QA plan was presented and reviewed during a QA meeting on 08/20/16, and reviewed during a second QA meeting on 08/22/16. Interview revealed QA meetings would continue to be scheduled each week to monitor progress, and to determine the continuing frequency of ongoing audits. Continued interview with the Administrator, revealed corporate oversight would be provided three (3) times a week by the Signature Clinical Consultant and/or the Regional Vice President.

Based on observation, interview, and a review of facility policy and Material Safety Data Sheets it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible. Cabinets in four community bathrooms were observed to contain denture cleansing tablets, Cucumber Melon body wash/shampoo, deodorant, manicure sticks with sharp points, razors, sharps containers, Barbasol shaving cream, and body and baby lotion. All of the cabinets observed were locked; however, all of the locks had the keys stored in the locks and were accessible to residents. In addition, the key to the Biohazard room was attached to an expandable key ring that was within reach of the lock and was also accessible to residents. The findings include: A review of the Chemical Safety and Storage policy, dated 2006, revealed chemicals that were hazardous and/or toxic were to be stored in a secured area. Observations on 07/31/12, at 1:00 PM, 1:10 PM, and 1:20 PM, and on 08/01/12, at 11:00 AM, revealed chemicals and bathing supplies were stored inside cabinets located in the shower rooms. Although each cabinet was locked, the key was in the lock and was accessible to residents. Observation of shower room "D" on 07/31/12, at 1:00 PM, revealed the cabinet contained six bottles of baby lotion, three spray antiperspirant containers, two containers of body wash, three disposable razors, one can of Barbasol shave cream, and one box of manicure sticks with sharp points. The E Wing shower room cabinet was observed to contain five gallon-size containers of Cucumber Melon Body Wash/Shampoo, a sharps container, three bottles of perineal wash, one can of Barbasol shaving cream, four containers of spray deodorant, one bottle of baby lotion, and one gallon-size container of bleach. Observation of the Pink Wing women's shower room on 07/31/12, at 1:10 PM, revealed the cabinet had one box of denture cleaning tablets, one bottle of Avon lotion, two bottles of Sensi Care lotion, eight containers of perineal wash, one bottle of mouthwash, one Cotton Candy Body Fantasy lotion, one box of manicure sticks, and one sharps container. Observation of the men's shower cabinet on the Pink Wing on 07/31/12, at 1:20 PM, revealed the cabinet contained one box of disposable razors, one box of denture cleaning tablets, one bottle of Cetaphil lotion, three bottles of shampoo, six containers of deodorant, one bottle of mouthwash, and one bottle of hand gel sanitizer. An additional observation of the men's shower room on the Pink Wing on 08/01/12, at 11:00 AM, revealed the key was in the lock to the door. Review of the Material Safety Data Sheet (MSDS) for Cucumber Melon Conditioning Shampoo and Body Wash revealed the product had the potential to cause mild eye irritation with prolonged exposure to the concentrate and may be harmful if swallowed. Review of the MSDS for Hand and Body Lotion revealed the lotion had the potential to cause eye irritation and the need for possible medical attention. Review of the MSDS for Performance Plus Baby Lotion revealed the product could cause eye irritation and could be harmful if swallowed. Review of the MSDS for Barbasol Non-Aerosol Therapeutic Shave Cream revealed the product contained a hazardous ingredient, Boric Acid, with a potential health hazard that included acute caustic burns, severe gastrointestinal difficulty if ingested, and inflammation of the skin or scalp. Labeling stated "Precautions to be taken in handling & storage." Observation on 07/31/12, at 1:10 PM, revealed the key to the Biohazard room was attached to an expandable key chain that was attached to the wall adjacent to the door of the room, and was easily accessible to the lock on the door. There were five gallon-size bottles of bleach in the Biohazard room. Review of the MSDS for Clorox liquid bleach revealed the product could cause eye injury, irritate the skin, cause nausea and vomiting if ingested, and may irritate nose, throat, and lungs with exposure to the vapor or mist. An interview with Certified Nursing Assistant (CNA) #1 on 07/31/12, at 2:45 PM, revealed the staff had been in-serviced to make sure the bath items and supplies were to be locked in the bathroom cabinets. The CNA further stated she was aware the keys were in the cabinets but since the cabinets were locked it was "okay." An interview with the facility Administrator and the Director of Nursing (DON) on 07/31/12, at 3:20 PM, revealed the facility had "always" locked the cabinets and left the keys in the locks. In addition, the Administrator stated they have always kept the key adjacent to the Biohazard door. The DON stated there were no residents who exhibited wandering behaviors in the facility. Documentation provided by the facility on the Resident Census and Conditions of Residents (completed on 07/31/12) revealed there were two residents in the facility that exhibited behaviors, however, the documentation was not specific as to the type of behaviors the residents exhibited. In addition, a review of the Roster/Sample Matrix completed by the facility on 07/31/12, revealed there were 62 cognitively impaired residents in the facility. An interview with Licensed Practical Nurse (LPN) #1 on 07/31/12, at 5:45 PM, revealed there was only one resident who "wanders some" and he/she was usually looking for a place to smoke. Observation on 08/01/12, at 12:30 PM, revealed Resident #7, who was assessed by the facility to be cognitively impaired, was ambulating in the hallway with the assistance of a walker. In addition, Resident #7's room was observed to be near the E Wing shower room. The cabinets in the shower rooms and the door to the Biohazard room were observed to be accessible to all residents in the facility.

Based on observation, interview, record review, review of the facility's investigation report and review of the facility's policy, it was determined the facility failed to develop a comprehensive plan of care to maintain a resident's highest practicable physical well-being for one (1) of three (3) sampled residents, (Resident #1). The facility assessed Resident #1 for being at risk for falls, upon admission on 03/12/12, related to his/her bilateral foot drop, decline in functional status due to an extended hospitalization , history of psychiatric problems, decreased safety awareness, and decreased mobility. However, the risk factor of Resident #1 standing from his/her wheelchair on his/her own (unassisted transfer) was not addressed in Resident #1's "Risk for Falls" Plan of Care to remind staff to ensure the resident's wheelchair was locked when dressing/undressing the resident. On 06/07/12, a facility staff member was assisting Resident #1 who required the assistance of one staff person with activities of daily living with undressing in the shower room while the resident was in his/her unlocked wheelchair. Resident #1 stood up out of the unlocked wheelchair unassisted. As Resident #1 fell back towards the unlocked wheelchair, the wheelchair rolled backwards with the resident approximately five (5) feet before the wheelchair hit the wall and Resident #1 fell out of the wheel chair onto his/her right side. A mobile x-ray was obtained which revealed Resident #1 had sustained a right [MEDICAL CONDITION]. Resident #1 was sent to the hospital and required an Open Reduction Internal Fixation (ORIF) surgery of the right hip. (Refer to F-323) The findings include: Review of the facility's policy entitled 'Comprehensive Care Plans', undated, revealed a comprehensive care plan shall be developed for each resident that included measurable objectives to meet the resident's medical, nursing, and psychological needs. Further review of the policy revealed the comprehensive care plan was designed to incorporate risk factors associated with identified problems, identify the professional services that were responsible for each element of care, and to prevent decline in the resident's functional status and/or functional levels. Medical record review revealed the facility admitted Resident #1 on 03/12/12, with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) Assessment, dated 03/21/12, revealed the facility assessed Resident #1 to have a Brief Interview Mental Status of four (4), indicating the resident was cognitively impaired. Further review of the MDS revealed Resident #1 required extensive assistance of two (2) people for transfers, dressing and personal hygiene, and utilized a wheelchair for mobility. Review of Resident #1's Care Area Assessment (CAA) Summary related to falls, dated 03/23/12, revealed Resident #1 was admitted to the facility for rehabilitation purposes, required extensive assistance from staff for Activities of Daily Living (ADLs) which included balance during transfers and maintaining standing. Further review of the CAA revealed Resident #1 had a sensor pad alarm to his/her wheelchair and bed to alert staff of attempted unassisted transfers. Review of the Comprehensive Care Plan, dated 03/30/12, revealed Resident #1 was at risk for falls related to his/her bilateral foot drop, decreased safety awareness and decreased mobility. Approaches to the plan of care included, assistance from staff for ADLs, monitor for correct position when in bed or in the wheelchair, monitor for safety needs and sensor pad alarm to bed and wheelchair to alert staff of attempted unassisted transfers. The facility failed to include in the comprehensive care plan to ensure the wheelchair was locked while providing care to Resident to prevent accidents. Review of physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of Nurse's Notes and the facility's investigative report, dated 06/07/12, revealed Resident #1 became agitated while he/she was being assisted with undressing for a shower by Certified Nursing Assistant (CNA) #1. Resident #1 stood up out of his/her wheelchair unassisted, became unsteady and fell back towards the wheelchair which rolled backwards with the resident approximately five (5) feet. Resident #1 fell to the floor on his/her right side. It was determined in the investigative report Resident #1's wheelchair was not locked. Review of an x-ray report, dated 06/08/12 , revealed Resident #1 had sustained a Right [MEDICAL CONDITION]. Resident #1 was sent to the hospital and required Open Reduction Internal Fixation (ORIF) surgery of the right hip. Interview with CNA #1, on 06/12/12 at 4:15 PM, revealed Resident #1 had a frequent behavior of just standing up out of his/her wheelchair unassisted. CNA #1 indicated she knew Resident #1 was at risk for falls as stated in the CNA care plan/assignment sheet. CNA #1 stated she had not locked Resident #1's wheelchair because she was only undressing the resident and not transferring him/her. She indicated the care plan/assignment sheet did not direct her to ensure Resident #1's wheelchair was locked while providing care, such as when she undressed the resident. Interview with LPN #1, on 06/13/12 at 9:45 AM, revealed she completed the the inial investigative report when Resident #1 had a fall on 06/07/12 and noted the resident's wheelchair was not locked while CNA was undressing the resident. She indicated even though it was not on Resident #1's plan of care to lock the wheelchair while providing care, it was "common sense" to lock it to prevent accidents from occurring. Interview with the Minimum Data Set Coordinator, on 06/13/12 at 11:45 AM, revealed she had seen Resident #1 stand up unassisted on several occasions. She stated a resident's wheelchair does not necessarily have to be locked while a CNA is providing care to a resident. She indicated; however, since Resident #1 was known to stand up unassisted then the wheelchair should be locked and it should have been addressed in the plan of care for Resident #1.

Based on observation, interview, record review, review of the facility's Census and Condition Report, review of facility's policy, review of the facility's investigation report and review of the equipment users manual, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On 06/07/12, at approximately 4:10 PM, a facility staff member was assisting Resident #1 with undressing to take a shower while the resident was in his/her wheelchair. At 4:15 PM, Resident #1 stood up out of the wheelchair unassisted. As Resident #1 fell back towards the wheelchair, the wheelchair rolled backwards with the resident approximately five (5) feet before the wheelchair hit the wall and Resident #1 fell out of the wheel chair onto his/her right side. It was determined the wheelchair was not locked. Resident #1 sustained a right hip fracture and required an Open Reduction Internal Fixation (ORIF) surgery of the right hip. In addition, the facility failed to ensure the residents' environment remained as free from accident hazards as possible when observations during the initial tour revealed the facility failed to ensure denture cleaning tablets, disposable razors, shampoo, body wash, shaving cream, body lotion, antiperspirant, manicure sticks with sharp points, and Calazime lotion were secured/locked and not accessible to residents. The facility failed to ensure a hair dryer was unplugged and not located in a sink and a red box sharps container (with used sharps) was sitting in an upright position to prevent contaminated sharps from being removed from the container. The findings include: 1. Review of the facility's policy entitled "Falls Management", dated 01/01/10, revealed the purpose of the policy was to establish a program to identify residents with risk factors that may place them at risk for falls and to manage those residents who experience a fall to minimize the risk of the fall reoccurring to minimize the risk of injury related to a fall. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 03/12/12, with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) Assessment, dated 03/21/12, revealed the facility assessed Resident #1 to have a Brief Interview Mental Status (BIMS) score of four (4), indicating the resident was cognitively impaired. In addition, the MDS revealed Resident #1 required extensive assistance of two (2) people for transfers, dressing and personal hygiene, and utilized a wheelchair for mobility. Review of Resident #1's Care Area Assessment (CAA) Summary related to falls, dated 03/23/12, revealed Resident #1 was admitted to the facility for rehabilitation purposes and the goal was for the resident to return home. Further review of the CAA summary revealed Resident #1 required extensive assistance from staff for Activities of Daily Living (ADLs) including balance during transfers and maintaining standing. Additional review of the CAA summary revealed Resident #1 had a sensor pad alarm to his/her wheelchair and bed to alert staff of attempted unassisted transfers. Review of the Comprehensive Care Plan, dated 03/30/12, revealed Resident #1 was at risk for falls related to his/her bilateral foot drop, decreased safety awareness and decreased mobility. Approaches to the plan of care included, assistance from staff for ADLs, monitor for correct position when in bed or in the wheelchair, monitor for safety needs and sensor pad alarm to bed and wheelchair to alert staff of attempted unassisted transfers. Review of Physical Therapy (PT) Notes and physician's orders [REDACTED]. Review of Occupational Notes (OT), dated 05/03/12, revealed Resident #1 had completed six (6) weeks of OT therapy and the resident would be discontinued from OT due to meeting goals and maximum potential with skills. Further record review revealed Resident #1 was now a one (1) person assist with transfers and was to have supervision with skills due to safety deficit and functional transfers. Review of Nurse's Notes and the facility's investigative report, dated 05/16/12 at 6:40 PM, revealed staff had responded to Resident #1's bed alarm sounding and Resident #1 was found sitting on the floor beside his/her bed. Staff assessed Resident #1 and no injuries were identified. Further review revealed Resident #1 had slid out of the bed due to an unsteady gait and the facility had educated the resident to keep shoes on while sitting on the side of the bed. Review of Nurse's Notes and the facility's investigative report, dated 06/07/12, revealed Resident #1 was being assisted with undressing for a shower by Certified Nursing Assistant (CNA) #1 at approximately 4:10 PM. Resident #1 became agitated when his/her shirt sleeves were difficult to get off and the resident stood up unassisted out of the wheelchair. Resident #1 became unsteady and fell back onto the wheelchair which rolled backwards with the resident and the resident fell to the floor on his/her right side. Licensed Practical Nurse (LPN) #1 assessed the resident and noted a reddened area to the resident's right shoulder and redness on the right elbow. It was determined in the investigative report Resident #1's wheelchair was not locked while CNA #1 was undressing the resident in his/her wheelchair. Continued review of Nurse's Notes revealed Resident #1 did not complain of pain related to the fall and CNA #1 assisted the resident with completing his/her shower. Interview with CNA #1, on 06/12/12 at 4:15 PM, revealed she was in the shower room on 06/07/12 at approximately 4:10 PM assisting Resident #1 to undress in preparation for taking a shower. CNA #1 stated Resident #1 had a long sleeved shirt on with cuffs and she and the resident were having a difficult time getting the shirt off. CNA #1 continued to reveal Resident #1 got mad and acted like a "two year old" by standing up out of his/her wheelchair, "stiffening" both his/her arms and when the resident took a step backwards the wheelchair began rolling backwards with the resident. CNA #1 indicated the wheelchair and the resident traveled backwards approximately five (5) feet. CNA #1 stated the wheelchair hit the wall and Resident #1 screamed out as he/she fell out of the wheelchair to the floor on his/her right side. Additional interview with CNA #1 revealed she had not locked Resident #1's wheelchair because she was only undressing the resident and not transferring him/her. CNA #1 indicated Resident #1 had a frequent behavior of just standing up out of his/her wheelchair and from his/her bed unassisted. Interview with CNA #6, on 06/13/12 at 3:00 PM, revealed she had heard a loud noise, like something or someone had fallen on the afternoon of 06/07/12 and then a scream. She entered the shower room and saw Resident #1 lying on his/her right side and CNA #1 next to Resident #1. CNA #6 indicated Resident #1 had a behavior of standing up out of his/her wheelchair unassisted since the resident's admission to the facility, on 03/12/12. Further interview revealed even though the resident's wheelchair had a sensor alarm to alert staff of unassisted transfers the wheelchair should be locked while staff were assisting the resident to undress in anticipation the resident might just stand up on his/her own as well as the potential the wheelchair could roll backward. Interview with LPN #1, on 06/13/12 at 9:45 AM, revealed she assessed Resident #1 after the fall on 06/07/12 and had completed the the initial investigative report. Further interview revealed CNA #1 told her, and observation of the wheelchair revealed, the wheelchair had not been locked. LPN #1 stated due to Resident #1's known behavior of frequently standing up out of the wheelchair, the wheelchair should have been locked as soon as CNA #1 had taken Resident #1 to the shower room prior to assisting the resident with undressing to prevent an accident from occurring. Additional interview revealed she made periodic rounds during her shift to ensure CNAs were providing the care that is needed to residents. She indicated that even though it wasn't on Resident #1's plan of care, it was "common sense" to lock the wheelchair while providing care. Review of Nurse's Notes, dated 06/07/12 at 5:50 PM, revealed Resident #1 was noted to be rubbing his/her right leg and right thigh area stating "it hurts, it hurts". Further review of Nurse's Notes revealed LPN #1 notified Resident #1's Physician and the resident's family. Continued review of Nurse's Notes and physician's orders [REDACTED].#1's right hip, right tibia/fibula, and right femur. Review of the final x-ray report, dated 06/08/12 , revealed Resident #1 had sustained a Right Hip Fracture. Review of Nurse's Notes, dated 06/08/12, revealed Resident #1 was sent to the hospital. Review of hospital records, dated 06/08/12, revealed Resident #1 had an Open Reduction Internal Fixation (ORIF) surgery of the right hip. Observation, on 06/13/12 at 12:00 PM, revealed a Veranda wheelchair manufactured by Invacare was next to Resident #1's bed. Interview with CNA #2, at that time, revealed Resident #1 was still in the hospital and the wheelchair next to the resident's bed was the wheelchair Resident #1 utilized from 03/12/12 until he/she went to the hospital. Review of User Manual for the Invacare Veranda Wheelchair, dated 2010, revealed safety and handling of the wheelchair required close attention of the wheelchair user as well as the assistant. Additional review of the manual revealed 'when transferring to and from the wheelchair ALWAYS engage both wheel locks'. Interview with CNA #5, on 06/13/12 at 3:45 PM, revealed Resident #1 had a behavior of standing up out of his/her wheelchair or bed and straightening his/her shirt and then sitting back down. CNA #5 stated although it was not on the CNA care plan to lock the wheelchair during care, "it is common sense" to lock the wheelchair while providing care to a resident in the wheelchair because the wheelchair could roll back causing the resident to get hurt or even injured, like Resident #1. Interview with the Occupational/Physical Therapy Manager, on 06/13/12 at 1:30 PM, revealed the therapy department was responsible for educating staff on the appropriate usage of equipment, such as wheelchairs. Further interview revealed although she did not have written documentation of the training, she conducted informal periodic safety education with staff as well as orientation to new hires related to ensuring the wheelchair was locked during transfers as well as during providing care such as dressing/undressing a resident while in the wheelchair to prevent accidents. She stated locking the wheelchair would not necessarily have to be a written instruction to a CNA because it was more "common sense". 2. Review of the Resident Census and Conditions, received from the facility on 06/12/12, revealed there were ninety-one (91) residents with sixty-two (62) listed under Section C with Dementia. Review of the facility's policy entitled, "Food and Non-Food Storage", undated, revealed chemical and cleaning supplies were stored in a clean, well-lit, well-ventilated storage area separated from food and service ware. Review of the facility's policy entitled, "Occupational Exposure to Bloodborne Pathogens - Exposure Control Plan", dated 02/02/11, revealed contaminated sharps that were not reusable were to be placed immediately, or as soon as possible, after use into appropriate sharps containers. Policy further revealed the sharps containers were puncture-resistant, labeled with a biohazard label and were leak-proof. Review of the facility's policy entitled, "Storage of Medication", undated, revealed drugs were to be stored in a secure and orderly manner under proper temperatures and were to be accessible only to licensed nursing and pharmacy personnel. Observation during the initial tour of the facility, on 06/12/12 at 1:30 PM , of the Shower Room labeled "Mens" on Hall B, revealed disposable razors, wood manicure sticks with sharp points, Efferdent denture tablets, McKesson Body Wash, Barbasol Shave Cream were in an unlocked and open cabinet. In addition, two (2) gallon sized bottles of Cucumber Melon Shower Wash were on the floor in shower as well as one (1) gallon sized bottle in a broken wire bracket container attached to the wall of same shower stall. Observation during the initial tour of the facility, on 06/12/12 at 1:45 PM, of the Shower Room labeled "Shower Room D" on Hall D, revealed disposable razors, a red sharps box turned onto it's side with open lid area exposed and two used razors hanging out of the lid, two (2) cans of Barbasol Shave Cream, McKesson Body Lotion, McKesson Antiperspirant pump bottle, McKesson Baby Lotion and Calazime prescription lotion belonging to unsampled residents were in an unlocked and open cabinet. Observation also revealed a hair dryer plugged into an electrical outlet lying in the sink. In addition, two (2) bottles of one(1) gallon size of body wash on floor in shower area. Observation during the initial tour of the facility, on 06/12/12 at 2:00 PM, of the Shower Room labeled "Women's" on Hall B, revealed disposable razors, wood manicure sticks with sharp points, Efferdent denture tablets, McKesson Baby Lotion, McKesson Body Lotion, Barbasol Shave Cream were in an unlocked and opened cabinet. Review of the Material Safety Data Sheet (MSDS), for Cucumber Melon Conditioning Shampoo and Body Wash, revealed the product had the potential to cause mild eye irritation with prolonged exposure to the concentrate and may be harmful if swallowed. Review of the MSDS, for Hand and Body Lotion revealed a potential to cause eye irritation and need for possible medical attention. Review of the MSDS for Performance Plus Baby Lotion, revealed the product may cause eye irritation and be harmful if swallowed. Review of the MSDS, for Barbasol Non-Aerosol Therapeutic Shave Cream, revealed the product contained a Hazardous Ingredient of Boric Acid with a potential health hazard that included acute caustic burns, severe gastrointestinal difficulty if ingested, and inflammation of the skin or scalp. Labeling stated "Precautions to be taken in handling & storage". Interview, on 06/13/12 at 2:15 PM, with CNA #4 revealed the cabinets were supposed to be locked after each use and the person giving the shower was responsible to do so. Interview further revealed there were confused residents that go into that shower room without assistance of staff. Interview, on 06/13/12 at 2:25 PM, with CNA #3 revealed the cabinets were to be locked but the cabinet in Shower Room D did not have a lock. CNA #3 revealed the staff who used the shower room was responsible for locking the cabinets. Further interview revealed CNA #3 thought the residents could get into the shower room and get hurt. Interview, on 06/13/12 at 2:35 PM, with LPN #3 revealed the cabinets were to be locked and it was the CNA's responsibility to lock it and the Nurse's responsibility to monitor the locks. Further interview revealed there was potential for a resident to get into the shower room unattended by staff for their safety. Interview, on 06/13/12 at 2:45 PM, with LPN #2 revealed the cabinets were supposed to be locked and it was the CNA's responsibility to lock the cabinet and the nurse's responsibility to monitor the locks.