Every finding on record at Signature Healthcare at North Hardin Rehab & Welln

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the daily nurse staffing posting was current for 1 of 4 days reviewed for staffing postings. On 07/07/2026, the facility's required daily nurse staffing posting located near the front entrance displayed the prior date of 07/06/2026.The findings include:Review of the facility policy titled, Posting of Nurse Staffing, last reviewed 01/30/2026, revealed the facility was required to post daily nurse staffing information at the beginning of each shift. Per review, the posting was required to include the facility's name, current date, resident census, and the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The policy further revealed the staffing data was to be posted in a clear and readable format, in a prominent place readily accessible to residents and visitors.Observation on 07/07/2026 at 9:18 AM, revealed the daily nurse staffing posting was located in the front lobby near the front entrance. Per observation, the posting displayed the date as Monday, July, 6, 2026. Observation at 12:48 PM and 3:36 PM on that same date, revealed the posting continued to display the same incorrect date.In interview with the Receptionist on 07/10/2026 at 10:12 AM, she said the facility's daily staffing posting was located by the front entry and was the posting residents, visitors, and staff would review for the facility's daily staffing information. She said there were no other daily staffing postings located elsewhere in the facility. The Receptionist further stated the facility's Scheduler typically posted the daily staffing first thing in the morning, around 7:00 AM or 7:30 AM.In interview with the Scheduler on 07/10/2026 at 11:26 AM, she stated she was responsible for posting the facility's daily staffing. She reported the posting was supposed to be updated very first thing in the morning. The Scheduler said her process was to update the staffing in the facility's schedule system, print the updated staffing, and replace the posting once daily, unless staffing changes occurred. She explained it was not normal for the facility to have incorrect staffing posted and she had not been aware the staffing posted for 07/07/2026 displayed 07/06/2026. The Scheduler said the entrance posting as a quick glance posting and stated the nursing stations had detailed assignment sheets for each hallway. She further stated if the posted staffing information was not current or displayed the wrong date, management, staff, and visitors would not have the correct information when an emergency arose.In interview with Clinical Consultant (CC) 2 on 07/10/2026 at 12:51 PM, she reported the Scheduler was responsible for ensuring the daily nurse staffing posting was current and accurate. CC2 explained the Scheduler printed and posted the staffing every day around 7:00 AM or 7:30 AM. She said the entrance/front desk posting was where the facility's required daily nurse staffing posting was located. She further stated she had not verified whether the entrance/front desk posting was updated to show the current date of 07/07/2026.In interview with the Administrator on 07/10/2026 at 1:14 PM, she reported the Scheduler was responsible for ensuring the daily nurse staffing posting was current and accurate; however, she, as Administrator, was ultimately responsible. She explained the Scheduler posted the daily staffing during the week, and the weekend supervisor posted it on weekends. The Administrator said any member of the team (staff) could verify the posting had been completed. She stated there was no specific staff member designated to do the posting, unless the Scheduler was out of the building. The Administrator verbally confirmed staffing was posted up front and there was no other required daily staffing postings in other areas of the facility. She reported the nursing station postings were staff assignment sheets only and were not the required daily staffing posting. The Administrator said she did not know if the entrance/front desk posting was current and accurate on 07/07/2026, because she had not verified it. She stated if the posting was not current, there was no other place in the building where staffing would be verifiable to visitors or anyone else. The Administrator further stated the consequence of failing to post current staffing information would be misinformation provided to individuals viewing the document.

Based on observation, interview, and facility policy review, the facility failed to ensure its dish machine and range hood grates were free of dust accumulation, which had the potential to affect 111 of 111 residents receiving meals from the kitchen. The findings include: Review of the facility policy titled, Equipment, revised 09/2017, revealed, All food service equipment will be clean, sanitary, and in proper working order. Further review revealed all non-food contact equipment will be clean and free of debris. Observations during the initial tour of the kitchen on 05/26/2025 at 9:07 AM, revealed the top of the dish machine was covered with dust. In addition, observation further revealed dust on two range hood grates, located over a six-burner stove and a convection oven/steamer/fryer. During interview on 05/28/2025 at 11:51 AM, the Food Service Manager (FSM) stated that the kitchen should have been maintained in a clean manner to include the dish machine and range hood grates. During interview on 05/29/2025 at 2:34 PM, the Administrator stated she expected staff to follow the facility's infection and sanitation policies.

Based on observation, interview, and facility policy review, the facility failed to ensure staff provided care within professional standards for 1 of 3 residents sampled during medication (med) pass out of the total sample of 57 Residents, (Resident (R)54). The findings include: Review of the facility policy titled, Medication Administration, revised 06/24/2024, revealed medications were administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Continued review revealed, 6. Medications should be administered at the time they are prepared. 7. The person who prepares the dose for administration should be the person who administers the dose. Review of the Resident Face Sheet for R54 revealed the facility admitted the resident on 11/06/2019, with diagnoses that included: hypertension, major depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/25/2025, revealed the facility assessed R54 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R54's Care Plan, revealed the facility had identified a problem area edited 03/09/2025, which noted the resident was at risk for cardiovascular complications related to diagnoses of hypertension and hyperlipidemia. Continued review revealed the interventions directed staff to administer medications as ordered. Per review of the Care Plan revealed the facility identified a problem area edited 03/09/2025 that indicated the resident had a diagnosis of diabetes and was at risk for adverse events. Further review revealed the facility identified R54 a problem area edited 05/22/2025, that indicated the resident had the potential for a nutrition risk related to vitamin D deficiency, hypertension, and dry mouth. Review of R54's Physician Order Report, for the timeframe from 04/27/2025 through 05/27/2025, revealed the following orders: an order dated 02/21/2025, for Biotene dry mouth oral rinse 30 milliliters (ml), with instructions to swish in mouth for 30 seconds twice daily; an order dated 02/21/2025, for diltiazem hydrochloride (HCI) extended release (blood pressure med) 300 milligrams (mg), to be administered by mouth once a day; an order dated 02/21/2025, for metformin (diabetic med) 500 mg, administer one tablet twice a day; an order dated 03/05/2025, for vitamin D3 50 micrograms (mcg), administer 50 mcg once a day; and an order dated 03/17/2025, for medroxyprogesterone (hormone) 10 mg, with instructions to administer 10 mg once a day. Observation of medication pass on 05/27/2025 at 7:37 AM, revealed CMA 7 prepared R54's Biotene, metformin, diltiazem, vitamin D3, and medroxyprogesterone for administration. Per observation, CMA 7 entered R54's room, placed the medications on the resident's bedside table and left the room, without observing the resident take the medications and returned to sign the medications off as given. In interview at the time of observation, CMA 7 said R54 was alert, oriented, and was able to take his/her medication without being watched. During a follow-up interview on 05/27/2025 at 7:47 AM, CMA 7 said she could not be sure if R54 had taken all of his/her medications as she had not watched the resident take them as required. CMA 7 stated she had received medication training and knew to watch residents. In interview on 05/27/2025 at 8:55 AM, R54 stated the nurses usually left his/her medications at his/her bedside for him/her to take. R54 further stated he/she was not opposed to being observed consuming the medications and said he/she did not wish to self-administer the medications. In interview on 05/27/2025 at 10:21 AM, Unit Manager (UM) 5 said nurses should never leave medications with residents. The UM further stated staff administering medications should watch residents take their medications before signing the medications off as given. In interview on 05/27/2025 at 10:35 AM, UM 6 stated nurses must watch residents take their medications to ensure nothing was left behind and prevent incidents like choking. In interview on 05/28/2025 at 10:00 AM, the Director of Nursing (DON) said nurses must stay with residents until they took their medication to verify the medications as taken. The DON stated if medications were not taken, the doctor should be notified, and medications should never be left unattended for the residents' safety. The DON further stated nurses were responsible for making sure medications were taken before signing the medications off. In interview on 05/29/2025 at 12:59 PM, the Administrator stated staff must follow the facility's policy by making sure residents took their medication before signing them off.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure a resident received meals in accordance with their food preferences and meal ticket for 1 of 11 sampled residents reviewed for food preferences, (Resident (R)68). The findings include: Review of the facility document titled, In-Service Attendance Record Dining Services Department, dated 03/19/2025, revealed the Food Service Manager (FSM) was to educate dietary staff on the facility's policy titled, Dining and Food Preferences. Review of the policy revealed, Individual dining, food, and beverage preferences are identified for all residents/patients. Further review of the policy revealed 6. The individual tray assembly ticket will identify all food items appropriate for the resident based on his/her diet order, allergies, intolerances and preferences. Review of the Resident Face Sheet for R68 revealed the facility admitted the resident on 12/31/2021 and most recently readmitted the resident on 03/09/2025. Review of the quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/07/2025, revealed the facility assessed R68 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. Review of R68's Care Plan for nutritional risk initiated on 01/10/2022, revealed the facility noted the resident was at nutritional risk related to dementia, dysphagia (difficulty swallowing), transient ischemic attack (TIA), hyperlipidemia, and gastroesophageal reflux disease (GERD). Further review revealed the interventions included an approach dated 01/10/2022 directing staff to honor the resident's food preferences. Review of R68's diet assembly ticket specified, all gravy on side not on food. During interview on 05/26/2025 at 10:57 AM, R68 stated he/she did not like gravy on his/her meat. R68 said gravy was supposed to be served on the side; however, his/her gravy was always served on top of his/her meat. In observation on 05/27/2025 at 1:40 PM, revealed R68's lunch tray included mashed potatoes, corn, a roll, and ground chicken which was topped with gravy. In interview at the time of observation, R68 again stated he/she always got gravy on top of his/her food. During observation on 05/27/2025 at 1:44 PM, the FSM looked at R68's meal tray and reviewed the resident's diet assembly ticket. In interview at the time of observation, the FSM confirmed R68 received gravy on top of his/her ground chicken which was not consistent with the resident's listed preferences. During interview on 05/29/2025 at 2:13 PM, the Director of Nursing (DON) stated she expected staff to provide the residents' meals based upon their preferences. During interview on 05/29/2025 at 2:54 PM, the Administrator stated she expected staff to follow the residents' diet preferences.

Based on observation, interview, and facility policy review, the facility failed to ensure staff secured all medications in a locked storage area/cart for 1 of 5 residents reviewed for accident hazards, (Resident (R)28). The findings include: Review of the facility policy titled, Medication Storage, 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. Review of the Resident Face Sheet for R28 revealed the facility admitted the resident on 02/22/2021, with diagnoses of chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia-secondary to chronic obstructive pulmonary disease (COPD) exacerbation, bacterial pneumonia, and pneumonia. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/01/2025, revealed the facility assessed R28 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Continued review of the MDS revealed the facility assessed R28 to experienced shortness of breath or trouble breathing with exertion and when lying flat. Further review revealed the facility assessed R28 to receive oxygen therapy and hospice care. Review of R28's Care Plan, revealed the facility identified a problem area edited on 03/27/2025, that noted the resident had impaired oxygen gas exchange (hypoxia, respiratory failure, and hypercapnia). Continued review revealed the interventions directed staff to offer and encourage the resident's medications, nebulizers, and Puffers (inhalers) as needed. Further review revealed however, no documented evidence the care plan indicated R28 was safe to self-administer medications or to have medications left at the bedside. Review of R28's Physician Order Report, dated 05/29/2025, revealed an order dated 03/26/2025, for albuterol sulfate hydrofluoroalkane (HFA) aerosol inhaler 90 micrograms (mcg) per actuation, with instructions to administer two puffs for shortness of air every four hours as needed. Continued review of the Physician Order Report revealed an order dated 04/16/2025, for Flonase Allergy Relief (fluticasone propionate) spray, suspension, 50 mcg per actuation, with instructions to administer two sprays in the resident's nostrils for seasonal allergies once a day. Further review of the Physician Order Report revealed no documented evidence of an order(s) to allow R28 to self administer any of his/her medications or to be allowed to keep medications at his/her bedside. Observation on 05/26/2025 at 1:03 PM, revealed R28 leaving the bathroom with his/her supplemental oxygen on. Continued observation revealed an over-the-bed table beside R28's bed which had an albuterol sulfate inhaler and a bottle of Flonase nasal spray on it. During the observation, Certified Medication Aide (CMA) 8 brought in two pills to administer to R28; however, the CMA did not take the inhaler or nasal spray from the resident's over-the-bed table when she left. Observation on 05/27/2025 at 1:15 PM, revealed R28 lying on his/her bed, with the inhaler and nasal spray remaining on the over-the-bed table. During interview on 05/27/2025 at 1:35 PM, R28 stated he/she usually took those medications (the albuterol sulfate HFA aerosol inhaler and Flonase Allergy Relief), but did not remember who brought the medication in. R28 stated she did not want to administer her own medication. R28 further stated she did not remember if the staff administered the medication (located on the over-there-bed table) that morning. During interview on 05/27/2025 at 1:36 PM, CMA 8 stated she had not administered R28's inhalers that morning, an agency nurse had administered the morning medications on R28's wing that morning. She said she only passed medications on R28's hall that afternoon. She said she would only leave medications at the resident's bedside if they had an order for the medication to be kept at bedside, and that was rare. CMA 8 reported she had not known R28's inhaler and the nasal spray had been left in the resident's room. In observation at the time of interview, CMA 8 went to R28's room and confirmed the resident's Flonase and albuterol had been left in the resident's room. During interview on 05/27/2025 at 3:33 PM, Registered Nurse (RN) 14 stated she completed the morning medication pass for R28. RN 14 said she talked to R28 after hearing that medications had been left in the resident's room. She reported when she administered medications such as Flonase and inhalers, she usually brought out whatever medications she took into a resident's room. During interview on 05/29/2025 at 11:39 AM, Unit Manager (UM) 5 stated staff should take the medications out of a resident's room when they left the room. UM 5 further stated nurses and CMA's should not leave medications in R28's room. During interview on 05/29/2025 at 2:35 PM, the Director of Nursing (DON) stated staff should not have left the medications at R28's bedside. The DON further stated the staff should have taken the medications back to the medication cart. During interview on 05/29/2025 at 3:13 PM, the Administrator stated medications should be stored in the medication cart. The Administrator further stated staff should not leave medications in the resident's room.

Based on observation, interview, and facility policy review, the facility failed to ensure staff disposed of medication appropriately for 1 of 3 residents observed during medication administration, (Resident (R)86). The findings include: Review of the facility policy titled, Disposal of Medication, Syringes and Needles Disposal of Medications, dated 01/2024, revealed the appropriate method for non-controlled medication destructions was as follows: Mixing medications with an undesirable substance, such as a commercially available chemical dissolution system, used coffee grounds or kitty litter, and putting them in impermeable, non-descript containers, such as empty cans or sealable bags; will further ensure the drugs are not diverted. Review of the Resident Face Sheet for R86 revealed the facility admitted the resident on 05/17/2025, with diagnoses of heart failure and hypertension. Review of the quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/12/2025, revealed the facility assessed R86 with a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderate cognitive impairment. Review of R86's Physician Order Report, for the timeframe from 04/27/2025 through 05/27/2025, revealed an order dated 05/17/2025 for Ramipril (medication used to treat high blood pressure, heart failure, and diabetic kidney disease) 5 milligrams (mg), with instructions to administer 5 mg once a day. Observation on 05/27/2025 at 10:17 AM, of a medication pass with Certified Medication Aide (CMA) 8 revealed the CMA dropped R86's Ramipril 5 mg capsule, which landed on the medication cart. Continued observation revealed CMA 8 picked the capsule up and threw it in the trash can located on the side of the medication cart. In interview at the time of observation, CMA 8 stated she should have disposed of the capsule properly because it was hazardous. She said she had been trained on the proper disposal of medications. Unit Manager (UM) 5, who was also present during the observation and observed the CMA dispose of the medication in the trash can, said disposing of medication in regular trash cans was not the proper way to dispose of the medication. The UM stated it was hazardous to dispose of that way, and the capsule could be retrieved by someone from the trash. In interview on 05/28/2025 at 10:04 AM, the Director of Nursing (DON) stated the dropped medication should have been disposed of in the drug buster (a medication disposal system). The DON further stated proper disposal was important for the safety of others, and facility staff had been trained on that, and must follow the facility policy. In interview on 05/29/2025 at 1:08 PM, the Administrator stated staff were expected to follow the facility's policy and procedures for medication waste disposal.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 residents sampled for communication and sensory problems out of a total sample of 57, (Resident (R) 3). The findings include: Review of the facility policy titled, Vision and Hearing, revised 06/24/2024, revealed the facility was to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities. Per review, the facility must, if necessary, assist the resident in making appointments. Continued review revealed the facility was to assist residents and their representatives in locating and utilizing any available resources such as, Medicare or Medicaid program payments, local health organizations offering items and services which were available and free to the community for the provision of the services the residents needed. Further review revealed that included making appointments and arranging transportation to obtain needed services. In addition, the policy revealed in situations where the resident had lost their assistive device, the facility was to assist residents and/or their representative in locating resources, as well as in making appointments, and arranging for transportation to replace the lost device(s). Review of the facility policy titled, Social Services, revised 06/24/2024, revealed the facility was to provide medically-related social services (SS) to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Per policy review, the facility was to identify the need for medically-related SS for residents and ensure those services were provided. Review of the policy further revealed examples of medically related SS included, but were not limited to the following: Making referrals and obtaining needed services from outside entities. Review of the Resident Face Sheet for R3 revealed the facility admitted the resident on 09/05/2014, with a diagnosis of needing for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/19/2025, revealed the facility assessed R3 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Further review of the MDS revealed the facility assessed R3 as having adequate ability to hear with hearing aids or other appliance use. Review of R3's Care Plan, revealed the facility identified a problem initiated on 08/18/2022, that indicated the resident had impaired communication as it related to hearing impairment. Continued review revealed the interventions included staff to assist and encourage R3 to use hearing aids and for staff to report changes in communication status to the physician. Review of R3's provider notes for an Ear Care Visit dated 04/08/2025, revealed the resident had been seen by a nurse practitioner (NP) for hearing loss. Per review of the note, R3 presented with chronic hearing loss and wanted to have his/her ears checked for wax buildup. Continued review revealed R3 had hearing aids which had been lost and the resident was interested in obtaining new hearing aids. Further review revealed R3 was assessed and found to have a diagnosis of bilateral unspecified hearing loss. In addition, review of the note revealed the Patient Plan indicated the provider recommended an audiology referral at that time for an evaluation for R3. Review further revealed in was noted R3 wished to pursue the referral, and under the Follow Up section it was documented, Refer to Audiologist. During interview on 05/27/2025 at 10:42 AM, R3 stated he/she could not hear because his/her hearing aids had been lost. During the interview R3 answered multiple questions with I can't hear. During interview on 05/27/2025 at 1:49 PM, Licensed Practical Nurse (LPN) 10 stated a vendor typically came to the facility and dealt with residents' hearing issues. LPN 10 said if a resident lost their hearing aids, she would notify the physician, SS, the Director of Nursing (DON), Administrator, and the unit manager (UM), then fill out a grievance form. She further stated the grievance forms would then go to SS, who took over from there. During interview on 05/27/2025 at 1:59 PM, the Social Service Assistant (SSA) stated if a resident needed services, SS staff spoke with the vendor after nursing staff or the resident's family let them know of the need. During an additional interview on 05/28/2025 at 8:34 AM, the SSA stated SS set up appointments with the contracted vendor for residents, and the contracted vendor did their own follow-up for in-house appointments. She said any outside appointments were typically scheduled by nursing or the UM. The SSA further stated she was not aware of the recommended contracted vendor visit for R3 on 04/08/2025. She additionally stated the contracted vendor typically let them know about any recommendations. During interview on 05/28/2025 at 8:56 AM, UM 6 stated SS received referrals or recommendations and let her know of those. She said she would then get approval from the NP, would document the information in the resident's notes, check for insurance, and find an appropriate vendor. The UM further stated that she was not aware of the 04/08/2025 recommendation for R3 to have an audiologist referral. During interview on 05/28/2025 at 9:26 AM, the Medical Records Director (MRD) stated R3 had one outside appointment scheduled for April 2025, and no outside appointments scheduled for May 2025. She said she was not aware R3 needed to be seen by audiology. The MRD provided the State Survey Agency (SSA) Surveyor R3's Resident Calendar for April and May 2025, that noted the resident had a pulmonologist appointment on 04/16/2025, and no entries documented for May. During interview on 05/29/2025 at 2:18 PM, the Administrator stated, related to ancillary services, the facility was to schedule the services with the provider, and if it were an outside setting, the facility scheduled transportation if the family did not want to use their own transport. She said recommendations were reviewed with the clinical team and the NP and then put in place. The Administrator reported she had not been in the clinical meeting, so she was not aware of the recommendations for R3. She further stated however, the clinical team should have followed the facility's procedures. The Administrator additionally said her expectation was for the facility's policy and procedure to be followed. During interview on 05/29/2025 at 3:22 PM, the DON stated her expectation was that if a recommendation was made for a resident, staff should set up the appointment and send the resident to the appropriate vendor. She said she expected the contracted vendor to communicate with the facility at the time of their exit to include communication of all recommendations and follow-up as needed. The DON further stated staff were to follow up on all recommendations right away.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure residents received necessary assistance to carry out their activities of daily living (ADLs) for 2 of 6 residents sampled for ADLs out of the total sample of 57 Residents, (Residents (Rs)73 and 224). The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), reviewed 01/31/2025, revealed ADL assistance was to be provided on a level appropriate to the resident's level of functioning and learning and/or the responsible party's level of support and contribution to resident care. Per review, direct healthcare staff were to assist, support and encourage the resident to maintain adequate ADLs while attempting to allow the resident to maintain as much independence as possible with their ADLs, such as bathing and grooming. Further review revealed, For those residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares. 1. Review of the Resident Face Sheet for R73 revealed the facility admitted R73 on 12/17/2022, with a diagnosis of need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/22/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident was moderately cognitively impaired. Further review revealed the facility assessed R73 as dependent upon staff for showers/baths and personal hygiene. Review of R73's Care Plan revealed the facility identified a problem area with a start date of 07/04/2024, that indicated the resident had a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL cares. Further review revealed the interventions included an approach started on 07/04/2024, directing staff to provide the amount of assistance the resident needed for the completion of ADL care. Review of the facility document titled, Tuesday & Friday Shower List revealed R73 was scheduled to receive showers on Tuesdays and Fridays. Observation on 05/26/2025 at 3:50 PM, revealed R73 had long, dirty fingernails on both hands. In interview at the time of observation R73 stated he/she had not received a shower/bath, and no one had trimmed his/her fingernails. Observation on 05/27/2025 at 4:18 PM, revealed R73's fingernails remained long and dirty with a dirt-like substance under the nails. During interview on 05/27/2025 at 4:20 PM, R73 stated he/she had been promised by staff for weeks that they would clean and trim his/her fingernails; however, no one had done so. The resident further stated he/she would love for staff to trim and clean his/her nails and have a bath/shower. Review of R73's Point of Care History, for the timeframe from 05/01/2025 through 05/29/2025, revealed documentation reflected R73 had last been provided a bath on 05/22/2025. During interview on 05/28/2025 at 1:40 PM, Certified Nursing Assistant (CNA) 1 stated R73 was scheduled to receive a shower/bath on Tuesday, 05/27/2025, The CNA further stated however, R73 had not received a shower/bath the CNA had been busy and had not gotten to the resident. During a follow-up interview on 05/28/2025 at 1:59 PM, CNA 1 stated she was usually the designated shower aide. She stated a list was maintained at the nurses' station that reflected which days each resident was to receive their baths/showers. CNA 1 reported the CNAs assigned to resident care should ask the shower aide if any residents still needed showers and if so, they should provide them, if needed. She further stated trimming and cleaning nails were part of routine ADL care, but she also checked nails during showers. In interview on 05/28/2025 at 1:55 PM, Certified Medication Aide (CMA) 2 stated residents' showers/baths and nail care were part of their ADL care. CMA 2 reported if he saw a resident with long or dirty fingernails he would offer to trim them, but he had never offered to trim or clean R73's fingernails. He observed and confirmed R73's fingernails were long and dirty. CMA 2 further stated the facility had a shower aide and he was not sure what day R73 was scheduled to receive showers/baths, but he had not offered to shower or bathe the resident in the past week. Observation on 05/28/2025 at 2:03 PM, revealed Licensed Practical Nurse (LPN) 3 observed R73's fingernails and confirmed the resident's fingernails were long and dirty. LPN 3 said the resident's nails needed to be trimmed and cleaned. She reported it was very important to keep residents' nails trimmed and clean to prevent the residents from scratching themselves or staff. LPN 3 further stated she was not aware R73 had not received his/her bath/shower as scheduled. 2. Review of the Resident Face Sheet for R224 revealed the facility admitted the resident on 04/11/2025, with a diagnosis of need for assistance with personal care. Review of the admission MDS Assessment with an ARD of 04/20/2025, revealed the facility assessed R224 to have a BIMS score of 14 out of 15, which indicated the resident had intact cognition. Continued review of the MDS revealed the facility assessed R224 as dependent on staff for personal hygiene. Further review revealed the facility noted showers/baths had not been attempted during the assessment look-back period due to the resident's medical condition or safety concern. Review of R224's Care Plan revealed the facility identified a problem area with a start date of 04/11/2025, that noted the resident had a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL cares. Further review revealed the facility developed an approach, started on 04/11/2025, which directed staff to provide the amount of assistance the resident needed for completion of all ADL cares. Review of the facility document titled, Wednesday & Saturday Shower List revealed R224 was scheduled to receive showers on Wednesdays and Saturdays. Review of R224's Point of Care History for the timeframe from 05/01/2025 through 05/29/2025, revealed documentation noting the resident received partial bed baths on 05/02/2025 and 05/05/2025, a shower on 05/06/2025, a complete bed bath on 05/07/2025. Further review revealed R224 was noted to have received showers on 05/09/2025 and 05/17/2025, partial bed baths on 05/18/2025 and 05/20/2025, and a complete bed bath on 05/21/2025. Observation on 05/26/2025 at 11:30 AM, revealed R224's hair appeared oily, and the resident had noticeable body odor. In interview at the time of observation, R224 stated he/she had not had a bath or shower since they were moved into their current room approximately two weeks ago. During a follow-up interview on 05/27/2025 at 8:10 AM, R224 again stated they had not yet received a bath/shower since moving into his/her new room. The resident stated staff had not mentioned anything about a bed bath or a shower, and the resident was not sure what days he/she was scheduled to receive baths/showers. During an additional interview on 05/29/2025 at 12:41 PM, R224 stated he/she still had not received a bath or shower. During interview on 05/28/2025 at 1:55 PM, CMA 2 stated ADL care included showers/baths. CMA 2 reported the facility had a shower aide to do residents' showers/baths. He said he was not sure what day R224 was scheduled to receive his/her showers/baths. The CMA further stated he had not offered to shower or bathe R224 in the past week. During interview on 05/28/2025 at 1:59 PM, CNA 1 stated she was usually the designated shower aide. She stated a list was maintained at the nurses' station that reflected which days each resident was to receive baths/showers. CNA 1 reported the CNAs assigned to each resident's care should ask the shower aide if any residents still needed showers and they should provide them, if needed. During a follow-up interview on 05/29/2025 at 2:00 PM, CNA 1 stated R224 was on the schedule to receive a bath or shower the day prior, on Wednesday, 05/28/2025; however, she had not provided the resident one. During interview on 05/29/2025 at 2:13 PM, the DON stated she expected staff to provide baths/showers in accordance with the shower schedule and expected staff to provide ADL care daily, including ensuring residents received their showers/baths. She further stated she expected staff to provide ADL care daily, including nail care and ensuring residents received their showers/baths.

Based on observation, interview, and facility policy review, the facility failed to ensure the personal privacy and confidentiality of residents' personal health information (PHI) for 1 of 57 sampled residents (Resident (R)112). The findings include: Review of the facility policy titled, Safeguard: Safeguarding and Storing Protected Health Information, reviewed 01/31/2025, revealed all stakeholders (facility staff) were responsible for the security of the residents' active medical records at the nursing stations or other designated areas within the facility. Per review, that included, but was not limited to, making sure computer screens were not left unattended while displaying residents' PHI. Review of the Resident Face Sheet for R112 revealed the facility admitted the resident on 04/21/2025 and readmitted the resident on 05/26/2025. Continued review revealed R112's diagnoses included: hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left dominant side; dysphagia (difficulty swallowing) following cerebral infarction; congestive heart failure; aphasia (language disorder) following cerebral infarction; epilepsy and epileptic syndromes; and chronic kidney disease. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/30/2025, revealed the facility assessed R112 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident had moderate cognitive impairment. Observation on 05/27/2025 at 8:17 AM revealed a computer screen open that had R112's PHI displayed. Continued observation revealed information visible on the computer screen included the resident's name, date of birth , allergies, diagnoses, diet, and code status. Further observation revealed the open computer screen was visible to individuals in the hallway. During interview on 05/27/2025 at 8:26 AM, Unit Manager (UM) 6 acknowledged the computer screen had been left open and unlocked. She stated anyone walking by would be able to see R112's PHI which included: medications, diagnoses, birthdate, and diet. UM 6 further stated the computer screen should have been locked to protect R112's PHI as required. In observation and interview on 05/27/2025 at 8:30 AM, Licensed Practical Nurse (LPN) 3 was observed to return to the computer. She stated stated she was the person responsible for logging out when she stepped away; however, should have ensured the computer was locked when she left to protect the resident's PHI. During interview on 05/27/2025 at 10:21 AM, UM 5 stated nurses were trained to lock the computer screens when stepping away to prevent unauthorized access to residents' PHI. During interview on 05/28/2025 at 10:01 AM, the Director of Nursing (DON) stated computer screens must be locked, and no resident PHI should be left visible to others. The DON further stated nursing staff were expected to protect residents' PHI as required.

Based on interview, record review, and review of the facility policy, the facility failed to ensure an allegation of abuse was reported to the Administrator and to the State Survey Agency within 2 hours for one of seven sampled residents, Resident (R)1. On 01/08/2025, a Certified Nurse Aide (CNA) reported to facility leadership an allegation of abuse involving R1 which allegedly occurred on 01/07/2025, approximately twenty-four hours prior the CNA reporting the allegation. The findings include: Review of the facility policy Abuse, Neglect and Misappropriation of Property last reviewed 09/13/2024, revealed the facility intended to prevent occurrence of abuse and assure all alleged violations of federal and state laws which involve abuse were reported immediately to the Administrator and State Survey Agency. The facility would include reporting to provide protection for the health, welfare, and rights of each resident. Every Stakeholder must intervene immediately, protect the alleged victim, and integrity of the investigation. If a Stakeholder observes any form of abuse, the Stakeholder will intervene immediately and assure the resident's safety. Further review of the policy, revealed every Stakeholder shall immediately report any allegation of abuse to the Administrator. Review of the facility policy Resident Rights last reviewed 09/13/2024, revealed all residents had the right to be treated with respect and dignity. These rights would be protected by the facility. Further review of the policy revealed the facility will make every effort to assure the resident was treated with respect, kindness, and dignity. Review of the facility investigation revealed on 01/08/2025 at 10:30 PM, the Administrator was notified a staff member voiced a care concern related to evening care provided to R1. The CNA reported redirection approaches to prevent the R1 from falling while the resident was agitated. CNA2 reported the following occurred: CNA9 pulled R1 down by his gown when the resident attempted to stand; CNA8 and CNA10 held the resident's gown and sat him back down when he stood up; CNA8 tapped R1 on the back of his head; and Licensed Practical Nurse (LPN)2 put R1's medications in yogurt, and placed the medications in the resident's mouth after he refused to take medication from the Certified Medication Technician (CMT). Continued review of the facility investigation revealed CNA2's witness statement dated 01/08/2025, revealed she had witnessed the above incidents with R1 on 01/07/2025. Further review of the investigation revealed the facility reported an allegation of abuse to the State Survey Agency on 01/08/2025, with date and time confirmation, on 01/09/2025 at 12:23 AM. The allegation was reported by Certified Nurse Aide (CNA)2 and alleged concerns against CNA8, CNA9, CNA10, and an agency Licensed Practical Nurse, (LPN)2. Review of a Stakeholder Suspension Form dated 01/08/2025 revealed CNA2 was suspended from working, pending the facility's completed investigation. Review of the facility staffing schedule revealed CNA9 was not scheduled to work on 01/07/2025 but all the staff (CNA8, CNA9, CNA10 and LPN2) which CNA2 reported abused R1 were scheduled to work on 01/06/2025. Additionally, CNA2 also was scheduled to work on 01/06/2025. In interview on 01/21/2025 at 8:11 AM and on 01/23/2025 at 7:01 AM, CNA2 stated she reported to the Weekend Manager allegation involving R1. CNA2 stated she failed to report the alleged incident timely and reported approximately 24-hours after the event occurred. CNA2 stated she was trained on abuse when she was employed in October 2024 and understood that allegations of abuse were to be reported immediately. CNA2 stated she was also suspended for not reporting timely. She further stated she did not report the allegation earlier as CNA8 told her to keep my mouth shut. Per CNA2, the purpose of reporting timely was to keep all residents safe. In interview on 01/23/2025 at 1:04 PM, the Director of Nursing (DON) stated CNA2 reported to the Weekend Manager, who then called her (the DON). She stated she (the DON) and the Administrator came in to talk with CNA2 as the aide did not feel comfortable speaking on the phone. The DON stated the CNA witnessed the incidents with R1 several days prior to voicing to anyone. The DON further stated CNA2 was suspended from work for not reporting allegations immediately. She also stated CNA2 was re-educated on timeliness of reporting abuse and to whom to report. The DON stated the purpose of reporting timely was to have an intervention in place for the resident's safety. Interview with Weekend Manager on 01/23/2025 at 1:45 PM revealed CNA2 called her on Wednesday (01/08/2025) to report abuse of R1 which CNA2 reported happened the night before. She stated she asked CNA2 why she did not call the Administrator when it happened, and the aide told her she did not know what to do. The Weekend Manager further stated she told CNA2 the facility had 2 hours to act, and she immediately called the DON. She stated the purpose of reporting in 2 hours was for the protection and safety of the elders (residents). She also stated an obligation to report as soon as staff see it (alleged abuse). In interview on 01/23/2025 at 1:59 PM, the Administrator stated CNA2 was suspended for failure to report timely. Per the Administrator, CNA2 reported the allegation about one day after the incident allegedly occurred. She stated staff were trained on abuse and that abuse allegations should be reported to herself and the DON immediately. She further stated the purpose of reporting in 2 hours was to perform an investigation and ensure the resident's safety.

Based on observation, interview and review of facility policy, it was determined the facility failed to store food in accordance with professional standards for food service safety related to food items opened, not dated, and/or labeled. This had the potential to affect 115 of 120 residents. Observation during the initial kitchen tour on [DATE] at 9:40 AM, revealed assorted food items/containers not labeled, dated, or expired in both walk-in cooler #1 and walk-in cooler #2. The findings include: Review of the facility policy Food Storage, Dry Goods, revised ,d+[DATE], revealed all dry goods would be appropriately stored in accordance with the FDA food code. All items would be stored on shelves at least 6 inches above the floor. Review of the facility policy Labeling and Dating, dated 2017, revealed proper labeling and dating ensured all foods were stored and rotated. All foods would be dated upon receipt before being stored. Leftovers must be labeled and dated with the date they were prepared and the use-by date. All ready-to-eat foods held for more than 24 hours at a temperature of 40 degrees Fahrenheit or less would be labeled and dated with a prepared date being day one (1) and a use-by date, day seven (7). Always defer to state and local regulations as they supersede general guidelines. Observation during the initial kitchen tour walk-in cooler #1, revealed a gallon size plastic container that was ,d+[DATE] full of sliced bologna, that was not labeled or dated, a plastic container dated [DATE] with 7 cooked chicken strips, not labeled or dated, a metal container that was ,d+[DATE] full of mechanical soft chicken, not labeled or dated, a plastic container containing 3 cooked pork chops, not labeled or dated, a container of beef base ,d+[DATE] full dated [DATE] and ,d+[DATE] gallon of milk that was expired with a date of [DATE]. Continued observation of walk-in cooler #2 revealed 4 boxes of produce items sitting on the floor, 2 containers of thickened orange juice were opened, not labeled, or dated, 1 container of whipped topping, was opened, not labeled, or dated and ,d+[DATE] bag of shredded cheese opened, not labeled, or dated. In an interview with the Interim Dietary Manager on [DATE] at 9:45 AM, she stated the produce was sitting on the floor because it was delivered the previous day and she had not had time to put it away. She stated she was aware items could not be sitting on the floor. Continued interview revealed she expected all food to be labeled and dated before placing in the coolers. She stated there were signs posted everywhere in the kitchen. The DM stated there were no potentials related to residents becoming ill as the dietary staff would not serve outdated food. She stated she checks the cooler daily and she had not had a chance to check them when surveyors came in. In an interview with the District Manager on [DATE] at 11:18 AM, he stated all items were to be labeled and dated before storing. He stated there were no potential outcomes as staff would not serve foods that were not dated. In an interview with the Director of Nursing (DON) on [DATE] at 3:22 PM she stated she would expect the kitchen staff to label and date items before storing. She stated she would hope that there would be no potential outcomes for the residents. In an interview with the Administrator on [DATE] at 4:08 PM, he stated he expected staff to follow policies and guidelines related to labeling and dating foods and leftovers. He stated he could not speak to outcomes or what-ifs; he stated the kitchen strived to label and date foods in the kitchen to the best of their abilities.

Based on observation, interview, and review of the Diet Guide Sheet, it was determined the facility failed to ensure menu items were served in the recommended portion sizes which were approved to meet the nutritional needs of the residents. Staff failed to follow the portion sizes on the menu guide which was approved by a Registered Dietician. Observation on 05/02/2024 during the noon meal revealed, pureed meal tray portions were small and the server was using a blue-handled scoop. The server stated the scoop was 2 ounces. Continued observation revealed 2 ounces of the meatless entree and 2 ounces of pureed bread being placed on the plate. The findings include: Review of week 2 of the Diet Guide Sheet, for the noon meal, revealed the pureed meal consisted of pureed cheese lasagna, 8 ounces; pureed marinated mixed vegetables, 3.25 ounces; pureed potato salad, 4 ounces; pureed garlic bread 4 ounces and fruit cocktail 3 ounces. Review of the facility policy Therapeutic Diets, revised 10/2022, revealed all residents would have a diet order including regular therapeutic and texture modification, prescribed by the attending physician in accordance with the applicable regulatory guidelines. Continued review revealed diets would be prepared in accordance with guidelines in the approved Diet Manual and the individualized care plan. Continued review revealed a mechanically altered diet was one in which the texture of the diet was altered. During an interview with the Interim Dietary Manager on 05/02/2024 at 4:17 PM, she stated someone at the corporate level completed the menus. She stated for portion size the recipe printed specifics such as what size scoop to use. She stated they followed what it said. She stated the blue handled scoop was two (2) ounces. She stated she would have to look at the guidelines about the portion sizes. In an interview with the Regional Dietician on 05/02/2024 at 4:33 PM, she stated corporate dieticians aproved the menus. She stated she would have to check the guideline for portion size and production size. She stated she could not speak to 2 ounces of a meatless entree and would have to check the guidelines. She further stated portion sizes can change daily. In an interview with the District Manager on 05/03/2024 at 1:57 PM, he stated a Registered Dietician at corporate signed off on the menus. He stated the menu guide translates to what the diet is and creates the meal ticket. He stated traditionally, residents would have been served 6-8 ounces of a meatless entree. He further stated the menus were created to equal out nurtients for the day. Additionally, he stated this was only the second week of using the new menus In an interview with the Director of Operation on 05/03/2024 at 2:08 PM, she stated residents receiving a pureed diet should have received eight (8) ounces of the entree. She stated potential outcomes of not receiving correct portion sizes could be residents may want more food. She stated this was an isolated incident and there were no potentials for weight loss. She further stated there were always snacks available for the residents. In an interview with the Director of Nursing (DON) on 05/03/2024 at 3:22 PM, she stated she expected dietary to follow the physicians order for meals. She stated a resident could still be hungry if they received small portions. She stated there were snacks available. In an interview with the Administrator on 05/03/2024 at 4:08 PM, he stated he expected dietary to follow the guidelines on portion sizes. He stated the diet guide was developed and it should be used and followed. The Administrator did not speak to outcomes for residents.

Based on observation, interview, policy review, and record review, the facility failed to provide [CONDITION(S)] services for one (1) of three (3) sampled residents in the facility (Resident #1). On [DATE], the facility failed to schedule transportation, which resulted in a missed [CONDITION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the policy titled, Transportation, Resident, dated [DATE], revealed the facility assisted residents to arrange transportation to and from appointments outside of the facility. The policy revealed the facility would assist residents or responsible parties with transportation arrangement, if or when needed. Review of the policy titled, Admissions to the Facility, dated [DATE], revealed the facility gathered pertinent information regarding the resident, medications, and treatments to ensure the facility can provide the care needed. Review of the policy titled, Care of Resident Receiving [CONDITION(S)], dated [DATE], revealed interventions which included to monitor resident for fluid overload, care of skin issues, encouragement to participate in activities, monitor the [CONDITION(S)] access site for signs of infection or bleeding, and arrange [CONDITION(S)] treatment as ordered. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview Mental Status (BIMS) of five (5), indicated the resident was cognitively impaired. Review of Resident #1's physician orders, for the month of [DATE], revealed [CONDITION(S)] treatments were ordered three (3) days a week on Tuesday, Thursday, and Saturday. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff documented administration of medications per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan, initiated on [DATE] and last revised on [DATE], revealed interventions to include [CONDITION(S)] on Tuesday, Thursday, and Saturday. The goal was for Resident #1 to remain free from complications related to [CONDITION(S)] and [CONDITION(S)]. According to the care plan, the facility nursing staff would monitor the resident for signs of infection, bleeding, and fluid overload. The nursing interventions included communication with the [CONDITION(S)] center regarding medications, labs, and diet. The nursing staff was also responsible to coordinate and collaborate with the [CONDITION(S)] center in providing care to Resident #1. Review of Resident #1's progress notes revealed Resident #1 returned from the hospital on [DATE]. On [DATE], Registered Nurse (RN) #4 documented the resident missed his/her [CONDITION(S)] treatment due to the resident's transportation had not been scheduled. Continued review revealed RN #4 documented communication with the [CONDITION(S)] center and an alternate treatment time was not available. Further review of the progress notes revealed the [CONDITION(S)] center communicated with the facility staff to monitor Resident #1 for any signs of fluid overload and notify the physician if Resident #1 became symptomatic. Resident #1 expired at the hospital on [DATE]. Interview with RN #2, on [DATE] at 1:21 PM, revealed the unit managers and the Director of Nursing (DON) communicated with the front office regarding [CONDITION(S)] transportation. She stated missing an ordered [CONDITION(S)] treatment could cause Resident #'s condition to worsen. Interview with Registered Nurse (RN) #4, on [DATE] at 2:40 PM, revealed Resident #1 missed a [CONDITION(S)] treatment because the facility had not scheduled transportation for [DATE]. RN #4 stated she was able to reschedule the transportation for later on the same day; and contacted the [CONDITION(S)] center, but an alternative treatment time was not available. The [CONDITION(S)] center directed RN #4 to monitor Resident #1 for fluid overload and contact the physician if Resident #1 became symptomatic. She stated nursing staff monitored Resident #1 for symptoms of fluid overload, which included swelling, shortness of breath, difficulty breathing, vital sign changes, and a change in level of consciousness. Interview with Medical Records #1, on [DATE] at 2:34 PM, revealed she arranged transportation for a month at a time for transportation to [CONDITION(S)] treatments. She stated transportation arrived at the facility on a day Resident #1 was in the hospital with future transportation appointments canceled. She stated she was unsure who canceled the appointments. She stated she was unaware Resident #1 had returned from the hospital on [DATE] and that was why transportation to [CONDITION(S)] on [DATE] did not occur. Interview with the Admissions Director, on [DATE] at 8:37, revealed she was off on [DATE] when Resident #1 returned to the facility from the hospital and there was another staff member to fill in for that day in regards to admissions or readmissions. She stated the on-call person would have been responsible for admissions and readmissions on [DATE] and would notify Medical Records to schedule transportation. Interview with the Receptionist, on [DATE] at 11:31 AM, revealed she was on-call for the Admissions Director on [DATE] but was unaware Resident #1 received [CONDITION(S)] and did not notify Medical Records #1 for scheduling transportation to [CONDITION(S)]. Interview with the DON, on [DATE] at 10:35 AM, revealed when residents return to the facility, Medical Records #1 received notification to schedule transportation as needed for treatments. She stated Resident #1 missed his/her [CONDITION(S)] treatment on [DATE] due to a failure in communication when Resident #1 returned from the hospital on [DATE]. Interview with the Administrator, on [DATE] at 11:06 AM, revealed the facility had not experienced any issues with scheduling transportation for [CONDITION(S)] residents before [DATE]. Per interview, the Administrator revealed the facility has developed a new system to ensure residents make their needed medical appointments and/or treatments outside of the facility. She further stated the facility has utilized a dry erase board which identified all resident's appointments whether it was a doctor's appointment or [CONDITION(S)].

Based on observation, interview, record review, and policy review it was determined the facility failed to maintain infection control practices to prevent the development and transmission of communicable diseases and infections for three (3) of thirty-three (33) sampled residents (Residents #46, #97, and #171). On 06/04/19 at 10:06 AM a wound care observation of Resident #171 revealed staff failed to follow appropriate infection control practices and hand hygiene. On 06/03/19, Resident #46's urinary catheter drainage bag was observed to be leaking urine, which was draining into another open plastic bag. In addition, observations on 06/04/19, revealed staff failed to use personal protective equipment (PPE) when providing care to Resident #97, who had [MEDICAL CONDITION] Resistant Staph Aureus present in a decubitus wound. The findings include: Review of the facility's policy, Infection Control, dated (MONTH) 2014, revealed the facility's infection control practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Further review of the policy revealed that all personnel would be trained on the infection control policy and practices and the depth of the training would be appropriate to the degree of direct resident contact and job responsibilities. The findings include: 1. Review of the facility's policy, Handwashing/Hand Hygiene, dated (MONTH) (YEAR), revealed all personnel would follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. Further review of the policy revealed the staff would perform hand hygiene before handling clean or soiled dressings, after contact with a resident's intact skin, and after contact with blood or bodily fluids. Review of Resident #171's medical record revealed the facility admitted the resident on 05/21/19 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident #171's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had [MEDICAL CONDITION] (bacterial skin infection) of the left foot. Review of Resident #171's care plan dated 05/21/19 revealed the facility identified Resident #171 to have impaired skin integrity related to [MEDICAL CONDITION] of the left foot. Further review of the care plan revealed a goal that the resident's wound would show evidence of healing and be free from infection. Observation on 06/04/19 at 10:06 AM of wound care provided to Resident #171 revealed LPN #3 washed hands, donned gloves, and removed ace wrap and gauze dressing from the resident's left lower leg. Observation of the soiled gauze revealed a small amount of dried blood and yellow-tinged substance on the gauze. Further observation revealed LPN #3 placed the ace wrap and soiled gauze directly on the carpeted floor in the resident's room. Further observation of the wound care revealed LPN #3 removed her soiled gloves, washed her hands, applied clean gloves, and applied [MEDICATION NAME] cream to the resident's skin on the lower leg. Further observation revealed LPN #3 picked up the clean gauze lying on the overbed table with the soiled gloves and wrapped the resident's lower leg with the clean gauze. Further observation revealed LPN #3 then picked up the ace wrap and wrapped the resident's lower leg with the ace wrap. Interview on 06/04/19 at 10:20 AM with LPN #3 revealed the LPN stated she should have had a garbage bag available to place the soiled dressings in, instead of placing the soiled dressings on the carpeted floor. Further interview revealed she did not wash her hands and change gloves between applying the cream to the affected area and prior to applying the clean gauze. Interview on 06/05/19 at 1:44 PM with the Assistant Director of Nursing (ADON) revealed the staff should place soiled dressing in a garbage bag or biohazard bag at the bedside and should not lay a soiled dressing on the resident's floor. Further interview revealed the LPN should have washed her hands and changed gloves after applying cream to the affected area and prior to applying a clean dressing. Interview on 06/07/19 at 9:00 AM with the Director of Nursing (DON) revealed the staff were expected to place soiled dressing in a disposable bag or biohazard bag and it was not acceptable to place the soiled dressing on the floor. Further interview revealed the DON expected staff to remove soiled gloves and wash their hands after applying cream to the wound and prior to applying the gauze over the area. 2. Review of the facility's policy, Catheter Care Procedure, revised 09/07/17, revealed urinary drainage bags were to be positioned in a manner that allowed the urine to flow freely into the bag and should be emptied every three (3) to six (6) hours. Review of Resident #46's medical record revealed the facility admitted the resident to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #46's Minimum Data Set (MDS) assessment, dated 04/03/19, revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed the resident had an indwelling catheter and required extensive assistance of two (2) or more persons for the activities of bed mobility, transfer, dressing, toilet use, and personal hygiene. Observation and interview with Resident #46 on 06/03/19 during the initial tour at approximately 3:00 PM revealed the resident was in bed with his/her catheter draining into a connected drainage bag, which was placed inside a large plastic bag. Further observation revealed urine had leaked out of the connected drainage bag and into the plastic bag in which it was placed. Interview with the resident revealed the urinary catheter bag had been leaking since he/she returned from [MEDICAL TREATMENT] on 06/01/19. The resident also stated he/she had informed staff that the catheter collection bag was leaking and did not know why it had not been changed. Observation and interview with Resident #46 on 06/04/19 at 11:24 AM, revealed the resident had a new drainage bag hanging on the bedside. The resident stated it had been replaced last evening after his/her son-in-law pitched a fit. Interview with State Registered Nurse Aide (SRNA) #6 on 06/05/19 at 10:21 AM, revealed she had just completed catheter care on Resident #46. She stated she was not aware of the catheter bag leaking on 06/01/19, 06/02/19, and 06/03/19. She also stated she was not usually assigned to work the unit where Resident #46 resided. Interview with Certified Medical Technician (CMT) #1 on 06/05/19 at 2:18 PM, revealed she did not work the past weekend or on Monday, 06/03/19, and did not have knowledge that Resident #46's catheter bag was leaking. Interview with Registered Nurse (RN) #2 on 06/06/19 at 8:55 AM, revealed she had worked on 06/01/19, 06/02/19, and 06/03/19. However, she stated she did not recall anyone informing her that the resident's catheter bag was leaking. She stated she became aware of the bag leaking and draining into another bag when the resident's family member complained about it. Interview with LPN #5 on 06/06/19 at 4:57 PM, revealed she worked 06/01/19 and 06/02/19 and started her shift at 6:30 PM. She stated the first she knew of the catheter bag leaking was on the evening of Monday, 06/03/19, when she came on to start her shift. She stated when she changed the bag it was draining into another plastic bag. She also stated she had no idea who placed the drainage bag into the plastic bag. Interview with the Assistant Director of Nursing on 06/06/19 at 1:10 PM, revealed she worked the unit where Resident #46 resided on 06/01/19 starting at 6:30 PM. She stated no one informed her the catheter bag was leaking. She further stated the urinary drainage bag draining into another open bag was a break in infection control. Interview with the Director of Nursing (DON) on 06/07/19 at 8:59 AM, revealed she was unsure who the infection control nurse was, and was not sure when education related to infection control had last been provided to the staff. The DON also stated the leaking catheter bag was an infection control problem due to it no longer being a closed system. She further stated she was not able to identify who placed the bag into the plastic bag. 3. Review of the facility's policy titled Isolation-Initiating Transmission-Based Precautions, not dated, revealed transmission-based precautions would be used only when the spread of infection could not be reasonably prevented by less restrictive measures. The policy further stated that appropriate equipment (i.e., gloves, gowns, and mask) would be maintained outside the resident's room so that anyone entering the room could apply the equipment. Review of the medical record for Resident #97 revealed the facility admitted the resident on 05/10/19 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #97 dated 05/17/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was interviewable. Review of a physician's progress note for Resident #97 dated 05/10/19 revealed the resident had a [DIAGNOSES REDACTED]. Observation on 06/04/19 at 8:30 AM revealed personal protective equipment (PPE) was stored in a cart outside of Resident #97's room, including gowns, masks, and gloves. Signage on the resident's door indicated staff were to don the PPE prior to entering the resident's room. During the observation, LPN #8 stated Resident #97's sacral decubitus ulcer was infected with [MEDICAL CONDITION] Resistant Staph Auras (MRSA). Observation on 06/04/19 at 2:01 PM, 2:05 PM, and 2:09 PM revealed State Registered Nurse Aide (SRNA) #12 entered Resident #97's room, but failed to don the PPE. Observation on 06/04/19 at 2:06 PM revealed SRNA #13 who was providing care to Resident #97 was not wearing the PPE. Interview with SRNA #13 on 06/05/19 at 10:20 AM revealed she had been trained to use PPE when providing care to Resident #97. However, SRNA #13 stated she was busy and forgot to wear the PPE. Interview with SRNA #12 on 06/05/19 at 10:54 AM revealed she was aware that PPE was available for use when entering or providing care to Resident #97. SRNA #12 stated she was just busy and forgot to wear the PPE. Interview with LPN #10 on 06/05/19 at 1:35 PM revealed the expectation was that staff would wear appropriate PPE when entering Resident #97's room and when providing care. LPN #10 stated she monitored staff to ensure compliance with the use of PPE and had not identified any concerns. Interview with the Director of Nursing (DON) on 06/07/19 at 11:30 AM revealed staff were expected to follow the facility policy regarding PPE use. The DON stated she made rounds several times per day and monitored to ensure resident care was provided appropriately. The DON stated she had not identified any concerns regarding staff's failure to use PPE.

Based on interview and record review it was determined that the facility failed to transmit a completed discharge record for one (1) of thirty-three (33) sampled residents (Resident #1). The facility completed a 14-day discharge assessment for Resident #1 on 01/13/19; however, the facility failed to transmit the discharge information as required. The findings include: Interview on 06/07/19 at 8:15 AM with the facility Administrator revealed the facility utilized the Resident Assessment Instrument (RAI) 3.0 Instruction Manual (RAI) to complete a MDS assessment. Review of the Resident Assessment Instrument (RAI) 3.0 Instruction Manual (RAI) revealed Transmitted means electronically transmitting to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of the final completion date of the record. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS (The Centers for Medicare and Medicaid Services) System, including following a subset of items upon a resident's transfer, reentry, discharge, and death. Review of Resident #1's medical record revealed the facility admitted the resident on 12/28/18 and the resident was discharged on [DATE]. Review of Resident #1's MDS record revealed the facility completed a 14-day/discharge return not anticipated assessment on 01/13/19; however, there was no evidence that the facility transmitted the discharge information as required by CMS. Interview on 06/06/19 at 3:34 PM with the MDS Coordinator and MDS Nurse #2 confirmed that the assessment was completed; however, the discharge assessment was never transmitted. They stated the nurse who completed the assessment was no longer employed at the facility.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to complete Minimum Data Set (MDS) assessments for one (1) of thirty-three (33) sampled residents (Resident #9). Resident #9 was admitted to hospice on 05/16/19; however, the facility failed to conduct a Significant Change in Status MDS assessment. The findings include: Interview with the Director of Nursing (DON) on 06/07/19 at 9:11 AM revealed the facility utilized the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) (YEAR), as a resource for completion of MDS assessments. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, page 2-23, revealed a Significant Change in Status Assessment is required to be completed when a terminally ill resident enrolls in a hospice program and remains a resident in the facility. The manual stated that the assessment must be completed within fourteen (14) days from the effective date of hospice election. Further review revealed the Significant Change in Status Assessment requires Section O, Line 0100K to be checked, indicating hospice election has occurred. A review of Resident #9's medical record revealed the facility readmitted the resident on 05/16/19, with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment completed on 05/16/19 revealed the resident was admitted to hospice on 05/16/19 upon discharge from the hospital and before returning to the facility on [DATE]. Review of Resident #9's medical record revealed no documented evidence that the facility had completed a Significant Change MDS assessment on or before 05/29/19, fourteen days after hospice election. Interview with the MDS Coordinator on 06/07/19 at 9:46 AM, revealed a Significant Change MDS assessment should have been completed and hospice should have been coded for Resident #9 on or before 05/29/19. The MDS Coordinator stated it was an oversight. Interview with the Director of Nursing (DON) on 06/07/19 at 9:11 AM, revealed she was not responsible for ensuring the timeliness/accuracy of MDS assessments. The DON revealed the person completing the MDS assessment was responsible for its accuracy and timeliness.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of thirty-three (33) sampled residents (Resident #97) was treated with dignity and respect. During observation of wound care on 06/04/19 at 2:15 PM, Licensed Practical Nurse (LPN) #8 opened the door to the hallway and exposed Resident #97's nude buttocks. The findings include: Review of the facility policy titled Resident Rights, revised 08/16/18, revealed the facility would ensure that all residents would be treated with respect and dignity. The policy further stated that residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the medical record for Resident #97 revealed the facility admitted the resident on 05/10/19 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #97 dated 05/17/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was interviewable. On 06/04/19 at 2:15 PM during observation of wound care for a pressure ulcer to Resident #97's sacrum (bottom), LPN #8 opened the door leading to the hallway while the resident's buttocks were exposed. Resident #97 was turned away from the door and was not aware that the door was open. Interview conducted with LPN #8 on 06/07/19 at 10:10 AM revealed she should have covered Resident #97 prior to opening the door. LPN #8 acknowledged that all residents should be treated with dignity and respect. Interview with the Director of Nursing (DON) on 06/07/19 at 11:30 AM revealed the expectation was that staff would treat all residents in a manner that promoted dignity and respect. The DON stated LPN #8 should have ensured that Resident #97 was covered prior to opening the door. The DON reported that she made rounds throughout the day and had not identified any concerns with staff not treating residents with dignity and respect.

Based on observation and interview, it was determined that the facility failed to maintain the interior in good repair for one (1) of thirty-three (33) sampled residents (Resident #114). Observation revealed multiple holes in the wall below the window in Resident #114's room. The findings include: Observation on 06/04/19 at 8:46 AM of Resident #114's room revealed multiple holes and damage to the drywall located below the window and next to the heater unit. Interview with Resident #114 revealed the resident backed his/her motorized wheelchair into the wall while trying to open the blinds. According to interview with Resident #114, the damage to the wall occurred a few months ago. Further observation revealed a typed sign next to the window to remind staff to open the blinds for the resident. Interview on 06/06/19 at 2:40 PM with the Maintenance Director revealed he/she was not aware of the damage and holes to the wall in Resident #114's room. Further interview revealed that the staff had a maintenance log on the unit to communicate any needed repairs to the Maintenance Department. Interview on 06/06/19 at 3:07 PM with LPN #3, the Unit Coordinator on the East Wing, revealed Unit Coordinators made daily rounds and visited residents that they were assigned to monitor. According to interview, the damaged area on the wall below the window was not present when he/she rounded last week. Interview on 06/06/19 at 2:55 PM with the Administrator revealed she was not aware of a problem with the wallboard being damaged in Resident #114's room. According to interview, the staff frequently called the Maintenance Director for repairs, and they had a log to communicate with the Maintenance Director for any necessary repairs.

Based on interview and record review, it was determined that the facility failed to ensure each resident is assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments for one (1) of 33 (thirty-three) sampled residents (Resident #2). Review of Resident #2's Minimum Data Set (MDS) assessments revealed the facility completed a quarterly assessment on 01/22/19, but failed to complete another quarterly MDS assessment until 05/24/19, forty-one (41) days late. The findings include: Interview on 06/07/19 at 8:15 AM with the facility Administrator revealed the facility did not have a policy regarding MDS assessments, but followed the Resident Assessment Instrument (RAI) Instruction manual for completion of MDS assessments. Review of the Resident Assessment Instrument (RAI) 3.0 Instruction Manual revealed a Quarterly Review Assessment is an OBRA '87-required, non-comprehensive assessment that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Review of Resident #2's medical record revealed the facility admitted the resident on 12/06/16. Review of the resident's Quarterly MDS assessment revealed the facility completed the assessment on 01/22/19. However, there was no documented evidence the facility completed another Quarterly MDS assessment until 05/24/19, 133 days later. Interview on 06/06/19 at 3:34 PM with the MDS Coordinator and MDS nurse #2 confirmed Resident #2's quarterly assessment was completed late. The staff stated that the nurse who completed the assessment was no longer employed at the facility.

The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two (2) of thirty-three (33) sampled residents (Resident #60 and #68). The facility failed to ensure Resident #68's admission MDS assessment stated that the resident required [MEDICAL CONDITION] care, suctioning, and [MEDICAL TREATMENT]. In addition, the facility failed to ensure Resident #60's Admission MDS stated that the resident utilized an indwelling urinary catheter. The findings include: Review of the Resident Assessment Instrument (RAI) 3.0 manual, dated (MONTH) (YEAR), revealed Medicare and Medicaid participating long term care (LTC) facilities are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. 1. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #68's medical record revealed the resident was sent out of the facility on Monday, Wednesday, and Friday to receive [MEDICAL TREATMENT]. Review of Resident #68's admission physician orders [REDACTED]. Further review revealed an order dated 04/29/19 to perform [MEDICAL CONDITION] care every shift and as needed. Review of the MDS admission assessment, dated 04/23/19, revealed Resident #68 was totally dependent on staff for transfers and eating. Further review of the MDS revealed no documented evidence that the facility identified and documented on the MDS that the resident had a [MEDICAL CONDITION], which required care and suctioning nor did the MDS reveal the resident was receiving [MEDICAL TREATMENT] treatment. 2. Review of the medical record for Resident #60 revealed the facility admitted the resident on 03/22/19 and readmitted the resident on 05/02/19, with [DIAGNOSES REDACTED]. Observation of Resident #60 on 06/04/19 at 8:50 AM, revealed the resident had an indwelling urinary catheter to a bedside drainage bag. Review of the physician orders [REDACTED].#60 revealed an order for [REDACTED].>Review of Resident #60's Treatment Administration Record (TAR) for (MONTH) 2019 revealed the resident received catheter care every shift from 03/22/19, the date of admission, through 03/31/19. Interview with Licensed Practical Nurse (LPN) #4, the Unit Manager, on 06/07/19 at 10:15 AM, revealed Resident #60 had an indwelling urinary catheter upon admission to the facility and continued to utilize an indwelling urinary catheter for elimination. However, a review of Resident #60's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility documented in Section H, Sub-Section H0100 that the resident did not have an indwelling urinary catheter upon admission. Further review of the MDS revealed the resident was severely cognitively impaired and was not interviewable. Interview with the MDS Coordinator on 06/07/19 at 9:48 AM revealed Resident #60's Admission MDS should have reflected the use of an indwelling urinary catheter. The MDS Coordinator stated the nurse who completed the assessment was no longer employed at the facility. Interview with the Director of Nursing (DON) on 06/07/19 at 9:11 AM confirmed the Admission MDS assessment for Resident #60 should have stated that the resident utilized an indwelling urinary catheter for elimination. The DON further revealed the MDS Coordinator was responsible for ensuring the accuracy of the MDS assessment.

Based on interview, record review and policy review, it was determined the facility failed to ensure all applicants for nursing positions had a current license before caring for residents. The facility allowed an Unlicensed Graduate Nurse to work as a licensed nurse performing all nursing duties independently, placing all residents the nurse cared for at risk for harm or death. The Unlicensed Graduate Nurse cared for residents on one (1) of the two (2) units that had four (4) hallways, involving potentially forty-six (46) residents. Kentucky Board of Nursing (KBN) Laws KRS 314.051 and KRS 314.031 In addition, the facility failed to implement the interim care plan for one (1) of twelve (12) sampled residents (Resident #4). The resident was assessed by the facility to be at high risk for falls. The facility failed to provide appropriate assistance during a shower; the resident fell sustaining fractures to the left humerus,7th left rib, and 9th [MEDICATION NAME] vertebrae. The facility's failure to ensure all nursing staff had a current license and was qualified to perform nursing duties, as well as ensure staff implemented the interim care plan for residents placed residents at risk for severe injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 03/30/16; the facility was notified on 03/30/16. The facility provided an acceptable Allegation of Compliance (AOC) on 04/04/16, which alleged removal of the IJ on 04/05/16. The State Survey Agency (SSA) verified the IJ was not removed on 04/05/16 as alleged. It was determined the IJ was removed on 04/07/16 (facility allowed a nurse to return to work without training on 04/06/16) prior to exit on 04/08/16. The Scope and Severity (S/S) was lowered to an G while the facility develops and implements the plan of correction and the Quality Assurance (QA) monitors for effectiveness of the systemic changes. The findings include: 1. Review of the facility's Licensure and Certification Compliance Functions Policy, revised November 2015, revealed it was the policy of the company that all positions requiring professional licenses or certifications would be filled only by persons holding such licenses or certifications. Review of the facility's Stakeholders Orientation Policy, effective 2008, revealed it was the policy of the company that Stakeholders attend Orientation within two (2) weeks of date of hire. Interview with the Nurse Consultant, on 03/30/16 at 4:42 PM, revealed the facility did not have a policy on Licensed Practical Nurse Applicants (LPNA), Registered Nurse Applicants (RNA), or Student Nurses. The facility was in the process for developing one. Review of the Kentucky Board of Nursing Law, KRS 314.051 revealed an LPNA shall only work under the direct supervision of a nurse and shall not engage in independent nursing practice. No other person shall assume the title or use the abbreviation or any other words, letters, signs, or figures to indicate that the person using the same is a licensed practical nurse. No person shall practice as a licensed practical nurse unless licensed under this chapter. Refer to KBN 314.031 Review of the KBN website, with a copyright date of 2016, revealed a provisional license would be issued within fourteen (14) days of meeting all application requirements. The provisional license would be valid for a period of six (6) months from the date issued. It instructed the potential employee to not begin employment as an Licensed Practical Nurse Applicant (LPNA) until they had been issued a provisional license by the KBN. Review of the Unlicensed Graduate Nurse's employee file, revealed she was hired as an LPNA on 11/30/15 (under the previous corporation) and was to start work on the second (2nd) shift. There was no evidence in the employee's file of a provisional license to work as a Nurse Applicant. Review of the Charge Nurse (Licensed Practical Nurse (LPN) or Registered Nurse (RN) Job Description, dated 12/04/15, had LPNA hand written on the top. The Unlicensed Graduate Nurse signed the job description for a LPN Charge Nurse. Review of the Job Description Summary, revealed a LPNA would provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. The job description further stated such supervision must be in accordance with current Federal, State and Local standards, guidelines, and regulations that govern the facility, and as may also be required by the Director of Nursing to maintain the highest degree of quality care at all times. Some Essential Duties and Responsibilities were: to direct the day-to-day functions of the nursing assistants in accordance with rules; regulations and confirm that all nursing personnel assigned comply with the written policies and procedures; make written and oral reports/recommendations concerning the activities of your shift; periodically review the residents' written discharge plans; participate in the updating of the residents' written discharge plans; admit transfer and discharge residents; complete accident and incident reports as necessary; complete and file required forms/charts; receive telephone orders from physicians and record on the physician's orders [REDACTED]. reflect that the care plan was being followed when administering nursing care or treatment; prepare and administer medication; order prescribed medications; verify narcotic records were accurate; make rounds with the physicians; and, consult with the resident's physician. The Job Requirement stated the nurse was to have the ability to work with minimal supervision, take initiative and make independent decisions. Review of the Unlicensed Graduate Nurse's Employee Schedule, dated 12/02/15, 12/03/15, 12/04/15, 12/07/15 and 12/08/15 revealed she worked on the unit with a Preceptor. However, on 12/10/15 the Unlicensed Graduate Nurse began to work the Rehabilitation Unit by herself, with no Preceptor. Review of the Unlicensed Graduate Nurse's employee file, revealed no evidence that an orientee checklist had been completed by the Preceptor. Interview with Licensed Practical Nurse (LPN) #8, on 03/29/16 at 4:00 PM, revealed she witnessed the Unlicensed Graduate Nurse work as a nurse on the 600 Unit (Rehabilitation Unit). LPN #8 stated she completed narcotic counts and gave report to the Unlicensed Graduate Nurse. Further interview with LPN #8 revealed she was not aware that the Unlicensed Graduate Nurse did not have a nursing or provisional (temporary) license. Interview with Registered Nurse (RN) #3, on 03/30/16 at 2:56 PM, revealed she precepted the Unlicensed Graduate Nurse and taught her the daily operations such as; taking telephone orders, documenting and doing assessments. RN #3 stated she was not required to sign behind the orientee. She stated when completing medication pass or treatments she had the orientee sign off that the medication was given or that the treatment was completed. Further interview with RN #3 revealed she also had the orientee sign if she administered a narcotic. RN #3 stated she was aware the Unlicensed Graduate Nurse was a new nurse, but did not know she did not have a license. She stated she remembered a check list that the Unlicensed Graduate Nurse kept with her. RN #3 stated she precepted the Unlicensed Graduate Nurse for one (1) to two (2) days; and, then the Unlicensed Graduate Nurse started working on the West Wing (Rehabilitation Unit) on second (2nd) shift, by herself. Interview with Registered Nurse (RN) #1, on 03/31/16 at 8:55 AM, revealed she had precepted new nurses during orientation. RN #1 stated there had been some nurses who had an orientee checklist and some who did not have the checklist. When the Unlicensed Graduate Nurse was hired the facility did not have a policy regarding orientation checklists; however, according to the new corporation's facility's policy, all orientees should have a orientation check list. RN #1 stated she had also precepted new graduate applicant nurses. She stated she would observe them do their tasks and then she would sign that the task had been completed; the nurse applicant did not sign that the tasks had been completed. Interview with RN #2, on 03/31/16 at 10:15 AM, revealed she worked from 6:30 AM to 6:30 PM and had precepted the Unlicensed Graduate Nurse. RN #2 stated she remembered educating the Unlicensed Graduate Nurse on the facility's nursing forms; Medication Administration Records, Treatment records, telephone orders, and how to complete a proper medication pass. RN #2 stated she remembered there was an orientee checklist on how to provide tracheotomy care, wounds, gastric tubes, vitals and assessments. RN #2 stated she did not remember the Unlicensed Graduate Nurse providing a new orientee checklist for review. She stated she was not aware the Unlicensed Graduate Nurse did not have a provisional license to work. RN #2 stated she would not have taken on the preceptor role for someone who did not have a license (provisional or regular). RN #2 stated she was with the Unlicensed Graduate Nurse the whole time she precepted with her. She stated she thought the Unlicensed Graduate Nurse was an LPNA and had not sat for her nursing boards yet. Interview with the Staff Development Coordinator (SDC), on 03/29/16 at 11:35 AM, revealed the Preceptor was responsible for the hands on training of staff. New Orientees were given a minimum of five (5) days on the unit for training. The SDC stated the Unlicensed Graduate Nurse did all of the activities a LPN did, such as medication pass, treatments, laboratory draws and antibiotic therapy, including using an intravenous (IV) access. Interview with the Unlicensed Graduate Nurse, on 03/31/16 at 10:30 AM, revealed she functioned as a LPN and completed such tasks as medication pass, treatments, initiated care plans, took off physician's orders [REDACTED]. The Unlicensed Graduate Nurse stated she worked all shifts and at night she would have as many as two (2) halls on the West Unit. She stated no one followed up with the care she provided. Further interview with the Unlicensed Graduate Nurse revealed she was given a name badge that stated LPN and her name badge was never corrected by Unit Manager #1 on the West Hall. Review of Narcotic Record Sheets for Resident #4, revealed Unlicensed Graduate Nurse provided Zolipem [MEDICATION NAME] (Sleeping pill) five (5) Milligrams (mg) on 02/10/16 at 9:00 PM. There was no written documentation that another licensed staff member signed that they had witnessed the Unlicensed Graduate Nurse complete this task. Review of the Narcotic Record Sheets for Resident #5, revealed the Unlicensed Graduate Nurse [MEDICATION NAME](sleeping pill)10 mg to the resident on 02/24/16 at 8:00 PM. In addition, the Unlicensed Graduate Nurse completed the full Nursing Assessment; she took vitals, reviewed the resident's past surgical history, assessed the resident's cognition, communication, bed mobility, transfer status, dressing, eating, toileting, and hygiene status. The Unlicensed Graduate Nurse assessed Resident #5's neurological, respiratory, gastrointestinal, cardiovascular and urinary systems. Further review revealed the Unlicensed Graduate Nurse documented a full skin assessment of the resident, noting that the resident had a surgical wound to his/her coccyx. The Unlicensed Graduate Nurse completed a pressure ulcer risk assessment, pain evaluation and falls' risk evaluation for Resident #5. All of these tasks were completed with no staff member observing or signing that they witnessed that these actions occurred. Review of Unsampled Resident B's Daily Skilled Nurses' Notes, dated, 03/06/16, 03/08/16, 03/09/16 and 03/10/16, revealed the Unlicensed Graduate Nurse monitored and administered Gastrostomy-tube ([DEVICE]) feeding to ensure Glucerna (supplemental feeding) was being administered at forty-five (45) cubic centimeters per hour (cc/hr). The Unlicensed Graduate Nurse administered Humalog (insulin) per sliding scale to Unsampled Resident B, on 01/08/16, 01/09/16, 01/10/16 and 01/11/16. The Unlicensed Graduate Nurse administered an Levimir Flex Pen (insulin) on 01/08/16, 01/09/16, 01/10/16 and 01/11/16. Further review revealed the Unlicensed Graduate Nurse completed [MEDICATION NAME] (blood thinner) flushes of three (3) milliliters (ml) with a Normal Saline flush of five (5) ml in Unsampled Resident B's Peripherally Inserted Central Catheter (PICC) line (for intravenous administration of medications), on 03/08/16, 03/09/16 and 03/10/16. No staff member signed that they witnessed the Unlicensed Graduate Nurse complete these tasks. Review of Unsampled Resident C's MAR, dated 03/08/16, 03/09/16; and, on 03/11/16, revealed the Unlicensed Graduate Nurse administered [MEDICATION NAME] (breathing treatments) treatments at 6:00 PM. No staff member signed that they witnessed the Unlicensed Graduate Nurse complete these tasks. Review of Unsampled Resident D's Medication Administration Record (MAR) and Treatment Administration Record (TAR), revealed Un-sampled Resident D had a [DIAGNOSES REDACTED]. The MAR and TAR also revealed the Unlicensed Graduate Nurse signed that she checked the placement and residual (feeding left in the stomach) of the [DEVICE] prior to administering medications, flushed the [DEVICE] with thirty (30) milliliters (ml) of water after each medication administration, cleaned the [DEVICE] site during her shift. No staff member signed that they witnessed the Unlicensed Graduate Nurse complete the tasks. Review of Unsampled Resident E's Nursing Admission Information sheet, dated 02/16/16 at 7:00 PM, revealed the Unlicensed Graduate Nurse completed the full Nursing Assessment; she took vital signs, reviewed the resident's past surgical history, assessed the resident's cognition, communication, bed mobility, transfer status, dressing, eating, toileting, and hygiene status. The Unlicensed Graduate Nurse assessed the resident's Vascular Access Device (Port-Cath) (a device implanted under the skin to receive medications) and stated there was no redness, swelling or drainage. The Unlicensed Graduate Nurse assessed Unsampled Resident E's neurological, respiratory, gastrointestinal, cardiovascular and urinary systems. The Unlicensed Graduate Nurse documented a full skin assessment of the resident, noting the resident had tissue damage to his/her feet. Further review of the clinical record revealed the Unlicensed Graduate Nurse completed a pressure ulcer risk assessment, pain evaluation and fall risk evaluation for Unsampled Resident E. All of these tasks were completed with no staff member signing that they witnessed these actions completed. Review of Narcotic Record sheets for Unsampled Resident F, revealed the Unlicensed Graduate Nurse provided [MEDICATION NAME]-[MEDICATION NAME] (pain medication) 5/325 mg on 01/17/16, 01/18/16, 01/19/16, 01/20/16, 01/21/16 and, on 01/24/16 at 8:00 PM. No staff member signed that they witnessed the Unlicensed Graduate Nurse complete the tasks. Review of Narcotic Record sheets, for Unsampled Resident H, revealed the Unlicensed Graduate Nurse provided [MEDICATION NAME]-APAP ([MEDICATION NAME]) (pain medication) 5/325 mg on 01/05/16 at 8:00 PM. There was no documented evidence that another staff member signed that they witnessed the Unlicensed Graduate Nurse complete these tasks. Review of the Narcotic Record sheets, for Unsampled Resident I, revealed the Unlicensed Graduate Nurse provided [MEDICATION NAME]-APAP 5/325 mg on 02/18/16 at 5:30 PM; and, on 02/20/16 at 10:00 PM. No staff member signed that they witnessed the Unlicensed Graduate Nurse complete these tasks. Review of the Midnight Nursing Census, revealed the Unlicensed Graduate Nurse provided care to as many as forty-two (42) residents at one time by herself with no preceptor, with no one ensuring she was performing these tasks correctly. Interview with the Staff Development Coordinator, on 03/30/16 at 10:37 AM, revealed the process for monitoring a nurse with a provisional license, was to monitor until the nurse was comfortable on the unit. The Staff Development Coordinator stated some nurses with provisional licenses could ask for more time with orientation if they needed the help. She stated the Preceptor was the person who reviewed the provisional licensed nurse's work, but they did not have to sign that they witnessed the licensed nurse's care. The Staff Development Coordinator stated there was no policy that stated the Preceptor had to co-sign each document the provisional licensed nurse signed. The Staff Development Coordinator stated she did not monitor to ensure the provisional licensed nurses completed competencies. She further stated she did not give any oversight. However, the Unlicensed Graduate Nurse did not have a provisional license and could not work independently. The KBN instructed the potential employee to not begin employment or function as an LPNA until they had been issued a provisional license by the KBN. Interview with the Staff Development Coordinator (SDC), on 03/30/16 at 8:55 AM, revealed there was no oversight with the preceptor educating nurse applicants. She stated she did go over Foley (brand of indwelling catheter) catheter care, reach care and core competencies once a year. Interview via telephone with Director of Nursing (DON) #2, on 03/31/16 at 9:28 AM, revealed when the Unlicensed Graduate Nurse worked, there was always a Registered Nurse (RN) on the unit. DON #2 stated the rule was for an RN to supervise the Unlicensed Graduate Nurse. The DON could not say if that was everyday; there was not always an RN during the night shift while she was the DON. DON #2 stated she felt the Unlicensed Graduate Nurse could complete a medication pass and do treatments with a provisional license as long as an RN was available for questions. However, this Unlicensed Graduate Nurse did not have a provisional license. Interview with DON #3, on 03/29/16 at 10:55 AM, revealed there should not be any new graduates on the therapy (rehabilitation) halls. She stated only experienced nurses were to work the rehabilitation halls, because the care was like a medical surgical unit. DON #3 stated that nursing judgement, assessments and skills were needed on the Rehabilitation Hall. Interview with the Staff Development Coordinator (SDC), on 03/31/16 at 10:00 AM, revealed she did not receive a competency check off list from the Unlicensed Graduate Nurse. The SDC stated that a new hire had ninety (90) days to turn in the check off list. She stated she did not ask the graduate nurse for the documentation and she did not think it was concerning to have the graduate nurse work without the SDC having the checklist to verify because the prior corporation did not require the checklist, nor did they have a process to monitor the orientation. 2. Review of the facility's Interim Plan of Care Policy, last reviewed 06/01/15, revealed an interim care plan would be developed to meet the resident's immediate needs within twenty-four hours of the resident's admission. The Interim Care Plan would be used until a comprehensive assessment could be conducted and an interdisciplinary care plan was developed. The Interdisciplinary Team would review the physician's orders [REDACTED]. In addition, the nursing evaluation, history and physical, discharge summary report and other pertinent information were to be reviewed. Closed record review of Resident #4's clinical record revealed the facility admitted the resident on 01/15/16 at 11:30 PM with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 01/15/16, revealed the nurse assessed the resident to require assistance of two (2) staff for bed mobility, transfers, and ambulation. The Fall Risk Evaluation (included in the Admission Assessment) identified the resident as high risk for falling due to a score of eleven (11), (a score above ten (10) was a high risk) with a problem with balance. The nurse assessed the resident's balance to be unsteady, and only able to stabilize with physical assistance. Further review of the Fall Assessment revealed the resident had a fall on 01/11/16 prior to admission. Review of the Interim Care Plan, dated 01/15/16, revealed falls were identified as a problem with interventions to verbally remind the resident not to ambulate alone and observe for any unsafe actions and intervene as needed. Continued review of the clinical record revealed the resident's Interim Care Plan was not developed until 02/04/16, to address the resident's injurious fall. Review of a Nurse's Note, dated 01/20/16 at 8:45 PM, revealed the resident was in the shower room with Certified Nursing Assistant (CNA)#5, when he/she attempted an unassisted transfer, and fell on to the wet shower floor. The Note stated the resident tried to catch himself/herself and suffered skin tears to his/her bilateral forearms and complained of severe pain in his/her left shoulder. The Nurse Practitioner was called and an order was received to send the resident to the emergency room for evaluation of the fall. The resident was transferred to a Trauma Center and then placed in the Intensive Care Unit for management of multiple medical problems including fractures to the left humerus, 7th left rib, and 9th [MEDICATION NAME] vertebrae. The resident was in the hospital from 01/21/16 through 01/26/16. Refer to F323. Interview with CNA #8, on 03/17/16 at 2:40 PM, revealed this was the first time he had given Resident #4 a shower and he thought the resident only required supervision with transfers. He had finished bathing the resident and turned around to get his/her clothing to dress the resident. CNA #8 stated he stepped away from the resident a short distance to the sink counter where the resident's clothing was located. He said he saw the resident take a step out of the shower chair and slip on the wet shower floor, face first. CNA #8 stated he thought the nurse aide care plan stated the resident required only supervision with transfers. Request for the nurse aide care plan revealed it was the facility's process not to keep the nurse aide care plans. Once a resident was discharged from the facility, the nurse aide care plan was deleted. The facility could not provide any documented evidence the nurse aide care plan instructed the nurse aides to transfer the resident with supervision only. Interview with the West Wing Unit Manager #1, on 03/17/16 at 3:10 PM, revealed she conducted the fall investigation for Resident #4. She revealed she was not at the facility when the fall occurred, but investigated the fall the next day. She stated she didn't recall what mode of transfer was on the nurse aide care plan before the resident's fall. Further interview revealed she could not provide a copy of the care plan since the resident had been discharged from the facility. Interview with the West Wing Unit Manager #1, on 03/17/16 at 5:37 PM, revealed the facility used the interim care plan until the comprehensive care plan was developed. The resident's care needs (including transfer mode) were communicated to the nurse aides through their care plans. A telephone interview with CNA #7, on 03/17/16 at 6:45 PM, revealed she had cared for Resident #4 on 01/19/16. She stated the resident required assistance of one person for transfers. She stated the resident used an electric wheelchair and was independent once in the chair. She stated the nurse aide care plan instructed staff to transfer the resident with two (2) persons. Interview with Licensed Practical Nurse (LPN) #11, on 04/06/16 at 4:30 PM, revealed she was the nurse who had assessed Resident #4 after the fall in the West Wing Shower Room on 01/20/16. When she entered the shower room she saw Resident #4 laying on the shower floor in front of the shower chair, face down with both arms under him/her. She stated the aide told her he/she had turned around from the resident and the resident attempted an unassisted transfer from the shower chair. The Nurse Aide care plans were updated with changes and the aides were to follow the care plans. She stated the nurse who had completed the admission paperwork would have initiated the interim care plan using the information from the hospital and the nursing assessment. LPN #11 stated she could not recall what the interim care plan or the nurse aide care plan said. She recalled the resident was to be transferred with a physical assist of one (1) or two (2) persons, but after the fall, the resident was a total assist. The facility took the following actions to remove the Immediate Jeopardy: 1. On 03/14/16, Director of Nursing (DON) #3 removed the stakeholder (Unlicensed Graduate Nurse), who did not have a provisional, from the LPNA role. On 03/28/16, the Administrator suspended the stakeholder. 2. The Corporate Care Consultants reviewed and validated thirty-one (31) stakeholders working as licensed nurses on 03/28/16; and, seven (7) were validated on 04/01/16 via the Kentucky Board of Nursing (KBN) online verification report. No stakeholder was found to be working without a valid nursing license. 3. The Corporate Care Consultants reviewed all current residents medical records that were assigned to the non-licensed stakeholder. Forty-one (41) charts were reviewed on 03/31/16; and, nine (9) were reviewed on 04/01/16. Of the fifty (50) charts reviewed, no care issues were noted related to the non-licensed stakeholder. The facility identified twenty-one (21) clinical records that had missing credentials. The DON and Nurse Managers began education addressing appropriate signage of the medical record including credentials for the unlicensed nurse. The facility implemented a Medical Record Review Process on 04/04/16 by the DON. The DON and/or Nurse Managers would review the medical record (physician's orders [REDACTED]. Five (5) percent of the current census would be reviewed for physician orders, nurses' notes and assessments in the daily clinical meeting (Monday-Friday) for two (2) weeks; if compliance was maintained, audits would decrease to 5% three (3) times a week for four (4) weeks, and then monthly for three (3) months. 4. The Consultants provided education to the DON and Nurse Managers on 04/01/16, on the process of auditing of the medical record(s). The education consisted of: legible signature to include credentials; physician orders [REDACTED]. The Nurse Managers, Staff Developed Coordinator (SDC), and DON #3 provided the above education to all licensed nursing stakeholders 04/01/16 through 04/04/16. Any licensed stakeholder that had not received the education by 04/04/16 would be issued a certified letter with the training material. Education and Post Education Competency would be completed by the DON and/or Nurse Managers in person and/or via phone for licensed nurses from 04/01/16 through 04/04/16. When conducting the Post Education Competency via phone, the SDC and/or Nurse Managers would ask the examination questions and document the licensed nurse's response on the examination. The SDC and/or Nurse Managers would follow up with the nurse in person to go over the training material verbally and the stakeholder would complete a written examination with the stakeholder's signature. The SDC and/or Nurse Managers would provide the training to a new stakeholder through the orientation program. The SDC and/or Nurse Manager would provide the Administrator and DON with a verbal progress report of the new stakeholder's performance and/or education skills needed during the orientation process. 5. The Human Resources (HR) Personnel, Receptionist, or Nurse Managers would conduct a KBN online validation report during the interview process for stakeholders applying for a licensed position and when a licensed position status change had occurred. The validation would be printed, reviewed, and signed by the DON, HR Personnel, Receptionist, or Nurse Manager as proof of validation status. The Administrator would conduct the final review. The HR Personnel, Receptionist, or Nurse Managers would conduct monthly and/or needed licensure review via KBN online validation report to ensure licenses were valid for three (3) months. If compliance is maintained, audits would be reduced to quarterly for two (2) quarters then annually thereafter. The Corporate Care Consultants would review completed KBN online validation reports daily (Monday-Friday) for four (4) weeks. If compliance is maintained, audits would decrease to two (2) times per week for four (4) weeks to ensure the validation process was completed. The audits would decrease to monthly for three (3) months during their facility visits. 6. The Corporate Care Consultants, Regional Vice President, and/or HR Advisory Personnel would provide ongoing education as needed for new administrative staff. The consultants would provide facility visits a minimum of five (5) days per week for two (2) weeks to review action plan and assist with education needs. If compliance was maintained, the visits would decrease to three (3) per week for eight (8) weeks, then a minimum of monthly thereafter. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 03/28/16 to review the survey findings and the facility's licensure validation process. Those in attendance included the Administrator, DON, HR Director, Unit Nurse Managers, and the Medical Director. On 03/30/16, a second Ad Hoc QAPI meeting was conducted with the Administrator, DON, Medical Director, Social Services, SDC, and Unit Managers to review policies and procedures related to the hiring and orientation process, and the supervision of LPNAs, RNAs, and student nurses. No changes were made to the hiring process or the Orientation Checklist. The Orientation Checklist for licensed stakeholders would be utilized for LPNAs and RNAs with direct supervision. A new Supervision Policy was created for LPNAs, RNAs, and student nurses on 03/30/16 during the QAPI meeting with the approval of the Medical Director. In addition, the Physical Order/Supplies and Scheduling of Medical Appointments Process was reviewed with no changes. A third Ad Hoc meeting was held on 04/01/16 with the Administrator, DON, and Medical Director via phone to review all recent survey citations and action plans. On 04/04/16, the Administrator and DON met with the Medical Director for overview of the survey findings: F281-discussed the incident with a non-licensed nurse related to Professional Standards with implementation of Licensure Validation Process; F282-discussion of oversight to ensure the care plan was followed; F309-discussed the failure to follow physician orders, provision of supplies, and scheduling of medical appointments; F490-reviewed the role of the Administrator to provide oversight for facility operations. Guidance and oversight would be provided by the Regional Vice President. The Administrator would review all audits and conduct observation rounds. F499- recapped the process for preventing non-licensed staff from working as licensed staff by completing the Licensure Validation Process. F514-reviewed education provided to maintain compliance in the deficient areas, including a post examination. Al

Based on interview, record review and policy review, it was determined the facility failed to ensure the Administrator was onsite providing oversight to the Administrator In Training (AIT) and providing assistance with administrative decision making. On 11/30/15, the AIT signed for approval to hire an unlicensed Graduate Nurse who did not possess a valid provisional license to function as a Practical Nurse Applicant. The facility's failure to ensure Administrative oversight to an AIT and provision of assistance with administrative decision making placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 03/31/16 and determined to exist on 11/30/15. The facility was notified on the Immediate Jeopardy on 03/31/16. The facility provided an acceptable Allegation of Compliance (AOC) on 04/04/16, which alleged removal of Immediate Jeopardy on 04/05/16. The State Survey Agency (SSA) verified the Immediate Jeopardy was not removed on 04/05/16 as alleged, but on 04/07/16 (facility allowed a nurse to return to work without training on 04/06/16) prior to exit on 04/08/16. The scope and severity was lowered to an E while the facility develops and implements a plan of correction and the Quality Assurance monitors for effectiveness of the systemic changes. The findings include: Interview with the Human Resource (HR) Assistant, on 03/30/16 at 2:05 PM, revealed it was her job to print off the nurse aid abuse check, nursing license and background checks (Investigative Information Report Form) and place it in the Administrators mailbox for review. Review of the Unlicensed Graduate Nurse's Investigative Information Report Form, request date of 11/18/15, revealed the Administrator signed her signature and dated the form 11/30/15. Interview with the Administrator in Training (AIT)/Admission Coordinator, on 03/30/15 at 1:35 PM, revealed she was the Administrator in Training from late October 2015 until February 2016 and was under a couple of Interim Administrators; Interim Administrator #1, #2 and #3. The AIT/Admission Coordinator stated some of her tasks included to sign off on background checks. She would check for felonies, misdemeanors and if they occurred she would look back at how many years. The AIT/Admission Coordinator stated she remembered the Staff Development Coordinator shoving in her face documents to sign and she thought she was signing the form for the background check, not to give approval for the employment of the Unlicensed Graduate Nurse. She stated she was told to sign the form because the background check had to be reviewed. She further stated she had not been educated on the hiring process. The AIT/Admission Coordinator stated when there was an Administrator in Training there was to be an Administrator on the premises. She stated some days Interim Administrator #1 was not present and instructed her to call if she had questions. She stated sometimes she would not get a response back if she had a question about a document. The AIT/Admission Coordinator stated she told Corporate at the time of her concern and she thought the Corporation felt there was no concern. The AIT/Admission Coordinator reviewed the Unlicensed Graduate Nurse's new hire documents and stated it looked like she gave the approval for hire and she was not aware she was doing that. The AIT/Admission Coordinator stated she thought if nurses did not have a license they could not work and there was no policy about graduate nurses working for ninety (90) days without a provisional license. Interview with the Staff Development Coordinator (SDC), on 03/30/16 at 2:00 PM, revealed she did not recall having the AIT sign the approval for the Unlicensed Graduate Nurse to work. Interview via telephone with Interim Administrator #1, on 03/31/16 at 9:07 AM, revealed he worked in the facility as the Interim Administrator from October 2015 until 11/30/15. He stated 11/30/15 was his last day. Interim Administrator #1 stated there was an Administrator In Training and he was aware she did not have a license, although she was functioning as the Assistant Administrator. He stated there were times when the Administrator in Training was left working by herself, stating that it was not required to have a Licensed Administrator in the building at all times. According to Interim Administrator #1 the AIT was essentially an Assistant to the Administrator and was not making administrative decisions. Interim Administrator #1 stated he was not familiar with the Unlicensed Graduate Nurse and was not aware nor involved with the hiring of the employee. According to Interim Administrator #1, he was not sure if he trained the AIT regarding the reviewing of Human Resource Documents. The AIT should have called him if she had any questions. The Unlicensed Graduate Nurse should not have been hired without a license. Interview via telephone with Interim Administrator #2, on 03/30/16 at 3:37 PM, revealed he worked from 12/01/15 through January 2016 about twenty-five (25) days as the Interim Administrator. Further interview revealed that he and the Administrator in Training would look at questionable background checks of new employees and would sign for approval to hire. According to Interim Administrator #2, he was always with the Administrator in Training and an Administrator in Training was not to be left alone. Further interview with Interim Administrator #2 revealed he worked seven (7) days a week and did not know of any Unlicensed Graduate Nurse working as a nurse. He stated if the Administrator In Training signed for the approval of a new hire, he would want to see the form to review. The Interim Administrator stated he signed all documents after 12/01/16. Interview with the current Director of Nursing (DON) #3, on 03/30/16 at 3:45 PM, revealed Interim Administrator #1 was the Administrator until 11/30/15. DON #3 stated Interim Administrator #1 would leave the Administrator In Training by her self all the time. She stated if the facility had questions they would call Interim Administrator #1. DON #3 further stated she did not remember the Interim Administrator being in the building. Interview with DON #2, on 03/31/16 at 9:28 AM, revealed the SDC was completing all of the new hires at that time and Corporate was sending the SDC resumes of potential hires. The DON stated so if a nurse did not have a provisional license she should not have been working because the residents could have been harmed. Interview with Administrator #3, on 03/30/16 at 3:55 PM, revealed if there was a question about a staff member's background check, the staff would ask the Administrator for approval to hire. Administrator #3 stated she would review the Investigative Information Report Form and look at the whole document. The Administrator stated she would check the offenses, but probably not the Kentucky Board of Nursing licensure, because she would assume that had already been checked by Human Resources. Administrator #3 stated an AIT would not make Administrative decisions because they do not have a license and that was out of their scope of practice. She stated the AIT staff could not be left alone in a facility to make Administrative decisions. The facility took the following actions to remove the Immediate Jeopardy: 1. On 03/14/16, DON #3 removed the stakeholder (Unlicensed Graduate Nurse), who did not have a provisional, from the LPNA role. On 03/28/16, the Administrator suspended the stakeholder. 2. The Corporate Care Consultants reviewed and validated thirty-one (31) stakeholders working as licensed nurses on 03/28/16; and, seven (7) were validated on 04/01/16 via the Kentucky Board of Nursing (KBN) online verification report. No stakeholder was found to be working without a valid nursing license. 3. The Corporate Care Consultants reviewed all current residents medical records that were assigned to the non-licensed stakeholder. Forty-one (41) charts were reviewed on 03/31/16; and, nine (9) were reviewed on 04/01/16. Of the fifty (50) charts reviewed, no care issues were noted related to the non-licensed stakeholder. The facility identified twenty-one (21) clinical records that had missing credentials. The DON and Nurse Managers began education addressing appropriate signage of the medical record including credentials for the unlicensed nursee. The facility implemented a Medical Record Review Process on 04/04/16 by the DON. The DON and/or Nurse Managers would review the medical record (physician's orders [REDACTED]. Five (5) percent of the current census would be reviewed for physician orders, nurses's notes and assessments in the daily clinical meeting (Monday-Friday) for two (2) weeks; if compliance was maintained, audits would decrease to 5% three (3) times a week for four (4) weeks, and then monthly for three (3) months. 4. The Consultants provided education to the DON and Nurse Managers on 04/01/16, on the process of auditing of the medical record(s). The education consisted of: legible signature to include credentials; physician orders [REDACTED]. The Nurse Managers, Staff Developed Coordinator (SDC), and DON #3 provided the above education to all licensed nursing stakeholders 04/01/16 through 04/04/16. Any licensed stakeholder that had not received the education by 04/04/16 would be issued a certified letter with the training material. Education and Post Education Competency would be completed by the DON and/or Nurse Managers in person and/or via phone for licensed nurses from 04/01/16 through 04/04/16. When conducting the Post Education Competency via phone, the SDC and/or Nurse Managers would ask the examination questions and document the licensed nurse's response on the examination. The SDC and/or Nurse Managers would follow up with the nurse in person to go over the training material verbally and the stakeholder would complete a written examination with the stakeholder's signature. The SDC and/or Nurse Managers would provide the training to a new stakeholder through the orientation program. The SDC and/or Nurse Manager would provide the Administrator and DON with a verbal progress report of the new stakeholder's performance and/or education skills needed during the orientation process. 5. The Human Resources (HR) Personnel, Receptionist, or Nurse Managers would conduct a KBN online validation report during the interview process for stakeholders applying for a licensed position and when a licensed position status change had occurred. The validation would be printed, reviewed, and signed by the DON, HR Personnel, Receptionist, or Nurse Manager as proof of validation status. The Administrator would conduct the final review. The HR Personnel, Receptionist, or Nurse Managers would conduct monthly and/or needed licensure review via KBN online validation report to ensure licenses were valid for three (3) months. If compliance is maintained, audits would be reduced to quarterly for two (2) quarters then annually thereafter. The Corporate Care Consultants would review completed KBN online validation reports daily (Monday-Friday) for four (4) weeks. If compliance is maintained, audits would decrease to two (2) times per week for four (4) weeks to ensure the validation process was completed. The audits would decrease to monthly for three (3) months during their facility visits. 6. The Corporate Care Consultants, Regional Vice President, and/or HR Advisory Personnel would provide ongoing education as needed for new administrative staff. The consultants would provide facility visits a minimum of five (5) days per week for two (2) weeks to review action plan and assist with education needs. If compliance was maintained, the visits would decrease to three (3) per week for eight (8) weeks, then a minimum of monthly thereafter. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 03/28/16 to review the survey findings and the facility's licensure validation process. Those in attendance included the Administrator, DON, HR Director, Unit Nurse Managers, and the Medical Director. On 03/30/16, a second Ad Hoc QAPI meeting was conducted with the Administrator, DON, Medical Director, Social Services, SDC, and Unit Managers to review policies and procedures related to the hiring and orientation process, and the supervision of LPNAs, RNAs, and student nurses. No changes were made to the hiring process or the Orientation Checklist. The Orientation Checklist for licensed stakeholders would be utilized for LPNAs and RNAs with direct supervision. A new Supervision Policy was created for LPNAs, RNAs, and student nurses on 03/30/16 during the QAPI meeting with the approval of the Medical Director. In addition, the Physical Order/Supplies and Scheduling of Medical Appointments Process was reviewed with no changes. A third Ad Hoc meeting was held on 04/01/16 with the Administrator, DON, and Medical Director via phone to review all recent survey citations and action plans. On 04/04/16, the Administrator and DON met with the Medical Director for overview of the survey findings: F281-discussed the incident with a non-licensed nurse related to Professional Standards with implementation of Licensure Validation Process; F282-discussion of oversight to ensure the care plan was followed; F309-discussed the failure to follow physician orders, provision of supplies, and scheduling of medical appointments; F490-reviewed the role of the Administrator to provide oversight for facility operations. Guidance and oversight would be provided by the Regional Vice President. The Administrator would review all audits and conduct observation rounds. F499- recapped the process for preventing non-licensed staff from working as licensed staff by completing the Licensure Validation Process. F514-reviewed education provided to maintain compliance in the deficient areas, including a post examination. Also reviewed the audit system/tools implemented to monitor processes. Audits would be discussed in the morning meeting, weekly QAPI and monthly QAPI. The IDT team will meet weekly times four (4) weeks to review all audit findings. If compliance was maintained, will reduce to monthly. 8. Order/Supply Process: Licensed nurse (s) would place physician orders [REDACTED]. Medical appointments would be scheduled as ordered, including transportation and logged on the monthly calendar. Unit Managers (Nurse Mangers) would review admission/readmission and/or new telephone orders and discuss in the morning clinical meetings (Monday-Friday). Ordered supplies would be discussed in the morning clinical meeting to ensure supplies were available for the resident (s). If the supplies cannot be obtained, a licensed nurse would contact the resident's physician for alternative orders until the supplies were available. 9. The Regional Vice President reviewed administrative duties that included: hiring process, licensure validation, facility oversight, role of the Administrator-in-training, and the job description with the Administrator on 04/04/16. The Regional Vice President will conduct weekly telephone calls with the Administrator for four (4) weeks to discuss current action plans and audit findings. If the facility's operations and oversight meet the residents' needs, the conference call would decrease to monthly for three (3) months, and then quarterly thereafter. If non-compliance is noted, the Vice President would modify oversight as needed to meet the needs of the residents. The State Agency validated removal of the Immediate Jeopardy on 04/07/16 as follows: 1. Review of the Stakeholder Suspension Form revealed the unlicensed stakeholder was suspended on 03/28/16 by the Administrator. Review of a written statement from DON #3 revealed she removed the employee from any licensed nurse duties on 03/14/16. Interview with the DON, on 04/06/16 at 3:29 PM and Administrator, on 04/06/16 at 5:03 PM, validated the stakeholder was suspended on 03/28/16. 2. Review of the facility's licensed staff roster revealed thirty-eight (38) nurses were employed as of 04/06/16. All thirty-eight (38) nurses had a KBN validation report validating they had a valid nursing license. Interview with Corporate Care Consultants #2, and #3, on 04/07/16 at 1:03 AM, revealed the facility had obtained validation of license for all nurses employed by the facility. Received validation reports from the KBN and no stakeholder was working without a license. 3. Review of the medical record review audit sheet revealed forty-three (43) records were reviewed with no problem identified. The audits were conducted on 03/31/16 and 04/01/16 by three (3) Corporate Care Consultants. Interview with Corporate Care Consultants #2 and #3, on 04/07/16 at 10:03 AM, revealed the review of the clinical record found no resident experienced a negative outcome related to the non-licensed stakeholder. The audit did find the nurses were not always signing with credentials. Review of the Medical Record Audit sheets, dated 04/01/16 through 04/06/16, revealed eight (8) to ten (10) residents' records were audited daily by the DON, Nurse Managers, and Corporate Care Consultants. Interview with Consultants #2 and #3, on 04/07/16 at 10:03 AM, West Wing Unit Manager, on 04/06/16 at 3:10 PM, and DON #3, on 04/06/16 at 3:29 PM, revealed medical record audits were being conducted for 5% of the resident census to ensure physician orders [REDACTED]. 4. Review of the training records revealed DON #3, East Unit Manager and West Unit Manager revealed they received training on 04/01/16 on how to audit the medical record and education on legible signatures with credentials, physician orders, supervision of LPNAs, RNAs, and nursing students, following care plans, and scheduling appointments. A post test was taken with the DON and managers scoring 100%. Interview with DON #3, on 04/06/16 at 3:29 PM, revealed she had received the education on the topic above. She then provided training to all licensed nursing stakeholders. She was trained on how to conduct the medical record audits and was involved in conducting those audits. Interview with the East Wing Unit Manager, on 04/06/16 at 11:25 AM, revealed she had been trained to do the medical record audits; however, she had not conducted the audits to date. She revealed she had only been in this position for three (3) weeks and was still learning. Further interview revealed she validated she had received training on physician orders, care plans, scheduling of appointments, documentation to be legible and to include credentials; and, supervision of LPNAs and RNAs. She had not conducted training of the nurses. Interview with the West Wing Unit Manager, on 04/06/16 at 3:10 PM, revealed she had been trained on how to conduct audits of the medical record and had conducted a few over the weekend. She validated she received training on physician orders, documentation in the medical record to be legible with credentials, care plans, scheduling of appointments, physician orders, and supervision of LPNAs and RNAs. She had not conducted training of the nurses. Review of the training records and post test revealed thirty-three (33) licensed nurses and four (4) Certified Medication Technicians were trained on documentation in the medical record that was complete, legible and included credentials. In addition, physician orders, care plans, scheduled appointments, and supervision of LPNAs and RNAs was also reviewed by the survey team. All had passed the post test with a score of 100. Record review revealed five (5) stakeholders had not received the training as of 04/04/16. Certified letters were sent on 04/04/16 to those employees. Copies of the letters were reviewed and the certified mail receipts. A letter written by the Administrator, dated 04/04/16, accompanied the training material. In the letter, the Administrator instructed the licensed nurses they must review the enclosed education material and complete a post test before returning to work. The stakeholder was instructed to turn in the post test and sign the training roster before returning to the facility for a scheduled shift. Validation interviews were conducted on 04/06/16 with LPN #12 at 10:46 AM, LPN #9 at 11:08 AM, LPN #6 at 1:46 PM, LPN #11 at 4:23 PM, and LPN #3 at 4:38 PM, revealed they had received the training and taken the post test. Each nurse had good knowledge of the training topics. Interview with LPN #8, on 04/06/16 at 11:42 AM revealed she needed to complete the training. She stated she had been informed of a certified letter, but she had not been to the post office to pick up the certified letter. Therefore, she did not know what the letter contained. She stated she started her work shift today at 6:30 AM and nobody had informed her that she had to complete the training before caring for residents. She stated the Unit Manager had not said anything to her and she had not received any training over the phone. Interview with the West Unit Manager, on 04/16/16 at 11:58 AM, revealed she was unaware the nurse had not received the training. She stated she did realize the DON had not provided training over the phone until the nurse could receive the training in person and taken the post test. Interview with DON #3, on 04/06/16 at 12:06 AM and 12:12 PM, revealed she had called LPN #8 twice and never could reach her. She assumed the nurse had received the certified letter with the training material. She stated she had reviewed the working schedule and didn't realize the nurse was working (that day). She stated it was an oversight and she or the Unit Manager realized she had not been trained. Verification of the nurse's training with a post test was provided to the surveyor on 04/16/16 at 12:10 PM. 5. Review of a newly hired nurse, on 03/29/16, validation check revealed the facility conducted a KBN online validation report on 03/29/16 that revealed the nurse had a valid license. The validation report was reviewed by the HR Personnel, DON #3, Administrator, and Corporate Consultant as indicated by their signatures on the validation report. Review of the training revealed the newly hired nurse had received education on the topics that were included in the AOC. Interview with the HR Director, on 04/06/16 at 4:05 PM, revealed she had received training on the validation process. She stated once an application was received and before an offer letter was sent, she would conduct a validation check with the KBN. After the offer letter was sent another check was conducted at the KBN for abuse registry and a Criminal Background Check would be conducted. She stated she would review the validation report from the KBN then the DON, and the Administrator would do the final check. She stated she assisted with the validation of license for the facility's nurses. The Corporate Consultant signed off as reviewing the hire packet for the newly hired nurse on 04/01/16. The consultant reviewed and signed off on the nurses who are in the interviewing process. 6. Interview with Corporate Care Consultants #2 and #3 and the Special Project Consultant, on 04/07/16 at 10:03 AM revealed they would be providing oversight and assistance to the facility for some time. They stated they have been at the facility daily including some weekend days to conduct audits and assist with educational needs. Consultants #1, #2, and #3 would be at the facility Monday-Friday for several weeks to review action plans, audits, and training before they decrease to three (3) times a week. Once they identify any non-compliance, re-education would be conducted. They were looking at the clinical matrix, and the development of education topics that may include other disciplines beside nursing. The facility did not have a new Administrator in training at the time of the survey. A consultant will attend the clinical meetings to ensure a meeting is held as stated and topics discussed. The consultants reviewed the audits to ensure they were being conducted correctly and to see if there were any training issues. They were in the process of developing an afternoon meeting to recap the day. 7. Review of the QAPI signature sheet, dated 03/28/16, revealed the survey findings were discussed. The Medical Director, Administrator, DON, Corporate Consultant #1, and five (5) other committee members. On 03/30/16, an Ad Hoc meeting was held to discuss the Immediate Jeopardy findings. The Administrator, DON, Unit Managers and SDC was present with the Medical Director via phone conference. Additional Ad Hoc QAPI meetings were held on 04/01/16, 04/04/16 and 04/06/16. Interview with the Administrator, on 04/06/16 at 5:03 PM, validated the above QAPI meetings were held. She stated she conducted the meetings and the Medical Director was either present in person or via phone. She stated the frequent QAPI meetings were to review what process had been changed and were they effective. The committee reviewed the audits. She stated the audits were also reviewed in the morning meetings before they were reviewed in the QAPI meetings. She stated she will conduct a weekly QAPI meeting for the next month. In addition, the IDT meet weekly to review the audits. Interview with the Medical Director, on 04/06/16 at 4:48 PM, revealed he had been involved in the whole process since the beginning of the Immediate Jeopardy. The facility's Administrator provided him an overview of the survey findings and requested his input in the corrective plans. He reviewed the policies and validation process and discussed the physician orders [REDACTED]. 8. Review of Unsampled Residents L's and M's record revealed physician orders [REDACTED]. Review of the appointment calendar revealed the scheduled appointment had been placed in the calendar with transportation obtained. Review of the appointment calendars for the East and West Units and audits revealed no missed appointments. 9. Review of the education provided by the Regional Vice President to the Administrator and DON #3, on 04/04/16, revealed the training was on F490 and review of the Administrator's job description. A telephone interview with the Regional Vice President, on 04/07/16 at 9:54 AM, revealed he validated the training provided to the facility's Administrator. He stated he reviewed the role of the Administrator and responsibilities related to the hiring process, licensure validation, facility oversight, and Administrator in training. He stated the Administrator would provide oversight through observation rounds and review of clinical meeting findings. He stated he would conduct weekly telephone conference calls with the Administrator to discuss current corrective action plans, audit findings, facility operation, and oversight met the residents' needs. He would conduct the weekly calls for four (4) weeks and then decrease to monthly times three (3) months, then quarterly.

Based on observation, interview, record review, facility policy review and review of the Kentucky Board of Nursing Laws, it was determined the facility failed to ensure an Unlicensed Graduate Nurse was licensed in accordance with state laws (Kentucy Regulatory Statutes 314.031 and 314.051) for one (1) of one (1) Unlicensed Graduate Nurse of the Licensed Practical Nurse (LPN) Program. On 11/30/15, the facility hired an Unlicensed Graduate Nurse of a Licensed Practical Nurse Program to function as an Licensed Practical Nurse Applicant (LPNA). However, the facility failed to ensure the Graduate Nurse held a provisional license to perform the duties as a Licensed Practical Nurse Applicant. Duties of a LPNA included direct the day-to-day functions of the nursing assistants; make reports and recommendations of shift, periodically review/update discharge plans, admit, transfer and discharge residents, complete accident and incident reports, complete and file forms/charts, physicians orders, medication cards, treatments and care plans, record new/changed diet orders, routine charting and entries, nurses notes, prepare and administer medication, order prescribed medications, verify narcotic records were accurate, round and consult with physicians. The Unlicensed Graduate Nurse documented the care she provided to residents including clinical assessments, medication administration, treatments, diabetic care that included insulin injections, and [MEDICATION NAME] flushes for an intravenous (IV) line as a Licensed Practical Nurse Applicant (LPNA). The facility failed to have an effective system in place for hiring and ensuring unlicensed professional staff had the appropriate credentials upon hire, placing residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 03/30/16 and determined to exist on 11/30/15. The facility was notified of the Immediate Jeopardy on 03/30/16. The facility provided an acceptable Allegation of Compliance (AOC) on 04/04/16, which alleged removal of Immediate Jeopardy on 04/05/16. The State Survey Agency (SSA) verified the Immediate Jeopardy was not removed on 04/05/16 as alleged, but on 04/07/16 (facility allowed a nurse to return to work without training on 04/06/16) prior to exit on 04/08/16. The scope and severity was lowered to an E while the facility develops and implements the plan of correction and the Quality Assurance monitors for effectiveness of the systemic changes. The findings include: Review of the facility's Licensure and Certification Compliance Functions Policy, revised November 2015, revealed it was the policy of the company that all positions requiring professional licenses or certifications would be filled only by persons holding such license or certifications. It was the obligation of the Stakeholder to verify their information with their respective licensure/certification boards and maintain their license/certification. Any actions taken against a stakeholder's license would be subject to review by the company, and employment action may be taken, up to and including termination. It was the responsibility of the Compliance Department to ensure that all appropriate adjustments were completed based on lapse, inactive, invalid or termination license or certification. Review of the Kentucky Board of Nursing (KBN), Kentucky Nursing Laws, effective June 01, 2007, Unlawful Acts Related to Nursing, page 8, KRS 314.031 revealed it shall be unlawful for any person to call or hold herself or himself out as or use the title of nurse or to practice or offer to practice as a nurse unless licensed or privileged under the provisions of this chapter. It shall be unlawful for any person knowingly to employee a nurse unless the nurse is licensed or privileged under the provisions of this chapter. It shall be unlawful if not reported to the board a person who is [MEDICATION NAME] nursing without a current active license, privilege, or valid temporary work permit issued by the board. KRS 314.051 revealed an LPNA shall only work under the direct supervision of a nurse and shall not engage in independent nursing practice. No other person shall assume the title or use the abbreviation or any other words, letters, signs, or figures to indicate that the person using the same is a licensed practical nurse. No person shall practice as a licensed practical nurse unless licensed under this chapter. Review of the KBN website, not dated, revealed a provisional license would be issued within fourteen (14) days of meeting all application requirements. The provisional license would be valid for a period of six (6) months from the date issued. It instructed the potential employee to not begin employment as an Licensed Practical Nurse Applicant (LPNA) until they had been issued a provisional license by the KBN. Review of the Charge Nurse Licensed Practical Nurse (LPN) or Registered Nurse (RN) Job Description with a handwritten notation at the top of LPNA, dated 12/04/15, revealed the Unlicensed Graduate Nurse signed the job description for a Charge Nurse. Review of the Job Description Summary, revealed the Licensed Practical Nurse Applicant would provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State and Local standards, guidelines, and regulations that govern the facility, and may also be required by the Director of Nursing to maintain the highest degree of quality care at all times. Some Essential Duties and Responsibilities were; to direct the day-to-day functions of the nursing assistants in accordance with rules, regulations and confirm that all nursing personnel assigned comply with the written policies and procedures, make written and oral reports/recommendations concerning the activities of your shift, periodically review the residents' written discharge plans, participate in the updating of the residents' written discharge plans, admit transfer and discharge residents, complete accident and incident reports as necessary, complete and file required forms/charts, receive telephone orders from physicians and record on the Physicians' Order form, transcribe physician orders [REDACTED].'s physician. The Job Requirement stated the nurse was to have the ability to work with minimal supervision, take initiative and make independent decisions. This description was for a LPNA; however, the Graduate Nurse was not a LPNA. Interview with LPN #7, on 03/29/15 at 1:45 PM, revealed she began work at the facility when she had a provisional license. She stated the facility would not let her work until she had one. Interview with LPN #8, on 03/29/16 at 4:00 PM, revealed she had been a nurse since 2006 and had a license when she was hired by the facility. LPN #8 stated she witnessed an Unlicensed Graduate Nurse work as a nurse on the 600 Unit (Rehabilitation Unit). LPN #8 stated she completed narcotic counts and had given report to the Unlicensed Graduate Nurse; however, LPN #8 was not aware the Unlicensed Graduate Nurse did not have a license. Interview with LPN #10, on 03/29/16 at 4:10 PM, revealed she had worked with the Unlicensed Graduate Nurse. She stated she observed the Unlicensed Graduate Nurse completing medication pass, treatments, and obtaining and writing orders from physicians. LPN #10 stated she even helped the Graduate Nurse with an Intravenous (IV). LPN #10 stated the Unlicensed Graduate Nurse reported she had a provisional license. Interview with the Director of the Night Time (PM) Practical Nursing Program for the Unlicensed Graduate Nurse, on 03/30/16 at 4:25 PM, revealed the Unlicensed Graduate Nurse graduated from a Practical Nurse Program on September of 2015. He stated the nursing students were to have a provisional license before they could work and once they received their provisional license they could sit for boards (test to get license). The Director of the PM Practical Nursing Program stated if an unlicensed nurse was working without a provisional license, they would be working out of their scope of practice. Review of the Unlicensed Graduate Nurse's employee file, revealed she was hired as an LPNA on 11/30/15 and was to start work on the second (2nd) shift. Interview with the Unlicensed Graduate Nurse, on 03/28/16 at 1:56 PM, revealed she was told she could work for ninety (90) days before she obtained her license. She started working at the facility on 11/30/15. The Unlicensed Graduate Nurse stated the Director of Nursing (DON) #1 was well aware she did not have a provisional license and she had given the DON all the paper work after she had given it to the KBN for her provisional license. However, the Unlicensed Graduate Nurse stated the background check was not acceptable to the KBN and needed further review, thus a provisional license was not issued to her. The Unlicensed Graduate Nurse stated she was told by the school to obtain a provisional license, but no one informed her that she could not work without the provisional license. Further interview with the Unlicensed Graduate Nurse, on 03/31/16 at 10:30 AM, revealed she also let the Staff Development Coordinator (SDC) know when she was hired that she had applied for a provisional license. The SDC was one-hundred (100) percent (%) aware of everything. Interview with the Staff Development Coordinator (SDC), on 03/30/16 at 9:52 AM, revealed she remembered completing the Unlicensed Graduate Nurse new hire interview and the Unlicensed Graduate Nurse told the SDC that she was applying for an LPNA position. The SDC stated she asked the Unlicensed Graduate Nurse questions like; what type of education, work experience, prior facilities worked, what was her best work experience and what would you do if a resident was yelling at you? The SDC stated the Unlicensed Graduate Nurse informed her she had completed her nursing education, but did not recall her saying she worked anywhere else. On the Unlicensed Practical Nurse's application it showed that it was completed and signed for approval to hire. The SDC stated she was under the impression that graduate nurses could work without a provisional license for ninety (90) days and she did not check if there was a provisional license. Further interview with the SDC, 03/29/16 at 11:35 AM, revealed she was told by DON #1 that she could hire the Unlicensed Graduate Nurse for ninety (90) days as a nurse and to start orientation as a Licensed Practical Nurse Applicant (LPNA). The SDC stated the person responsible to validate licensure was the Human Resource (HR) Department. The HR Department completed the background checks and the check list. The SDC stated she asked the Unlicensed Graduate Nurse about a license and the scheduling of boards, but the Unlicensed Graduate Nurse stated she was clearing something off of her record with the KBN before she could sit for boards. The SDC stated she was not aware applicants could not work without a provisional license. Interview with Director of Nursing (DON) #1, on 03/30/16 at 9:30 AM, revealed her last day in the facility was on 12/11/15. DON #1 stated she knew that as a Licensed Practical Nurse Applicant (LPNA) the graduate nurse could work for ninety (90) days. If there was a policy that did not support the fact that the Unlicensed Graduate Nurse could work for ninety (90) days without a license; DON #1 was not aware. According to DON #1 the only time she got involved with the hiring process was when she would meet with the individual to see if she wanted to hire them. She stated the SDC was responsible to interview new hires and the SDC agreed the Unlicensed Graduate Nurse could work as an LPNA. DON #1 stated it was not her role to check licensure and no one came to her asking her to verify the license of the Unlicensed Graduate Nurse. DON #1 further stated she did not tell anyone that it was the policy of the facility that an unlicensed staff member could work for ninety (90) days without a license. DON #1 never spoke to DON #2 about the Unlicensed Graduate Nurse. DON #1 stated that criminal charges could occur if a staff member was working without a license on a nursing unit. Interview with DON #2, on 03/31/16 at 9:28 AM, revealed she worked at the facility from 01/14/16 through 03/10/16 and remembered the Unlicensed Graduate Nurse; however, she was not aware the Unlicensed Graduate Nurse did not have a provisional license to work. DON #2 stated she remembered talking to the SDC and Human Resource (did not remember what date) about when the Unlicensed Graduate Nurse was going to take his/her nursing boards. According to DON #2 the SDC told her at that time, the Unlicensed Graduate Nurse was a LPNA and had thirty (30) days left until she was to take the nursing boards. DON #2 stated if she would have known the Unlicensed Graduate Nurse did not have a provisional license, she would not have let her work. Interview with Human Resource (HR), on 03/30/16 at 9:10 AM, revealed when the Unlicensed Graduate Nurse was hired she was in orientation and was not involved in the hiring process. HR stated she remembered late February and early March the SDC mentioned that DON #1 had informed her the Unlicensed Graduate Nurse could work for ninety (90) days before obtaining a license. The HR remembered then taking this information to DON #2. DON #2 stated they were working on it and it had been resolved. March 10th was DON #2's last day at the facility. HR stated she had never been trained that an individual could work for ninety (90) days without a license. Only licensed staff could work as a nurse. Interview with the Staff Development Coordinator (SDC), 03/29/16 at 11:35 AM, revealed after DON #2 left the facility, the SDC went to DON #3 to inform her of the Unlicensed Graduate Nurse not having a license and that her ninety (90) days were up. Interview with DON #3, on 03/29/16 at 10:55 AM, revealed she could not answer to all of the care that was provided by the Unlicensed Graduate Nurse. DON #3 stated she knew she worked since November 2015. DON #3 stated she honestly thought the Unlicensed Graduate Nurse was an LPN. DON #3 stated the Staff Development Coordinator and LPN #10 approached her and informed her the Unlicensed Graduate Nurse did not have a license to work, nor had she taken her boards. According to DON #3, she then went to Human Resources. Human Resources stated DON #2 had informed her the Unlicensed Graduate Nurse could work for ninety (90) days on a temporary license. DON #3 stated she then went to the Kentucky Board of Nursing web site and could not find a license for the Unlicensed Graduate Nurse. DON #3 then stated she interviewed the Unlicensed Graduate Nurse who informed her she had not completed boards, nor did she have a provisional license. The Unlicensed Graduate Nurse stated the Kentucky Board of Nursing was working on an issue with her background check. Further interview revealed the Unlicensed Graduate Nurse gave DON #3 the number to the legal department at the Kentucky Board of Nursing and they stated there was a drug and alcohol situation documented on her background check and the Unlicensed Graduate Nurse could not sit for boards. DON #3 stated the Legal Department at the KBN had to review all of her documents and had to develop an agreement regarding monthly drug testing for a year before the provisional license could be issued to the Unlicensed Graduate Nurse. The legal department stated the Unlicensed Graduate Nurse could work as a Certified Nursing Assistant (CNA), but not a nurse. She could not complete treatments, medication pass or assessments. DON #3 stated when she was the Unit Manager on the East Unit, as far as she knew the Unlicensed Graduate Nurse did not work on her unit. It was common knowledge that she was a nurse and completed nursing tasks. DON #3 stated she then told the Unlicensed Graduate Nurse that she could not work until she informed the Administrator. She stated the Administrator then talked to the Unlicensed Graduate Nurse and decided to let the Unlicensed Graduate Nurse work as an assistant to the CNA. After review by DON #3 of the Unlicensed Graduate Nurse's employee file, it was determined the Unlicensed Graduate Nurse had applied to the facility as an LPN. Interview with the Administrator #3, on 03/29/16 at 10:45 AM, revealed DON #2 did not make her aware that the Unlicensed Graduate Nurse was actually not a nurse. DON #1 who was responsible for hiring at the time led the Human Resource (HR) Department to believe that they could hire a non-licensed staff member for ninety (90) days. Administrator #3 stated she found out about the Unlicensed Graduate Nurse not having a provisional license on 03/11/16 by DON #3. She stated HR was asking DON #3 about the status of the Unlicensed Graduate Nurse's license. DON #3 then called the Kentucky Board of Nursing to validate if someone could work without a provisional license and the answer was No, so they took the Unlicensed Graduate Nurse off the floor as a nurse immediately on 03/11/16. Administrator #3 stated she was not sure of all of the services or assignments the Unlicensed Graduate Nurse completed. Administrator #3 stated she informed the Unlicensed Graduate Nurse that working as a nurse could jeopardize her ability to become a nurse. Interview with the Nurse Consultant, on 03/29/16 at 5:32 PM, revealed the company she worked for took over on 12/01/15 and to her understanding there were people who went through the employee files and checked for job descriptions, drug screens and background checks. Further interview with the Nurse Consultant, on 03/30/16 at 8:30 AM, revealed prior to 12/01/15 and prior to the hire of the Unlicensed Graduate Nurse the new corporation had completed licensure checks on all licensed staff. After that the facility was responsible to check licensure on any new staff licensed. Interview with the Corporate Team who assisted with acquisition (change over from one corporation to another corporation), on 03/30/16 at 4:10 PM, revealed the process was for the corporation to request an employee census of basic information, then load the information into the corporations computer. She then would use this information to complete credentialing including licensure checks. There was no concerns identified. The Corporate Team then would reconcile with any information found within thirty (30) days. She stated they were in the facility throughout November of 2015. There was HR training with a webinar. The process for educating the staff to knew policies and procedures was not an immediate process, because it was a blending of the old corporation with the new corporation. The facility took the following actions to remove the Immediate Jeopardy: 1. On 03/14/16, DON #3 removed the stakeholder (Unlicensed Graduate Nurse), who did not have a provisional, from the LPNA role. On 03/28/16, the Administrator suspended the stakeholder. 2. The Corporate Care Consultants reviewed and validated thirty-one (31) stakeholders working as licensed nurses on 03/28/16; and, seven (7) were validated on 04/01/16 via the Kentucky Board of Nursing (KBN) online verification report. No stakeholder was found to be working without a valid nursing license. 3. The Corporate Care Consultants reviewed all current residents medical records that were assigned to the non-licensed stakeholder. Forty-one (41) charts were reviewed on 03/31/16; and, nine (9) were reviewed on 04/01/16. Of the fifty (50) charts reviewed, no care issues were noted related to the non-licensed stakeholder. The facility identified twenty-one (21) clinical records that had missing credentials. The DON and Nurse Managers began education addressing appropriate signage of the medical record including credentials for the unlicensed nursee. The facility implemented a Medical Record Review Process on 04/04/16 by the DON. The DON and/or Nurse Managers would review the medical record (physician's orders [REDACTED]. Five (5) percent of the current census would be reviewed for physician orders, nurses's notes and assessments in the daily clinical meeting (Monday-Friday) for two (2) weeks; if compliance was maintained, audits would decrease to 5% three (3) times a week for four (4) weeks, and then monthly for three (3) months. 4. The Consultants provided education to the DON and Nurse Managers on 04/01/16, on the process of auditing of the medical record(s). The education consisted of: legible signature to include credentials; physician orders [REDACTED]. The Nurse Managers, Staff Developed Coordinator (SDC), and DON #3 provided the above education to all licensed nursing stakeholders 04/01/16 through 04/04/16. Any licensed stakeholder that had not received the education by 04/04/16 would be issued a certified letter with the training material. Education and Post Education Competency would be completed by the DON and/or Nurse Managers in person and/or via phone for licensed nurses from 04/01/16 through 04/04/16. When conducting the Post Education Competency via phone, the SDC and/or Nurse Managers would ask the examination questions and document the licensed nurse's response on the examination. The SDC and/or Nurse Managers would follow up with the nurse in person to go over the training material verbally and the stakeholder would complete a written examination with the stakeholder's signature. The SDC and/or Nurse Managers would provide the training to a new stakeholder through the orientation program. The SDC and/or Nurse Manager would provide the Administrator and DON with a verbal progress report of the new stakeholder's performance and/or education skills needed during the orientation process. 5. The Human Resources (HR) Personnel, Receptionist, or Nurse Managers would conduct a KBN online validation report during the interview process for stakeholders applying for a licensed position and when a licensed position status change had occurred. The validation would be printed, reviewed, and signed by the DON, HR Personnel, Receptionist, or Nurse Manager as proof of validation status. The Administrator would conduct the final review. The HR Personnel, Receptionist, or Nurse Managers would conduct monthly and/or needed licensure review via KBN online validation report to ensure licenses were valid for three (3) months. If compliance is maintained, audits would be reduced to quarterly for two (2) quarters then annually thereafter. The Corporate Care Consultants would review completed KBN online validation reports daily (Monday-Friday) for four (4) weeks. If compliance is maintained, audits would decrease to two (2) times per week for four (4) weeks to ensure the validation process was completed. The audits would decrease to monthly for three (3) months during their facility visits. 6. The Corporate Care Consultants, Regional Vice President, and/or HR Advisory Personnel would provide ongoing education as needed for new administrative staff. The consultants would provide facility visits a minimum of five (5) days per week for two (2) weeks to review action plan and assist with education needs. If compliance was maintained, the visits would decrease to three (3) per week for eight (8) weeks, then a minimum of monthly thereafter. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 03/28/16 to review the survey findings and the facility's licensure validation process. Those in attendance included the Administrator, DON, HR Director, Unit Nurse Managers, and the Medical Director. On 03/30/16, a second Ad Hoc QAPI meeting was conducted with the Administrator, DON, Medical Director, Social Services, SDC, and Unit Managers to review policies and procedures related to the hiring and orientation process, and the supervision of LPNAs, RNAs, and student nurses. No changes were made to the hiring process or the Orientation Checklist. The Orientation Checklist for licensed stakeholders would be utilized for LPNAs and RNAs with direct supervision. A new Supervision Policy was created for LPNAs, RNAs, and student nurses on 03/30/16 during the QAPI meeting with the approval of the Medical Director. In addition, the Physical Order/Supplies and Scheduling of Medical Appointments Process was reviewed with no changes. A third Ad Hoc meeting was held on 04/01/16 with the Administrator, DON, and Medical Director via phone to review all recent survey citations and action plans. On 04/04/16, the Administrator and DON met with the Medical Director for overview of the survey findings: F281-discussed the incident with a non-licensed nurse related to Professional Standards with implementation of Licensure Validation Process; F282-discussion of oversight to ensure the care plan was followed; F309-discussed the failure to follow physician orders, provision of supplies, and scheduling of medical appointments; F490-reviewed the role of the Administrator to provide oversight for facility operations. Guidance and oversight would be provided by the Regional Vice President. The Administrator would review all audits and conduct observation rounds. F499- recapped the process for preventing non-licensed staff from working as licensed staff by completing the Licensure Validation Process. F514-reviewed education provided to maintain compliance in the deficient areas, including a post examination. Also reviewed the audit system/tools implemented to monitor processes. Audits would be discussed in the morning meeting, weekly QAPI and monthly QAPI. The IDT team will meet weekly times four (4) weeks to review all audit findings. If compliance was maintained, will reduce to monthly. 8. Order/Supply Process: Licensed nurse (s) would place physician orders [REDACTED]. Medical appointments would be scheduled as ordered, including transportation and logged on the monthly calendar. Unit Managers (Nurse Mangers) would review admission/readmission and/or new telephone orders and discuss in the morning clinical meetings (Monday-Friday). Ordered supplies would be discussed in the morning clinical meeting to ensure supplies were available for the resident (s). If the supplies cannot be obtained, a licensed nurse would contact the resident's physician for alternative orders until the supplies were available. 9. The Regional Vice President reviewed administrative duties that included: hiring process, licensure validation, facility oversight, role of the Administrator-in-training, and the job description with the Administrator on 04/04/16. The Regional Vice President will conduct weekly telephone calls with the Administrator for four (4) weeks to discuss current action plans and audit findings. If the facility's operations and oversight meet the residents' needs, the conference call would decrease to monthly for three (3) months, and then quarterly thereafter. If non-compliance is noted, the Vice President would modify oversight as needed to meet the needs of the residents. The State Agency validated removal of the Immediate Jeopardy on 04/07/16 as follows: 1. Review of the Stakeholder Suspension Form revealed the unlicensed stakeholder was suspended on 03/28/16 by the Administrator. Review of a written statement from DON #3 revealed she removed the employee from any licensed nurse duties on 03/14/16. Interview with the DON, on 04/06/16 at 3:29 PM and Administrator, on 04/06/16 at 5:03 PM, validated the stakeholder was suspended on 03/28/16. 2. Review of the facility's licensed staff roster revealed thirty-eight (38) nurses were employed as of 04/06/16. All thirty-eight (38) nurses had a KBN validation report validating they had a valid nursing license. Interview with Corporate Care Consultants #2, and #3, on 04/07/16 at 1:03 AM, revealed the facility had obtained validation of license for all nurses employed by the facility. Received validation reports from the KBN and no stakeholder was working without a license. 3. Review of the medical record review audit sheet revealed forty-three (43) records were reviewed with no problem identified. The audits were conducted on 03/31/16 and 04/01/16 by three (3) Corporate Care Consultants. Interview with Corporate Care Consultants #2 and #3, on 04/07/16 at 10:03 AM, revealed the review of the clinical record found no resident experienced a negative outcome related to the non-licensed stakeholder. The audit did find the nurses were not always signing with credentials. Review of the Medical Record Audit sheets, dated 04/01/16 through 04/06/16, revealed eight (8) to ten (10) residents' records were audited daily by the DON, Nurse Managers, and Corporate Care Consultants. Interview with Consultants #2 and #3, on 04/07/16 at 10:03 AM, West Wing Unit Manager, on 04/06/16 at 3:10 PM, and DON #3, on 04/06/16 at 3:29 PM, revealed medical record audits were being conducted for 5% of the resident census to ensure physician orders [REDACTED]. 4. Review of the training records revealed DON #3, East Unit Manager and West Unit Manager revealed they received training on 04/01/16 on how to audit the medical record and education on legible signatures with credentials, physician orders, supervision of LPNAs, RNAs, and nursing students, following care plans, and scheduling appointments. A post test was taken with the DON and managers scoring 100%. Interview with DON #3, on 04/06/16 at 3:29 PM, revealed she had received the education on the topic above. She then provided training to all licensed nursing stakeholders. She was trained on how to conduct the medical record audits and was involved in conducting those audits. Interview with the East Wing Unit Manager, on 04/06/16 at 11:25 AM, revealed she had been trained to do the medical record audits; however, she had not conducted the audits to date. She revealed she had only been in this position for three (3) weeks and was still learning. Further interview revealed she validated she had received training on physician orders, care plans, scheduling of appointments, documentation to be legible and to include credentials; and, supervision of LPNAs and RNAs. She had not conducted training of the nurses. Interview with the West Wing Unit Manager, on 04/06/16 at 3:10 PM, revealed she had been trained on how to conduct audits of the medical record and had conducted a few over the weekend. She validated she received training on physician orders, documentation in the medical record to be legible with credentials, care plans, scheduling of appointments, physician orders, and supervision of LPNAs and RNAs. She had not conducted training of the nurses. Review of the training records and post test revealed thirty-three (33) licensed nurses and four (4) Certified Medication Technicians were trained on documentation in the medical record that was complete, legible and included credentials. In addition, physician orders, care plans, scheduled appointments, and supervision of LPNAs and RNAs was also reviewed by the survey team. All had passed the post test with a score of 100. Record review revealed five (5) stakeholders had not received the training as of 04/04/16. Certified letters were sent on 04/04/16 to those employees. Copies of the letters were reviewed and the certified mail receipts. A letter written by the Admini

Based on interview, record review and facility policy review, it was determined the facility failed to ensure the clinical records were accurate in regards to unlicensed staff documenting with legal credentials for one (1) of twelve (12) sampled residents (Resident #5); and, three (3) of thirteen (13) unsampled residents, (Unsampled Residents B, E, and J). In addition, the facility failed to ensure Resident #5's records were documented completely and accurately as it pertained to a [DEVICE] Assisted Closure (V.A.C.) and Negative-pressure Wound Therapy (NPWT) dressing changes on Tuesdays, Thursdays and Saturdays. On 11/30/15 the facility hired an Unlicensed Graduate Nurse to function as a Practical Nurse Applicant. The Unlicensed Graduate Nurse documented the care provided to residents including clinical assessments, medication administration, treatments, diabetic care that included insulin injections, and [MEDICATION NAME] flushes for an intravenous (IV) line as a Practical Nurse Applicant. The facility's failure to have an effective system in place to ensure clinical assessments, medication administration, treatments, diabetic care and IV medications were documented by qualified personnel who were legally credentialed placed residents at risk for severe injury, harm, impairment or death. The facility provided an acceptable Allegation of Compliance (AOC) on 04/04/16, which alleged removal of Immediate Jeopardy on 04/05/16. The State Survey Agency (SSA) verified the Immediate Jeopardy was not removed on 04/05/16 as alleged, but on 04/07/16 (facility allowed a nurse to return to work without training on 04/06/16) prior to exit on 04/08/16. The scope and severity was lowered to an E while the facility develops and implements the plan of correction and the Quality Assurance monitors for effectiveness of the systemic changes. The findings include: Review of the facility's Charting and Documentation Policy, no date given, revealed documenting of procedures and treatments should include care-specific details and shall include at a minimum the signature and title of the individual documenting. Interview with Licensed Practical Nurse (LPN) #10, on 03/29/16 at 4:10 PM, revealed when a nurse signed a document he/she was to place LPN or Registered Nurse (RN) credentials after their name on any documentation. 1. Review of Resident #5's, admission orders [REDACTED]. Review of Unsampled Resident B's Daily Skilled Nurses Notes, dated 03/06/16 at 5:00 PM, 03/08/16 at 5:40 PM, 03/09/16 at 9:45 PM; and, on 03/10/16 at 9:45 PM, revealed the Unlicensed Graduate Nurse documented her name with the credential of LPN (although she was not a licensed nurse). Review of Unsampled Resident B's physician's orders [REDACTED]. Review of Unsampled Resident E's Nursing Admission Information, dated 02/16/16, revealed the Unlicensed Graduate Nurse signed she completed the assessment with no credentials documented. Review of Unsampled Resident E's Physician order [REDACTED]. All orders were signed with no credentials. Review of Unsampled Resident E's Daily Skilled Nurses Notes, dated 03/10/16 at 10:00 PM, revealed the Unlicensed Graduate Nurse documented her name with the credential of LPN (though she was not a licensed nurse). Review of Unsampled Resident J's admission orders [REDACTED]. Review of Unsampled Resident J's Daily Skilled Nurses Notes, dated 01/31/16 at 6:00 PM, revealed the Unlicensed Graduate Nurse signed her signature with no credentials. Interview via telephone with Director of Nursing (DON) #2, on 03/31/16 at 9:28 AM, revealed she did not check documentation or complete record reviews of random residents' records. DON #2 stated she was not aware the Unlicensed Graduate Nurse was signing LPN after her name and not documenting any credentials on some records. DON #2 stated it was the Unit Managers' responsibility to ensure the staff's documentation contained the appropriate signatures. Interview with DON #3, on 03/29/16 at 10:55 AM, revealed she was not aware the Unlicensed Graduate Nurse's employee badge had LPN after her name instead of LPNA (however, she was not a LPNA, as she had not applied for a license). Nor was DON #3 aware the Unlicensed Graduate Nurse documented LPN in the clinical records. DON #3 stated the nursing staff was to sign their title when completing documents. If the nurse did not document credentials legally then the document was not valid. Interview with Unit Manager #2 of the West Hall, on 03/30/16 at 3:20 PM, revealed when she reviewed the telephone orders, she would look to see that the nurse signed her signature and had placed her credentials legibly. The nursing staff should be documenting their credentials. If a nurse was a graduate nurse with no license, you should not see any credentials behind their name. Unit Manager #2 of the West Hall stated after she reviewed some of the records she identified that the Unlicensed Graduate Nurse worked a lot and should not have worked at all. Interview with DON #3, on 03/28/16 at 12:03 PM, revealed to her knowledge there was no evidence that a nurse had co-signed behind the Unlicensed Graduate Nurse to validate direct supervision of the task provided by the graduate nurse. 2. Review of the facility's Charting and Documentation Policy, no date given, revealed services provided to the resident, or any changes in the resident's medical condition, would be documented in the resident's medical record. Incidents, accidents, or changes in the resident's condition must be recorded. The documentation of the procedure and treatment should include care-specific details and should include at a minimum the date and time the procedure/treatment was provided; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment and whether the resident refused the procedure/treatment. Review of Resident #5's Treatment Administration Record (TAR) for the month of February 2016, revealed on 02/06/16, 02/09/16 and 02/13/16 there was no documented evidence from the nursing staff that the wound V.A.C. was changed. Interview with the Unlicensed Graduate Nurse, on 03/17/16 at 3:21 PM, revealed after reviewing the TAR and the documentation, it appeared the wound V.A.C. dressing had not been completed. According to the Unlicensed Graduate Nurse, if something was not documented, then it was not done. The Unlicensed Graduate Nurse said she would have to say the record was not complete because the documentation had not been completed. Interview with the facility's Wound Nurse, on 03/17/16 at 3:59 PM, revealed no nurse expressed to her that they could not complete the dressing change or that they did not know how to do the dressing. According to the Wound Nurse, she did not look to see if the wound V.A.C. had been changed out timely. When the Wound Nurse reviewed the TAR documentation, she stated if the nurses did not document that they completed a task, then the treatment was not done. Interview with Director of Nursing (DON) #3, on 03/17/16 at 5:50 PM, revealed after reviewing Resident #5's TAR documentation, she could see gaps. The DON stated she had not seen any documentation until 02/13/16. If the TAR was not signed then the wound V.A.C. was not changed and this was not a complete record; however, she had not identified this as a concern. The facility took the following actions to remove the Immediate Jeopardy: 1. On 03/14/16, DON #3 removed the stakeholder (Unlicensed Graduate Nurse), who did not have a provisional, from the LPNA role. On 03/28/16, the Administrator suspended the stakeholder. 2. The Corporate Care Consultants reviewed and validated thirty-one (31) stakeholders working as licensed nurses on 03/28/16; and, seven (7) were validated on 04/01/16 via the Kentucky Board of Nursing (KBN) online verification report. No stakeholder was found to be working without a valid nursing license. 3. The Corporate Care Consultants reviewed all current residents medical records that were assigned to the non-licensed stakeholder. Forty-one (41) charts were reviewed on 03/31/16; and, nine (9) were reviewed on 04/01/16. Of the fifty (50) charts reviewed, no care issues were noted related to the non-licensed stakeholder. The facility identified twenty-one (21) clinical records that had missing credentials. The DON and Nurse Managers began education addressing appropriate signage of the medical record including credentials for the unlicensed nursee. The facility implemented a Medical Record Review Process on 04/04/16 by the DON. The DON and/or Nurse Managers would review the medical record (physician's orders [REDACTED]. Five (5) percent of the current census would be reviewed for physician orders, nurses's notes and assessments in the daily clinical meeting (Monday-Friday) for two (2) weeks; if compliance was maintained, audits would decrease to 5% three (3) times a week for four (4) weeks, and then monthly for three (3) months. 4. The Consultants provided education to the DON and Nurse Managers on 04/01/16, on the process of auditing of the medical record(s). The education consisted of: legible signature to include credentials; physician orders [REDACTED]. The Nurse Managers, Staff Developed Coordinator (SDC), and DON #3 provided the above education to all licensed nursing stakeholders 04/01/16 through 04/04/16. Any licensed stakeholder that had not received the education by 04/04/16 would be issued a certified letter with the training material. Education and Post Education Competency would be completed by the DON and/or Nurse Managers in person and/or via phone for licensed nurses from 04/01/16 through 04/04/16. When conducting the Post Education Competency via phone, the SDC and/or Nurse Managers would ask the examination questions and document the licensed nurse's response on the examination. The SDC and/or Nurse Managers would follow up with the nurse in person to go over the training material verbally and the stakeholder would complete a written examination with the stakeholder's signature. The SDC and/or Nurse Managers would provide the training to a new stakeholder through the orientation program. The SDC and/or Nurse Manager would provide the Administrator and DON with a verbal progress report of the new stakeholder's performance and/or education skills needed during the orientation process. 5. The Human Resources (HR) Personnel, Receptionist, or Nurse Managers would conduct a KBN online validation report during the interview process for stakeholders applying for a licensed position and when a licensed position status change had occurred. The validation would be printed, reviewed, and signed by the DON, HR Personnel, Receptionist, or Nurse Manager as proof of validation status. The Administrator would conduct the final review. The HR Personnel, Receptionist, or Nurse Managers would conduct monthly and/or needed licensure review via KBN online validation report to ensure licenses were valid for three (3) months. If compliance is maintained, audits would be reduced to quarterly for two (2) quarters then annually thereafter. The Corporate Care Consultants would review completed KBN online validation reports daily (Monday-Friday) for four (4) weeks. If compliance is maintained, audits would decrease to two (2) times per week for four (4) weeks to ensure the validation process was completed. The audits would decrease to monthly for three (3) months during their facility visits. 6. The Corporate Care Consultants, Regional Vice President, and/or HR Advisory Personnel would provide ongoing education as needed for new administrative staff. The consultants would provide facility visits a minimum of five (5) days per week for two (2) weeks to review action plan and assist with education needs. If compliance was maintained, the visits would decrease to three (3) per week for eight (8) weeks, then a minimum of monthly thereafter. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 03/28/16 to review the survey findings and the facility's licensure validation process. Those in attendance included the Administrator, DON, HR Director, Unit Nurse Managers, and the Medical Director. On 03/30/16, a second Ad Hoc QAPI meeting was conducted with the Administrator, DON, Medical Director, Social Services, SDC, and Unit Managers to review policies and procedures related to the hiring and orientation process, and the supervision of LPNAs, RNAs, and student nurses. No changes were made to the hiring process or the Orientation Checklist. The Orientation Checklist for licensed stakeholders would be utilized for LPNAs and RNAs with direct supervision. A new Supervision Policy was created for LPNAs, RNAs, and student nurses on 03/30/16 during the QAPI meeting with the approval of the Medical Director. In addition, the Physical Order/Supplies and Scheduling of Medical Appointments Process was reviewed with no changes. A third Ad Hoc meeting was held on 04/01/16 with the Administrator, DON, and Medical Director via phone to review all recent survey citations and action plans. On 04/04/16, the Administrator and DON met with the Medical Director for overview of the survey findings: F281-discussed the incident with a non-licensed nurse related to Professional Standards with implementation of Licensure Validation Process; F282-discussion of oversight to ensure the care plan was followed; F309-discussed the failure to follow physician orders, provision of supplies, and scheduling of medical appointments; F490-reviewed the role of the Administrator to provide oversight for facility operations. Guidance and oversight would be provided by the Regional Vice President. The Administrator would review all audits and conduct observation rounds. F499- recapped the process for preventing non-licensed staff from working as licensed staff by completing the Licensure Validation Process. F514-reviewed education provided to maintain compliance in the deficient areas, including a post examination. Also reviewed the audit system/tools implemented to monitor processes. Audits would be discussed in the morning meeting, weekly QAPI and monthly QAPI. The IDT team will meet weekly times four (4) weeks to review all audit findings. If compliance was maintained, will reduce to monthly. 8. Order/Supply Process: Licensed nurse (s) would place physician orders [REDACTED]. Medical appointments would be scheduled as ordered, including transportation and logged on the monthly calendar. Unit Managers (Nurse Mangers) would review admission/readmission and/or new telephone orders and discuss in the morning clinical meetings (Monday-Friday). Ordered supplies would be discussed in the morning clinical meeting to ensure supplies were available for the resident (s). If the supplies cannot be obtained, a licensed nurse would contact the resident's physician for alternative orders until the supplies were available. 9. The Regional Vice President reviewed administrative duties that included: hiring process, licensure validation, facility oversight, role of the Administrator-in-training, and the job description with the Administrator on 04/04/16. The Regional Vice President will conduct weekly telephone calls with the Administrator for four (4) weeks to discuss current action plans and audit findings. If the facility's operations and oversight meet the residents' needs, the conference call would decrease to monthly for three (3) months, and then quarterly thereafter. If non-compliance is noted, the Vice President would modify oversight as needed to meet the needs of the residents. The State Agency validated removal of the Immediate Jeopardy on 04/07/16 as follows: 1. Review of the Stakeholder Suspension Form revealed the unlicensed stakeholder was suspended on 03/28/16 by the Administrator. Review of a written statement from DON #3 revealed she removed the employee from any licensed nurse duties on 03/14/16. Interview with the DON, on 04/06/16 at 3:29 PM and Administrator, on 04/06/16 at 5:03 PM, validated the stakeholder was suspended on 03/28/16. 2. Review of the facility's licensed staff roster revealed thirty-eight (38) nurses were employed as of 04/06/16. All thirty-eight (38) nurses had a KBN validation report validating they had a valid nursing license. Interview with Corporate Care Consultants #2, and #3, on 04/07/16 at 1:03 AM, revealed the facility had obtained validation of license for all nurses employed by the facility. Received validation reports from the KBN and no stakeholder was working without a license. 3. Review of the medical record review audit sheet revealed forty-three (43) records were reviewed with no problem identified. The audits were conducted on 03/31/16 and 04/01/16 by three (3) Corporate Care Consultants. Interview with Corporate Care Consultants #2 and #3, on 04/07/16 at 10:03 AM, revealed the review of the clinical record found no resident experienced a negative outcome related to the non-licensed stakeholder. The audit did find the nurses were not always signing with credentials. Review of the Medical Record Audit sheets, dated 04/01/16 through 04/06/16, revealed eight (8) to ten (10) residents' records were audited daily by the DON, Nurse Managers, and Corporate Care Consultants. Interview with Consultants #2 and #3, on 04/07/16 at 10:03 AM, West Wing Unit Manager, on 04/06/16 at 3:10 PM, and DON #3, on 04/06/16 at 3:29 PM, revealed medical record audits were being conducted for 5% of the resident census to ensure physician orders [REDACTED]. 4. Review of the training records revealed DON #3, East Unit Manager and West Unit Manager revealed they received training on 04/01/16 on how to audit the medical record and education on legible signatures with credentials, physician orders, supervision of LPNAs, RNAs, and nursing students, following care plans, and scheduling appointments. A post test was taken with the DON and managers scoring 100%. Interview with DON #3, on 04/06/16 at 3:29 PM, revealed she had received the education on the topic above. She then provided training to all licensed nursing stakeholders. She was trained on how to conduct the medical record audits and was involved in conducting those audits. Interview with the East Wing Unit Manager, on 04/06/16 at 11:25 AM, revealed she had been trained to do the medical record audits; however, she had not conducted the audits to date. She revealed she had only been in this position for three (3) weeks and was still learning. Further interview revealed she validated she had received training on physician orders, care plans, scheduling of appointments, documentation to be legible and to include credentials; and, supervision of LPNAs and RNAs. She had not conducted training of the nurses. Interview with the West Wing Unit Manager, on 04/06/16 at 3:10 PM, revealed she had been trained on how to conduct audits of the medical record and had conducted a few over the weekend. She validated she received training on physician orders, documentation in the medical record to be legible with credentials, care plans, scheduling of appointments, physician orders, and supervision of LPNAs and RNAs. She had not conducted training of the nurses. Review of the training records and post test revealed thirty-three (33) licensed nurses and four (4) Certified Medication Technicians were trained on documentation in the medical record that was complete, legible and included credentials. In addition, physician orders, care plans, scheduled appointments, and supervision of LPNAs and RNAs was also reviewed by the survey team. All had passed the post test with a score of 100. Record review revealed five (5) stakeholders had not received the training as of 04/04/16. Certified letters were sent on 04/04/16 to those employees. Copies of the letters were reviewed and the certified mail receipts. A letter written by the Administrator, dated 04/04/16, accompanied the training material. In the letter, the Administrator instructed the licensed nurses they must review the enclosed education material and complete a post test before returning to work. The stakeholder was instructed to turn in the post test and sign the training roster before returning to the facility for a scheduled shift. Validation interviews were conducted on 04/06/16 with LPN #12 at 10:46 AM, LPN #9 at 11:08 AM, LPN #6 at 1:46 PM, LPN #11 at 4:23 PM, and LPN #3 at 4:38 PM, revealed they had received the training and taken the post test. Each nurse had good knowledge of the training topics. Interview with LPN #8, on 04/06/16 at 11:42 AM revealed she needed to complete the training. She stated she had been informed of a certified letter, but she had not been to the post office to pick up the certified letter. Therefore, she did not know what the letter contained. She stated she started her work shift today at 6:30 AM and nobody had informed her that she had to complete the training before caring for residents. She stated the Unit Manager had not said anything to her and she had not received any training over the phone. Interview with the West Unit Manager, on 04/16/16 at 11:58 AM, revealed she was unaware the nurse had not received the training. She stated she did realize the DON had not provided training over the phone until the nurse could receive the training in person and taken the post test. Interview with DON #3, on 04/06/16 at 12:06 AM and 12:12 PM, revealed she had called LPN #8 twice and never could reach her. She assumed the nurse had received the certified letter with the training material. She stated she had reviewed the working schedule and didn't realize the nurse was working (that day). She stated it was an oversight and she or the Unit Manager realized she had not been trained. Verification of the nurse's training with a post test was provided to the surveyor on 04/16/16 at 12:10 PM. 5. Review of a newly hired nurse, on 03/29/16, validation check revealed the facility conducted a KBN online validation report on 03/29/16 that revealed the nurse had a valid license. The validation report was reviewed by the HR Personnel, DON #3, Administrator, and Corporate Consultant as indicated by their signatures on the validation report. Review of the training revealed the newly hired nurse had received education on the topics that were included in the AOC. Interview with the HR Director, on 04/06/16 at 4:05 PM, revealed she had received training on the validation process. She stated once an application was received and before an offer letter was sent, she would conduct a validation check with the KBN. After the offer letter was sent another check was conducted at the KBN for abuse registry and a Criminal Background Check would be conducted. She stated she would review the validation report from the KBN then the DON, and the Administrator would do the final check. She stated she assisted with the validation of license for the facility's nurses. The Corporate Consultant signed off as reviewing the hire packet for the newly hired nurse on 04/01/16. The consultant reviewed and signed off on the nurses who are in the interviewing process. 6. Interview with Corporate Care Consultants #2 and #3 and the Special Project Consultant, on 04/07/16 at 10:03 AM revealed they would be providing oversight and assistance to the facility for some time. They stated they have been at the facility daily including some weekend days to conduct audits and assist with educational needs. Consultants #1, #2, and #3 would be at the facility Monday-Friday for several weeks to review action plans, audits, and training before they decrease to three (3) times a week. Once they identify any non-compliance, re-education would be conducted. They were looking at the clinical matrix, and the development of education topics that may include other disciplines beside nursing. The facility did not have a new Administrator in training at the time of the survey. A consultant will attend the clinical meetings to ensure a meeting is held as stated and topics discussed. The consultants reviewed the audits to ensure they were being conducted correctly and to see if there were any training issues. They were in the process of developing an afternoon meeting to recap the day. 7. Review of the QAPI signature sheet, dated 03/28/16, revealed the survey findings were discussed. The Medical Director, Administrator, DON, Corporate Consultant #1, and five (5) other committee members. On 03/30/16, an Ad Hoc meeting was held to discuss the Immediate Jeopardy findings. The Administrator, DON, Unit Managers and SDC was present with the Medical Director via phone conference. Additional Ad Hoc QAPI meetings were held on 04/01/16, 04/04/16 and 04/06/16. Interview with the Administrator, on 04/06/16 at 5:03 PM, validated the above QAPI meetings were held. She stated she conducted the meetings and the Medical Director was either present in person or via phone. She stated the frequent QAPI meetings were to review what process had been changed and were they effective. The committee reviewed the audits. She stated the audits were also reviewed in the morning meetings before they were reviewed in the QAPI meetings. She stated she will conduct a weekly QAPI meeting for the next month. In addition, the IDT meet weekly to review the audits. Interview with the Medical Director, on 04/06/16 at 4:48 PM, revealed he had been involved in the whole process since the beginning of the Immediate Jeopardy. The facility's Administrator provided him an overview of the survey findings and requested his input in the corrective plans. He reviewed the policies and validation process and discussed the physician orders [REDACTED]. 8. Review of Unsampled Residents L's and M's record revealed physician orders [REDACTED]. Review of the appointment calendar revealed the scheduled appointment had been placed in the calendar with transportation obtained. Review of the appointment calendars for the East and West Units and audits revealed no missed appointments. 9. Review of the education provided by the Regional Vice President to the Administrator and DON #3, on 04/04/16, revealed the training was on F490 and review of the Administrator's job description. A telephone interview with the Regional Vice President, on 04/07/16 at 9:54 AM, revealed he validated the training provided to the facility's Administrator. He stated he reviewed the role of the Administrator and responsibilities related to the hiring process, licensure validation, facility oversight, and Administrator in training. He stated the Administrator would provide oversight through observation rounds and review of clinical meeting findings. He stated he would conduct weekly telephone conference calls with the Administrator to discuss current corrective action plans, audit findings, facility operation, and oversight met the residents' needs. He would conduct the weekly calls for four (4) weeks and then decrease to monthly times three (3) months, then quarterly.

Based on observation, interview, record review and policy review, it was determined the facility failed to follow the Physician's Orders for one (1) of twelve (12) sampled residents (Resident #5). On 02/16/16, student nurses were in the facility for clinical instruction and were completing the treatments. The student nurse instructor packed Resident #5's wound with Kerlix without a physician's order when there was not enough supplies to properly apply a wound V.A.C. (Vacuum Assisted Closure) which is a NPWT (Negative-pressure Wound Therapy) as ordered to Resident #5's left groin wound. However, the Advanced Practice Registered Nurse (APRN) removed two (2) feet of Kerlix from Resident #5's abdomen on 02/19/16 and notified the physician on that date. In addition, the Unlicensed Graduate Nurse failed to place appointment dates on the calendar for 02/04/16 and 02/18/16 to ensure Resident #5 went to his/her Wound Clinic appointment every Thursday as ordered. Resident #5 missed both appointments and the wound was not evaluated at the wound clinic by the physician. The facility's failure to have an effective system in place to ensure residents received wound treatments and wound appointments as ordered by the physician placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 03/30/16 and determined to exist on 11/30/15. The facility was notified on the Immediate Jeopardy on 03/30/16. The facility provided an acceptable Allegation of Compliance (AOC) on 04/04/16, which alleged removal of Immediate Jeopardy on 04/05/16. The State Survey Agency (SSA) verified the Immediate Jeopardy was not removed on 04/05/16 as alleged, but on 04/07/16 (facility allowed a nurse to return to work without training on 04/06/16) prior to exit on 04/08/16. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and the Quality Assurance monitors for effectiveness of the systemic changes. The findings include: Review of the Physician's Orders Policy, last reviewed 06/01/15, revealed no documentation, as it pertained to the nursing staff following the physicians' orders. Interview with the Nurse Consultant, on 03/30/16 at 4:42 PM, revealed the facility did not have a policy regarding Student Nurses and/or Unlicensed Graduate Nurses working in the facility. 1. Review of Resident #5's closed record, revealed the facility admitted Resident #5 on 02/03/16 with [DIAGNOSES REDACTED]. Review of Resident #5's Physician's Orders, dated 02/03/16, revealed Resident #5 had an order to have a wound V.A.C. to the left groin. Interview with the facility's Wound Nurse, on 03/16/16 at 5:24 PM, revealed she changed Resident #5's Kerlix dressing to the wound V.A.C. the day he/she was admitted on [DATE]. The Wound Nurse stated there were supplies that came with the resident from the hospital such as a black/gray sponge, drapes and canisters to complete the treatment. However, on 02/16/16 the Nursing Instructor only found a small oval shaped sponge approximately six (6) inches. It was determined there was not enough supplies to complete future treatments and she did not think to request more supplies. According to the Wound Nurse, after she changed the initial dressing, she did not change any more of Resident #5's dressings because the dressing would have been changed on 02/04/16 at the wound clinic. The Wound Nurse just monitored the drainage that was coming from the wound V.A.C. Interview with Licensed Practical Nurse (LPN) #4, on 03/17/16 at 9:08 AM, revealed on 02/16/16 (Tuesday), nursing students were in the facility and were completing treatments. According to LPN #4 the Nursing Instructor informed her they did not have all the supplies they needed. LPN #4 then called the Wound Nurse to inform her that the Nursing Instructor said she could use gauze/Kerlix and place the smaller black sponge on top. LPN #4 stated the wound nurse said that would be fine. According to LPN #4, she then called the wound V.A.C. company to inform them the facility was in need of supplies. Further interview with LPN #4 revealed she did not call the Physician to obtain new orders for the use of the gauze/Kerlix that the Nursing Instructor applied to Resident #5's surgical wound. Interview with the Wound Nurse, on 03/17/16 at 3:59 PM, revealed LPN #4 had mentioned the use of Kerlix on Resident #5's abdominal wound and she told LPN #4 that the Nursing Instructor could not use Kerlix on Resident #5's surgical wound. The Wound Nurse stated LPN #4 should have notified her, the Director of Nursing (DON) or the Unit Secretary if she had run out of supplies for Resident #5's wound V.A.C. Review of Resident #5's Physician's Orders revealed no new orders were in place for packing gauze or Kerlix in the resident's surgical wound on 02/16/16. Interview with LPN #1, on 03/17/16 at 2:51 PM, revealed she worked on Friday 02/19/16 and remembered receiving report from the Unit Manager who had worked the night shift. The Unit Manager informed her there had not been any wound V.A.C. supplies for three (3) days, since Tuesday 02/16/16. The Unit Manager informed her that the supplies were coming as soon as possible and to expect the supplies to come in that day. Interview with the Unit Secretary, on 03/17/16 at 3:54 PM, revealed she called the wound V.A.C. vendor to re-order supplies. The vendor stated they would send the supplies the next day. The Unit Secretary could not remember which day she called to order the supplies, nor could she remember which nurse requested the supplies be ordered. Further interview with LPN #1, on 03/17/16 at 2:51 PM, revealed when the supplies came in she and the Advanced Practical Registered Nurse (APRN) changed the dressing to Resident #5's abdomen. LPN #1 stated she remembered removing a black sponge and tube and then irrigated the wound. She stated she then saw this white thing and when she grabbed it she discovered it was Kerlix. LPN #1 stated it was hard to pull out. According to LPN #1, the Treatment Administrative Record (TAR), did not say to pack the surgical wound with Kerlix and if they did not have supplies, Resident #5's wound could become infected and make the resident become septic. LPN #1 further stated the nursing staff was expected to follow the Physician's Orders. Interview with the Advanced Practical Registered Nurse (APRN), on 03/16/16 at 3:05 PM, revealed she assisted LPN #1 with Resident #5's wound V.A.C. on 02/19/16. She stated she heard the nurse say they had run out of supplies for the wound V.A.C. and the supplies had just arrived. According to the APRN, Resident #5's wound had some tunneling and it was deep. The APRN removed the black foam and began to flush the dressing. The APRN then saw some white stuff, after pulling it out there was two (2) feet of Kerlix tucked into Resident #5's abdomen. The APRN called Doctor #1 (the attending) and informed him that Resident #5's wound was tunneling and deep. Doctor #1 agreed with her to change the order from the wound V.A.C. to wet to dry dressings so that the wound would heal from the inside out. The APRN stated the hospital had not reported the wound was tunneling. Record review revealed there was no hospital documentation that stated the wound was tunneling. Further interview with the APRN, on 03/17/16 at 5:10 PM, revealed the instructor should not have placed the Kerlix in Resident #5's wound. She stated no one called to ask to change the order from the wound V.A.C. to a wet to dry dressing. The APRN stated she expected the staff to follow physician orders. Interview with the Staff Development Coordinator (SDC), on 03/30/16 at 8:55 AM, revealed there was no oversight provided for the clinical students. Their Clinical Instructor was their oversight. The SDC stated the Clinical Instructors just asked her when they could come to the facility and she would then ask the Director of Nursing for approval. 2. Review of Resident #5's admission Physician Orders, dated 02/03/16, revealed the nursing staff was to change Resident #5's wound V.A.C. on Tuesday and Saturday; and, the Wound Clinic was to change the wound V.A.C. every Thursday. Review of Resident #5's Treatment Administration Record (TAR) for the month of February 2016, revealed the only day that was signed for the resident to attend the wound clinic was on Thursday, 02/11/16. Review of the February 2016 Appointment Calendar, revealed the resident was to go to [MEDICAL TREATMENT] on Monday, Wednesday and Friday; and, on 02/11/16, Resident #5 was to go to the Wound Clinic for treatment. Resident #5 should have been scheduled to go to the Wound Clinic on 02/04/16 and 02/18/16 (Thursdays after admission). However, review of the Appointment Calendar revealed Resident #5 was not scheduled to go to the Wound Clinic on 02/04/16 and 02/18/16. Interview with the Unlicensed Graduate Nurse, on 03/17/16 at 3:21 PM, revealed she was the admission nurse for Resident #5 and was responsible for the completion of all aspects of an admission. Placing appointments on the calendar would have been one of the admission duties. Further interview with the Unlicensed Graduate Nurse, on 03/17/16 at 5:28 PM, revealed she was ultimately responsible to ensure Resident #5's appointment was on the Appointment Calendar because she signed that the order was taken off, and staff was expected to follow the physician orders. However, she did not add the appointment dates to the calendar. According to the Unlicensed Graduate Nurse, if something was not documented then the task was not done. Interview with LPN #7, on 03/29/15 at 1:45 PM, revealed when admitting a new resident to the facility the nurse hand writes the orders onto the Medication Administration Record [REDACTED]. The nurse calls the doctor to verify the orders and a second nurse checks the MARs and TARS for accuracy. Interview with the Unit Secretary, on 03/17/16 at 5:42 PM, revealed she did not set up appointments or place the appointments on the Appointment Calendar. The Unit Secretary stated Medical Records was responsible to complete this task. According to the Unit Secretary, the nursing staff usually left a note for Medical Records to inform her of the appointment and she did not remember an order for [REDACTED]. Interview with Medical Records, on 03/17/16 at 5:48 PM, revealed she was responsible to set up the resident appointments. According to Medical Records she only set up an appointment for 02/11/16. Medical Records said no one had voiced to her that the appointment had to be scheduled for every Thursday with the Wound clinic. Interview with the Unit Manager, on 03/17/16 at 4:33 PM, revealed Resident #5's Wound Clinic appointment was supposed to be documented on the Appointment Calendar and the only appointment documented for Resident #5 was the one scheduled on 02/11/16. According to the Unit Manager, the nurse should have placed the appointment on the Appointment Calendar for every Thursday as ordered. If Resident #5 did not attend his/her appointment, the nursing staff should document the reason why the resident did not attend the appointment. The Unit Manager stated the staff was responsible for following physician's orders. Review of Resident #5's Nursing Notes, revealed no evidence as to why Resident #5 did not attend the 02/04/16 and 02/18/16 Wound Clinic appointments. Interview with the current Director of Nursing, (DON) #3, on 03/17/16 at 5:31 PM, revealed the nursing staff should have verified the appointment with the Wound Clinic and placed it on the Appointment Calendar where schedules were documented. The nursing staff should have asked the resident if his/her family was taking them to the appointment or if the resident would need other transportation provided. According to the DON, usually the Unit Secretary placed the appointments on the Calendar and the Unit Manager would look at the admission's information to verify that the orders were taken off correctly. Interview with the Wound Clinic Manager, on 03/17/16 at 11:02 AM, revealed Resident #5 was ordered to come to the Wound Clinic on Thursdays, but had not come a single time. The Manager stated there were conversations with the facility about the resident not feeling well or that no family was available to interpret because the resident spoke a different language. According to the Wound Clinic Manager, the goal was for Resident #5 to have the wound V.A.C., changed three (3) times a week, two (2) times at the facility and once (1) at the Wound Clinic for Doctor #2 (the wound care doctor) to see. Interview with Doctor #2, on 03/17/16 at 11:20 AM, revealed she saw Resident #5 briefly on 02/11/16 in the emergency room when Resident #5 was seen for chest pain. Doctor #2 stated the wound was dressed as ordered and looked good. According to Doctor #2, the reason she ordered the Wound V.A.C. was because the surgical wound was large and when you looked at the surface the surgical wound had an opening, underneath the abdominal wall, the distance and length longer than the hand. Doctor #2 was observed to hold her forearm the length of the surgical wound. Doctor #2 stated the wound V.A.C. was known to heal the wounds quicker. She stated the wound was not tunneling; however, it was more like a cavern. She stated when she saw Resident #5, on 02/25/16, his/her wound had a small pocket trying to form. She utilized her finger to open the wound and was able to place the wound V.A.C. in the wound without difficulty. Interview with DON #3, on 03/28/16 at 12:03 PM, revealed when she found out the Unlicensed Graduate Nurse did not have a provisional license, she was confused. DON #3 stated she then had concerns that the Unlicensed Graduate Nurse was working on the Rehabilitation Unit. The DON stated some of the things that occurred to Resident #5 could have been prevented. There should have been a licensed nurse doing the admission for Resident #5. DON #3 stated to her knowledge there was no evidence that a nurse had documented behind her to ensure they monitored the care the Unlicensed Graduate Nurse provided. The facility took the following actions to remove the Immediate Jeopardy: 1. On 03/14/16, DON #3 removed the stakeholder (Unlicensed Graduate Nurse), who did not have a provisional, from the LPNA role. On 03/28/16, the Administrator suspended the stakeholder. 2. The Corporate Care Consultants reviewed and validated thirty-one (31) stakeholders working as licensed nurses on 03/28/16; and, seven (7) were validated on 04/01/16 via the Kentucky Board of Nursing (KBN) online verification report. No stakeholder was found to be working without a valid nursing license. 3. The Corporate Care Consultants reviewed all current residents medical records that were assigned to the non-licensed stakeholder. Forty-one (41) charts were reviewed on 03/31/16; and, nine (9) were reviewed on 04/01/16. Of the fifty (50) charts reviewed, no care issues were noted related to the non-licensed stakeholder. The facility identified twenty-one (21) clinical records that had missing credentials. The DON and Nurse Managers began education addressing appropriate signage of the medical record including credentials for the unlicensed nursee. The facility implemented a Medical Record Review Process on 04/04/16 by the DON. The DON and/or Nurse Managers would review the medical record (Physician's Orders, Nurse's Notes, assessments, etc) to ensure appropriate signage including credentials was completed by the licensed nurse. Five (5) percent of the current census would be reviewed for physician orders, nurses's notes and assessments in the daily clinical meeting (Monday-Friday) for two (2) weeks; if compliance was maintained, audits would decrease to 5% three (3) times a week for four (4) weeks, and then monthly for three (3) months. 4. The Consultants provided education to the DON and Nurse Managers on 04/01/16, on the process of auditing of the medical record(s). The education consisted of: legible signature to include credentials; physician orders with transcription, processing, and following physician's orders; supervision of LPNAs, RNAs, and nursing students; following care plans; and scheduling appointments. The Nurse Managers, Staff Developed Coordinator (SDC), and DON #3 provided the above education to all licensed nursing stakeholders 04/01/16 through 04/04/16. Any licensed stakeholder that had not received the education by 04/04/16 would be issued a certified letter with the training material. Education and Post Education Competency would be completed by the DON and/or Nurse Managers in person and/or via phone for licensed nurses from 04/01/16 through 04/04/16. When conducting the Post Education Competency via phone, the SDC and/or Nurse Managers would ask the examination questions and document the licensed nurse's response on the examination. The SDC and/or Nurse Managers would follow up with the nurse in person to go over the training material verbally and the stakeholder would complete a written examination with the stakeholder's signature. The SDC and/or Nurse Managers would provide the training to a new stakeholder through the orientation program. The SDC and/or Nurse Manager would provide the Administrator and DON with a verbal progress report of the new stakeholder's performance and/or education skills needed during the orientation process. 5. The Human Resources (HR) Personnel, Receptionist, or Nurse Managers would conduct a KBN online validation report during the interview process for stakeholders applying for a licensed position and when a licensed position status change had occurred. The validation would be printed, reviewed, and signed by the DON, HR Personnel, Receptionist, or Nurse Manager as proof of validation status. The Administrator would conduct the final review. The HR Personnel, Receptionist, or Nurse Managers would conduct monthly and/or needed licensure review via KBN online validation report to ensure licenses were valid for three (3) months. If compliance is maintained, audits would be reduced to quarterly for two (2) quarters then annually thereafter. The Corporate Care Consultants would review completed KBN online validation reports daily (Monday-Friday) for four (4) weeks. If compliance is maintained, audits would decrease to two (2) times per week for four (4) weeks to ensure the validation process was completed. The audits would decrease to monthly for three (3) months during their facility visits. 6. The Corporate Care Consultants, Regional Vice President, and/or HR Advisory Personnel would provide ongoing education as needed for new administrative staff. The consultants would provide facility visits a minimum of five (5) days per week for two (2) weeks to review action plan and assist with education needs. If compliance was maintained, the visits would decrease to three (3) per week for eight (8) weeks, then a minimum of monthly thereafter. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 03/28/16 to review the survey findings and the facility's licensure validation process. Those in attendance included the Administrator, DON, HR Director, Unit Nurse Managers, and the Medical Director. On 03/30/16, a second Ad Hoc QAPI meeting was conducted with the Administrator, DON, Medical Director, Social Services, SDC, and Unit Managers to review policies and procedures related to the hiring and orientation process, and the supervision of LPNAs, RNAs, and student nurses. No changes were made to the hiring process or the Orientation Checklist. The Orientation Checklist for licensed stakeholders would be utilized for LPNAs and RNAs with direct supervision. A new Supervision Policy was created for LPNAs, RNAs, and student nurses on 03/30/16 during the QAPI meeting with the approval of the Medical Director. In addition, the Physical Order/Supplies and Scheduling of Medical Appointments Process was reviewed with no changes. A third Ad Hoc meeting was held on 04/01/16 with the Administrator, DON, and Medical Director via phone to review all recent survey citations and action plans. On 04/04/16, the Administrator and DON met with the Medical Director for overview of the survey findings: F281-discussed the incident with a non-licensed nurse related to Professional Standards with implementation of Licensure Validation Process; F282-discussion of oversight to ensure the care plan was followed; F309-discussed the failure to follow physician orders, provision of supplies, and scheduling of medical appointments; F490-reviewed the role of the Administrator to provide oversight for facility operations. Guidance and oversight would be provided by the Regional Vice President. The Administrator would review all audits and conduct observation rounds. F499- recapped the process for preventing non-licensed staff from working as licensed staff by completing the Licensure Validation Process. F514-reviewed education provided to maintain compliance in the deficient areas, including a post examination. Also reviewed the audit system/tools implemented to monitor processes. Audits would be discussed in the morning meeting, weekly QAPI and monthly QAPI. The IDT team will meet weekly times four (4) weeks to review all audit findings. If compliance was maintained, will reduce to monthly. 8. Order/Supply Process: Licensed nurse (s) would place physician orders on the Medication Record as received. Medical appointments would be scheduled as ordered, including transportation and logged on the monthly calendar. Unit Managers (Nurse Mangers) would review admission/readmission and/or new telephone orders and discuss in the morning clinical meetings (Monday-Friday). Ordered supplies would be discussed in the morning clinical meeting to ensure supplies were available for the resident (s). If the supplies cannot be obtained, a licensed nurse would contact the resident's physician for alternative orders until the supplies were available. 9. The Regional Vice President reviewed administrative duties that included: hiring process, licensure validation, facility oversight, role of the Administrator-in-training, and the job description with the Administrator on 04/04/16. The Regional Vice President will conduct weekly telephone calls with the Administrator for four (4) weeks to discuss current action plans and audit findings. If the facility's operations and oversight meet the residents' needs, the conference call would decrease to monthly for three (3) months, and then quarterly thereafter. If non-compliance is noted, the Vice President would modify oversight as needed to meet the needs of the residents. The State Agency validated removal of the Immediate Jeopardy on 04/07/16 as follows: 1. Review of the Stakeholder Suspension Form revealed the unlicensed stakeholder was suspended on 03/28/16 by the Administrator. Review of a written statement from DON #3 revealed she removed the employee from any licensed nurse duties on 03/14/16. Interview with the DON, on 04/06/16 at 3:29 PM and Administrator, on 04/06/16 at 5:03 PM, validated the stakeholder was suspended on 03/28/16. 2. Review of the facility's licensed staff roster revealed thirty-eight (38) nurses were employed as of 04/06/16. All thirty-eight (38) nurses had a KBN validation report validating they had a valid nursing license. Interview with Corporate Care Consultants #2, and #3, on 04/07/16 at 1:03 AM, revealed the facility had obtained validation of license for all nurses employed by the facility. Received validation reports from the KBN and no stakeholder was working without a license. 3. Review of the medical record review audit sheet revealed forty-three (43) records were reviewed with no problem identified. The audits were conducted on 03/31/16 and 04/01/16 by three (3) Corporate Care Consultants. Interview with Corporate Care Consultants #2 and #3, on 04/07/16 at 10:03 AM, revealed the review of the clinical record found no resident experienced a negative outcome related to the non-licensed stakeholder. The audit did find the nurses were not always signing with credentials. Review of the Medical Record Audit sheets, dated 04/01/16 through 04/06/16, revealed eight (8) to ten (10) residents' records were audited daily by the DON, Nurse Managers, and Corporate Care Consultants. Interview with Consultants #2 and #3, on 04/07/16 at 10:03 AM, West Wing Unit Manager, on 04/06/16 at 3:10 PM, and DON #3, on 04/06/16 at 3:29 PM, revealed medical record audits were being conducted for 5% of the resident census to ensure physician orders were transcribed and processed correctly, licence nurses signed with credentials, and appointments were scheduled as ordered. 4. Review of the training records revealed DON #3, East Unit Manager and West Unit Manager revealed they received training on 04/01/16 on how to audit the medical record and education on legible signatures with credentials, physician orders, supervision of LPNAs, RNAs, and nursing students, following care plans, and scheduling appointments. A post test was taken with the DON and managers scoring 100%. Interview with DON #3, on 04/06/16 at 3:29 PM, revealed she had received the education on the topic above. She then provided training to all licensed nursing stakeholders. She was trained on how to conduct the medical record audits and was involved in conducting those audits. Interview with the East Wing Unit Manager, on 04/06/16 at 11:25 AM, revealed she had been trained to do the medical record audits; however, she had not conducted the audits to date. She revealed she had only been in this position for three (3) weeks and was still learning. Further interview revealed she validated she had received training on physician orders, care plans, scheduling of appointments, documentation to be legible and to include credentials; and, supervision of LPNAs and RNAs. She had not conducted training of the nurses. Interview with the West Wing Unit Manager, on 04/06/16 at 3:10 PM, revealed she had been trained on how to conduct audits of the medical record and had conducted a few over the weekend. She validated she received training on physician orders, documentation in the medical record to be legible with credentials, care plans, scheduling of appointments, physician orders, and supervision of LPNAs and RNAs. She had not conducted training of the nurses. Review of the training records and post test revealed thirty-three (33) licensed nurses and four (4) Certified Medication Technicians were trained on documentation in the medical record that was complete, legible and included credentials. In addition, physician orders, care plans, scheduled appointments, and supervision of LPNAs and RNAs was also reviewed by the survey team. All had passed the post test with a score of 100. Record review revealed five (5) stakeholders had not received the training as of 04/04/16. Certified letters were sent on 04/04/16 to those employees. Copies of the letters were reviewed and the certified mail receipts. A letter written by the Administrator, dated 04/04/16, accompanied the training material. In the letter, the Administrator instructed the licensed nurses they must review the enclosed education material and complete a post test before returning to work. The stakeholder was instructed to turn in the post test and sign the training roster before returning to the facility for a scheduled shift. Validation interviews were conducted on 04/06/16 with LPN #12 at 10:46 AM, LPN #9 at 11:08 AM, LPN #6 at 1:46 PM, LPN #11 at 4:23 PM, and LPN #3 at 4:38 PM, revealed they had received the training and taken the post test. Each nurse had good knowledge of the training topics. Interview with LPN #8, on 04/06/16 at 11:42 AM revealed she needed to complete the training. She stated she had been informed of a certified letter, but she had not been to the post office to pick up the certified letter. Therefore, she did not know what the letter contained. She stated she started her work shift today at 6:30 AM and nobody had informed her that she had to complete the training before caring for residents. She stated the Unit Manager had not said anything to her and she had not received any training over the phone. Interview with the West Unit Manager, on 04/16/16 at 11:58 AM, revealed she was unaware the nurse had not received the training. She stated she did realize the DON had not provided training over the phone until the nurse could receive the training in person and taken the post test. Interview with DON #3, on 04/06/16 at 12:06 AM and 12:12 PM, revealed she had called LPN #8 twice and never could reach her. She assumed the nurse had received the certified letter with the training material. She stated she had reviewed the working schedule and didn't realize the nurse was working (that day). She stated it was an oversight and she or the Unit Manager realized she had not been trained. Verification of the nurse's training with a post test was provided to the surveyor on 04/16/16 at 12:10 PM. 5. Review of a newly hired nurse, on 03/29/16, validation check revealed the facility conducted a KBN online validation report on 03/29/16 that revealed the nurse had a valid license. The validation report was reviewed by the HR Personnel, DON #3, Administrator, and Corporate Consultant as indicated by their signatures on the validation report. Review of the training revealed the newly hired nurse had received education on the topics that were included in the AOC. Interview with the HR Director, on 04/06/16 at 4:05 PM, revealed she had received training on the validation process. She stated once an application was received and before an offer letter was sent, she would conduct a validation check with the KBN. After the offer letter was sent another check was conducted at the KBN for abuse registry and a Criminal Background Check would be conducted. She stated she would review the validation report from the KBN then the DON, and the Administrator would do the final check. She stated she assisted with the validation of license for the facility's nurses. The Corporate Consultant signed off as reviewing the hire packet for the newly hired nurse on 04/01/16. The consultant reviewed and signed off on the nurses who are in the interviewing process. 6. Interview with Corporate Care Consultants #2 and #3 and the Special Project Consultant, on 04/07/16 at 10:03 AM revealed they would be providing oversight and assistance to the facility for some time. They stated they have been at the facility daily including some weekend days to conduct audits and assist with educational needs. Consultants #1, #2, and #3 would be at the facility Monday-Friday for several weeks to review action plans, audits, and training before they decrease to three (3) times a week. Once they identify any non-compliance, re-education would be conducted. They were looking at the clinical matrix, and the development of education topics that may include other disciplines beside nursing. The facility did not have a new Administrator in training at the time of the survey. A consultant will attend the clinical meetings to ensure a meeting is held as stated and topics discussed. The consultants reviewed the audits to ensure they were being conducted correctly and to see if there were any training issues. They were in the process of developing an afternoon meeting to recap the day. 7. Review of the QAPI signature sheet, dated 03/28/16, revealed the survey findings were discussed. The Medical Director, Administrator, DON, Corporate Consultant #1, and five (5) other committee members. On 03/30/16, an Ad Hoc meeting was held to discuss the Immediate Jeopardy findings. The Administrator, DON, Unit Managers and SDC was present with the Medical Director

Based on interviews, record review, and review of the facility's policy and investigation, it was determined the facility failed to ensure an allegation of physical abuse was immediately reported to the Administrator; and, failed to protect residents from further abuse for one (1) of twelve (12) sampled residents (Resident #2). On 03/02/16, during the evening meal, Certified Nursing Assistant (CNA) #4 slapped Resident #2 twice on the forearm. The incident was witnessed by CNA #2 and #3. However, the staff failed to immediately report the alleged abuse to the Charge Nurse per facility policy. The abuse allegation was not reported to the Administrator until 03/07/16 at approximately 10:30 PM. Interviews and review of CNA #4's time sheet revealed the aide continued to care for Resident #2 and other residents after the observed abuse. The facility's failure to have an effective system in place to ensure staff immediately reported observed abuse of residents; placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 03/18/16 and determined to exist on 03/02/16. The facility was notified of the IJ on 03/18/16. An acceptable Allegation of Compliance (AOC) was received on 03/22/16, which alleged removal of the IJ on 03/19/16. A Partial Extended Survey was initiated on 03/28/16. The State Survey Agency (SSA) determined IJ was removed on 03/19/16 as alleged, which lowered the Scope and Severity (S/S) to D while the facility developed and implemented the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of systemic changes. The findings include: Review of the facility's Abuse and Neglect Policy, revised March 2013, revealed a person(s) who observed abuse would immediately report to the Charge Nurse. The Charge Nurse would immediately remove the suspected perpetrator from resident care, obtain the staff member's witness statement and immediately suspend the employee. The Charge Nurse would immediately notify the Administrator, Director of Nursing (DON), and/or Abuse Coordinator. The person(s) observing the incident would immediately report and provide a written statement that included the name of the resident, date and time it occurred, where it occurred, staff involved, and a description of what occurred. The Administrator or DON would notify state agencies according to the reporting guidelines. Review of the facility's investigation, dated 03/08/16, revealed CNA #2 reported to Registered Nurse (RN) #1 (on 03/07/16 at 7:15 PM) that she had observed CNA #4 smack Resident #2 on the arm last week. The Administrator and the Assistant Director of Nursing (ADON) were notified. The Administrator directed the nurse to interview CNA #4 and then suspend the aide. RN #1 documented CNA #4 admitted to swatting the resident's forearm when the resident attempted to grab at a food tray. The investigative report stated there were two (2) aides that had witnessed the abuse; however, they had not reported the abuse. The facility suspended the three (3) aides on 03/07/16. Review of the final report, dated 03/11/16, revealed the facility substantiated the allegation of abuse when CNA #4 admitted to hitting the resident on the forearm. The facility's investigation stated the two (2) aides that had witnessed the abuse (on 03/02/06 during the evening meal) had not reported the abuse. The facility notified the state agencies on 03/08/16. The local police were called, responded to the facility and took the information; however, stated they would not be pressing charges because it did not meet their criteria. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 07/24/09. Review of the most current [DIAGNOSES REDACTED]. The facility was unable to conduct a Brief Interview for Mental Status (BIMS) as the resident had a severe cognition loss. Review of the most recent Minimum Data Set (MDS) assessment, conducted on 02/22/16, revealed the resident required extensive assistance with eating. Review of the Comprehensive Care Plan, dated 02/22/16, addressing a communication deficit revealed Resident #2's communications skills were impaired and the resident was unable to understand or be understood. The goal directed staff to anticipate the needs of the resident. On 03/07/16, a new intervention was added to the care plan and instructed staff to place the resident's food tray out of the reach of the resident. Interview with CNA #3, on 03/15/16, at 4:57 PM, revealed he observed CNA #4 slap Resident #2's forearm in the dining room on 03/02/16. He stated CNA #4 was assisting Resident #2 with the evening meal when the resident reached for the food tray. He stated the resident had a history of [REDACTED]. When the resident reached for the food tray, CNA #4 slapped the resident on the forearm. The resident reached for the food tray again and the aide slapped the resident on the forearm again. He said the resident said, Ouch. He told the aide that he should not do that, but CNA #4 told him it was okay. He told the aide it was not okay. He stated License Practical Nurse (LPN) #5 was in the dining room when CNA #4 slapped the resident and he assumed she saw the same thing he witnessed. The nurse told him she would take care of it and he thought the nurse had reported the abuse. However, he did not see her speak with CNA #4 that night and the aide continued to care for residents. He said CNA #2 came to him several nights later (03/07/16) and said he needed to speak with RN #1 regarding what they observed in the dining room. He stated there was a miscommunication and he did not realize the alleged abuse had not been reported. He assumed LPN #5 had reported the abuse. A telephone interview with CNA #2, on 03/17/16 at 9:15 AM, revealed she had observed CNA #4 slap Resident #2 on the forearm twice on 03/02/16. She stated she did not report the allegation of abuse because a nurse was in the dining room at the same time of her observation and she assumed the nurse reported the abuse. She stated the resident was grabbing for a food tray and CNA #4 smacked the resident on the forearm with an opened hand. She said the resident reached for the food tray again and CNA #4 smacked the resident again on the forearm. However, this time the resident said,Ouch, and began rubbing his/her arm. The CNA stated she knew this was wrong, but since the nurse was in the dining room, she assumed she saw the same thing and would report the incident. When she saw CNA #4 working on 03/07/16 caring for residents, she realized the alleged abuse had not been reported. She stated she was uncomfortable with CNA #4 working with residents after what she observed and was afraid he would hit another resident in private. She then reported what she observed to a staff nurse. A telephone interview with LPN #5, on 03/16/16 at 8:49 PM, revealed she did not observe the alleged abuse and she had not reported any abuse. The nurse stated she was not in the dining room for the whole meal and did not witness the alleged abuse. She stated she was new to the facility and was still in the learning mode. She stated nobody came to her that night to report the alleged abuse. Review of CNA #4's work schedule and time sheet revealed the aide worked and cared for residents on March 2nd, 3rd, 5th, 6th, and 7th, 2016. Telephone interview with CNA #4, on 03/16/16 at 8:26 PM, revealed he denied hitting the resident, instead he said he pushed the resident's hand away. The aide stated the resident almost pulled the food tray onto the floor and he had held the resident's hand. However, he then touched the resident's arm. He stated he told the resident, No, No, while he was holding the resident's hand. The aide stated he continued to assist the resident with his/her meal and then transported the resident to the sunroom. Further interview revealed he continued to work with residents throughout the evening on 03/02/16. The aide validated he worked on March 3rd, 5th, 6th, and 7th, 2016 after the incident in the dining room caring for Resident #2. On 03/07/16, the aide stated a nurse came to him and told him he was suspended and had to go home. He said the Administrator called him a few days later and told him he was terminated. Interview with the Administrator and the current Director of Nursing (DON) #3, on 03/16/16 at 9:12 AM, revealed the alleged physical abuse was reported to them on 03/07/16 after CNA #2 reported the abuse to a nurse. Upon knowledge of the alleged abuse, CNA #4 was suspended on 03/07/16. The Administrator stated CNAs #2 and #3 were also suspended for not reporting the alleged abuse. She stated when CNA #4 was interviewed, he admitted to smacking the resident's forearm twice. She stated she terminated the aide because he could not understand what he did was wrong and she was not sure the aide would not slap another resident again. She stated she substantiated the allegation and the facility's investigation found the two (2) aides failed to report the alleged abuse to the nurse according to facility policy. The Administrator stated there were no changes made to the Abuse Policy. She stated that training of staff began on 03/08/16 and was ongoing. Interview with the Administrator and DON #3, on 03/17/16 at 4:25 PM, revealed the facility had not implemented any monitoring processes to ensure the training provided to staff was effective. DON #3, stated she had planned a staff meeting for 03/21/16 to go over the Abuse Policy and develop audits to ensure staff understood how to report abuse. However, they had not implemented those processes yet. The Administrator revealed she was waiting to have a Quality Assurance (QA) meeting scheduled for 03/24/16 after the monitoring audits were developed and implemented. The Administrator stated she was ensuring compliance through the complaint/grievance process. The facility implemented the following actions to remove the IJ: 1. The allegation of abuse against Resident #2 was reported to the State Agencies on 03/08/16. The facility's initial investigation was initiated on 03/07/16 by the Administrator, DON #2, and RN Nurse Manager. The facility suspended CNAs #2, #3, and #4 on 03/07/16. 2. The RN Unit Manager performed a skin assessment for Resident #2, on 03/07/16 and found no signs of abuse. On 03/10/16, skin assessments were conducted on those residents with a Brief Interview of Mental Status (BIMS) score of less than eight (8). No evidence of abuse was identified for any of those residents. 3. The facility (Social Services) interviewed residents with a BIMS score of eight (8) and above utilizing the Investigation Questions for Resident Interview, beginning on 03/08/16. 4. The Administrator notified the local law enforcement of the alleged abuse on 03/07/16. In addition, Resident #2's Physician and responsible party were notified of the alleged abuse on 03/07/16 by the RN Unit Manager. 5. The facility's Abuse Policy was reviewed by DON #3, Corporate Nurse Consultant and via telephone with the Medical Director on 03/07/16 and the Interdisciplinary Team on 03/18/16, with no revision required. 6. The Social Service Director assessed Resident #2 for possible psychosocial issues. No negative outcome was noted. 7. Resident #2's care plan was reviewed and revised on 03/07/16 by the RN Unit Manager. The care plan was revised to reflect a new order for Geri Sleeves to be applied to the resident's bilateral arms to prevent the resident from scratching his/her arms. 8. All staff received training on the Abuse Policy with a post test. Staff had to score 100% or retake the test. One hundred forty-one (141) out of one hundred sixty (160) employees received the training with the post test. Those who had not received the training were sent the training material with the post test via certified mail on 03/14/16. Employees will not be allowed to work until they had received the training and take the post test. The Staff Development Nurse will provide abuse training during the orientation program for all new employees. 9. Beginning 03/18/16, DON #3 and the Unit Managers would conduct random skin checks for residents with a BIMS' score less than eight (8) and Social Services would conduct interviews with residents with a BIMS' score greater than eight (8). The audits would be 10% of daily census for each group and conducted daily for two (2) weeks to ensure residents were free from abuse. The audits would decrease to 5% for five (5) days a week for two (2) weeks, then 5% three (3) times a week for one month. Staff interviews with a post test validation began on 03/18/16 where 10% of staff daily were given the abuse post test to ensure ongoing knowledge of various types of abuse and when and whom to report allegations of abuse. 10. An Ad Hoc QA meeting was conducted on 03/18/16 with the Medical Director via phone conference. The survey findings and AOC corrective plan were reviewed. The IDT team would meet weekly for four (4) weeks to review the audit findings until compliance is achieved. The SSA validated removal of the IJ on 03/19/16 as follows: 1. Review of the facility's investigation revealed the abuse investigation was initiated on 03/07/16 and the faxed report was sent to the Office of Inspector General (OIG) on 03/08/16 at 11:37 AM. Review of the Stakeholder Suspension Form, dated 03/17/16, revealed CNAs #2, #3, and #4 were suspended. CNA #2 and #3 received a counseling session on 03/09/16 for failure to follow the facility's policy and would be re-educated on the Abuse Policy. Interview with CNA #2, on 03/17/16 at 9:15 AM, revealed she had been suspended for not reporting the abuse. Interview with CNA #3, on 03/15/16, at 4:57 PM, revealed he had been suspended for not reporting the abuse. A telephone interview with CNA #4, on 03/16/16 at 8:26 PM, revealed he had been suspended on 03/07/16 and a few days later the Administrator had called and informed him he had been terminated. 2. Review of Resident #2's clinical record revealed a skin assessment was performed by the East Unit Manager, on 03/07/16 at 10:30 PM, with no bruises, only scratches noted to the underside of the resident's forearms, between the wrist and elbow. The resident's physician was notified of the scratches by the RN Unit Manager on 03/07/16 with an order for [REDACTED].>Interview with the RN Manager (now DON #3), on 03/15/16 at 9:10 AM, revealed she had called the resident's physician and obtained the order for the Geri Sleeves. Review of the AOC book revealed fifty-seven (57) skin assessments were conducted by the DON, Unit Managers and RN Charge Nurse on 03/10/16 with no evidence of abuse found. 3. Review of the resident's interviews revealed sixty-seven (67) residents were interviewed by Social Services beginning 03/08/16 with no concerns of abuse or mistreatment expressed. Interview with sampled Resident #1, on 03/16/16 at 8:25 AM, Resident #6 on 03/15/16 at 3:28 PM, Resident #7 on 03/16/16 at 10:02 AM, and Resident #9 on 03/28/16 at 9:37 AM, revealed the residents had not experienced any abuse and had not observed any abuse toward other residents. 4. Review of documentation with the local police contact information revealed the police was at the facility on 03/07/16. Interview with the Administrator and DON #3, on 03/16/16 at 9:12 AM, revealed the local police was called and came to the facility and tried to interview the resident. No charges were filed. DON #3 stated she had notified the resident's responsible party that night. On 03/07/16, DON #3 notified the Medical Director, who was on call as the resident's Primary Physician of the alleged abuse. 5. Review of the facility's Abuse Policy, dated March 2013, revealed no revisions were made. Interview with the Administrator, on 03/16/16 at 9:12 AM, revealed there had been no changes to the Abuse Policy. 6. Review of the Social Service Progress Note, dated 03/08/16 at 2:20 PM, revealed the Social Service Worker attempted to interview Resident #2 without success. She documented the resident was sitting in a common area and was smiling. She documented observations of the resident, on 03/09/16 at 11:30 AM, and 03/10/16 at 2:00 PM, of the resident out of their room either beside the Nurses' Station or in the dining room smiling at staff when they spoke to him/her. No behaviors were noted. Interview with the Social Worker, on 03/29/16 at 12:15 PM, revealed she had observed the resident for three (3) days and saw no behaviors or negative outcome from the abuse. 7. Review of the clinical record revealed an order for [REDACTED]. Observation of Resident #2, on 03/15/16 at 3:24 PM, revealed the resident was in bed with Geri Sleeves applied. 8. Review of the training records revealed one hundred and sixty (160) employees had been trained by 03/18/16 by the Staff Development Nurse on the facility's Abuse Policy and had taken a post test. The only employees that had not received the abuse training were the four (4) employees on Family and Medical Leave Act (FMLA). Interview with CNA #9, on 03/16/16 at 8:30 AM, revealed she had recent training on abuse last week. She stated the training went over the Abuse Policy regarding protecting the resident first then reporting the abuse to the Nurse Supervisor. Interview with the Maintenance Director, on 03/16/16 at 8:40 AM, revealed he had training last week on the different types of abuse and what to do if you witnessed abuse. He stated he would report the abuse immediately to the nurse. Interview with Housekeeper #1, on 03/16/16 at 8:47 AM, revealed she received training on abuse last week. She stated a post test was given. Housekeeper #1 stated the different types of abuse were discussed and when and to whom to report the allegation of abuse. Interview with Occupational Therapist #1, on 03/16/16 at 8:50 AM, revealed she had received training on abuse many times. The most recent was last week. She stated the different types of abuse were discussed and how to report abuse and to whom. She stated the Abuse Hotline was discussed and the number was posted in the facility. Staff interviews, on 03/29/16 with LPN #8 at 1:26 PM, LPN #9 at 1:38 PM, LPN #7 at 1:42 PM, and LPN #6 at 1:55 PM, revealed they had received re-education on the facility's Abuse Policy on the different types of abuse, how, when, and whom to report abuse. They had taken a post test and had to score 100%. Interview with CNA #12 at 1:30 PM and CNA #11 at 1:57 PM, revealed they had received recent training on abuse and had good knowledge on how, when, and to whom they were supposed to report allegations of abuse. They had to take a post test and score 100%. Interview with two (2) new employees (working under a Preceptor to become CNAs) on 03/29/16 at 1:35 PM, and 1:46 PM, revealed the new employees were both hired on 03/23/16. They stated they had received training on abuse during their classroom orientation regarding the different types of abuse, and how to report abuse. They were in the process of watching the Hand in Hand modules regarding abuse. In addition, they were required to take a post test and score 100%. 9. Review of the skin audits and resident interviews revealed the facility had conducted those audits as stated in the AOC. Interview with the Social Worker, on 03/29/16 at 12:15 PM, revealed she had conducted random audits of 10% of the daily census for interviews with the residents regarding abuse. She stated she ensured the residents knew to whom to report an allegation of abuse and that they felt comfortable. The Social Worker validated she received training on the Abuse Policy with a post test. She stated no resident had alleged any type of abuse during her interviews. Interview with the East Wing Unit Manager, on 03/29/16 at 2:00 PM, revealed she had received recent training on abuse from the DON. She then provided abuse training to the direct care staff starting on 03/08/16 and a post test was required. She stated she assisted the DON with audits of staff interview regarding their knowledge of how to report abuse. She also assisted in performing skin assessments on the residents. Interview with the West Wing Unit Manager, on 03/29/16 at 3:44 PM, revealed she just started the position on 03/24/16. She stated she received training on the Abuse Policy and took the required post test and scored 100%. The West Wing Unit Manager stated she had assisted in performing skin assessment audits and attended a QA meeting on 03/28/16. Interview with DON #3 and the Administrator, on 03/29/16 at 3:46 PM, revealed the facility had conducted audits (10% daily) of staff and residents through interviews to determine their knowledge of how to report abuse. The Administrator stated she implemented and educated the Abuse Coordinator Staff. She told the staff if the DON or the Administrator had not reached out to them after an allegation of abuse was received, they were to contact her. Daily skin assessments and resident interviews were conducted looking for any abuse. She stated the DON and Unit Managers would review the skin assessment audits and discuss in the morning meeting. The audits were then reviewed in the QA meetings. The Medical Director reviewed the corrective plans and was informed of the audits. She stated the IDT met every morning to review the audits and in the QA meetings. Interview with the Corporate Nurse Consultant, on 03/29/16 at 1:50 PM, revealed she had assisted with staff education, grading post tests, and reviewing daily audits. When she reviewed the audits; she wanted to ensure staff understood who and when to report abuse. The audits revealed staff had a good understanding of the abuse training that was provided with 100% score on the post test. She was providing oversight and working on survey readiness. She stated the new corporation was still implementing their polices and daily processes. However, she would be available for support and assistance and her goal was to visit the facility two (2) to three (3) times a week until compliance was achieved and then weekly. Review of the daily audits of staff interviews and the post test revealed five (5) staff were interviewed and given the examination daily. Interview with the Social Worker, on 03/28/16 at 12:15 PM, revealed she had been chosen for interview and post test frequently. Interview with LPN #8, on 03/29/16 at 1:26 PM, revealed she had been asked examination questions regarding her abuse training recently. Interview with CNA #9, on 03/29/16 at 1:28 PM, revealed she had been asked examination questions regarding the Abuse Policy since her training. 10. Review of the QA signature sheets revealed a QA meeting was conducted on 03/18/16 with the Medical Director participating via phone conference. In addition, those in attendance included: Administrator, DON, Social Worker, IDT team, and Human Resource Director. Interview with the Administrator, on 03/29/16 at 3:46 PM, revealed the QA meeting held on 03/18/16 was to discuss the survey findings and develop corrective plans. Review of the e-mail between the Administrator and the Medical Director, dated 03/18/16 at 8:18 PM, validated he participated in the QA meeting that day, had reviewed the Abuse Policy, and recommended no changes. He stated he agreed with the facility's plan of correction.

Based on interviews, record review, and review of the facility's investigation report and policy, it was determined the facility failed to have an effective system in place to ensure the facility's policies and procedures related to reporting abuse and protection of residents were implemented for one (1) of twelve (12) sampled residents (Resident #2). Interview and record review revealed on 03/02/16, during the evening meal, two (2) Certified Nursing Assistants (CNA #2 and #3) witnessed CNA #4 slap Resident #2 twice on the forearm. The staff failed to follow its policies and procedures as they did not immediately report the alleged abuse to the charge nurse per facility policy. The physical abuse occurrence was not reported to the Charge Nurse until 03/07/16 at 7:30 PM five (5) days later. The abuse allegation was not reported to the Administrator until approximately 10:30 PM on 03/07/16, five (5) days after the occurrence of the event. Interviews and review of CNA #4's time sheet revealed the aide continued to care for Resident #2 and other residents after the observed abuse. Review of the work schedule and time sheet for CNA #4 revealed the aide worked and cared for resident on March 2, 3, 5, 6, and 7, 2016. The facility's failure to have an effective system in place to ensure staff reported observed abuse of residents immediately and ensure residents were protected from further abuse placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 03/18/16, and determined to exist on 03/02/16. The facility was notified of the IJ on 03/18/16. An acceptable Allegation of Compliance (AOC) was received on 03/22/16, which alleged removal of the IJ on 03/19/16. A Partial Extended Survey was initiated on 03/28/16. The State Survey Agency (SSA) determined the IJ was removed on 03/19/16 as alleged, which lowered the Scope and Severity (S/S) to D while the facility developed and implemented the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of systemic changes. The findings include: Review of the facility's Abuse and Neglect Policy, revised March 2013, revealed a person(s) who observed abuse would immediately report to the Charge Nurse immediately. The Charge Nurse would immediately remove the suspected perpetrator from resident care, obtain the staff member's witness statement and immediately suspend the employee. The Charge Nurse would immediately notify the Administrator, Director of Nursing (DON), and/or Abuse Coordinator. The person(s) observing the incident would immediately report and provide a written statement that included the name of the resident, date and time it occurred, where it occurred, staff involved, and a description of what occurred. The Administrator or DON would notify state agencies according to the reporting guidelines. Review of the facility's investigation, dated 03/08/16, revealed on 03/07/16 at 7:15 PM, CNA #2 reported to Registered Nurse (RN) #1 that she had observed CNA #4 smack Resident #2 on the arm last week. The Administrator and the Assistant Director of Nursing (ADON) were not notified until 10:30 PM on 03/07/16. The Administrator directed the nurse to interview CNA #4 and then suspend the aide. RN #1 documented CNA #4 admitted to swatting the resident's forearm when the resident attempted to grab at a food tray. Further review of the investigative report revealed there were two (2) aides that had witnessed the abuse; however, they had not reported the abuse. All three (3) aides were suspended on 03/07/16. Review of the final report, dated 03/11/16, revealed the facility substantiated the allegation of abuse when CNA #4 admitted to hitting the resident on the forearm. The facility's investigation revealed the two (2) aides that had witnessed the abuse (on 03/02/06 during the evening meal) had not followed the facility's policy, as they had not reported the abuse. The facility notified the state agencies on 03/08/16. The facility began education on their Abuse Policy on 03/08/16. Record review revealed the facility admitted Resident #2 in July 2009. The resident's [DIAGNOSES REDACTED]. The facility assessed the resident to have a severe cognition loss and was unable to conduct a Brief Interview of Mental Status (BIMS) test. Review of the most recent Minimum Data Set (MDS) assessment, conducted on 02/22/16, revealed the resident required extensive assistance with eating. Review of the Comprehensive Care Plan, for the problem of communication, dated 02/22/16, revealed the resident's communication was impaired and the resident was unable to understand or be understood. The goal was for the resident's needs to be anticipated by staff. A new intervention to place the resident's food tray out of reach of the resident, was added to the care plan on 03/07/16. Interview with CNA #3, on 03/15/16, at 4:57 PM, revealed he observed CNA #4 slap Resident #2's forearm in the dining room on 03/02/16. He stated CNA #4 was assisting Resident #2 with the evening meal when the resident reached for the food tray. He stated the resident had a history of [REDACTED]. When the resident reached for the food tray, CNA #4 slapped the resident on the forearm. When the resident reached for the food tray again, CNA #4 slapped the resident on the forearm again. CNA #3 stated the resident said, Ouch, the second time. CNA #3 told CNA #4 that he should not do that, but CNA #4 told him it was okay. CNA #3 told CNA #4 it was not okay. He stated License Practical Nurse (LPN) #5 was in the dining room when CNA #4 slapped the resident and he assumed she saw the same thing he witnessed. Further interview revealed the nurse told him she would take care of it and he thought the nurse had reported the abuse. However, he did not see her speak with CNA #4 that night and the aide continued to care for residents. He stated that CNA #2 came to him several nights later (03/07/16) and told him he needed to speak with RN #1 regarding what they observed in the dining room. He assumed that LPN #5 had reported the abuse. Interview, via telephone, with CNA #2, on 03/17/16 at 9:15 AM, revealed she had observed CNA #4 slap Resident #2 on the forearm twice on 03/02/16. She stated the resident grabbed for the food tray and CNA #4 smacked the resident on the forearm with an opened hand, and when the resident again reached for the food tray CNA #4 smacked the resident again on the forearm. However, this time the resident said,Ouch, and began rubbing his/her arm. Continued interview with CNA #2 revealed she did not report the allegation of abuse because a nurse was in the dining room at the same time. CNA #2 stated she knew this was wrong, but since the nurse was in the dining room, she assumed she saw the same thing and would report the incident. The CNA stated when she saw CNA #4 working on 03/07/16 caring for residents, she realized the alleged abuse had not been reported. She stated she was uncomfortable with CNA #4 working with residents after what she had observed. CNA #2 stated she was afraid he (CNA #4) would hit another resident in private. She then reported what she had observed to a staff nurse. Interview with LPN #5, on 03/16/16 at 8:49 PM, via telephone, revealed she did not observe the alleged abuse and she had not reported any abuse. LPN #5 stated she was not in the dining room for the whole meal and she did not witness the alleged abuse. She stated she was new to the facility and was still in the learning mode. She stated nobody came to her that night and reported the alleged abuse. Telephone interview with CNA #4, on 03/16/16 at 8:26 PM, revealed he denied hitting the resident, he stated he pushed the resident's hand away. The aide stated when the resident almost pulled the food tray onto the floor, he held the resident's hand. However, he then stated he touched the resident's arm. CNA #4 stated he told the resident, No, No, while he was holding the resident's hand. The aide stated he continued to assist the resident with his/her meal and then transported the resident to the sunroom and continued to work with residents throughout the evening on 03/02/16. The aide validated he worked on March 3, 5, 6, and 7, after the incident in the dining room caring for Resident #2. Further interview revealed on 03/07/16, a nurse came to him and told him he he had to go home, as he was suspended. A few days later the Administrator called him and told him he was terminated. Review of the work schedule and time sheet for CNA #4 revealed the aide worked on March 2, 3, 5, 6, and 7, 2016 caring for residents. Interview with the Administrator and the current Director of Nursing (DON) #3, on 03/16/16 at 9:12 AM, revealed the alleged physical abuse was reported to them on 03/07/16 after CNA #2 reported the abuse to a nurse. Upon knowledge of the alleged abuse, CNA #4 was suspended on 03/07/16. The Administrator stated CNAs #2 and #3 were also suspended for not following the facility's policy, as they did not report the alleged abuse. She stated when CNA #4 was interviewed, he admitted to smacking the resident's forearm twice. She stated she terminated the aide because he could not understand what he had done wrong and she was not sure the aide would not slap another resident again. She stated she substantiated the allegation and the facility's investigation found the that the two (2) aides failed to report the alleged abuse to the nurse according to the facility's policy. The Administrator stated there were no changes made to the Abuse Policy. She stated training of staff began on 03/08/16 and was ongoing. Interview with the Administrator and DON #3, on 03/17/16 at 4:25 PM, revealed the facility had not implemented any monitoring processes to ensure the training provided to staff was effective. DON #3, stated she had planned a staff meeting for 03/21/16 to go over the Abuse Policy and develop audits to ensure staff understood how to report abuse. However, they had not implemented those processes yet. The Administrator revealed she was waiting to have a Quality Assurance (QA) meeting scheduled for 03/24/16 after the monitoring audits were developed and implemented. The Administrator stated she was ensuring compliance through the complaint/grievance process. The facility implemented the following actions to remove the IJ: 1. The allegation of abuse against Resident #2 was reported to the State Agencies on 03/08/16. The facility's initial investigation was initiated on 03/07/16 by the Administrator, DON #2, and RN Nurse Manager. The facility suspended CNAs #2, #3, and #4 on 03/07/16. 2. The RN Unit Manager performed a skin assessment for Resident #2, on 03/07/16 and found no signs of abuse. On 03/10/16, skin assessments were conducted on those residents with a Brief Interview of Mental Status (BIMS) score of less than eight (8). No evidence of abuse was identified for any of those residents. 3. The facility (Social Services) interviewed residents with a BIMS score of eight (8) and above utilizing the Investigation Questions for Resident Interview, beginning on 03/08/16. 4. The Administrator notified the local law enforcement of the alleged abuse on 03/07/16. In addition, Resident #2's Physician and Responsible Party were notified of the alleged abuse on 03/07/16 by the RN Unit Manager. 5. The facility's Abuse Policy was reviewed by DON #3, Corporate Nurse Consultant and via telephone with the Medical Director on 03/07/16 and the Interdisciplinary Team on 03/18/16, with no revision required. 6. The Social Service Director assessed Resident #2 for possible psychosocial issues. No negative outcome was noted. 7. Resident #2's care plan was reviewed and revised on 03/07/16 by the RN Unit Manager. The care plan was revised to reflect a new order for Geri Sleeves to be applied to the resident's bilateral arms to prevent the resident from scratching his/her arms. 8. All staff received training on the Abuse Policy with a post test. Staff had to score 100% or retake the test. One hundred forty-one (141) out of one hundred sixty (160) employees received the training with the post test. Those who had not received the training were sent the training material with the post test via certified mail on 03/14/16. Employees will not be allowed to work until they had received the training and taken the post test. The Staff Development Nurse will provide abuse training during the orientation program for all new employees. 9. Beginning 03/18/16, DON #3 and the Unit Managers would conduct random skin checks for residents with a BIMS score less than eight (8) and Social Services would conduct interviews with residents with a BIMS' score greater than eight (8). The audits would be 10% of daily census for each group and conducted daily for two (2) weeks to ensure residents were free from abuse. The audits would decrease to 5% for five (5) days a week for two (2) weeks, then 5% three (3) times a week for one month. Staff interviews with a post test validation began on 03/18/16 where 10% of staff daily were given the abuse post test to ensure ongoing knowledge of various types of abuse and when and whom to report allegations of abuse. 10. An Ad Hoc QA meeting was conducted on 03/18/16 with the Medical Director via phone conference. The survey findings and AOC corrective plan were reviewed. The IDT team would meet weekly for four (4) weeks to review the audit findings until compliance is achieved. The SSA validated removal of the IJ on 03/19/16 as follows: 1. Review of the facility's investigation revealed the abuse investigation was initiated on 03/07/16 and the faxed report was sent to the Office of Inspector General (OIG) on 03/08/16 at 11:37 AM. Review of the Stakeholder Suspension Form, dated 03/17/16, revealed CNAs #2, #3, and #4 were suspended. CNA #2 and #3 received a counseling session on 03/09/16 for failure to follow the facility's policy and would be re-educated on the Abuse Policy. Interview with CNA #2, on 03/17/16 at 9:15 AM, revealed she had been suspended for not reporting the abuse. Interview with CNA #3, on 03/15/16, at 4:57 PM, revealed he had been suspended for not reporting the abuse. A telephone interview with CNA #4, on 03/16/16 at 8:26 PM, revealed he had been suspended on 03/07/16 and a few days later the Administrator had called and informed him he had been terminated. 2. Review of Resident #2's clinical record revealed a skin assessment was performed by the East Unit Manager, on 03/07/16 at 10:30 PM, with no bruises, only scratches noted to the underside of the resident's forearms, between the wrist and elbow. The resident's physician was notified of the scratches by the RN Unit Manager on 03/07/16 with an order for [REDACTED].>Interview with the RN Manager (now DON #3), on 03/15/16 at 9:10 AM, revealed she had called the resident's physician and obtained the order for the Geri Sleeves. Review of the AOC book revealed fifty-seven (57) skin assessments were conducted by the DON, Unit Managers and RN Charge Nurse on 03/10/16 with no evidence of abuse found. 3. Review of the resident's interviews revealed sixty-seven (67) residents were interviewed by Social Services beginning 03/08/16 with no concerns of abuse or mistreatment expressed. Interview with sampled Resident #1, on 03/16/16 at 8:25 AM, Resident #6 on 03/15/16 at 3:28 PM, Resident #7 on 03/16/16 at 10:02 AM, and Resident #9 on 03/28/16 at 9:37 AM, revealed the residents had not experienced any abuse and had not observed any abuse toward other residents. 4. Review of documentation with the local law enforcement contact information revealed the police were at the facility on 03/07/16. Interview with the Administrator and DON #3, on 03/16/16 at 9:12 AM, revealed the local police was called and came to the facility and tried to interview the resident. No charges were filed. DON #3 stated she had notified the resident's responsible party that night. On 03/07/16, DON #3 notified the Medical Director, who was on call as the resident's Primary Physician of the alleged abuse. 5. Review of the facility's Abuse Policy, dated March 2013, revealed no revisions were made. Interview with the Administrator, on 03/16/16 at 9:12 AM, revealed there had been no changes to the Abuse Policy. 6. Review of the Social Service Progress Note, dated 03/08/16 at 2:20 PM, revealed the Social Service Worker attempted to interview Resident #2 without success. She documented the resident was sitting in a common area and was smiling. She documented observations of the resident, on 03/09/16 at 11:30 AM, and 03/10/16 at 2:00 PM, of the resident out of their room either beside the Nurses' Station or in the dining room smiling at staff when they spoke to him/her. No behaviors were noted. Interview with the Social Worker, on 03/29/16 at 12:15 PM, revealed she had observed the resident for three (3) days and saw no behaviors or negative outcome from the abuse. 7. Review of the clinical record revealed an order for [REDACTED]. Observation of Resident #2, on 03/15/16 at 3:24 PM, revealed the resident was in bed with Geri Sleeves applied. 8. Review of the training records revealed one hundred and sixty (160) employees had been trained by 03/18/16 by the Staff Development Nurse on the facility's Abuse Policy and had taken a post test. The only employees that had not received the abuse training were the four (4) employees on Family and Medical Leave Act (FMLA). Interview with CNA #9, on 03/16/16 at 8:30 AM, revealed she had recent training on abuse last week. She stated the training went over the Abuse Policy regarding protecting the resident first then reporting the abuse to the Nurse Supervisor. Interview with the Maintenance Director, on 03/16/16 at 8:40 AM, revealed he had training last week on the different types of abuse and what to do if you witnessed abuse. He stated he would report the abuse immediately to the nurse. Interview with Housekeeper #1, on 03/16/16 at 8:47 AM, revealed she received training on abuse last week. She stated a post test was given. Housekeeper #1 stated the different types of abuse were discussed and when and to whom to report the allegation of abuse. Interview with Occupational Therapist #1, on 03/16/16 at 8:50 AM, revealed she had received training on abuse many times. The most recent was last week. She stated the different types of abuse were discussed and how to report abuse and to whom. She stated the Abuse Hotline was discussed and the number was posted in the facility. Staff interviews, on 03/29/16 with LPN #8 at 1:26 PM, LPN #9 at 1:38 PM, LPN #7 at 1:42 PM, and LPN #6 at 1:55 PM, revealed they had received re-education on the facility's Abuse Policy on the different types of abuse, how, when, and whom to report abuse. They had taken a post test and had to score 100%. Interview with CNA #12 at 1:30 PM and CNA #11 at 1:57 PM, revealed they had received recent training on abuse and had good knowledge on how, when, and to whom they were supposed to report allegations of abuse. They had to take a post test and score 100%. Interview with two (2) new employees (working under a Preceptor to become CNAs) on 03/29/16 at 1:35 PM, and 1:46 PM, revealed the new employees were both hired on 03/23/16. They stated they had received training on abuse during their classroom orientation regarding the different types of abuse, and how to report abuse. They were in the process of watching the Hand in Hand modules regarding abuse. In addition, they were required to take a post test and score 100%. 9. Review of the skin audits and resident interviews revealed the facility had conducted those audits as stated in the AOC. Interview with the Social Worker, on 03/29/16 at 12:15 PM, revealed she had conducted random audits of 10% of the daily census for interviews with the residents regarding abuse. She stated she ensured the residents knew to whom to report an allegation of abuse and that they felt comfortable. The Social Worker validated she received training on the Abuse Policy with a post test. She stated no resident had alleged any type of abuse during her interviews. Interview with the East Wing Unit Manager, on 03/29/16 at 2:00 PM, revealed she had received recent training on abuse from the DON. She then provided abuse training to the direct care staff starting on 03/08/16 and a post test was required. She stated she assisted the DON with audits of staff interview regarding their knowledge of how to report abuse. She also assisted in performing skin assessments on the residents. Interview with the West Wing Unit Manager, on 03/29/16 at 3:44 PM, revealed she just took that position on 03/24/16. She stated she received training on the Abuse Policy and took the required post test and scored 100%. The West Wing Unit Manager stated she had assisted in performing skin assessment audits and attended a QA meeting on 03/28/16. Interview with DON #3 and the Administrator, on 03/29/16 at 3:46 PM, revealed the facility had conducted audits (10% daily) of staff and residents through interviews to determine their knowledge of how to report abuse. The Administrator stated she implemented and educated the Abuse Coordinator Staff. She told the staff if the DON or the Administrator had not reached out to them after an allegation of abuse was received, they were to contact her. Daily skin assessments and resident interviews were conducted looking for any abuse. She stated the DON and Unit Managers would review the skin assessment audits and discuss in the morning meeting. The audits were then reviewed in the QA meetings. The Medical Director reviewed the corrective plans and was informed of the audits. She stated the IDT met every morning to review the audits and in the QA meetings. Interview with the Corporate Nurse Consultant, on 03/29/16 at 1:50 PM, revealed she had assisted with staff education, grading post tests, and reviewing daily audits. When she reviewed the audits; she wanted to ensure staff understood who and when to report abuse. The audits revealed staff had a good understanding of the abuse training that was provided with 100% score on the post test. She was providing oversight and working on survey readiness. She stated the new corporation was still implementing their polices and daily processes. However, she would be available for support and assistance and her goal was to visit the facility two (2) to three (3) times a week until compliance was achieved and then weekly. Review of the daily audits of staff interviews and the post test revealed five (5) staff were interviewed and given the examination daily. Interview with the Social Worker, on 03/28/16 at 12:15 PM, revealed she had been chosen for interview and post test frequently. Interview with LPN #8, on 03/29/16 at 1:26 PM, revealed she had been asked examination questions regarding her abuse training recently. Interview with CNA #9, on 03/29/16 at 1:28 PM, revealed she had been asked examination questions regarding the Abuse Policy since her training. 10. Review of the QA signature sheets revealed a QA meeting was conducted on 03/18/16 with the Medical Director participating via phone conference. In addition, those in attendance included: Administrator, DON, Social Worker, IDT team, and Human Resource Director. Interview with the Administrator, on 03/29/16 at 3:46 PM, revealed the QA meeting held on 03/18/16 was to discuss the survey findings and develop corrective plans. Review of the e-mail between the Administrator and the Medical Director, dated 03/18/16 at 8:18 PM, validated he participated in the QA meeting that day, had reviewed the Abuse Policy, and recommended no changes. He stated he agreed with the facility's plan of correction.

Based on interviews, record review, and review of the facility's Abuse Policy and investigation, it was determined the facility failed to ensure each resident was free from abuse for one of twelve (12) sampled residents (Resident #2). On 03/02/16, during the evening meal, Certified Nursing Assistants (CNA) #2 and #3 observed CNA #4 strike Resident #2 twice on the forearm. CNA #4 admitted to swatting the resident's forearm when the resident attempted to grab at a food tray. The facility failed to have an effective system in place to ensure residents were free from abuse placed residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 03/18/16 and determined to exist on 03/02/16. The facility was notified of the IJ on 03/18/16. An acceptable Allegation of Compliance (AOC) was received on 03/22/16 and the State Survey Agency (SSA) validated the IJ was removed on 03/19/16, as alleged. The Scope and Severity (S/S) was lowered to a D while the facility developed and implemented the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitored the effectiveness of the systemic changes. The findings include: Review of the facility's Abuse and Neglect Policy, revised March 2013, revealed verbal, sexual, physical, and mental abuse, corporate punishment, neglect involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property were prohibited. Review of the facility's investigation, dated 03/08/16, revealed CNA #2 reported to Registered Nurse (RN) #1, on 03/07/16 at 7:15 PM, that she had observed CNA #4 smack Resident #2 on the arm last week. The Administrator and the Assistant Director of Nursing (ADON) were notified. The Administrator directed RN #1 to interview CNA #4 and then suspend the aide. RN #1 documented that CNA #4 admitted to swatting the resident's forearm when the resident attempted to grab at a food tray. The investigative report stated there were two (2) aides that had witnessed the abuse; however, they had not reported the abuse. All three (3) aides were suspended on 03/07/16. Review of the final report, dated 03/11/16, revealed the facility substantiated the allegation of abuse when CNA #4 admitted to hitting the resident on the forearm. The facility's investigation revealed the two (2) aides that had witnessed the abuse (on 03/02/06 during the evening meal) had not reported the abuse. The facility notified the state agencies on 03/08/16. The facility began education on their Abuse Policy on 03/08/16. Record review revealed Resident #2 had resided at the facility since July 2009. Review of the most current [DIAGNOSES REDACTED]. Record review revealed the facility had assessed the resident to have a severe cognition loss and was unable to conduct a Brief Interview of Mental Status (BIMS) test. Review of the most recent Minimum Data Set (MDS) assessment, conducted on 02/22/16, revealed the resident required extensive assistance with eating. Review of the comprehensive care plan for the problem of communication, dated 02/22/16, revealed the Resident #2's communication was impaired and the resident was unable to understand or be understood. The goal was for the resident's needs to be anticipated by staff. A new intervention was added on 03/07/16 to place the resident's food tray out of reach of the resident. Interview with CNA #3, on 03/15/16, at 4:57 PM, revealed he observed CNA #4 slap Resident #2's forearm in the dining room on 03/02/16. He stated CNA #4 was assisting Resident #2 with the evening meal when the resident reached for the food tray. He stated the resident had a history of [REDACTED]. When the resident reached for the food tray, CNA #4 slapped the resident on the forearm and slapped the resident again when he/she reached for the food tray. This time the resident said, Ouch. CNA #3 told the aide he did not want to do that, but CNA #4 told him it was okay. CNA #3 told the aide it was not okay. He stated License Practical Nurse (LPN) #5 was in the dining room at that time and told him she would take care of it and he thought the nurse had reported the abuse. However, he did not see her speak with CNA #4 that night and the aide continued to care for residents. Further interview revealed CNA #2 came to him several nights later (03/07/16) and said he needed to speak with RN #1 about what they had observed in the dining room. He stated there was a miscommunication and he didn't realize the alleged abuse had not been reported. He assumed that LPN #5 had reported the abuse. A telephone interview with CNA #2, on 03/17/16 at 9:15 AM, revealed she had observed CNA #4 slap Resident #2 on the forearm twice on 03/02/16. She stated she did not report the allegation of abuse because a nurse was in the dining room at the same time of her observation and she assumed the nurse reported the abuse. She stated the resident was grabbing for the food tray and CNA #4 smacked the resident on the forearm with an opened hand. When the resident reached for the food tray again and CNA #4 smacked the resident again on the forearm. However, this time the resident said,Ouch, and began rubbing his/her arm. The CNA stated she knew this was wrong but since the nurse was in the dining room, she assumed she saw the same thing and would report the incident. When she saw CNA #4 working on 03/07/16 caring for residents, she realized the alleged abuse had not been reported. She stated she was uncomfortable with CNA #4 working with residents after what she observed and she was afraid he would hit another resident in private. She then reported what she observed to a staff nurse. A telephone interview with LPN #5, on 03/16/16 at 8:49 PM, revealed the nurse did not observe the alleged abuse and had not reported any abuse. The nurse stated she was not in the dining room for the whole meal and she did not witness the alleged abuse. LPN #5 stated she was new to the facility and was still in the learning mode. She stated nobody came to her that night and reported the alleged abuse. Telephone interview with CNA #4, on 03/16/16 at 8:26 PM, revealed he denied hitting the resident; he stated he pushed the resident's hand away. The aide stated the resident almost pulled the food tray onto the floor so he held the resident's hand. However, he then stated he touched the resident's arm. He stated he told the resident, No, No, while he was holding the resident's hand. The aide stated he continued to assist the resident with his/her meal and then transported the resident to the sunroom. He stated he continued to work with residents throughout the evening on 03/02/16. The aide validated he worked on March 3, 5, 6, and 7, 2016 after the incident in the dining room, and continued to care for Resident #2. Review of the work schedule and time sheet for CNA #4 revealed the aide worked on March 2, 3, 5, 6, and 7, 2016 caring for residents. On 03/07/16, the aide stated a nurse came to him and told him he was suspended and had to go home. He said the Administrator called him a few days later and told him he was terminated. Interview with the Administrator and the current Director of Nursing (DON) #3, on 03/16/16 at 9:12 AM, revealed the alleged physical abuse was reported to them on 03/07/16 after CNA #2 reported the abuse to a nurse. Upon knowledge of the alleged abuse, CNA #4 was suspended on 03/07/16. The Administrator stated CNA #2 and #3 were also suspended for not reporting the alleged abuse. According to the Administrator, when CNA #4 was interviewed, he admitted to smacking the resident's forearm twice. She terminated the aide because he (the aide) could not understand what he did was wrong and she was not sure the aide would not slap another resident again. She substantiated the allegation and the facility's investigation found the two (2) aides failed to report the alleged abuse to the nurse according to facility policy. The Administrator further stated there were no changes made to the Abuse Policy and training of staff began on 03/08/16 and was ongoing. Additional interview with the Administrator and DON #3, on 03/17/16 at 4:25 PM, revealed the facility had not implemented any monitoring processes to ensure the training provided to staff was effective. DON #3 stated she had planned a staff meeting for 03/21/16 to go over the Abuse Policy and develop audits to ensure staff understood how to report abuse. However, they had not implemented the processes yet. The Administrator stated she was waiting to have a Quality Assurance (QA) meeting scheduled for 03/24/16 after the monitoring audits were developed and implemented. The Administrator further stated she was ensuring compliance through the complaint/grievance process. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The allegation of abuse against Resident #2 was reported to the State Agencies on 03/08/16. The facility's initial investigation was initiated on 03/07/16 by the Administrator, DON #2, and RN Nurse Manager. The facility suspended CNAs #2, #3, and #4 on 03/07/16. 2. The RN Unit Manager performed a skin assessment for Resident #2, on 03/07/16 and found no signs of abuse. On 03/10/16, skin assessments were conducted on those residents with a BIMS score of less than eight (8). No evidence of abuse was identified for any of those residents. 3. The facility (Social Services) interviewed residents with a BIMS scores of eight (8) and above utilizing the Investigation Questions for Resident Interview, beginning on 03/08/16. 4. The Administrator notified local law enforcement of the alleged abuse on 03/07/16. In addition, on 03/07/16 the RN Unit Manager notified Resident #2's Physician and Responsible Party of the alleged abuse. 5. The facility's Abuse Policy was reviewed by DON #3, Corporate Nurse Consultant and via telephone with the Medical Director on 03/07/16 and the Interdisciplinary Team on 03/18/16, with no revision required. 6. The Social Service Director assessed Resident #2 for possible psychosocial issues. No negative outcome was noted. 7. Resident #2's care plan was reviewed and revised on 03/07/16 by the RN Unit Manager. The care plan was revised to reflect a new order for Geri Sleeves to be applied to the resident's bilateral arms to prevent the resident from scratching his/her arms. 8. All staff received training on the Abuse Policy with a post test. Staff had to score 100% or retake the test. One hundred forty-one (141) out of one hundred sixty (160) employees received the training with the post test. Those who had not received the training were sent the training material with the post test via certified mail on 03/14/16. Employees will not be allowed to work until they had received the training and taken the post test. The Staff Development Nurse will provide abuse training during the orientation program for all new employees. 9. Beginning 03/18/16, DON #3 and the Unit Managers would conduct random skin checks for residents with a BIMS score less than eight (8) and Social Services would conduct interviews with residents with a BIMS' score greater than eight (8). The audits would be 10% of daily census for each group and conducted daily for two (2) weeks to ensure residents were free from abuse. The audits would decrease to 5% for five (5) days a week for two (2) weeks, then 5% three (3) times a week for one month. Staff interviews with a post test validation began on 03/18/16 where 10% of staff daily were given the abuse post test to ensure ongoing knowledge of various types of abuse and when and whom to report allegations of abuse. 10. An Ad Hoc QA meeting was conducted on 03/18/16 with the Medical Director via phone conference. The survey findings and AOC corrective plan were reviewed. The IDT team would meet weekly for four (4) weeks to review the audit findings until compliance is achieved. The SSA validated removal of the IJ on 03/19/16 as follows: 1. Review of the facility's investigation revealed the abuse investigation was initiated on 03/07/16 and the faxed report was sent to the Office of Inspector General (OIG) on 03/08/16 at 11:37 AM. Review of the Stakeholder Suspension Form, dated 03/17/16, revealed CNAs #2, #3, and #4 were suspended. CNA #2 and #3 received a counseling session on 03/09/16 for failure to follow the facility's policy and would be re-educated on the Abuse Policy. Interview with CNA #2, on 03/17/16 at 9:15 AM, revealed she had been suspended for not reporting the abuse. Interview with CNA #3, on 03/15/16, at 4:57 PM, revealed he had been suspended for not reporting the abuse. A telephone interview with CNA #4, on 03/16/16 at 8:26 PM, revealed he had been suspended on 03/07/16 and a few days later the Administrator had called and informed him he had been terminated. 2. Review of Resident #2's clinical record revealed a skin assessment was performed by the East Unit Manager, on 03/07/16 at 10:30 PM, with no bruises, only scratches noted to the underside of the resident's forearms, between the wrist and elbow. The resident's physician was notified of the scratches by the RN Unit Manager on 03/07/16 with an order for [REDACTED].>Interview with the RN Manager (now DON #3), on 03/15/16 at 9:10 AM, revealed she had called the resident's physician and obtained the order for the Geri Sleeves. Review of the AOC book revealed fifty-seven (57) skin assessments were conducted by the DON, Unit Managers and RN Charge Nurse on 03/10/16 with no evidence of abuse found. 3. Review of the resident's interviews revealed sixty-seven (67) residents were interviewed by Social Services beginning 03/08/16 with no concerns of abuse or mistreatment expressed. Interview with sampled Resident #1, on 03/16/16 at 8:25 AM, Resident #6 on 03/15/16 at 3:28 PM, Resident #7 on 03/16/16 at 10:02 AM, and Resident #9 on 03/28/16 at 9:37 AM, revealed the residents had not experienced any abuse and had not observed any abuse toward other residents. 4. Review of documentation with the local police contact information revealed the police were at the facility on 03/07/16. Interview with the Administrator and DON #3, on 03/16/16 at 9:12 AM, revealed local law enforcement was called and responded to the facility and tried to interview the resident. No charges were filed. DON #3 stated she had notified the resident's Responsible Party that night. On 03/07/16 DON #3 notified the Medical Director, who was on call as the resident's Primary Physician of the alleged abuse. 5. Review of the facility's Abuse Policy, dated March 2013, revealed no revisions were made. Interview with the Administrator, on 03/16/16 at 9:12 AM, revealed there had been no changes to the Abuse Policy. 6. Review of the Social Service Progress Note, dated 03/08/16 at 2:20 PM, revealed the Social Service Worker attempted to interview Resident #2 without success. She documented the resident was sitting in a common area and was smiling. She documented observations of the resident, on 03/09/16 at 11:30 AM, and 03/10/16 at 2:00 PM, of the resident out of their room either beside the Nurses' Station or in the dining room smiling at staff when they spoke to him/her. No behaviors were noted. Interview with the Social Worker, on 03/29/16 at 12:15 PM, revealed she had observed the resident for three (3) days and saw no behaviors or negative outcome from the abuse. 7. Review of the clinical record revealed an order for [REDACTED]. Observation of Resident #2, on 03/15/16 at 3:24 PM, revealed the resident was in bed with Geri Sleeves applied. 8. Review of the training records revealed one hundred and sixty (160) employees had been trained by 03/18/16 by the Staff Development Nurse on the facility's Abuse Policy and had taken a post test. The only employees who had not received the abuse training were the four (4) employees on Family and Medical Leave Act (FMLA). Interview with CNA #9, on 03/16/16 at 8:30 AM, revealed she had recent training on abuse last week. She stated the training went over the Abuse Policy regarding protecting the resident first then reporting the abuse to the Nurse Supervisor. Interview with the Maintenance Director, on 03/16/16 at 8:40 AM, revealed he had training last week on the different types of abuse and what to do if abuse was witnessed. He stated he would report the abuse immediately to the nurse. Interview with Housekeeper #1, on 03/16/16 at 8:47 AM, revealed she received training on abuse last week. She stated a post test was given. Housekeeper #1 stated the different types of abuse were discussed and when and to whom to report the allegation of abuse. Interview with Occupational Therapist #1, on 03/16/16 at 8:50 AM, revealed she had received training on abuse many times. The most recent was last week. She stated the different types of abuse were discussed and how to report abuse and to whom. She stated the Abuse Hotline was discussed and the number was posted in the facility. Staff interviews, on 03/29/16 with LPN #8 at 1:26 PM, LPN #9 at 1:38 PM, LPN #7 at 1:42 PM, and LPN #6 at 1:55 PM, revealed they had received re-education on the facility's Abuse Policy on the different types of abuse, how, when, and whom to report abuse. They had taken a post test and had to score 100%. Interview with CNA #12 at 1:30 PM and CNA #11 at 1:57 PM, revealed they had received recent training on abuse and had good knowledge on how, when, and to whom they were supposed to report allegations of abuse. They had to take a post test and score 100%. Interview with two (2) new employees (working under a Preceptor to become CNAs) on 03/29/16 at 1:35 PM, and 1:46 PM, revealed the new employees were both hired on 03/23/16. They stated they had received training on abuse during their classroom orientation regarding the different types of abuse, and how to report abuse. They were in the process of watching the Hand in Hand modules regarding abuse. In addition, they were required to take a post test and score 100%. 9. Review of the skin audits and resident interviews revealed the facility had conducted those audits as stated in the AOC. Interview with the Social Worker, on 03/29/16 at 12:15 PM, revealed she had conducted random audits of 10% of the daily census for interviews with the residents regarding abuse. She stated she ensured the residents knew to whom to report an allegation of abuse and that they felt comfortable. The Social Worker validated she received training on the Abuse Policy with a post test. She stated no resident had alleged any type of abuse during her interviews. Interview with the East Wing Unit Manager, on 03/29/16 at 2:00 PM, revealed she had received recent training on abuse from the DON. She then provided abuse training to the direct care staff starting on 03/08/16 and a post test was required. She stated she assisted the DON with audits of staff interview regarding their knowledge of how to report abuse. She also assisted in performing skin assessments on the residents. Interview with the West Wing Unit Manager, on 03/29/16 at 3:44 PM, revealed she just started the position on 03/24/16. She stated she received training on the Abuse Policy and took the required post test and scored 100%. The West Wing Unit Manager stated she had assisted in performing skin assessment audits and attended a QA meeting on 03/28/16. Interview with DON #3 and the Administrator, on 03/29/16 at 3:46 PM, revealed the facility had conducted audits (10% daily) of staff and residents through interviews to determine their knowledge of how to report abuse. The Administrator stated she implemented and educated the Abuse Coordinator Staff. She told the staff if the DON or the Administrator had not reached out to them after an allegation of abuse was received, they were to contact her. Daily skin assessments and resident interviews were conducted looking for any abuse. She stated the DON and Unit Managers would review the skin assessment audits and discuss in the morning meeting. The audits were then reviewed in the QA meetings. The Medical Director reviewed the corrective plans and was informed of the audits. She stated the IDT met every morning to review the audits and in the QA meetings. Interview with the Corporate Nurse Consultant, on 03/29/16 at 1:50 PM, revealed she had assisted with staff education, grading post tests, and reviewing daily audits. When she reviewed the audits; she wanted to ensure staff understood who and when to report abuse. The audits revealed staff had a good understanding of the abuse training that was provided with 100% score on the post test. She was providing oversight and working on survey readiness. She stated the new corporation was still implementing their polices and daily processes. However, she would be available for support and assistance and her goal was to visit the facility two (2) to three (3) times a week until compliance was achieved and then weekly. Review of the daily audits of staff interviews and the post test revealed five (5) staff were interviewed and given the examination daily. Interview with the Social Worker, on 03/28/16 at 12:15 PM, revealed she had been chosen for interview and post test frequently. Interview with LPN #8, on 03/29/16 at 1:26 PM, revealed she had been asked examination questions regarding her abuse training recently. Interview with CNA #9, on 03/29/16 at 1:28 PM, revealed she had been asked examination questions regarding the Abuse Policy since her training. 10. Review of the QA signature sheets revealed a QA meeting was conducted on 03/18/16 with the Medical Director participating via phone conference. In addition, those in attendance included: Administrator, DON, Social Worker, IDT team, and Human Resource Director. Interview with the Administrator, on 03/29/16 at 3:46 PM, revealed the QA meeting held on 03/18/16 was to discuss the survey findings and develop corrective plans. Review of the e-mail between the Administrator and the Medical Director, dated 03/18/16 at 8:18 PM, validated he participated in the QA meeting that day, had reviewed the Abuse Policy, and recommended no changes. He stated he agreed with the facility's plan of correction.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure staff followed the care plan in regards to physician ordered appointments (Wound Care Clinic) for one (1) of twelve (12) sampled residents (Resident #5). An Unlicensed Graduate Nurse, who was not working under a Preceptor at the time, and did not have a provisional license, failed to put the weekly appointment for Resident #5's wound care on the appointment calendar, thus causing Resident #5 to miss at least two (2) appointments, one on 02/04/16; and, another one on 02/18/16. The facility failed to have an effective system in place to ensure staff followed the plans of care for residents, placing residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 03/30/16 and determined to exist on 11/30/15. The facility was notified of the Immediate Jeopardy (IJ) on 03/30/16. The facility provided an acceptable Allegation of Compliance (AOC) on 04/04/16, which alleged removal of the (IJ) on 04/05/16. The State Survey Agency (SSA) verified the IJ was not removed on 04/05/16, as alleged, but on 04/07/16 (facility allowed a nurse to return to work without training on 04/06/16) prior to exit on 04/08/16. The Scope and Severity (S/S) was lowered to a D while the facility develops and implements the plan of correction and the Quality Assurance (QA) monitors for effectiveness of the systemic changes. The findings include: Review of the facility's Care Plan Policy, not dated, revealed the facility would incorporate goals and objectives that would lead to the resident's highest obtainable level of independence. Review of Resident #5's closed record, revealed the facility admitted the resident on 02/03/16, with [DIAGNOSES REDACTED]. Review of Resident #5's Comprehensive Care Plan; for Impaired Skin Integrity, dated 02/04/16, revealed Resident #5 was to follow up with the Wound Clinic as ordered. Review of Resident #5's Physician Orders, dated 02/03/16, revealed Resident #5 was ordered to go to the Wound Clinic every Thursday to change the wound V.A.C. (Vacuum Assisted Closure) which was a NPWT (Negative-pressure Wound Therapy). Review of the February 2016 Appointment Calendar, revealed on 02/11/16 Resident #5 was to go to the Wound Clinic for wound V.A.C. treatment, but was sent to the emergency room for chest pain. However, the resident had a physician's orders [REDACTED].#5. Interview with the Wound Clinic Manager, on 03/17/16 at 11:02 AM, revealed Resident #5 had orders to come to the Wound Clinic on Thursdays, but Resident #5 had not come for his/her appointment a single time. Interview with Medical Records staff, on 03/17/16 at 5:48 PM, revealed she was responsible for scheduling resident appointments. Further interview revealed she had only set up an appointment for 02/11/16 for Resident #5 to be seen at the wound clinic. According to the Medical Records' staff, no one had voiced to her that Resident #5 was to have an appointment scheduled for every Thursday with the Wound Clinic. Interview with the Unlicensed Graduate Nurse, on 03/17/16 at 3:21 PM, revealed the nursing staff completed the initial care plan. Further interview revealed the care plan for Resident #5 stated the resident was to go to the Wound Clinic as ordered. The Unlicensed Graduate Nurse stated she did not know Resident #5 was not transported to his/her Wound Clinic Appointment, and it appeared the staff was not following the care plan as directed. She stated she was the Admission Nurse for Resident #5 and was responsible for the completion of all aspects of an admission, which would include placing appointments on the calendar. Further interview at 5:28 PM, revealed she was ultimately responsible to ensure Resident #5's appointments were on the Appointment Calendar because she signed that the order was taken off, and staff was expected to follow the physician's orders [REDACTED]. Interview with Unit Manager #1 (Manager on the West Hall), on 03/17/16 at 4:33 PM, revealed the care plan was not followed for Resident #5 as it pertained to the resident going to the wound clinic on Thursdays. The Unit Manager stated the staff was expected to follow the care plan. Interview with the Minimum Data Set (MDS) Coordinator, on 03/17/16 at 5:44 PM, revealed Resident #5's family had informed her that Resident #5 was to go to the wound clinic on Thursdays during her initial assessment. According to the MDS Coordinator, the nurses completed the initial care plan and MDS Coordinator completed the comprehensive care plan. The MDS Coordinator stated she expected the staff to follow the care plan. Interview with the current Director of Nursing (DON) #3, on 03/17/16 at 5:50 PM, revealed upon admission, the nurses completed the initial care plan and the MDS Coordinators completed the comprehensive care plan. The DON stated the nursing staff was not following the care plan if they had not ensured Resident #5 got to his/her Wound Clinic appointment. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 03/14/16, Director of Nursing (DON) #3 removed the stakeholder (Unlicensed Graduate Nurse), who did not have a provisional, from the LPNA role. On 03/28/16, the Administrator suspended the stakeholder. 2. The Corporate Care Consultants reviewed and validated thirty-one (31) stakeholders working as licensed nurses on 03/28/16; and, seven (7) were validated on 04/01/16 via the Kentucky Board of Nursing (KBN) online verification report. No stakeholder was found to be working without a valid nursing license. 3. The Corporate Care Consultants reviewed all current residents medical records that were assigned to the non-licensed stakeholder. Forty-one (41) charts were reviewed on 03/31/16; and, nine (9) were reviewed on 04/01/16. Of the fifty (50) charts reviewed, no care issues were noted related to the non-licensed stakeholder. The facility identified twenty-one (21) clinical records that had missing credentials. The DON and Nurse Managers began education addressing appropriate signage of the medical record including credentials for the unlicensed nurse. The facility implemented a Medical Record Review Process on 04/04/16 by the DON. The DON and/or Nurse Managers would review the medical record (physician's orders [REDACTED]. Five (5) percent of the current census would be reviewed for physician orders, nurses' notes and assessments in the daily clinical meeting (Monday-Friday) for two (2) weeks; if compliance was maintained, audits would decrease to 5% three (3) times a week for four (4) weeks, and then monthly for three (3) months. 4. The Consultants provided education to the DON and Nurse Managers on 04/01/16, on the process of auditing of the medical record(s). The education consisted of: legible signature to include credentials; physician orders [REDACTED]. The Nurse Managers, Staff Developed Coordinator (SDC), and DON #3 provided the above education to all licensed nursing stakeholders 04/01/16 through 04/04/16. Any licensed stakeholder that had not received the education by 04/04/16 would be issued a certified letter with the training material. Education and Post Education Competency would be completed by the DON and/or Nurse Managers in person and/or via phone for licensed nurses from 04/01/16 through 04/04/16. When conducting the Post Education Competency via phone, the SDC and/or Nurse Managers would ask the examination questions and document the licensed nurse's response on the examination. The SDC and/or Nurse Managers would follow up with the nurse in person to go over the training material verbally and the stakeholder would complete a written examination with the stakeholder's signature. The SDC and/or Nurse Managers would provide the training to a new stakeholder through the orientation program. The SDC and/or Nurse Manager would provide the Administrator and DON with a verbal progress report of the new stakeholder's performance and/or education skills needed during the orientation process. 5. The Human Resources (HR) Personnel, Receptionist, or Nurse Managers would conduct a KBN online validation report during the interview process for stakeholders applying for a licensed position and when a licensed position status change had occurred. The validation would be printed, reviewed, and signed by the DON, HR Personnel, Receptionist, or Nurse Manager as proof of validation status. The Administrator would conduct the final review. The HR Personnel, Receptionist, or Nurse Managers would conduct monthly and/or needed licensure review via KBN online validation report to ensure licenses were valid for three (3) months. If compliance is maintained, audits would be reduced to quarterly for two (2) quarters then annually thereafter. The Corporate Care Consultants would review completed KBN online validation reports daily (Monday-Friday) for four (4) weeks. If compliance is maintained, audits would decrease to two (2) times per week for four (4) weeks to ensure the validation process was completed. The audits would decrease to monthly for three (3) months during their facility visits. 6. The Corporate Care Consultants, Regional Vice President, and/or HR Advisory Personnel would provide ongoing education as needed for new administrative staff. The consultants would provide facility visits a minimum of five (5) days per week for two (2) weeks to review action plan and assist with education needs. If compliance was maintained, the visits would decrease to three (3) per week for eight (8) weeks, then a minimum of monthly thereafter. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 03/28/16 to review the survey findings and the facility's licensure validation process. Those in attendance included the Administrator, DON, HR Director, Unit Nurse Managers, and the Medical Director. On 03/30/16, a second Ad Hoc QAPI meeting was conducted with the Administrator, DON, Medical Director, Social Services, SDC, and Unit Managers to review policies and procedures related to the hiring and orientation process, and the supervision of LPNAs, RNAs, and student nurses. No changes were made to the hiring process or the Orientation Checklist. The Orientation Checklist for licensed stakeholders would be utilized for LPNAs and RNAs with direct supervision. A new Supervision Policy was created for LPNAs, RNAs, and student nurses on 03/30/16 during the QAPI meeting with the approval of the Medical Director. In addition, the Physical Order/Supplies and Scheduling of Medical Appointments Process was reviewed with no changes. A third Ad Hoc meeting was held on 04/01/16 with the Administrator, DON, and Medical Director via phone to review all recent survey citations and action plans. On 04/04/16, the Administrator and DON met with the Medical Director for overview of the survey findings: F281-discussed the incident with a non-licensed nurse related to Professional Standards with implementation of Licensure Validation Process; F282-discussion of oversight to ensure the care plan was followed; F309-discussed the failure to follow physician orders, provision of supplies, and scheduling of medical appointments; F490-reviewed the role of the Administrator to provide oversight for facility operations. Guidance and oversight would be provided by the Regional Vice President. The Administrator would review all audits and conduct observation rounds. F499- recapped the process for preventing non-licensed staff from working as licensed staff by completing the Licensure Validation Process. F514-reviewed education provided to maintain compliance in the deficient areas, including a post examination. Also reviewed the audit system/tools implemented to monitor processes. Audits would be discussed in the morning meeting, weekly QAPI and monthly QAPI. The IDT team will meet weekly times four (4) weeks to review all audit findings. If compliance was maintained, will reduce to monthly. 8. Order/Supply Process: Licensed nurse (s) would place physician orders [REDACTED]. Medical appointments would be scheduled as ordered, including transportation and logged on the monthly calendar. Unit Managers (Nurse Mangers) would review admission/readmission and/or new telephone orders and discuss in the morning clinical meetings (Monday-Friday). Ordered supplies would be discussed in the morning clinical meeting to ensure supplies were available for the resident (s). If the supplies cannot be obtained, a licensed nurse would contact the resident's physician for alternative orders until the supplies were available. 9. The Regional Vice President reviewed administrative duties that included: hiring process, licensure validation, facility oversight, role of the Administrator-in-training, and the job description with the Administrator on 04/04/16. The Regional Vice President will conduct weekly telephone calls with the Administrator for four (4) weeks to discuss current action plans and audit findings. If the facility's operations and oversight meet the residents' needs, the conference call would decrease to monthly for three (3) months, and then quarterly thereafter. If non-compliance is noted, the Vice President would modify oversight as needed to meet the needs of the residents. The State Agency validated removal of the Immediate Jeopardy on 04/07/16 as follows: 1. Review of the Stakeholder Suspension Form revealed the unlicensed stakeholder was suspended on 03/28/16 by the Administrator. Review of a written statement from DON #3 revealed she removed the employee from any licensed nurse duties on 03/14/16. Interview with the DON, on 04/06/16 at 3:29 PM and Administrator, on 04/06/16 at 5:03 PM, validated the stakeholder was suspended on 03/28/16. 2. Review of the facility's licensed staff roster revealed thirty-eight (38) nurses were employed as of 04/06/16. All thirty-eight (38) nurses had a KBN validation report validating they had a valid nursing license. Interview with Corporate Care Consultants #2, and #3, on 04/07/16 at 1:03 AM, revealed the facility had obtained validation of license for all nurses employed by the facility. Received validation reports from the KBN and no stakeholder was working without a license. 3. Review of the medical record review audit sheet revealed forty-three (43) records were reviewed with no problem identified. The audits were conducted on 03/31/16 and 04/01/16 by three (3) Corporate Care Consultants. Interview with Corporate Care Consultants #2 and #3, on 04/07/16 at 10:03 AM, revealed the review of the clinical record found no resident experienced a negative outcome related to the non-licensed stakeholder. The audit did find the nurses were not always signing with credentials. Review of the Medical Record Audit sheets, dated 04/01/16 through 04/06/16, revealed eight (8) to ten (10) residents' records were audited daily by the DON, Nurse Managers, and Corporate Care Consultants. Interview with Consultants #2 and #3, on 04/07/16 at 10:03 AM, West Wing Unit Manager, on 04/06/16 at 3:10 PM, and DON #3, on 04/06/16 at 3:29 PM, revealed medical record audits were being conducted for 5% of the resident census to ensure physician orders [REDACTED]. 4. Review of the training records revealed DON #3, East Unit Manager and West Unit Manager revealed they received training on 04/01/16 on how to audit the medical record and education on legible signatures with credentials, physician orders, supervision of LPNAs, RNAs, and nursing students, following care plans, and scheduling appointments. A post test was taken with the DON and managers scoring 100%. Interview with DON #3, on 04/06/16 at 3:29 PM, revealed she had received the education on the topic above. She then provided training to all licensed nursing stakeholders. She was trained on how to conduct the medical record audits and was involved in conducting those audits. Interview with the East Wing Unit Manager, on 04/06/16 at 11:25 AM, revealed she had been trained to do the medical record audits; however, she had not conducted the audits to date. She revealed she had only been in this position for three (3) weeks and was still learning. Further interview revealed she validated she had received training on physician orders, care plans, scheduling of appointments, documentation to be legible and to include credentials; and, supervision of LPNAs and RNAs. She had not conducted training of the nurses. Interview with the West Wing Unit Manager, on 04/06/16 at 3:10 PM, revealed she had been trained on how to conduct audits of the medical record and had conducted a few over the weekend. She validated she received training on physician orders, documentation in the medical record to be legible with credentials, care plans, scheduling of appointments, physician orders, and supervision of LPNAs and RNAs. She had not conducted training of the nurses. Review of the training records and post test revealed thirty-three (33) licensed nurses and four (4) Certified Medication Technicians were trained on documentation in the medical record that was complete, legible and included credentials. In addition, physician orders, care plans, scheduled appointments, and supervision of LPNAs and RNAs was also reviewed by the survey team. All had passed the post test with a score of 100. Record review revealed five (5) stakeholders had not received the training as of 04/04/16. Certified letters were sent on 04/04/16 to those employees. Copies of the letters were reviewed and the certified mail receipts. A letter written by the Administrator, dated 04/04/16, accompanied the training material. In the letter, the Administrator instructed the licensed nurses they must review the enclosed education material and complete a post test before returning to work. The stakeholder was instructed to turn in the post test and sign the training roster before returning to the facility for a scheduled shift. Validation interviews were conducted on 04/06/16 with LPN #12 at 10:46 AM, LPN #9 at 11:08 AM, LPN #6 at 1:46 PM, LPN #11 at 4:23 PM, and LPN #3 at 4:38 PM, revealed they had received the training and taken the post test. Each nurse had good knowledge of the training topics. Interview with LPN #8, on 04/06/16 at 11:42 AM revealed she needed to complete the training. She stated she had been informed of a certified letter, but she had not been to the post office to pick up the certified letter. Therefore, she did not know what the letter contained. She stated she started her work shift today at 6:30 AM and nobody had informed her that she had to complete the training before caring for residents. She stated the Unit Manager had not said anything to her and she had not received any training over the phone. Interview with the West Unit Manager, on 04/16/16 at 11:58 AM, revealed she was unaware the nurse had not received the training. She stated she did realize the DON had not provided training over the phone until the nurse could receive the training in person and taken the post test. Interview with DON #3, on 04/06/16 at 12:06 AM and 12:12 PM, revealed she had called LPN #8 twice and never could reach her. She assumed the nurse had received the certified letter with the training material. She stated she had reviewed the working schedule and didn't realize the nurse was working (that day). She stated it was an oversight and she or the Unit Manager realized she had not been trained. Verification of the nurse's training with a post test was provided to the surveyor on 04/16/16 at 12:10 PM. 5. Review of a newly hired nurse, on 03/29/16, validation check revealed the facility conducted a KBN online validation report on 03/29/16 that revealed the nurse had a valid license. The validation report was reviewed by the HR Personnel, DON #3, Administrator, and Corporate Consultant as indicated by their signatures on the validation report. Review of the training revealed the newly hired nurse had received education on the topics that were included in the AOC. Interview with the HR Director, on 04/06/16 at 4:05 PM, revealed she had received training on the validation process. She stated once an application was received and before an offer letter was sent, she would conduct a validation check with the KBN. After the offer letter was sent another check was conducted at the KBN for abuse registry and a Criminal Background Check would be conducted. She stated she would review the validation report from the KBN then the DON, and the Administrator would do the final check. She stated she assisted with the validation of license for the facility's nurses. The Corporate Consultant signed off as reviewing the hire packet for the newly hired nurse on 04/01/16. The consultant reviewed and signed off on the nurses who are in the interviewing process. 6. Interview with Corporate Care Consultants #2 and #3 and the Special Project Consultant, on 04/07/16 at 10:03 AM revealed they would be providing oversight and assistance to the facility for some time. They stated they have been at the facility daily including some weekend days to conduct audits and assist with educational needs. Consultants #1, #2, and #3 would be at the facility Monday-Friday for several weeks to review action plans, audits, and training before they decrease to three (3) times a week. Once they identify any non-compliance, re-education would be conducted. They were looking at the clinical matrix, and the development of education topics that may include other disciplines beside nursing. The facility did not have a new Administrator in training at the time of the survey. A consultant will attend the clinical meetings to ensure a meeting is held as stated and topics discussed. The consultants reviewed the audits to ensure they were being conducted correctly and to see if there were any training issues. They were in the process of developing an afternoon meeting to recap the day. 7. Review of the QAPI signature sheet, dated 03/28/16, revealed the survey findings were discussed. The Medical Director, Administrator, DON, Corporate Consultant #1, and five (5) other committee members. On 03/30/16, an Ad Hoc meeting was held to discuss the Immediate Jeopardy findings. The Administrator, DON, Unit Managers and SDC was present with the Medical Director via phone conference. Additional Ad Hoc QAPI meetings were held on 04/01/16, 04/04/16 and 04/06/16. Interview with the Administrator, on 04/06/16 at 5:03 PM, validated the above QAPI meetings were held. She stated she conducted the meetings and the Medical Director was either present in person or via phone. She stated the frequent QAPI meetings were to review what process had been changed and were they effective. The committee reviewed the audits. She stated the audits were also reviewed in the morning meetings before they were reviewed in the QAPI meetings. She stated she will conduct a weekly QAPI meeting for the next month. In addition, the IDT meet weekly to review the audits. Interview with the Medical Director, on 04/06/16 at 4:48 PM, revealed he had been involved in the whole process since the beginning of the Immediate Jeopardy. The facility's Administrator provided him an overview of the survey findings and requested his input in the corrective plans. He reviewed the policies and validation process and discussed the physician orders [REDACTED]. 8. Review of Unsampled Residents L's and M's record revealed physician orders [REDACTED]. Review of the appointment calendar revealed the scheduled appointment had been placed in the calendar with transportation obtained. Review of the appointment calendars for the East and West Units and audits revealed no missed appointments. 9. Review of the education provided by the Regional Vice President to the Administrator and DON #3, on 04/04/16, revealed the training was on F490 and review of the Administrator's job description. A telephone interview with the Regional Vice President, on 04/07/16 at 9:54 AM, revealed he validated the training provided to the facility's Administrator. He stated he reviewed the role of the Administrator and responsibilities related to the hiring process, licensure validation, facility oversight, and Administrator in training. He stated the Administrator would provide oversight through observation rounds and review of clinical meeting findings. He stated he would conduct weekly telephone conference calls with the Administrator to discuss current corrective action plans, audit findings, facility operation, and oversight met the residents' needs. He would conduct the weekly calls for four (4) weeks and then decrease to monthly times three (3) months, then quarterly.

Based on interviews, record review, and review of the facility's policy and fall event report, it was determined the facility failed to provide adequate supervision to prevent an injurious fall for one of twelve (12) sampled residents (Resident #4). The facility admitted the resident after hospitalization related to a fall at home. The facility assessed the resident to be at risk for additional falls and identified that the resident required physical assistance and supervision during all transfers. On 01/20/16, the resident slipped on the wet shower floor during an unassisted transfer sustaining a fracture to the left humerus, 7th left rib, and 9th thoracic vertebrae. Interview with Certified Nursing Assistant (CNA) #8 revealed he thought the resident required supervision only and turned his back on the resident to obtain the resident's clothing across the shower room. The findings include: Review of the facility's Fall Policy, last reviewed 06/01/15, revealed all residents would have a fall risk assessment completed upon admission and appropriate care plan interventions would be implemented and evaluated, as indicated. After a fall, the Interdisciplinary Team (IDT) would determine the root cause of the fall. Falls resulting from environmental factors would be reviewed at the monthly Safety Committee meeting. Review of Resident #4's closed clinical record revealed the facility admitted the resident on 01/15/16 at 11:30 PM. The resident had [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 01/15/16, revealed the facility assessed the resident to require assistance of two (2) staff for bed mobility, transfers, and ambulation. The Fall Risk Evaluation (included in the Admission Assessment) identified the resident at high risk for falling due to a score of eleven (11), with a problem with balance. The nurse assessed the resident's balance to be unsteady, and only stabilized with physical assistance. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility completed a Brief Interview for Mental Status (BIMS) and assessed the resident with a score of fifteen (15) and determined the resident was cognitively intact. Review of the Fall Assessment, dated 01/15/16, revealed the resident had a fall on 01/11/16. Review of the Interim Care Plan, dated 01/15/16, revealed falls were identified as a problem with interventions to verbally remind the resident not to ambulate alone and observe for any unsafe actions and intervene, as needed. Review of the Occupational Therapy evaluation, conducted on 01/18/16, revealed the therapist assessed the resident to have decrease in strength, functional mobility, transfers, activity intolerance, and reduced static and dynamic balance with increased need for assistance from others. The resident was identified at risk for falls, decline in function, and mobility. The therapist assessed the resident's sitting balance to be fair and could maintain with minimum assist. The therapist assessed the resident to need contact guard assistance with all transfers. Review of the Physical Therapist Evaluation, conducted on 01/18/16, revealed the reason for the referral was due to the resident's recent fall and increased weakness. The resident presented with decreased coordination, weakness, and difficulty walking. The resident's standing balance was poor and required moderate assist with upper body support to stand. The therapist assessed the resident to need contact guard assistance of one with sit to stand transfers and gait. The therapist assessed the resident to be at risk for falls with decreased endurance, dizziness, and decreased coordination contributing factors. Review of the Daily Skilled Nurse's Notes, dated 01/19/16 and 01/20/16 revealed two (2) different nurses assessed the resident to require the extensive assistance of two (2) persons for transfers, toilet use, and locomotion. Both nurses assessed the resident to have an unsteady gait and balance problem. Review of a Nurse's Note, dated 01/20/16 at 8:45 PM, revealed the resident was in the shower room with CNA #8, when he/she attempted an unassisted transfer, and fell on to the wet shower floor. The Note stated the resident tried to catch himself/herself. This fall resulted in skin tears to the resident's bilateral forearms. The resident complained of severe pain in his/her left shoulder. The Nurse Practitioner was called and an order was received to send the resident to the emergency room for evaluation of the fall. The resident was transferred to a Trauma Center. Resident #4 was then admitted to the Intensive Care Unit for management of multiple medical problems and the fractures. The resident was in the hospital from 01/21/16 through 01/26/16. Review of the Fall Occurrence Report, dated 01/20/16 at 8:45 PM, revealed interventions in place before the fall included to assist the resident with transfers and ambulation and the environmental factors identified as a cause was the wet shower floor. Review of the functional evaluation section, revealed the facility had assessed the resident to have decreased mobility, needed more assistance with Activity of Daily Living (ADLs) and had falls at home. The root cause of the fall was determined to be related to the resident ambulating with walker and assist of nurse aide in the shower, slipped and fell causing the fractures. However, interview with CNA #8 revealed that was not how the fall occurred. CNA #8 stated the care plan interventions were to place a towel on the shower floor and the resident was to wear non-slip socks in the shower room. However, review of the Falls Occurance Report stated to place a towel on the floor in the shower to make sure it was not wet when getting up and wear non-skid socks at all times when ambulating. Review of a Falls Alert Progress Note, dated 01/21/16, revealed a summary of the fall by the West Wing Unit Manager. The Manager documented that the resident was ambulating in the shower room with a walker and assist of one nurse aide. The resident's weight shifted and the resident fell on to the shower floor causing the injury. She documented the resident was limited assist of one person for transfers and ambulation. Post fall interventions were as listed above. However, review of CNA #8's written statement revealed the resident fell when he/she was transferring the resident from the shower chair to a wheelchair unassisted. Interview with CNA #8, on 03/17/16 at 2:40 PM, revealed this was the first time he had given Resident #4 a shower. He stated he thought the resident only required supervision with no physical assistance with transfers. CNA #8 stated he brought the resident into the shower room via wheelchair and the resident transferred onto the shower chair. Continued interview revealed he had finished bathing the resident and turned around to get his/her clothing to dress the resident. CNA #8 stated he stepped away from the resident a short distance to the sink counter where the resident's clothing was located. He stated he saw the resident take a step out of the shower chair and slipped on the wet shower floor, face first. He yelled for the nurse and she came to assess the resident. Further interview revealed the Emergency Medical Service (EMS) was called and transported the resident to the hospital. CNA #8 stated he thought the resident was supervision only and didn't require physical assistance with transfers. He stated he thought that was what was on the nurse aide care plan that he was following the day of the resident's fall. However, interview with Unit Manager #1, 03/17/16 at 3:10 PM, revealed the facility's process was not to keep the nurse aide care plans. Once a resident was discharged from the facility, the nurse aide care plan was deleted. The facility did not provide any documented evidence the nurse aide care plan instructed the nurse aides to transfer the resident with supervision only. Continued interview with CNA #8 at 2:40 PM, revealed there was no walker in the shower room when the resident fell as indicated in the Occurrence Report. Another interview with CNA #8, on 04/06/16 at 5:40 PM, revealed he had turned away from the resident to get a towel and the resident's clothing from the sink. He stated he was not within arms length of the resident. The Maintenance Director measured the distance to be five (5) feet and nine (9) inches from the shower chair to the sink. Interview with Licence Practice Nurse (LPN) #11, on 04/06/16 at 4:30 PM, revealed she was standing at the Nurse's Station across from the West Wing Shower Room when CNA #8 yelled out for help. When she entered the shower room she saw Resident #4 laying on the shower floor in front of the shower chair, face down with both arms under him/her. She stated the aide told her he/she had turned around from the resident and the resident attempted an unassisted transfer from the shower chair. She stated the resident complained of left shoulder pain. Further interview revealed she called EMS and the resident was transported to the ER. LPN #11 stated the aides were to follow the nurse aide care plans, which were updated with any changes. She stated the nurse who had completed the admission paperwork, would have initiated the interim care plan using the information from the hospital and the nursing assessment. LPN #11 stated she could not recall what was included on the interim care plan or the nurse aide care plan. During further interview, she stated she recalled the resident was to be transferred with a physical assist of one or two (2) persons, but after the fall, the resident was a total assist. Interview with the West Wing Unit Manager #1, on 03/17/16 at 3:10 PM, revealed she conducted the fall investigation for Resident #4. She was not at the facility when the fall occurred, but investigated the fall the next day. The Unit Manager stated she did not recall what mode of transfer was on the nurse aide care plan before the resident's fall. She stated she could not provide a copy of the care plan since the resident had been discharged from the facility, and the facility does not keep the nurse aide care plans. She stated couldn't recall what was on the care plan. Continued interview with Unit Manager #1 revealed she determine the root cause of the fall to be the resident slipped in water on the shower floor when transferring from the shower chair. She stated during the investigation, it was reported to her the resident had a walker. During further interview she stated the resident's transfer mode was physical assistance of one person. She stated immediate interventions after the fall was to place towels on the shower floor and place non-slip socks on the resident in the shower room. Another interview with the West Wing Unit Manager #1, on 03/17/16 at 5:37 PM, revealed any fall a resident sustained [REDACTED]. However, she could not recall if Resident #4's fall was discussed. She stated she had interviewed the resident upon return to the facility (01/26/16) and the resident told her that he/she was trying to help and took a few steps and fell . The Unit Manager had no documented evidence of the interview with the resident; however, the Unit Manager had completed the fall Summary Note on 01/21/16, prior to the interview with the resident. She stated therapy attended the Morning Clinical meetings and discussed the resident's functional ability. The Unit Manager stated nursing had determined the resident needed the physical assistance of one person for transfers. She stated the facility used the nurse aide care plan to communicate the resident's assistance needs. A telephone interview with CNA #7, on 03/17/16 at 6:45 PM, revealed she had cared for Resident #4 on 01/19/16. She stated the resident required assistance of one person for transfers. According to CNA #7, the resident used an electric wheelchair and was independent once in the chair. She stated the nurse aide care plan instructed to transfer the resident with two (2) persons. Continued review of the clinical record revealed the Comprehensive Care Plan was not developed until 02/04/16 after the resident's injurious fall. Interview with the Occupational Therapist, on 03/29/16 at 10:55 AM, who conducted the above evaluation for Resident #4, revealed the resident was minimum assist of one (physical) for transfers from the toilet (sit to stand). The resident used a walker with encouragement, but had a powered chair. She stated the resident was at risk for falling. Further interview revealed the resident's sitting balance was fair when holding onto the gym bed for support and his/her standing balance was fair when the resident held onto a person or object. Interview with the Physical Therapist, on 03/29/16 at 10:55 AM, revealed the resident required contact guard assist from the bed to a chair. She stated physical touch, holding a hand, was required, but you did not have to physically pull the resident up from a chair. However, you needed to be right there beside the resident. She had conducted the evaluation of the resident on 01/18/16 and found the resident to be at risk for falls. She conducted a Tinetti test (assessment for balance and gait) with the resident scoring a twelve (12) out of possible twenty-eight (28) indicating high risk for falls. Below a 19 or 20 indicated high risk for falls. She stated during the working session the resident required minimum assistance of one person and would not be supervised only. She stated she had only begun working with the resident when he/she had the fall, but the resident would never have been supervision only. According to the Physical Therapist, communication between therapy and nursing regarding a resident's functional mobility would take place in the Clinical Meetings. Interview with the Administrator, on 03/17/16 at 5:45 PM, revealed falls resulting from environmental factors would be reviewed at the monthly Safety Committee Meeting. She stated the last meeting was held on 02/29/16. The Administrator stated the committee had not discussed this specific fall. During further interview, she stated she would not have considered wet floors in the shower rooms as an environmental cause as you would expect a wet floor. She stated the resident's fall would have been discussed at the Fall Committee Meeting. The Administrator stated that the committee tracks and trends the falls. She said white board meetings were held each morning and the resident's fall should have been discussed the following morning (01/21/16). She recalled talking about the aide turning to get something and the resident fell . An immediate intervention was to place towels on the floor. The facility tried to place black non-slip strips, but it did not work. A sticky substance had been put on the shower room floors. She stated the committee had not looked at the fact CNA #8 turned his back to the resident.

Based on observation, interview, record review, and review of facility's policies and documents, it was determined the facility failed to provide the necessary care and services in regard to pain management for one of five (5) sampled residents, Resident #1. The facility admitted Resident #1 on 02/25/16 at 4:00 PM status [REDACTED]. The resident's surgeon ordered [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 7.5-325 mg (1 or 2) to be given every four hours as needed for pain and had written the prescription for the controlled medication. The resident was given two (2) pain tablets at 1:00 PM at the hospital prior to transfer to the Nursing Facility. Once at the facility, the resident complained of pain and requested pain medication. The resident was told the admitting physician would not honor the surgeon's orders and the pharmacy had not delivered the resident's medication. The resident did not receive the pain medication as ordered until 7:30 PM, six and a half hours after the last dose at the hospital. The resident's pain was assessed to be severe at an eight (8) on the pain scale of one to ten (1-10). The findings include: Review of the facility's policy for ordering and receiving medication, dated September 2010, revealed new medications, where the first dose was scheduled to be given before the next regularly scheduled pharmacy delivery, needed to be called or transmitted to the pharmacy immediately upon receipt and the pharmacy informed of the need for prompt delivery. Timely delivery of new orders were required so that medication administration would not be delayed. If available, the emergency kit was to be used when a resident needed non-controlled medication prior to pharmacy delivery. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 01/25/16 at 4:05 PM via ambulance. The following [DIAGNOSES REDACTED]. Review of the Discharge Summary from the hospital, dated 01/25/16, revealed the resident had a Spondylolisthesis at L5-S1 fusion on 01/21/16. The resident had a bone graft of the Iliac Crest without apparent incident. Review of the hospital's discharge medication list revealed [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 milligrams (mg) (1 or 2) tablets by mouth every four (4) hours as needed (PRN) was ordered. In addition, [MEDICATION NAME] 75 mg two (2) tablets was ordered daily, one in the morning and one at bedtime and [MEDICATION NAME] 200 mg was ordered twice a day, one in the morning and one at night for the resident's RA. The hospital provided the facility a copy of the medication record that revealed the resident was given pain medication at 1:00 PM. Review of the nursing admission assessment, conducted at 5:00 PM, revealed the resident's pain was assessed to be very severe at an eight (8) on the pain scale (1-10). Review of the Nurses's notes, dated 01/25/16 at 5:00 PM, revealed the resident reported severe pain with facial grimacing and guarded movement. The nurse documented the resident was informed of the efforts to obtain ordered medications from the pharmacy at that time. Continued review of the admission assessment revealed the nurse documented the physician was notified of the admission and medication orders at 6:15 PM, on 01/25/16. A telephone interview with Licensed Practical Nurse (LPN) #1, on 02/25/16 at 12:10 PM, revealed she was the nurse who completed the admission paperwork for Resident #1 and called the Nurse Practitioner (NP) regarding medication orders from the hospital. According to LPN #1 there were two (2) prescriptions for controlled substance, one for the [MEDICATION NAME] pain medication and one for the [MEDICATION NAME]. She stated the prescription for the pain medication [MEDICATION NAME] had instructions to give one (1) or two (2) 7.5-325 mg tablets every four hours as needed for pain. When she called the NP and went over the hospital discharge medication orders, the NP told the nurse she could not do that amount of pain medication. She told the nurse she would agree to one tablet every six (6) hours at that dose (7.5-325 mg). When the nurse told the resident what the NP said, the resident became very upset stating the surgeon had ordered what the resident needed and he/she was in a lot of pain. According to the LPN the resident's spouse called the facility and was upset that the resident couldn't get the prescribed pain medication and threatened to report the facility. LPN #1 called the Administrator and was instructed to call the Medical Director to get the correct dose of pain medication. She stated the East Wing Unit Manager called the NP and she still refused to order the dose the surgeon had prescribed. The Medical Director was called and he ordered the correct dose that was prescribed by the surgeon. This was a few hours later. She stated the resident received pain medication around 7:30 PM that evening. Interview with the East Wing Unit Manager (UM), on 02/24/16 at 4:30 PM, revealed she had received a phone call from the Administrator on 01/25/16 at approximately 6:00 PM informing her there was a problem with getting a new resident's medication orders verified by the NP. She was told the NP would not agreed with the surgeon's medication orders regarding the pain medication [MEDICATION NAME]. The NP wanted to order [MEDICATION NAME] one (1) tablet every six (6) hours instead of two (2) every four (4) hours. The Unit Manager stated she called the NP and discussed the resident's diagnoses, surgery, and pain medication. The NP still refused to order the [MEDICATION NAME] at the dose the surgeon had prescribed. The NP told her they didn't do that anymore and said, No to that dose. The UM then called the Administrator and was told to call the Medical Director of the facility. She text the Medical Director and he agreed with the surgeon's orders. Record review revealed a telephone order was received from the Medical Director on 01/25/16 at 7:30 PM for [MEDICATION NAME] 7.5-325 mg two (2) tablets every six (6) hours for pain then the Medical ordered the pain medication for every four (4) hours at 9:40 PM on 01/25/16. Review of the Medication Administration Record [REDACTED]. Review of a nurse's note, dated 01/25/16 at 11:45 PM, revealed the resident complained of severe pain at the surgical sites. The resident was given two pain tablets ([MEDICATION NAME] 7.5-325 mg) from the EDK box. The resident voiced concern about the routine medication not available and the nurse explained to the resident how the pharmacy worked. On 01/26/16 at 6:00 AM, the nurse documented the resident's spouse came to the facility and the resident left Against Medical Advice (AMA). Telephone interview with LPN #1, on 02/25/16 at 12:10 PM, further revealed she faxed the medications orders to the pharmacy, but could not recall if she requested them to be delivered STAT (meaning immediately). The resident's routine medications had not been delivered before she left work that night at 11:00 PM. The nurse stated she went over all the medication orders with the NP, but she couldn't recall if they discussed the need of a prescription for [MEDICATION NAME]. A telephone interview with the Pharmacist, on 02/25/16 at 10:55 AM and 11:08 AM, revealed the facility had faxed the admission MEDICATION ORDERS FOR [REDACTED]. According to the Pharmacist there was no documented evidence the facility had requested the medications to be delivered STAT. The turn around time for STAT delivery was four (4) hours. The facility would normally call if they needed the medications STAT. She stated there was a prescription for the controlled substance medication [MEDICATION NAME] 7.5-325 mg and [MEDICATION NAME] 0.5 mg but not for the [MEDICATION NAME]. According to the Pharmacist the pharmacy had to call the facility and the physician at the Nursing Facility had to call in a prescription for the [MEDICATION NAME] the next day, 01/26/16. The [MEDICATION NAME] was filled and delivered to the facility on [DATE] at 5:10 PM; however, the resident had already left the facility. She stated the pharmacy was out of the RA medication, [MEDICATION NAME], but they located some and sent it the following day. Review of the pharmacy manifest revealed the resident's pain medication ([MEDICATION NAME]) was delivered on 01/26/16 at 2:50 AM. Continued review of the MAR indicated [REDACTED]. A telephone interview with LPN #2, on 02/25/16 at 1:05 PM, revealed she was not Resident #1's nurse that night, but she had given the resident pain medication at 6:00 AM on 01/26/16 and was present when the resident left the facility the next morning. When she went into the resident's room to give the pain medication at 6:00 AM, the resident was dressed, calm and polite. A little while later, the door bell rang at the front door, it was the resident's spouse. The spouse asked for a wheelchair, went to the resident's room, and packed up the resident's personal belongings. LPN #2 went to the resident's room and asked if the resident was leaving. She was told, Don't speak to us, and the spouse threw a duffle bag at her and told the nurse, We are leaving. LPN #2 stopped the conversation at that point and left the room. She stated another nurse had reported the incident to the East Wing Unit Manager. A telephone interview with Resident #1, on 02/24/16 at 1:08 PM, revealed the [MEDICATION NAME] was for [MEDICAL CONDITION] and [MEDICATION NAME] was for RA for maintenance coverage of the pain experienced with these diagnoses. The resident stated those medications must be taken on a routine schedule because if a dose of the medication was missed, the disease could flare up and the pain would become harder to control. According to the resident it was a long ride to the Nursing Facility and upon arrival the resident needed to go to the bathroom. The resident questioned the nurse when the pain medication and other medications would be available. He/she was told it took awhile to get the medications from the pharmacy. The resident told his/her spouse to go home around 6:00 PM and asked again about the pain medication. Then the resident was beginning to have a lot of pain. The nurse came back and told the resident the physician had only ordered one (1) tablet of pain medication instead of the two (2) the surgeon had ordered. The nurse told the resident he/she could only receive one pain tablet. The resident told the nurse that was not what the surgeon had ordered and due to the [MEDICAL CONDITION] and Arthritis, the resident had been taking two (2) tablets at that dose prior to the surgery. According to the resident it had been well over six (6) hours since he/she had a pain pill and they were hurting. The resident was on a pain management schedule at home related to the [MEDICAL CONDITION] and Arthritis and was taking [MEDICATION NAME] 7.5-325 mg at home prior to the surgery. The resident could not understand why the facility would not follow the surgeon's orders. Due to his/her persistence, the nurse finally gave the resident two (2) tablets of the pain medication [MEDICATION NAME] 7.5-325 mg (at 7:30 PM). The resident's pain was relieved. Around 11:00 PM, the resident was experiencing severe pain and requested pain medication again. The resident was told his/her maintenance medications ([MEDICATION NAME] and [MEDICATION NAME]) had not been delivered from the pharmacy. The resident stated if the maintenance medications were taken, the pain was better controlled. The resident received two (2) [MEDICATION NAME] 7.5-325 mg for pain. According to the resident he/she had not slept all night between not getting the help from staff to toilet and the pain, so the resident decided at 5:00 AM, to go home. The resident called their spouse to pick him/her up and when the spouse arrived, the resident left AMA. The resident never received a dose of the routine medications. Interview with the Administrator, on 02/25/16 at 8:20 AM, revealed there was a problem with getting Resident #1's pain medications. The Admission Coordinator called the Administrator to report the resident was upset about the Nursing Facility not honoring the pain medication prescription as prescribed by the surgeon. She was told the NP refused to order the pain medication as prescribed by the surgeon. She then called the East Wing Unit Manager and requested her to call and speak with the NP. The Unit Manager called her back and stated the NP still refused to order the pain medication at the higher dose so the Administrator instructed the UM to call the Medical Director and she did. The Medical Director ordered the [MEDICATION NAME] at 7.5-325 mg two (2) every four (4) hours according to the prescription. According to the Administrator she thought everything was okay until the next morning when she was notified the resident had left AMA. The Administrator stated she called the resident several times, but was unsuccessful in speaking with the resident. She said the resident's spouse called the next day and reported all the problems the resident had encountered during the brief stay at the facility. The spouse reported the resident was upset that the facility would not allow the resident to have two (2) pain pills. She apologized to the spouse and told him/her the problem had been resolved with the assistance from the Medical Director. She stated the spouse was not happy on how things had been handled and she apologized again.

Based on observation, interview, record review, and review of the facility policy and procedures and investigation, it was determined the facility failed to document multiple assessments completed by licensed nurses for one (1) of four (4) sampled residents (Resident #1). After Resident #1 sustained a Right Comminuted Femur Fracture during an incorrect transfer with the Maxi-Lift, on 12/27/12, the resident was assessed by the Shift Supervisor #2; however, the Supervisor failed to document the assessment in the clinical record or complete necessary documentation related to the incident. Further nursing assessments by Licensed Practical Nurse (LPN) #4, #3, #6, and the Assistant Director of Nursing for Resident #1, completed 12/28 through 12/29/12, revealed no evidence the assessments had been documented in the resident's record. The facility's failure to record and document the resident's condition delayed emergency treatment, causing Actual Harm to the resident. Refer to F323, F157, F282. The findings include: Review of the facility's policy "Clinical Record Documentation Guidelines", dated 02/20/12, revealed a complete clinical record contains an accurate and functional representation of the experience of the resident in the facility and contains evidence of the effects of the care provided. Documentation should provide a picture of the resident's progress, including response to treatment, change in condition and changes in treatment. The record should contain sufficient information to identify the resident, individual assessments, plan of care and services provided. How to Document: Assessment, observations of the resident for signs and symptoms that may indicate actual or potential problems. What to Document: Incidents, MD notifications, Communication with MD, Family Notification and Communication, Injuries, and Unusual occurrences. Review of the facility's investigation by the Director of Nursing, initiated on 12/30/12, revealed CMT #2 approached Unit Manager #1 and 2nd Shift Supervisor #2 to inform them she had walked into Resident #1's room where CNAs #1 was transferring the resident in the Maxi-Lift alone. The CMT stated it appeared the resident was not positioned properly in the lift and she assisted CNAs #1 in getting Resident #1 in the bed. As the resident was being lowered in the bed, CMT #2 stated she heard a "snap". The investigation revealed the resident did not complain of pain at that time, and 2nd Shift Supervisor #2 entered the room and assessed the resident. The report stated at that time, the resident was not in distress, and had no complaints of pain and physically appeared fine. Interview with Resident #1, on 01/08/13 at 10:00 AM, revealed while being transferred with a lift, they dropped him/her and his/her leg went under him/her. Resident #1 stated he/she hit the floor. The resident stated they did check him/her, and he/she kept complaining for days before anyone did anything. He/she stated, "I broke my knee". Interview with Shift Supervisor #2, on 01/09/13 at 3:30 PM, revealed she was responsible for assessing, reporting, and initiating any investigations. She also stated she was responsible for completing a night report which was turned in to the Director of Nursing at the end of each shift. The Shift Supervisor stated she did not put the incident on the night report, because she didn't associate the resident's pain on turning with anything, just maybe arthritis. The Shift Supervisor also revealed the assessment was not documented in the nurse's notes, nor was there an incident report completed for the incident, or family and physician notified. Shift Supervisor #2 revealed she did not ask the resident what happened, only if he/she was in pain. The Supervisor stated she did not document her assessment of the resident, complete an incident report, or put the incident on the 24 hour report, because she did not see any evidence of injury. Interview with LPN #4, on 01/09/13 at 2:00 PM, who took care of Resident #1, on 12/28/12 on the day shift, revealed she did not document the assessment or the resident's pain in the clinical record that day, but should have done so, since the nurses were primarily responsible for documenting, nor did she complete an incident report. Interview with the Assistant Director of Nursing (ADON), on 01/08/12 at 4:45 PM, revealed upon assessment, the ADON stated there were no abnormalities, but the leg looked tight or cramped, like a muscle spasm. However, there was no evidence the assessment completed by the ADON had been documented in the nurse's notes, nor physician notified of the resident's pain on movement. Further interview with the ADON revealed she was not aware of the 12/27/12 incident at that time, since it had not been documented or passed on during shift report and would have looked at the issue differently if known. Interview, on 01/09/13 at 2:45 PM, with the evening shift LPN #3, revealed she had passed this information to the next shift; however, there was no evidence LPN #3 had documented her assessment of the resident's pain, completed an incident report, or notified the physician or family. Continued interview with LPN #3, who worked from 3:00 PM-7:00 PM, on 12/29/12 revealed she received no reports of pain from Resident #1 in the previous shift report. Although interview revealed LPN #3 reported the resident's pain upon movement to the night shift nurse LPN #6, LPN #3 failed to document the assessment, notify the physician, or the resident's family. LPN #3 stated she was unaware of the incident which had occurred with the lift on 12/27/12 at that time; however, should have documented the assessment and notified the physician and family. Interview with LPN #5, on 01/09/13 at 2:30 PM, revealed the incident had not been noted on the 24 hour report, nor documented in the nurse's note until 12/30/12 at 1:00 AM. Interview with the Director of Nursing (DON), on 01/08/13 at 10:20 AM, revealed she believed the assessment documentation would be present in the clinical record; however, it was not. The DON stated that during the investigation they found that there had been no incident report completed initially, nor family or physician notification of the incident until 12/30/12. In addition, there was no documentation on the facility 24 hour shift report, or assessment documentation by each nurse's assessment in Resident #1's record. The Director of Nursing stated this did not meet the facility expectation. Interview with the Administrator, on 01/10/12 at 1:30 PM, revealed the incident should have been documented and passed on during the shift reports. The Administrator stated the lack of assessment documentation was unacceptable.

Based on observation, interview, record review, and review of the facility policy and procedures and investigation, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of four (4) sampled residents. Certified Nurse Assistant (CNA) #1 failed to follow care plan interventions regarding use of the Maxi-Lift with two person assist for Resident #1. The resident was observed by Certified Medication Technician (CMT) #2, on 12/27/12, to be positioned incorrectly in the lift during transfer. CMT #2 was assisting CNA #1 with transferring the resident back to the bed and heard a loud popping sound. The incident was reported to the Shift Supervisor. However, there was no documented evidence of the initial assessment of the resident by Shift Supervisor #2 in the resident's clinical record. The record revealed continued complaints of pain by Resident #1 was reported by the CNAs on 12/28/12 through 12/29/12 to Licensed Practical Nurse #3, #4, and #5 and the Assistant Director of Nursing; however, no assessments had been documented in the clinical record, or the initial report of the incident. In addition, neither the physician or family were notified until 12/30/12 at 1:00 AM, or four (4) days after the 12/27/12 incident. On 12/30/12 Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. The facility's failure caused Actual Harm to Resident #1. Refer to F157, F282, and F514. The findings include: Review of the facility's "Policy on Lifting", not dated, revealed residents were to be transferred by the Maxi mechanical lifts only. The resident would be assessed for their transfer ability and it would be documented how they were to be transferred on the care plan and the nurse aide care plan. All staff would be in-serviced upon employment regarding the correct use of the lifts. Review of the facility's policy "Clinical Record Documentation Guidelines", dated 02/20/12, revealed a complete clinical record contains an accurate and functional representation of the experience of the resident and contains evidence of the effects of the care provided. Documentation should include response to treatment, change in condition and changes in treatment. The record should contain individual assessments, plan of care and services provided. In addition, the guidelines specified how to document assessments through observations of the resident related to signs and symptoms that may indicate an actual or a potential problem. It further specified what to document in relation to incidents, MD notifications, communication with the MD, family notification and any communication, any injuries, and any unusual occurrences. Review of the hospital's 12/30/12 admission History and Physical, revealed Resident #1, at the nursing facility, allegedly fell from a lift injuring his/her right leg approximately four days ago and had been complaining of pain when the resident was repositioned. The History and Physical also revealed Resident #1 had been bedfast for several months and the family had requested primarily palliative care over the past several months, with the resident's appetite poor and refusing food. Review of the X-ray report, dated 12/30/12, revealed a Comminuted Fracture of the Distal Right Femur. Review of the clinical record for Resident #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the resident's 08/31/12 re-admission comprehensive Minimum Data Set (MDS) assessment and 12/01/12 quarterly MDS assessment revealed the resident was non-ambulatory and required maximum assist with activities of daily living, such as bathing, dressing and grooming. Resident #1's cognition status had been assessed on the 08/31/12 re-admission comprehensive MDS assessment with the Brief Interview for Mental Status (BIMS) cognitive score of 11 which was considered interviewable; however, review of the 12/01/12 quarterly MDS assessment revealed the resident's cognition BIMS score had declined to 4, which now classified the resident as not interviewable. Review of Resident #1's comprehensive plan of care and the CNA care plan, dated 09/03/12, revealed the resident required assist with Activities of Daily Living related to a recent hospitalization (Pacemaker Insertion) and general weakness, with an approach to transfer per Maxi-Lift with two assist. Interview with Resident #1, on 01/08/13 at 10:00 AM, revealed the resident while being transferred with a lift, was dropped and his/her leg went under him/her. Resident #1 stated he/she hit the floor. The resident stated they did check him/her, and he/she kept complaining for days before anyone did anything. He/she stated, "I broke my knee". During the interview, Resident #1 pulled the sheet off his/her leg. Observation of the right knee revealed multiple staples positioned vertically along the center of the patella or knee cap, with three to four staples on each side of the patella, also vertically. The resident stated he/she had pain, but was receiving pain medication when requested. Review of the facility's investigation revealed that on 12/27/12, CMT #2 approached the Unit Manager and the 2nd Shift Supervisor #2, to inform them that she had walked into Resident #1's room where CNA #1 was transferring the resident in the Maxi-Lift alone. The CMT stated it appeared the resident was not positioned properly in the lift, she told CNA #1 she would assist in getting Resident #1 back in the bed. As the resident was being lowered in the bed, CMT #2 stated she heard a "snap". The investigation revealed the resident did not complain of pain at that time, and 2nd Shift Supervisor #2 entered the room and assessed the resident. The investigative report revealed the resident was not in distress at that time, and had no complaints of pain and physically appeared fine. Interview with the CMT #2, on 01/09/13 at 10:00 AM, revealed she had walked into the resident's room, on 12/27/12 around 4:45 PM, and observed CNA #1 transferring Resident #1 from the bed to the chair in the Maxi-Lift. The CMT stated Resident #1 was suspended in the air and positioned incorrectly on the resident's left side. The CMT stated she was afraid the resident was going to fall out of the lift, and told CNA #1 she would assist him in getting Resident #1 back to bed, so they could position the resident correctly in the lift. However, upon transfer back to the bed, CMT #2 heard a popping sound. Continued interview with CMT #2 revealed they returned Resident #1 to the bed, and did not get the resident up at that time, because they were not sure if the pop sound came from the resident or the lift. The CMT stated the resident's son was standing outside the door, but was not told about the incident at that time. CMT #2 stated she reported to the Shift Supervisor #2 and the Unit Manager #1 that something had happened during the transfer with Resident #1, they had heard a popping sound, and thought the resident should be checked out. In addition, CMT #2 stated the resident had sustained a skin tear during the transfer from the resident's watch and the watch had been pushed up under the skin. The CMT stated the resident did not complain of pain at the time of the incident. Interview with CNA #1, on 01/09/13 at 3:00 PM, revealed he had worked at the facility for one month and had received lift training during his orientation to the facility. CNA#1 stated the son of Resident #1 had asked him to get the resident up into the chair. CNA #1 stated he had placed Resident #1 on the lift pad, and attached the hooks to the lift; however, stated he was waiting for CMT #2 to come into the room to assist him with transferring the resident. CNA #1 denied the allegation that Resident #1 was suspended in the air when the CMT came into the room. CNA #1 stated CMT #2 told him when she came into the room the resident was not positioned in the sling correctly, then grabbed the residents leg, trying to reposition the resident and caused the leg to snap. CNA #1 stated the policy was for two people to use the lift, and his CNA care plan sheet stated that the resident required two people for lift transfers. Interview with Unit Manager #1, on 01/09/13 at 1:05 PM, revealed that between 5:30-6:30 PM on 12/27/12, CMT #2 reported to her and Shift Supervisor #2 that she observed CNA #1 transferring Resident #1 incorrectly with one person and the resident was lying "crooked" in the lift. The Unit Manager stated CMT #2 stated she thought she heard a pop sound when transferring Resident #1 per lift back to the bed. She also stated CMT #2 was very upset because she had walked into the room to check on CNA #1. CMT #2 stated Resident #1's son, who was standing outside the door, had requested her to check on the resident because CNA #1 had been in the room for a long time. The Unit Manager stated the Shift Supervisor went to assess the resident because she already had her coat on and was leaving for the day. Interview with Shift Supervisor #2, on 01/09/13 at 3:30 PM, revealed CMT #2 had reported to her, on 12/27/12 around 6:00 PM, that she had observed CNA #1 using the Maxi-Lift without the assist of two people, and observed Resident #1 suspended in the lift off the bed. The shift supervisor stated she was told by the CMT upon returning the resident to the bed, there was a popping sound, and said something might have happened with Resident #1. The Shift Supervisor stated she assessed the resident and looked for bruising, swelling, pain, and deformity, and at the time did not see any evidence of injury. The Shift Supervisor asked the resident if he/she was having pain, and the resident stated "no". Continued interview with the Shift Supervisor, on 01/09/13 at 3:30 PM, revealed CMT #2 reported to her later in the shift that when turning Resident #1, the resident said "oh". The Shift Supervisor went back to the re-assess the resident and still didn't see anything. Shift Supervisor #2 stated she was responsible for assessing, reporting, and initiating any investigations. She also stated she was responsible for completing a night report which was turned in to the Director of Nursing at the end of each shift. The Shift Supervisor stated she did not put the incident on the night report, because she didn't associate the resident's pain on turning with anything, just maybe arthritis. The Shift Supervisor also revealed the assessment was not documented in the nurse's notes, nor was there an incident report completed for the incident, or family and physician notified. Looking back, the shift supervisor stated the incident and assessment should have been documented. Interview with CNA #5, on 01/09/13 at 9:30 AM, revealed she was responsible for the care of Resident #1, on 12/28/12, from 7:00 AM-2:30 PM, and had noted that when turning the resident toward the window at 1:30 PM, the resident said "Oh!". The CNA stated the resident's leg was very tight and she reported this to LPN #4. Interview with LPN #4, on 01/09/13 at 2:00 PM, who took care of Resident #1, on 12/28/12 on the day shift, revealed CNA #5 called her to the resident's room around 2:00 PM to look at his/her leg. LPN #4 stated her assessment revealed the right leg looked tight and swollen, and the resident said he/she had fallen out of the lift when they weighed him/her, and the girl came in and dropped him/her. LPN #4 stated the resident could not identify any specific staff, so she called the ADON to come and assess the resident also. LPN #4 stated she did not document the assessment or the resident's pain in the clinical record that day, but should have done so, since the nurses were primarily responsible for documenting. Interview with the ADON, on 01/08/12 at 4:45 PM, revealed she was asked by CNA #5 and LPN #4 to assess Resident #1's leg, because the resident said "Ouch!" and his/her leg hurt when moved. Upon assessment, the ADON stated there were no abnormalities, but the leg looked tight or cramped, like a muscle spasm. The ADON stated the resident's son was visiting, and he was informed the resident's leg was hurting, like a muscle spasm, and a nursing intervention of warm compresses had been applied. However, record review revealed there was no documented evidence of the assessment by the ADON of the resident's pain nor physician notification of the resident's pain on movement. In addition, there was no evidence the resident's pain had been reported to the resident's POA (son). Further interview with the ADON revealed she was not aware of the 12/27/12 incident at that time, since it had not been documented or passed on during shift report. Interview, on 01/09/13 at 2:45 PM, with LPN #3 who worked the evening shift on 12/28/12, revealed she received the shift report that Resident #1 had been complaining of leg pain, and was stating he/she had been dropped from the Maxi-Lift while being weighed the day before. However, the LPN stated after speaking with the two CNAs who had weighed him/her, CNAs #3 and #4, it was determined there had been no incident with Resident #1 during the 12/27/12 day shift weight with the Maxi-Lift. Interview with LPN #3 revealed she reported this to the next shift; however, there was no evidence the LPN had documented her assessment of the resident's pain, completed an incident report, or notified the physician or family. Continued interview with LPN #3, who worked from 3:00-7:00 PM on 12/29/12, revealed she received no reports of pain from Resident #1 in the previous shift report; however, stated when she and LPN #5 tried to turn and reposition him/her at 6:00 PM, the resident said "Ouch!". LPN #3 stated when they assessed the resident's leg, it looked swollen above the knee, and when they lifted the leg, the resident did not complain of pain; however, the appearance had not changed from 12/28/12. Although interview revealed that LPN #3 reported the resident's pain upon movement to the night shift nurse LPN #6, LPN #3 failed to document the assessment, notify the physician, or the resident's family. The LPN stated she was unaware of the incident which had occurred with the lift on 12/27/12 at that time. Attempted interview with LPN #6, on 12/29/12 at 3:00 PM, was unsuccessful with no return call as of 01/10/13. Review of the nurse's notes, on 12/30/12 at 1:00 AM, revealed the night shift nurse LPN #6 documented the resident complaints of pain to the right upper thigh, and the physician was notified with an X-ray ordered to rule out a fracture. The nurse's note revealed the resident stated he/she "fell yesterday when being weighed in the lift, and his/her leg bent back". The record also revealed the resident was unable to verify any staff caring for him/her, and the portable X-ray service was notified at 1:00 AM. Pain medication (Tylenol 500 mg 2 tablets) was given at 1:00 AM for right leg pain with relief. The pain medication was offered again at 7:30 AM to the resident; however, the resident refused the medication. Review of the nurses notes, at 6:30 AM on 12/30/12, revealed the X-ray service had not arrived, so the facility paged them again. The nurses notes stated the service was called several times throughout the day, and was told they were on their way. A late entry in the nurse's note, on 12/30/12 at 2:45 PM, revealed the nurse noticed a deformity to the right thigh with the right leg turned in. The supervisor and physician was notified with new physician orders to transfer the resident to the hospital at that time. However, when the family was notified, they did not want the resident sent to the hospital until the results of the x-ray had been obtained, due to the resident being on comfort measures only. Review of the 4:00 PM nurses notes revealed the X-ray service arrived and completed the x-ray. Review of the 4:45 PM nurses notes revealed the results of the X-ray confirmed a Comminuted Fracture of the Distal Right Femur. The power of attorney (POA) was notified, and the resident was transferred to the hospital. The resident required surgical intervention for the Fractured Femur. Interview with LPN #5, on 01/09/13 at 2:30 PM, revealed she cared for Resident #1 on 12/30/12 during the day shift, and revealed throughout the day the resident complained of pain on turning, The LPN revealed around 2:00-2:30 PM, she noted a movement in his/her leg with rotation and notified the weekend supervisor Registered Nurse (RN) #1. LPN #5 stated they obtained an order at that time to go ahead and send the resident to the hospital; however, the family refused to allow transfer until the X-ray had been obtained. The LPN revealed the incident on 12/27/12 had not been noted on the 24 hour report, nor documented in the nurse's note until 12/30/12 at 1:00 AM. Interview with Resident #1's Power of Attorney (POA), on 01/09/13 at 1:10 PM, revealed he was not called about the incident with the lift until 12/30/12, and did not want the resident to be transferred until the x-ray results were obtained. The POA stated the facility told him on 12/29/12, they were putting hot compresses on the resident's leg for pain, but did not inform him of anything else. He had not seen or heard about an incident report. The POA stated the resident required rods and a number of screws in the fractured leg, "pretty serious stuff". Interview with the Director of Nursing (DON), on 01/08/13 at 10:20 AM, revealed she had not been notified of the 12/27/12 incident until, 1:00 AM on 12/30/12, when the night shift LPN #6 called her. Interview with the DON revealed all the mechanical lifts had been checked by the maintenance department on 12/31/12 with no mechanical problems found with Resident #1's lift. The DON stated she investigated the incident on Monday 12/31/12 when she returned to work and was sure there was going to be documentation of each assessment in the clinical record and there was not. Interview with the DON, on 01/10/13 at 1:30 PM, revealed during the investigation they found there had been no incident report completed initially, nor family or physician notified of the incident until 12/30/12. In addition, there was no documentation on the facility 24 hour shift report, or assessment documentation by LPN # 3, #4, #5 and the Assistant Director of Nursing. The Director of Nursing stated that although assessments had been completed for Resident #1 by the nurses, this did not meet the facility expectation. Interview with the Administrator, on 01/10/12 at 1:30 PM, revealed the incident could have been prevented with better communication with the staff and incident reporting passed on during the shift reports. The Administrator revealed the facility expectation would have been to call the physician and family initially, on 12/27/12, and to have all assessments documented and communicated to the next shifts. The Administrator also stated he would have expected an incident report completed at the time of the incident. The Administrator stated the lack of assessment documentation and reporting was unacceptable.

Based on observation, interview, record review, and review of the facility policy and procedure and investigation, it was determined the facility failed to follow the care plan relating to Maxi-Lift transfers for one (1) of four (4) sampled residents. Certified Nursing Assistant (CNA) #1 failed to follow care plan interventions for two person assist with the Maxi-Lift for Resident #1 on 12/27/12. The resident was observed by Certified Medication Technician (CMT) #2 to be positioned incorrectly in the lift during transfer, and in assisting with transferring the resident back to the bed, a popping sound was heard. Resident #1 sustained a Comminuted Fractured Right Femur. The facility's failure to follow the care plan for two assist resulted in Actual Harm to Resident #1. Refer to F323 The findings include: Review of the facility's policy "Resident Care Plan Policy", no date given, revealed approaches were to be stated in terms related to the staff, while problem/needs were related to the resident. Each discipline would follow up on the problems and achievement or non-achievement of the goals through communication with the appropriate staff. Review of the facility's policy "Clinical Record Documentation Guidelines", dated 02/20/12, revealed a procedure on how to document implementation of the care plan. Documentation should include [MEDICATION NAME] the plan of care that had been developed which included specific actions that the nurse needed to take to activate and implement that plan. Interview with the Director of Nursing (DON), on 01/09/13 at 2:00 PM, revealed there was no specific policy for following the care plan; however, she stated the shift supervisors and the floor managers have a daily round check list for monitoring completed tasks or care plan interventions that should have been done. The DON stated they also complete spot checks with staff still on probation. Review of the facility's investigation revealed that on 12/27/12, CMT #2 approached the Unit Manager and the 2nd Shift Supervisor #2, to inform them that she had walked into Resident #1's room where CNA #1 was transferring the resident in the Maxi-Lift alone. The CMT stated it appeared the resident was not positioned properly in the lift, she told CNA #1 she would assist in getting Resident #1 back in the bed. As the resident was being lowered in the bed, CMT #2 stated she heard a "snap". The investigation revealed the resident did not complain of pain at that time, and 2nd Shift Supervisor #2 entered the room and assessed the resident. The investigative report revealed the resident was not in distress at that time, and had no complaints of pain and physically appeared fine. A review of the comprehensive care plan and the CNA care plan for Resident #1, dated 09/03/12, revealed the resident required assist with Activities of Daily Living related to recent hospitalization for pacemaker insertion and general weakness, with an approach to transfer the resident per Maxi-Lift with the assist of two (2). Interview with Resident #1, on 01/08/13 at 10:00 AM, revealed the resident stated, while being transferred with a lift, they dropped him/her and his/her leg went under him/her. Resident #1 stated he/she hit the floor. The resident stated they did check him/her, and he/she kept complaining for days before anyone did anything. He/she stated, "I broke my knee". During the interview, Resident #1 pulled the sheet off his/her leg, observation of the knee revealed multiple staples noted vertically along the center of the patella or knee cap, with three to four staples on each side of the patella, also vertically. The resident stated he/she had pain, but was receiving pain medication when requested. Interview with CMT #2, on 01/09/13 at 10:00 AM, revealed that on 12/27/12 around 4:45 PM, she observed CNA #1 transferring Resident #1 from the bed to the chair in the Maxi-Lift. The CMT stated Resident #1 was suspended in the air and positioned incorrectly on the resident's left side. The CMT stated she was afraid the resident was going to fall out of the lift. CMT #2 assist CNA #1 in transferring Resident #1 back to bed, and upon transfer back to the bed, CMT #2 heard a popping sound. CMT #2 stated she reported the incident to Shift Supervisor #2 and Unit Manager #1 because she was not sure if the pop sound came from the resident or the lift, and the resident should be checked out. CMT #2 stated all residents who use the Maxi-Lift were to be transferred with 2 staff. The CMT stated the resident did not complain of pain at the time of the incident. Interview with CNA #1, on 01/09/13 at 3:00 PM, revealed he had worked at the facility for one month and had received lift training during his orientation to the facility. CNA#1 stated the son of Resident #1 had asked him to get the resident up into the chair on 12/27/12. CNA #1 stated he had placed Resident #1 on the lift pad, and attached the hooks to the lift; however, stated he was waiting for CMT #2 to come into the room to assist him with transferring the resident, because he knew the resident required two people to transfer and should not be lifted until the second person was there to assist. CNA #1 denied the allegation that Resident #1 was suspended in the air when the CMT came into the room. CNA #1 stated CMT #2 told him he did not have the resident positioned correctly in the lift, then she grabbed the resident's leg, trying to reposition the resident and caused the leg to snap. CNA #1 stated the policy was for two people to use the lift, and his CNA care plan sheet stated that the resident required two people for lift transfers. Interview with the Director of Nursing (DON), on 01/08/13 at 10:20 AM, revealed she had not been notified of the 12/27/12 incident until 1:00 AM on 12/30/12, when the night shift LPN #6 called her. The DON stated she investigated the incident on Monday when she returned to work, and revealed the expectation for following the plan of care lies with following the CNA care sheets that are carried with each CNA. Interview with the Staff Development Coordinator (SDC), on 01/10/13 at 12:00 PM, revealed CNA #1 was still on probation and had received lift training with return demonstration as well as completed all 29 skills competencies that are required for new staff within the first 60 days. The SDC stated that the nurses were responsible for supervising new staff, as well as spot checks and rounds check lists that were completed by unit managers and shift supervisors for all new staff. Interview with the Administrator, on 01/10/12 at 1:30 PM, revealed the facility findings were that CNA #1 failed to initially position and transfer the resident properly in the lift without the assistance required of two people as stated in the resident's care plan. The Administrator revealed the incident could have been prevented with better communication with the staff and following the care plan.

Based on observation, interview, record review, and review of the facility policy and procedures and investigation, it was determined the facility failed to notify the physician and family for one (1) of four (4) sampled residents (Resident #1) after an incorrect transfer in the Maxi-Lift was completed, resulting in a Right Comminuted Fractured Femur. The Shift Supervisor was notified by Certified Medication Technician (CMT) #2, and an initial assessment was completed for Resident #1; however, neither the Physician nor the Power of Attorney were notified of the incident. This facility failure delayed treatment and resulted in Actual Harm for Resident #1. Refer to F323 and F282 The findings include: Review of the facility's policy "Notification of Changes", dated 07/01/08, revealed this facility would immediately inform the resident; consult with the resident's physician; and notify the designated family member or resident's legal representative when there was an accident involving the resident which results in injury and had the potential for requiring physician intervention. Even when a resident was mentally competent, a designated family member should be notified of significant changes in the resident's health status, because the resident may not be able to notify them personally, especially in case of sudden illness or accident. Conditions that should be communicated to the physician: any accidents or incidents with or without injury. Review of the facility's investigation by the Director of Nursing, initiated on 12/30/12, revealed CMT #2 reported to the Unit Manager and 2nd Shift Supervisor #2 that she had walked into Resident #1's room where Certified Nurse Aide (CNA) #1 was transferring the resident in the Maxi-Lift alone. The CMT stated it appeared the resident was not positioned properly in the lift and she assisted CNA #1 in getting Resident #1 back to the bed. As the resident was being lowered in the bed, CMT #2 stated she heard a "snap". The investigation revealed the resident did not complain of pain at that time, and the 2nd Shift Supervisor #2 went to the room and assessed Resident #1. The report stated the resident was not in distress, and physically appeared fine. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 12/03/10, with [DIAGNOSES REDACTED]. Review of the 12/01/12 quarterly Minimum Data Set (MDS) assessment revealed the facility assessed Resident #1 with a decline since the 08/31/12 re-admission comprehensive MDS assessment, and had been placed on palliative care, on 10/28/12. Resident #1's 08/31/12 re-admission comprehensive MDS assessment and 12/01/12 quarterly MDS assessment revealed the facility assessed the resident as non-ambulatory and required maximum assistance with bathing, dressing and grooming, and was not interviewable. Interview with Resident #1, on 01/08/13 at 10:00 AM, revealed while being transferred with a lift, they dropped him/her and his/her leg went under him/her. Resident #1 stated he/she hit the floor. The resident stated they did check him/her, and he/she kept complaining for days before anyone did anything. He/she stated, "I broke my knee". After the resident pulled the sheet off his/her leg, observation of the knee revealed multiple staples noted vertically along the center of the patella or knee cap, with three to four staples on each side of the patella, also vertically. The resident stated he/she had pain, but was receiving pain medication when requested. Interview with Shift Supervisor #2, on 01/09/13 at 3:30 PM, revealed CMT #2 had reported to her, on 12/27/12 around 6:00 PM, that she had observed CNA #1 using the Maxi-Lift without assist of two people, as per facility policy, and observed Resident #1 suspended in the lift off the bed. The Shift Supervisor stated she was told by the CMT upon returning the resident to the bed, there was a popping sound, and said something might have happened with Resident #1. The Shift Supervisor stated she assessed the resident and looked for bruising, swelling, pain, and deformity, and at the time did not see any evidence of injury. The Shift Supervisor asked the resident if she was having pain, and the resident stated "no". Interview revealed there was no notification to the physician or family regarding the incident at that time. Continued interview with the Shift Supervisor revealed that later in the shift on 12/27/12, CMT #2 came to her again and reported upon turning Resident #1, the resident said "Oh!". The Shift Supervisor went back to re-assess the resident and still didn't see anything. Shift Supervisor #2 stated she was responsible for assessing, reporting, and initiating any investigations. She also stated she was responsible for completing a night report which was turned in to the Director of Nursing at the end of each shift. The Shift Supervisor stated she did not put the incident on the night report, because she didn't associate the resident's pain on turning with anything, just maybe arthritis. The Shift Supervisor also revealed the assessment was not documented in the nurse's notes, nor was there an incident report completed for the incident, or family and physician notified. Shift Supervisor #2 revealed she did not ask the resident what happened, only if she was in pain. Looking back, the Shift Supervisor stated the physician and family should have been notified. Interview with Licensed Practical Nurse (LPN) #4, on 01/09/13 at 2:00 PM, who took care of Resident #1, on 12/28/12 on the day shift, revealed CNA #5 called her to the resident's room around 2:00 PM to look at the resident's leg. She assessed the right leg, it looked tight and swollen, and the resident said he/she had fallen out of the lift when they weighed him/her, and that the girl came in and dropped him/her. LPN #4 stated the resident could not identify any specific staff, and she called the Assistant Director Of Nursing (ADON) to come and assess the resident also. LPN #4 stated she did not document the assessment or the resident's pain in the clinical record that day, but should have done so, since the nurses are primarily responsible for documenting, nor did she notify the resident's physician or family. Interview with the Assistant Director of Nursing (ADON), on 01/08/12 at 4:45 PM, revealed she was asked by CNA #5 and LPN #4 to assess Resident #1's leg, because the resident said "Ouch!" and said his/her leg hurt when moved. Upon assessment, the ADON stated there were no abnormalities, but the leg looked tight or cramped, like a muscle spasm. The ADON stated the resident's son was visiting, and he was informed the resident's leg was hurting like a muscle spasm, and a nursing intervention of warm compresses had been applied. However, there was no evidence the assessment completed by the ADON had been documented in the nurse's notes, nor physician notified of the resident's pain on movement. Further interview with the ADON revealed she was not aware of the 12/27/12 incident at that time, since it had not been documented or passed on during shift report. Interview, on 01/09/13 at 2:45 PM, with the evening shift LPN #3, revealed she had worked on 12/28/12 and received report that Resident #1 had been complaining of leg pain, and was stating he/she had been dropped with the lift during being weighed. However, review of the facility investigation regarding CNAs #3 and #4, who had weighed Resident #1 the previous day, revealed there had been no incident with the Maxi-Lift with Resident #1. Interview with LPN #3 also revealed she had passed this information to the next shift; however, there was no evidence LPN #3 had documented her assessment of the resident's pain, completed an incident report, or notified the physician or family. Continued interview with LPN #3, who worked from 3:00 PM-7:00 PM on 12/29/12, revealed she received no reports of pain from Resident #1 in the previous shift report; however, stated when she and LPN #5 tried to turn and reposition him/her at 6:00 PM, the resident said "Ouch!". LPN #3 stated when they assessed the resident's leg, it looked swollen above the knee, and when they lifted the leg, the resident did not complain of pain; the appearance of the leg had not changed from 12/28/12. Although interview revealed LPN #3 reported the resident's pain upon movement to the night shift nurse LPN #6, LPN #3 failed to document the assessment, notify the physician, or the resident's family. The LPN stated she was unaware of the incident which had occurred with the lift on 12/27/12 at that time; however, should have documented the assessment and notified the physician and family of her findings. Attempted interview with LPN #6, on 12/29/12 at 3:00 PM, was unsuccessful with no return call as of 01/10/13. Review of the nurse's notes, on 12/30/12 at 1:00 AM, revealed the night shift nurse LPN #6 documented the resident's complaints of pain to the right upper thigh, and the physician was initially notified and orders received to obtain an X-ray to rule out a fracture. Review of the nurses' note also revealed the resident stated he/she "fell yesterday when being weighed in the lift, and his/her leg bent back". The portable X-ray service was notified at 1:00 AM; however, even after multiple calls from the facility, did not arrive at the facility until 4:00 PM that day to obtain the X-ray. Pain medication (Tylenol 500 mg 2 tablets) was given at 1:00 AM for right leg pain with relief. The pain medication was offered again at 7:30 AM to the resident; however, the resident refused the medication. Interview with LPN #5, on 01/09/13 at 2:30 PM, revealed she cared for Resident #1 on 12/30/12 during the day shift, and revealed throughout the day the resident complained of pain on turning, and around 2:00 PM-2:30 PM, she noted a movement in his/her leg with rotation and notified the weekend supervisor Registered Nurse (RN) #1. LPN #5 stated they obtained an order at that time to go ahead and send the resident to the hospital; however, the family refused to allow transfer until the X-ray had been obtained. The LPN revealed she had not noted the incident on the 24 hour report, or documentation in the nurse's note until 12/30/12 at 1:00 AM. Interview with Resident #1's Power of Attorney (POA), on 01/09/13 at 1:10 PM, revealed he was not called about the incident with the lift until 12/30/12. He did not want him/her to be transferred until the X-ray results were obtained. The facility told him on Saturday 12/29/12 they were putting hot compresses on his/her leg for pain, but did not inform him of anything else. He had not seen or heard about an incident report. The POA stated the resident required surgery with rods and a number of screws in his/her fractured leg, "pretty serious stuff". Interview with the Director of Nursing (DON), on 01/08/13 at 10:20 AM, revealed she had not been notified of the 12/27/12 incident until 1:00 AM on 12/30/12, when the night shift LPN #6 called her. The DON stated she investigated the incident on Monday when she returned to work and found there was no documentation in the clinical record until 12/30/12, after LPN #6 called her. The DON stated that during the investigation they found there had been no incident report completed initially, nor family or physician notified of the incident until 12/30/12. In addition, there was no documentation on the facility's 24 hour shift report, or assessment documentation by each nurse in the resident's record of the incident. The Director of Nursing stated this did not meet the facility's expectation. Interview with the Administrator, on 01/10/12 at 1:30 PM, revealed the incident could have been prevented with better communication with the staff, notification of the physician and family, and the incident passed on during the shift reports. The Administrator revealed the facility expectation would have been to call the physician and family initially, on 12/27/12, and to have assessments documented and communicated to the next shifts. The Administrator stated the lack of assessment documentation and notifications were unacceptable.

Based on interview, record and policy review, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental psychosocial well-being for residents regarding adequate supervision to prevent accidents for two residents (#1 and 9) of fifteen (15) sampled residents. The facility administration failed to ensure the policies and procedures were implemented regarding falls. The facility administration failed to identify that their system to thoroughly investigate accidents, determine causal factors, and implement appropriate action plans in response was not being implemented effectively. On 03/07/11, facility staff inappropriately transferred Resident #1, during the transfer, the resident fell sustaining a hematoma to the back which required surgical intervention. The facility's investigation failed to identify the causal factor therefore preventing the facility from implementing interventions to prevent the recurrence. In addition, Resident #9 sustained an injurious fall on 04/20/11 during a self transfer from the bed. Record review revealed the resident had sustained eight (8) falls since January 2011 without the facility identifying a trend and implementing appropriate interventions to prevent additional falls. Refer to F323. Based on the above findings, it was determined the facility failure to ensure policies and procedures were implemented to thoroughly investigate accidents, determine causal factors, and implement appropriate action plans in response was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 03/07/11 at F282 "K", F323 "K", and F490 "K". The facility provided an acceptable credible allegation of removal of Jeopardy on 04/27/11. Immediate Jeopardy was verified to be removed prior to exit on 04/27/11 with remaining non-compliance at 42 CFR 483.20 Assessments (F282), 42 CFR 483.25 25 Quality of Care (F323) Accidents, and 42 CFR 483.75 (F490) Administration, at scope and severity at a "E". The findings include: Review of the Fall Management policy, effective date: January 1, 2010 revealed procedures to identify risk factors and manage residents who experienced a fall. Under the management of a fall, the facility stated a Post Fall Investigation Tool would be completed, review of current plan of care with necessary revised interventions, and falls would be tracked to analyze trends. Interview with West Wing Unit Coordinator on 04/20/11 at 11:45am and 04/21/11 at 8:45am revealed he reviews all incident reports regarding falls. He transfers the information from the incident reports and Post Fall Investigation reports into a Fall tracking log. That information is taken to the Fall Committee meeting that is held weekly on Wednesdays. He indicated each resident's fall is suppose to be reviewed for causal factors and look at interventions implemented to prevent additional falls. Interview with the Administrator on 04/21/11 at 9:00am revealed she had reviewed the incident report regarding Resident #1's fall on 03/07/11. She stated she had not identified the resident had been transferred using the wrong method (assist of one person rather than two) as indicated on the comprehensive care plan. She stated she relied on other administrative staff to identify root causes of the fall and bring forward that information to the fall committee. She stated it was apparent the care plan had not been followed and it upset her that the facility had not identified this failure. She revealed falls were discussed in each Quality Assurance (QA) meeting with the last QA meeting held on 04/18/11. However, since the problem with care plan implementation was not identified, it was not discussed at that QA meeting. In addition, she acknowledged the root cause analysis of the falls were not consistently identified and nobody was reviewing the care tracker information to ensure the nurse aides were providing care according to each resident's plan of care. Interview with the Vice President of Operations on 04/25/11 9:05am revealed she had identified a problem with the fall committee's knowledge of evaluating incident reports and fall log information on 04/22/11. She stated analysis of falls were not occurring. 1. Review of Resident #1's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility identified the resident to be at risk for falls upon admission due to sustaining two falls during hospitalization (June 23 & 29, 2010) that was documented in the hospital's discharge summary. The facility assessed and care planned (08/05/10, and revised on 01/11/11) the resident to require extensive assist of two-persons for bed mobility, transfers, and toilet use. On 03/07/11 at 4:50am, Resident #1 sustained a fall with injury. Review of the nurses' notes for 03/07/11 at 4:50am revealed the nurse found the resident lying on the floor beside the toilet. A large hematoma with an abrasion was observed on the resident's back which required surgical intervention on 03/22/11. There was no documented evidence the facility identified the causal factor of the fall was related to the CNA transferring the resident by herself despite Administrator review of the fall incident. Refer to F323. 2. Review of Resident #9's clinical record revealed the resident was identified at risk for falls. Resident #9 had falls on: 01/05/11, 01/29/11, 02/13/11, 03/07/11, 03/15/11, 03/31/11, and 04/12/11 where the resident was attempting self transfers due to toileting needs. On 04/20/11 at 9:30pm, documentation in the nurses' notes revealed the resident was found lying on the floor. A large hematoma was noted to the resident's right forehead and laceration across the bridge of the nose. An abrasion was noted to the right shoulder and bilateral knees. A skin tear was noted to the right forearm. The resident stated, "I was trying to go to the BR (bathroom) when I fell ." The resident was sent to the hospital for evaluation with the findings of a nasal fracture and C-2 (cervical) fracture to the neck. A hard collar neck brace was applied. Interview with the West Wing Unit Coordinator on 04/25/11 at approximately 2:30pm revealed most of the resident's falls occurred when the resident was attempting self-transfers. He indicated he had not identified a trend with the resident falling in the bathroom. There was no documented evidence that the administration had identified a failure in the investigation of incidents to identify causal factors despite being involved in the falls committee. An acceptable AOC was received on 04/27/11 and the Immediate Jeopardy was found to be corrected prior to exit on 04/27/11. The following measures were validated as completed prior to the survey exit on 04/27/11: * Facility reviewed all incident reports (back to January 2011) regarding falls on 04/22/11 to ensure the investigation was completed appropriately, causal factors were determined, interventions identified and implemented, and the interventions were appropriated and communicated to staff. This included care plan revision. * Facility reassessed all residents for accurate transfer status on 04/22/11. The facility identified two other falls related to wrong transfer status. The falls resulted in no injuries. Care plans and nurse aide care plans were revised to reflect any changes in transfer status. Completed on 04/22/11. * Caretracker reports were reviewed against sampled residents care plan, transfer status assessment, CNA care plan, and MDS assessment and was validated correct on 04/27/11. * Observation of transfers during the partial extended survey (april 25-27, 2011) validated the correct transfer method was used according to each resident's assessment and care plan. * The facility notified the Medical Director of the IJ on 04/21/11 and a special Quality Assurance meeting was held on 04/22/11 with the Medical Director in attendance. Validation through interview with the Medical Director on 04/25/11 and review of the QA sign in sheet dated 04/22/11. * The facility reeducated all nursing staff (04/22/11-04/24/11) on the use of the care plan, revision of care plan, and following the care plan. In addition, education on proper transfer methods (one-person, two-person, mechanical lift) was provided to all nursing staff. The training was validated through sign in sheets against the facility staff roster. In addition, interviews with 12 different CNAs on both west and east wing, 2 RNs, and 4 LPNs validated the staff was knowledgeable of what was presented in the training and how to apply that information. * Facility observed a minimum of 10 CNAs for proper transferring method April 22-24, 2011. Review of the transfer audits revealed 10 CNAs were observed performing different transfer methods (one-person, two-person, and mechanical lift) on April 22, 23, and 24th. Validation was also conducted through observation by the surveyors. * The Vice President of Operations educated the Administrative staff and fall committee on 04/25/11 on investigation of falls, review of incident reports, and appropriate interventions. Validation with the unit managers on 04/26/11 verified the training. * The facility developed a communication tool for a change in resident's transfer status. In addition, a master list of all residents requiring two-person assist or mechanical lift was created. Validation through review of these tools was conducted on 04/25/11. Immediate Jeopardy was verified removed prior to exit on 04/27/11 with remaining non-compliance at 42 CFR 483.75 Administration, scope and severity at a "E" while the facility's Quality Assurace monitors the effectiveness of transfer observation audits, caretracker reports, and accurrancy of transfer status assessments.

Based on observation, interview, record review, facility policy and falls tracking log review, it was determined the facility failed to ensure the fall management policy was implemented effectively. The facility failed to thoroughly investigate to determine causal factors, which prevented the facility from implementing effective interventions to prevent the recurrence of falls. The facility assessed Resident #1 as requiring assist of two staff with all transfers; however, on 03/07/11, the facility failed to transfer Resident #1 using two staff. Resident #1 fell during the transfer sustaining a large hematoma (localized collection of blood from broken blood vessels) to the lumbar (lower back) requiring surgical intervention. Resident #9 sustained an injurious fall on 04/20/11 during a self transfer from the bed. Record review revealed the resident had sustained eight (8) falls since January 2011 without the facility identifying a trend and implementing appropriate interventions to prevent additional falls. The facility failed to have an effective system to thoroughly investigate accidents, determine causal factors, and implement effective action plans in response. The failure and the facility's non-compliance has caused or is likely to cause Resident #1 and other residents identified at risk for falls, serious injury, harm, impairment,or death to a resident. A partially extended survey was conducted on 04/25/11 - 04/27/11 which determined Immediate Jeopardy existed from 03/07/11 - 04/26/11. The facility provided an acceptable credible Allegation of Compliance (AOC) for the removal of IJ on 04/27/11. The state agency verified Immediately Jeopardy was removed prior to exit on 04/27/11, with remaining non-compliance at 42 CFR 483.20 Assessments (F282), 42 CFR 483.25 25 Quality of Care (F323) Accidents, and 42 CFR 483.75 (F490) Administration, at scope and severity to a "E". The findings include: Review of the Fall Management policy, effective date: January 1, 2010 revealed procedures to identify risk factors and manage residents who experienced a fall, i.e. complete a fall risk screen upon admission and complete an incident report whenever a resident sustained [REDACTED]. 1. Interview with West Wing Unit Coordinator on 04/20/11 at 11:45am and 04/21/11 at 8:45am revealed he reviews all incident reports regarding falls. He transfers the information from the incident reports and Post Fall Investigation reports into a Fall tracking log. That information is forwarded to the Fall Committee meeting that is held weekly on Wednesdays. Continued interview with the West Wing Unit Coordinator revealed he had reviewed the fall incident report regarding Resident #1's fall on 03/07/11 and included that information on the fall tracking log that was forwarded to the fall committee. He indicated each resident's fall is suppose to be reviewed for causal factors and look at interventions implemented to prevent additional falls. He acknowledged the comprehensive care plan nor the nurse aide care plan was reviewed to ensure the care plan had been implemented. He stated information on the fall tracking log was obtained from the incident report only. In addition, the Unit Coordinator revealed the care tracker reports were not reviewed to ensure residents were being transferred by the correct method. Review of Resident #1's clinical record revealed the facility admitted Resident #1 on 07/26/10 with [DIAGNOSES REDACTED]. The facility identified the resident to be at risk for falls upon admission due to sustaining two falls during hospitalization (June 23 & 29, 2010) that was documented in the hospital's discharge summary. Review of the admission MDS (minimum data set) assessment completed on 08/06/10 revealed the facility assessed the resident to have a cognition deficit and unable to verbalize understanding of cues. The facility assessed the resident as having a balance deficit and required extensive assist of two-persons for bed mobility, transfers, and toilet use, and having sustained falls. Review of the comprehensive care plan (dated 08/05/10 and revised on 01/11/11 and 04/11/11) revealed the facility identified the resident was at risk for falls related to a history of falling and CVA (stroke). Review of the approaches revealed an alarming seat belt restraint was implemented on 08/07/10, bed/chair alarm, low bed, and "transfer with assist of 2 and gait belt". Review of January, February, March, and April 2011 nursing assistant care plans revealed instructions to have two persons to transfer the resident and use the gait belt with all transfers. Refer to F282. Interview with CNA#1, on 04/19/11 at 8:00pm, revealed on 03/07/11 (4:50am) she had transferred Resident #1 from the bed to the wheelchair, wheeled the resident into the bathroom, and was attempting to transfer the resident to the toilet. She stated she assisted the resident to a standing position when the resident started urinating on the floor. She indicated the resident slipped in the urine and fell on to the floor, hitting the toilet during the fall. CNA#1 stated she attempted to catch the resident but she could not prevent the resident from falling and the resident's back hit the toilet. She stated the resident was hurt so she left the resident lying in the floor to get the nurse. The CNA revealed she was unaware the resident was care planned to have two person assisted transfers and had not reviewed the CNA care plan prior to providing care. She stated she had transferred Resident #1 by herself many times prior to the fall on 03/07/11. Review of the nurse's notes, dated 03/07/11 at 4:50am, revealed Resident #1 sustained a fall with injury. The nurse documented CNA #1 reported Resident #1 had falling during a transfer from the wheelchair to the toilet. The nurse found the resident lying on the floor beside the toilet. A large hematoma with an abrasion was observed on the resident's midback. Interview with LPN#1 on 04/19/11 at 8:30pm revealed CNA#1 came running to inform her Resident #1 had falling on 03/07/11. She found the resident lying on the bathroom floor beside the toilet. Upon assessment, a large hematoma was noted to the resident's lumbar area. The nurse stated CNA#1 told her that she was transferring the resident from the wheelchair onto the toilet when the resident slipped in urine and fell . The CNA told the nurse she was unable to prevent the resident from falling. After assessing the resident, the nurse completed an incident report. She stated she never reviewed Resident #1's care plan to ensure the correct transfer method was used and indicated she was unaware the resident required a two-person assist with all transfers and toileting needs. At 6:30am, the nurse documented the hematoma had increased in size and felt "harder". The resident's physician was notified and a portable x-ray was obtained that revealed no fractures. On 03/11/11, the resident's primary physician assessed the hematoma and referred the resident to a surgical specialist. On 03/22/11, the resident had the hematoma surgically removed. The nurse documented the necrotic top skin layer and a baseball size clot was removed. Treatment orders were received to clean and dress the surgical wound twice a day. Review of the Post Fall Investigation Tool for Resident #1's fall on 03/07/11 revealed written documentation the resident was getting "off" the toilet and there was a wet floor. Under the evaluate findings section LPN#1 documented the Resident #1 was attempting self-transfer and slipped in urine. However, interview with LPN#1 and CNA#1 revealed this was not how the resident fell . Actions taken by the facility after Resident #1's fall were to apply ice to the injury and counsel the CNA on making sure the floor was dry. This report was reviewed by the West Wing Unit Coordinator, DON, and Administrator; however, there was no evidence that their review identified staff had not followed the plan of care. In addition, there was no evidence their review identified the incident report's inconsistencies related to the actual event, i.e. resident attempting to transfer self versus one staff assisting with transfer at the time of the fall. Interview with the Director of Nursing (DON) on 04/19/11 at 3:15pm revealed she had reviewed the incident report and was told the resident fell because the resident had slipped in urine on the bathroom floor. The DON stated she was unaware the resident had been transferred by the wrong method because she only focused on the resident slipping on the urine and did not consider the care plan had not been followed. Observation of staff toileting the resident on 04/20/10 at 9:40am revealed the resident was transferred by two CNAs (CNA#2 and CNA#3). Resident #1 was observed to require continuous verbal cues and hands-on touch to hold onto the grab bar beside the toilet and one CNA had to physically guide the resident's body in the direction of the toilet so the resident could sit on the commode. Observation revealed the resident attempted to get up without assistance and one CNA stood in front of the resident while the other CNA physically held the resident steady during the transfer from the toilet back into the wheelchair. The resident was observed to sway back and forward. Interview with CNA #2 and CNA#3 at the time of the observation revealed they were told by the nurse to be sure to do a two-person assisted transfer today. Both CNAs stated they had transferred Resident #1 by themselves prior to this observation. CNA#2 stated the resident was not steady during transfers and required verbal cues to perform any task. Review of the care tracker reports with dates of March 1-6, 2011 revealed nine (9) different CNAs had documented they had transferred Resident #1 with assist of only one person prior to the injuries fall on 03/07/11. In addition, continued review of the care tracker reports (03/07/11 through 04/19/11, beginning of the survey) the facility staff continued to transfer Resident #1 with only one person assist. Review of the transfer status assessment form completed on 07/28/10, 01/07/11, and 04/06/11 revealed the facility had assessed Resident #1 to required two staff for transfers. Interview with LPN#3 (nurse who completed the assessments) on 04/20/11 at 10:30am revealed the resident required two-person assist with all transfers to be safe. The nurse stated the resident is impulsive and doesn't retain safety instructions. She revealed whenever she had transferred the resident, she had always requested assistance from another staff. Interview with the Administrator on 04/21/11 at 9:00am revealed she had reviewed the incident report regarding Resident #1's fall on 03/07/11. She stated she had not identified the resident had been transferred using the wrong method (assist of one person rather than two) as indicated on the comprehensive care plan. She stated she relied on other administrative staff to identify root causes of the fall and bring forward that information to the fall committee. She stated it was apparent the care plan had not been followed. 2. Review of Resident #9's clinical record revealed an admitted [DATE] with a history of falling. The resident sustained [REDACTED]. Review of the admission MDS completed on 11/23/10 revealed the facility assessed the resident to require extensive assistance from one-person with bed mobility, transfers, and ambulation, and two-person assist with toilet use. The facility assessed the resident as having a balance deficit and unsteady gait. Review of the clinical record and the fall tracking log revealed Resident #9 had the following falls: 1. 01/05/11 at 7:20am (in the bathroom, self-transferring, lost balance, no injuries) facility action: staff to ensure resident had proper footwear for resident. 2. 01/29/11 at 12:45pm (resident slipped trying to get out of bed, no injuries) facility action: staff educated to have proper footwear. 3. 02/13/11 at 7:00pm (in bathroom, slipped on the floor during self-assisted transfer, no injuries) facility action: non-skid strips added in bathroom. 4. 03/07/11 at 5:00pm (missed the toilet and fell on to floor, unwitnessed, no injuries) facility action: "Isolated incident, independent with toileting: 5. 03/15/11 at 1:30pm (bathroom, slipped getting off the toilet unassisted, no injuries) facility action: "toilet riser." 6. 03/31/11 at 8:10am resident was leaving the bathroom, lost balance and fell . This was witnessed by CNA present at that time. Facility action: therapy ordered. 7. On 04/12/11 at 4:50pm (the resident fell during a self- transfer from the bed, no injuries), facility action: a bed alarm was placed to bed. Review of the fall tracking log revealed the 04/20/11 injurious fall was not listed. A physician order [REDACTED]. The most recent MDS assessment completed on 04/20/11 revealed the facility assessed the resident to require the same amount of assistance (one-person) with bed mobility, transfers, and ambulation. Toilet use was now completed with assist of one-person. Review of the CAA (Care area assessment) dated 04/14/11 revealed Resident #9 had four falls since the last review and appears to be unaware of safety needs. The resident has an unsteady gait during ambulation with a rolling walker. The report stated the resident has a [DIAGNOSES REDACTED]. The facility assessed the resident to have a cognition deficit. Review of the care plan dated 04/14/11 revealed the resident was to be a one-person assist with all transfers. On 04/21/11, the facility revised the care plan to a two-person assist. On 04/20/11 at 9:30pm, documentation in the nurses' notes revealed the resident was found lying on the floor. A large hematoma was noted to the resident's right forehead and laceration across the bridge of the nose. An abrasion was noted to the right shoulder and bilateral knees. A skin tear was noted to the right forearm. The resident stated, "I was trying to go to the BR (bathroom) when I fell ." The resident was sent to the hospital for evaluation with the findings of a nasal fracture and C-2 (cervical) fracture to the neck. A hard collar neck brace was applied. Observation of Resident #9 on 04/25/11 at 10:45am revealed the resident was sitting up in a wheelchair in the resident's room. A hard collar neck brace was applied. Bilateral bruising and orbital edema was noted under the resident's eyes. Profound bruising and edema was noted on the bridge of the nose. A large hematoma was observed on the resident's right forehead. The resident had eyes closed and did not response to conversation. Interview with the West Unit Coordinator on 04/25/11 at approximately 2:30pm revealed interventions were implemented after each fall and acknowledged staff education regarding proper footwear was the only intervention after consistent falls. He confirmed most falls occurred when the resident was attempting self-transfers. He indicated he had not identified a trend with the resident falling in the bathroom. He confirmed most of the falls occurred when the resident attempted self-transfers and was in the bathroom. He stated he had considered the 03/07/11 fall to be an isolated event; however, the resident was in the bathroom alone at the time of the fall. He stated the resident had been placed on a toileting schedule but the resident continued to self-transfer to the bathroom. He had not placed the 04/20/11 fall on the fall log because he was awaiting the next fall committee meeting. Interview with the Vice President of Operations on 04/25/11 at 9:05am revealed she had identified a problem with the fall committee's knowledge of evaluating incident reports and fall log information after review of the facility's systems. She stated analysis of falls were not occurring. An acceptable AOC was received on 04/27/11 and the Immediate Jeopardy was found to be corrected prior to exit on 04/27/11. The following measures were validated as completed prior to the survey exit on 04/27/11: * Facility reviewed all incident reports (back to January 2011) regarding falls on 04/22/11 to ensure the investigation was completed appropriately, causal factors were determined, interventions identified and implemented, and the interventions were appropriated and communicated to staff. This included care plan revision. * Facility reassessed all residents for accurate transfer status on 04/22/11. The facility identified two other falls related to wrong transfer status. The falls resulted in no injuries. Care plans and nurse aide care plans were revised to reflect any changes in transfer status. Completed on 04/22/11. * Caretracker reports were reviewed against sampled residents care plan, transfer status assessment, CNA care plan, and MDS assessment and was validated correct on 04/27/11. * Observation of transfers during the partial extended survey (april 25-27, 2011) validated the correct transfer method was used according to each resident's assessment and care plan. * The facility notified the Medical Director of the IJ on 04/21/11 and a special Quality Assurance meeting was held on 04/22/11 with the Medical Director in attendance. Validation through interview with the Medical Director on 04/25/11 and review of the QA sign in sheet dated 04/22/11. * The facility reeducated all nursing staff (04/22/11-04/24/11) on the use of the care plan, revision of care plan, and following the care plan. In addition, education on proper transfer methods (one-person, two-person, mechanical lift) was provided to all nursing staff. The training was validated through sign in sheets against the facility staff roster. In addition, interviews with 12 different CNAs on both west and east wing, 2 RNs, and 4 LPNs validated the staff was knowledgeable of what was presented in the training and how to apply that information. * Facility observed a minimum of 10 CNAs for proper transferring method April 22-24, 2011. Review of the transfer audits revealed 10 CNAs were observed performing different transfer methods (one-person, two-person, and mechanical lift) on April 22, 23, and 24th. Validation was also conducted through observation by the surveyors. * The Vice President of Operations educated the Administrative staff and fall committee on 04/25/11 on investigation of falls, review of incident reports, and appropriate interventions. Validation with the unit managers on 04/26/11 verified the training. * The facility developed a communication tool for a change in resident's transfer status. In addition, a master list of all residents requiring two-person assist or mechanical lift was created. Validation through review of these tools was conducted on 04/25/11. Immediate Jeopardy was verified removed prior to exit on 04/27/11 with remaining non-compliance at 42 CFR 483.25 Quality of Care, scope and severity at a "E" while the facility's Quality Assurace monitors the effectiveness of transfer observation audits, caretracker reports, and accurrancy of transfer status assessments.

Based on record review and interview it was determined the facility failed to provide care and services in accordance with the care plan for one (#1) of fifteen (15) sampled residents. The facility failed to ensure staff was knowledgeable and implemented the resident's plan of care. The facility assessed and care planned Resident #1 needing assistance of two persons for all transfers and toileting needs. However, on March 7, 2011, CNA #1 (certified nursing assistant) transferred Resident #1 from the wheelchair to the toilet by herself. The resident lost his/her balance, fell against the toilet and onto the bathroom floor. A large hematoma (size of a baseball) developed to the resident's lower back and had to be surgically removed leaving a large open area on the resident's back that requires treatment twice a day. The facility failed to identify the care plan was not followed and did not provide additional staff training or interventions to ensure all residents were transferred according to which method (one person, two person, or mechanical lift) the facility had assessed each resident to need for a safe transfer. This failure to identify the causal factor of the fall allowed the inappropriate transfers to continue to occur after the 03/07/11 fall with injury. A partially extended survey was conducted on 04/25/11 - 04/27/11 which determined Immediate Jeopardy existed from 03/07/11 - 04/26/11. The facility provided an acceptable credible Allegation of Compliance (AOC) for the removal of IJ on 04/27/11. The state agency verified Immediately Jeopardy was removed prior to exit on 04/27/11, with remaining non-compliance at 42 CFR 483.20 Assessments (F282), 42 CFR 483.25 25 Quality of Care (F323) Accidents, and 42 CFR 483.75 (F490) Administration, at scope and severity to a "E". The findings include: Review of the Fall Management policy effective date January 1, 2010, revealed when a resident sustain a fall, a review of the current plan of care and necessary revision of interventions are to be completed. Review of the comprehensive care plan (dated 08/05/10 and revised on 01/11/11 and 04/11/11) revealed the resident was at risk for falls related to a history of falling [MEDICAL CONDITION](stroke). Review of the approaches revealed an alarming seat belt restraint was implemented on 08/07/10, bed/chair alarm, low bed, and "transfer with assist of 2 and gait belt". Review of January, February, and March 2011 nursing assistant care plans revealed instructions to have two persons to transfer the resident and use the gait belt with all transfers. Review of the transfer status assessment completed on 07/28/10, 01/07/11 and 04/06/11 revealed the facility had assessed Resident #1 to require two staff for transfers. Interview with LPN#3(the nurse who had completed the assessments) on 04/20/11 at 10:30am revealed Resident #1 required two-person assist with all transfers to be safe. The nurse stated the resident was impulsive and doesn't retain safety instructions. Interview with CNA#1 on 04/19/11 at 8:00pm revealed on 03/07/11 (early morning) she had transferred Resident #1 by herself from the bed to the wheelchair, wheeled the resident into the bathroom, and was attempting to transfer the resident to the toilet. She stated the resident slipped in urine and fell on to the floor, hitting the toilet during the fall. The CNA revealed she was unaware the resident was care planned to have two person assisted transfers. She stated she had transferred Resident #1 by herself many times prior to the fall on 03/07/11. Continued interview with CNA #1 revealed she had worked at the facility since November 2011 and observed other staff transferring Resident #1 with one-person assist. She stated she thought this was the method used to transfer the resident; however, she did not review the care plan to ensure that was the correct method. She confirmed the nurse who assessed the resident after the fall, nor any other facility staff, questioned her regarding the one-person assist and following the care plan. The CNA stated she had been documenting one-person assisted transfers in the care tracker for awhile and nobody had told her it was wrong. She stated having another person available may have prevented the fall. Review of Resident #1's clinical record (nurse's notes, dated 03/07/11 at 4:50am) revealed the nurse was called to Resident #1s room by CNA #1 and found Resident #1 lying on the floor beside the commode. A large hematoma with an abrasion was observed on the resident's lower back. The facility nurse assessed the resident, applied ice to the injured area, administered pain medication, and made notification to the family. Interview with LPN#1 on 04/19/11 at 8:30pm revealed CNA#1 had reported Resident #1 had falling on 03/07/11. She found the resident lying on the bathroom floor beside the toilet. Upon assessment, a large hematoma was noted to the resident's lumbar area. The nurse stated CNA#1 told her that she was transferring the resident from the wheelchair onto the toilet when the resident slipped in urine and fell . The nurse confirmed she completed the incident report regarding the fall on 03/07/11; however, she stated she had not reviewed Resident #1's care plan to ensure the correct transfer method was used and indicated she was unaware the resident required a two-person assist with all transfers and toileting needs. Interview with LPN#1 on 04/19/11 at 8:30pm revealed CNA#1 came running to her and informed her Resident #1 had falling. The resident was found lying on the bathroom floor beside the toilet. Upon assessment, a large hematoma was noted to the resident's lumbar area. The nurse stated CNA#1 told her that she was transferring the resident from the wheelchair onto the toilet when the resident slipped in urine and fell . The CNA was unable to prevent the fall. After assessing the resident, the nurse completed an incident report. She revealed she never reviewed Resident #1's care plan to ensure the correct transfer method was used and indicated she was unaware the resident was to be a two-person assist with all transfers and toileting needs. Interview with West Wing Unit Coordinator on 04/20/11 at 11:45am and 04/21/11 at 8:45am revealed he reviewed the fall incident report for 03/07/11 involving Resident #1 and included that information on the fall tracking log. He acknowledged the comprehensive care plan nor the nurse aide care plan was reviewed to ensure the care plan had been implemented. He stated information on the fall tracking log was obtained from the incident report only. He confirmed he was unaware the resident had been transferred with an assist of one instead of two as indicated on the care plan. Interview with the Director of Nursing (DON) on 04/19/11 at 3:15pm revealed she had reviewed the incident report and was told the resident fell because the resident had slipped in urine on the bathroom floor. She stated Resident #1 sustained injury to the resident's lumbar (large hematoma) that required surgical intervention. the DON stated she was unaware the resident had been transferred by the wrong method because she only focused on the resident slipping in the urine and did not consider the care plan had not been followed. She acknowledged she did not know the resident was being transferred with only one assist instead of two as indicated by the care plan. Interview with the Administrator on 04/21/11 at 9:00am revealed she had reviewed the incident report regarding Resident #1's fall of 03/07/11. She stated she did not identify the resident had been transferred using the wrong method (assist of one person rather than two) as indicated on the comprehensive care plan. She stated she relied on other administrative staff to identify root causes of the fall and bring forward to the fall committee. She stated it was apparent the care plan had not been followed. An acceptable AOC was received on 04/27/11 and the Immediate Jeopardy was found to be corrected prior to exit on 04/27/11. The following measures were validated as completed prior to the survey exit on 04/27/11: * Facility reviewed all incident reports (back to January 2011) regarding falls on 04/22/11 to ensure the investigation was completed appropriately, causal factors were determined, interventions identified and implemented, and the interventions were appropriated and communicated to staff. This included care plan revision. * Facility reassessed all residents for accurate transfer status on 04/22/11. The facility identified two other falls related to wrong transfer status. The falls resulted in no injuries. Care plans and nurse aide care plans were revised to reflect any changes in transfer status. Completed on 04/22/11. * Caretracker reports were reviewed against sampled residents care plan, transfer status assessment, CNA care plan, and MDS assessment and was validated correct on 04/27/11. * Observation of transfers during the partial extended survey (april 25-27, 2011) validated the correct transfer method was used according to each resident's assessment and care plan. * The facility notified the Medical Director of the IJ on 04/21/11 and a special Quality Assurance meeting was held on 04/22/11 with the Medical Director in attendance. Validation through interview with the Medical Director on 04/25/11 and review of the QA sign in sheet dated 04/22/11. * The facility reeducated all nursing staff (04/22/11-04/24/11) on the use of the care plan, revision of care plan, and following the care plan. In addition, education on proper transfer methods (one-person, two-person, mechanical lift) was provided to all nursing staff. The training was validated through sign in sheets against the facility staff roster. In addition, interviews with 12 different CNAs on both west and east wing, 2 RNs, and 4 LPNs validated the staff was knowledgeable of what was presented in the training and how to apply that information. * Facility observed a minimum of 10 CNAs for proper transferring method April 22-24, 2011. Review of the transfer audits revealed 10 CNAs were observed performing different transfer methods (one-person, two-person, and mechanical lift) on April 22, 23, and 24th. Validation was also conducted through observation by the surveyors. * The Vice President of Operations educated the Administrative staff and fall committee on 04/25/11 on investigation of falls, review of incident reports, and appropriate interventions. Validation with the unit managers on 04/26/11 verified the training. * The facility developed a communication tool for a change in resident's transfer status. In addition, a master list of all residents requiring two-person assist or mechanical lift was created. Validation through review of these tools was conducted on 04/25/11. Immediate Jeopardy was verified removed prior to exit on 04/27/11 with remaining non-compliance at 42 CFR 483.20 Assessments, scope and severity at a "E" while the facility's Quality Assurace monitors the effectiveness of transfer observation audits, caretracker reports, and accurrancy of transfer status assessments.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one of twenty-seven (27) sampled residents. The facility failed to conduct a thorough investigation and assessment which resulted in the facility's failure to develop and implement effective interventions to prevent accidents for Resident #23. Resident #23 complained of left knee pain on 03/01/10 after Resident #23's left leg got caught under the wheelchair during staff transport. On 03/12/10, Resident #23 sustained a fracture of the left femur when Resident #23's left leg got caught under the wheelchair while facility staff transported the resident a second time. The findings include: Review of the closed medical record for Resident #23 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 02/09/10 Nursing Admission Assessment revealed the facility assessed Resident #23 as having partial loss of range of motion of the knee, limited to one side. Review of the 2/16/10 Admission Minimum Data Set(MDS) assessment revealed the facility assessed the resident as having no cognitive difficulties, independent with bed mobility, requiring two person extensive physical assistance, one person assistance and supervision needed with ambulation, and no limitation with range of motion. Review of the Resident Assessment Protocol Summary (RAPS) dated 02/16/10 for ADL functional/Rehabilitation potential revealed Resident #23 used a wheelchair for long distance as the resident "tires" easily. Resident #23 was documented as able to assist in activities, but not able to complete tasks alone. On 02/17/10, the facility care planned Resident #23 for ADL Functional/Rehabilitation because the resident needed extensive assistance with bed mobility and transfers. Review of the 03/02/10 Physical Therapy Notes revealed the "patient reports that the left foot got caught under the chair yesterday as it was being pushed and the left knee flexed beyond ninety degrees. Nursing reports patient has been cleared to continue physical therapy today. Patients left lower extremity exhibits pitiable edema from foot to six inches above the knee. An interview with Physical Therapy Assistant (PTA), on 09/23/10 at 10:38am, revealed she documented the note on 03/02/10 that Resident #23 got the foot caught under the wheelchair the previous day. The PTA stated the resident told her that a male "aide" had pushed her the night before in the wheelchair and the resident got his/her left leg caught. On 03/02/10 Resident #23 complained of pain when the PTA got the resident up to ambulate. The PTA stated she retrieved the nurse that was providing care for the resident, the nurse assessed the resident and cleared the resident for Therapy. Interview with Registered Nurse #1 on 09/23/10 at 1:20pm revealed she was the nurse working on the 3-11 shift on 03/01/10 when Resident #23 had the first incident. She stated she didn't get any report of a possible injury to Resident #23. She stated Resident # 23 had complained of pain and swelling of the left knee on the evening of 03/01/10 and that she assessed the leg for injury but didn't think anything was wrong. She stated she did not call the Physician because she didn't know of any incident/injury, and didn't think there was an injury. An interview with the Rehab Manager, on 09/22/10 at 9:15am, revealed she did recall a previous incident in which Resident #23 was in a wheelchair being pushed by staff, and the left leg dropped down, but she did not recall that it caused an injury. Interviews with Licensed Practical Nurse #5 (assigned to Resident #23 on 03/01/10), on 09/24/10 at 10:30am, with LPN #4, on 09/24/10 at 10:00am, and with the Director of Nursing (DON), on 09/24/10 at 11:30am, revealed they had no knowledge of the 03/01/10 incident where Resident #23 got his/her foot caught under the wheelchair. Furthermore, there was no evidence that the facility investigated to identify the causal factors of the resident's complaint of pain to the knee or the swelling which was noted by RN#1 on 03/01/10. Additionally, there is no evidence that the facility developed or implemented care plan interventions to prevent the recurrence of the resident's foot getting caught under the wheelchair. Review of the nurses notes, dated 03/12/10 at 12:45pm, revealed Resident #23 was being wheeled up the hallway by the Therapy Tech #2. The left leg drug under the wheelchair and the resident and the Therapy Tech heard a pop sound from the left knee. Facility staff placed Resident #23 in bed and applied ice to the knee. Resident #23 was sent to the hospital for an x-ray of the left knee. The x-ray confirmed the fracture of the left femur. Interview with Therapy Tech #2, on 09/23/10 at 9:53am, revealed she was the Tech that was transporting Resident #23 on 03/12/10 when the resident sustained [REDACTED]. The Tech stated that the resident propelled him/herself, but became tired so the Tech pushed the wheel chair for the resident. The Tech stated the resident's foot dropped, and that's when she heard the pop. The Tech stated she was not aware Resident #23 had a previous left knee replacement or that the resident had a previous similar incident where the left leg dropped and got caught under the wheelchair. Interview with Certified Nursing Assistant (CNA) #4, on 09/22/10 at 12:00pm, revealed she took care of Resident #23 regularly. The CNA stated that Therapy did take the resident in a wheelchair without foot rests. CNA #4 stated that it depended on how the resident felt for the day if the resident could hold his/her feet up. She stated that just before the resident had the fracture, the resident had a decline. CNA #4 stated that she would have put foot rests on the wheelchair for Resident #23 if she was transporting the resident because Resident #23 was short of air and would get tired very easily. An interview with Physical Therapy Assistant (PTA) on 09/23/10 at 10:38am revealed if she was pushing Resident #23 in the wheelchair, she would have put leg rests on the chair. She stated that would have been her standard of practice. An interview with the Rehab Manager, on 09/22/10 at 9:15am, revealed it was a standard of practice that if a resident has underlying conditions, staff should put leg rests on the resident's wheelchair. The Rehab Manager stated that looking back now, Resident #23 should have had leg rests on the wheelchair during transport. Further interview with the Director of Nursing (DON) revealed while not knowing of the previous report of an injury that occurred on 03/01/10 prior to the fracture that occurred on 03/12/10 she stated that facility staff should have conducted a more thorough assessment of Resident #23. While the facility implemented a policy dated 03/17/10 that any resident that is transported via wheelchair by therapy staff must have appropriate leg rests on the wheelchair; the facility could provide no evidence that interventions had been developed and implemented prior to the incident on 03/12/10 when Resident #23 sustained a fractured left femur after staff transported the resident a second time without leg rests.

Based on observation, interview and record review, it was determined the facility failed to develop a comprehensive care plan or revise a comprehensive care plan for three (3) of twenty-seven (27) sampled residents. The facility failed to develop and implement effective interventions to prevent accidents for Resident #23 when he/she complained of left knee pain on 03/01/10 after his/her left leg got caught under the wheelchair during staff transport. On 03/12/10, Resident #23 sustained a [MEDICAL CONDITION] femur when his/her left leg got caught under the wheelchair while facility staff transported the resident. The facility failed to update the skin problems care plan for Resident #13. The facility failed to develop a vision and cognition care plan for Resident #10. The findings include: Review of the facility policy for Care Plan Process, dated 04/10/2008, revealed the Care Plan uses the assessment to develop, review, and revise the resident's comprehensive plan of care and the care plan is reviewed and revised as the resident's status changes. 1. Review of the closed medical record for Resident #23 revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the 02/16/10 Admission Minimum Data Set (MDS) assessment for Resident #23 revealed the facility assessed the resident as independent with cognition, requiring two person extensive physical assist with bed mobility, requiring supervision and one person assist with ambulation and no limitation with range of motion. Review of the Resident Assessment Protocol Summary (RAPS) dated 02/16/10 for ADL functional/Rehabilitation potential revealed Resident #23 used a wheelchair for long distance as the resident "tires" easily. Review of the Falls summary revealed the facility documented that they would not care plan falls because the resident had not fallen at home, or since the resident arrived. It further detailed that Resident #23 was alert, oriented and able to make his/her needs known. Resident #23 was care planned for ADL Functional, Rehabilitation because he/she needed extensive assistance with bed mobility and transfers. The RAP summary indicated Resident #23 used a wheelchair for long distance as the resident "tires" easily. The Comprehensive Care Plan initiated on 02/17/10 stated the problem/need "requires assist with all ADL's, ranging from limited to total assist". The goal stated will be neat, clean, and well groomed through the next evaluation. Goal Date: 05/10. Interventions were detailed as: 1) set up supplies for am and pm cares and assist as needed. 2) remind to call for assist with all transfers, 3) transfer with assist of 1, 4) PT (Physical Therapy) and OT (Occupational Therapy) as ordered, 5) allow choices in care, 6) remind to use walker with transfer and ambulation. Review of the 03/02/10 Physical Therapy Notes revealed the "patient reports that the left foot got caught under the chair yesterday as it was being pushed and the left knee flexed beyond ninety degrees. Nursing reports patient has been cleared to continue physical therapy today. Patients left lower extremity exhibits pitiable [MEDICAL CONDITION] from foot to six inches above the knee. An interview with Physical Therapy Assistant (PTA), on 09/23/10 at 10:38am, revealed she documented the note on 03/02/10 that Resident #23 got the foot caught under the wheelchair the previous day. The PTA stated the resident told her that a male "aide" had pushed her the night before in the wheelchair and the resident got his/her left leg caught. On 03/02/10 Resident #23 complained of pain when the PTA got the resident up to ambulate. The PTA stated she retrieved the nurse that was providing care for the resident, the nurse assessed the resident and cleared the resident for Therapy. Interview with Registered Nurse #1 on 09/23/10 at 1:20pm revealed she was the nurse working on the 3-11 shift on 03/01/10 when Resident #23 had the first incident. She stated she didn't get any report of a possible injury to Resident #23. She stated Resident #23 had complained of pain and swelling of the left knee on the evening of 03/01/10 and that she assessed the leg for injury but didn't think anything was wrong. She stated she did not call the Physician because she didn't know of any incident/injury, and didn't think there was an injury. An interview with the Rehab Manager, on 09/22/10 at 9:15am, revealed she did recall a previous incident in which Resident #23 was in a wheelchair being pushed by staff, and the left leg dropped down, but she did not recall that it caused an injury. Interviews with Licensed Practical Nurse #5 (assigned to Resident #23 on 03/01/10), on 09/24/10 at 10:30am, with LPN #4, on 09/24/10 at 10:00am, and with the Director of Nursing (DON), on 09/24/10 at 11:30am, revealed they had no knowledge of the 03/01/10 incident where Resident #23 got his/her foot caught under the wheelchair. Furthermore, there was no evidence that the facility investigated to identify the causal factors of the resident's complaint of pain to the knee or the swelling which was noted by RN#1 on 03/01/10. Additionally, there is no evidence that the facility developed or implemented care plan interventions to prevent the recurrence of the resident's foot getting caught under the wheelchair. Further review of the Comprehensive Care Plan revealed the facility revised the care plan on 03/05/10 to include the following intervention: Bed alarm to bed to alert staff; however, there was no evidence that the facility revised the care plan to reflect an intervention to address the resident getting his/her leg caught under the wheelchair while being transported by staff. Review of the nurses notes, dated 03/12/10 at 12:45pm, revealed Resident #23 was being wheeled up the hallway by the Therapy Tech #2. The resident's left leg drug under the wheelchair. Both the resident and the Therapy Tech heard a pop sound from the left knee. Facility staff placed Resident #23 in bed and applied ice to the knee. Resident #23 was sent to the hospital for an x-ray of the left knee. The x-ray confirmed the [MEDICAL CONDITION] femur. Further review of the Comprehensive Care Plan revealed on 03/13/10 the facility revised the care plan with the following interventions: transfer with sheet lift with 4 or 5 assist; PT and OT were then put on hold. However, further review revealed no evidence the facility developed interventions to address the resident getting his/her leg caught under the wheelchair while being transported by staff. An interview with the Director of Nursing (DON), on 09/24/10 at 11:30am, revealed the Comprehensive Care Plans are initiated by the staff who complete the Minimum Data Set (MDS) assessment, but the nurses on the units are to add any updates to the care plans as the resident's status changed. The DON stated she did not know of a previous report of injury that occurred prior to the fracture sustained by Resident #23. 2. Review of Resident #13's care plan revealed "skin problem" with goal dates of 08/08/10 and 08/13/10 for wound improvement and resolution. An intervention for [MEDICATION NAME] soak for 14 days was dated 08/25/10. No further intervention or updates were available for review on 09/22/10. On 09/23/10 at 9:40am, observation of Resident #13's left heel wound care and assessment, performed by LPN #2, revealed an open wound described as pink tissue and having no drainage. [MEDICATION NAME] soak treatment was provided to the area. Interview with LPN #3 and the Director of Nursing (DON), on 09/24/10 at 11:00am, revealed on 09/22/10 the DON was consulted regarding the heel wound of Resident #13. The DON stated she removed a small piece of dried skin covering the wound and determined the wound was not healed. LPN #3 stated she contacted the physician's office and obtained an order to continue the [MEDICATION NAME] soaks, but did not complete a wound assessment or update the care plan. Review of the skin problem care plan confirmed that the care plan had not been revised to include the wound status or the physician's order for treatment. Further interview with the DON revealed the wound assessment and care plan revision should have been completed, and documented. 3. Medical record review revealed Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], Stress Incontinence, Constipation, Abnormal Gait, and a surgical knee replacement. Review of the Admission MDS assessment dated [DATE] revealed vision and cognitive needs were triggered on the RAP's. Review of the comprehensive care plan dated 05/25/10 revealed no evidence that the facility had developed a care plan to address the residents vision and cognitive deficits. Interview with the Director of Social Services, on 09/23/10 at 1:30pm, revealed when the care plan was reviewed, there were no measurable objectives for vision or cognitive needs included in Resident #10's comprehensive care plan.