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

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of six residents sampled for pain out of the total sample of 22, (Resident (R)20, R30, R59). 1. The facility failed to ensure R20 received prescribed scheduled doses of Hydrocodone 10 milligrams (mg)/Acetaminophen 325 mg (a narcotic pain medication used to treat moderate pain) every four hours as ordered, for 28 consecutive hours starting on 09/15/2024 at 6:00 AM through 09/16/2024 at 2:00 PM, with documentation noting the medication was not available. 2. The facility failed to ensure R30 received prescribed scheduled doses of Tramadol 25 mg (an opioid medication used to treat moderate to severe pain) three times a day on 08/14/2024 at 9:31 PM and 08/15/2024 at 4:51 PM. with the documentation noting the medication was unavailable, waiting on pharmacy. Also, the facility failed to ensure R30 received the Tramadol on 08/16/2024 at 12:09 PM and at 2:41 PM due to the medication again documented as not being available. 3. The facility failed to ensure R59 received prescribed scheduled doses of Tramadol 25 mg on 08/07/2024 at 9:53 PM and 09/27/2024 at 8:44 AM, with documentation noting the medication was not available and waiting for pharmacy. The findings include: Review of the facility policy titled, Pain Management, revised on 02/08/2024 revealed the facility must ensure pain management was provided to residents who required such services. Further review revealed the facility must ensure pain management was provided for residents: consistent with professional standards of practice; the comprehensive person-centered care plan; and the resident's goals and preferences. Review of the policy titled, Medication Ordering and Receiving from Pharmacy Provider - Ordering and Receiving Controlled Medications dated 01/2023, revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, were subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations. Per review of the policy section 5 revealed it outlined refill requests for scheduled drugs in the classification of CIII-CV or a partial fill quantity (CII's) drugs. Continued review of the policy revealed a refill request was to be requested from the pharmacy a minimum of three days in advance of need to assure an adequate supply was on hand. Review revealed if only one refill remained or only a partial fill quantity remained, the pharmacy was to simultaneously dispense the remaining fill, and, if necessary, proactively seek out a new, complete prescription from the provider for future use. Further review of the policy revealed the facility might be asked to contact the prescriber for a new prescription upon request for a medication with no remaining fills available. Review of the facility policy titled, Medication Ordering and Receiving from Pharmacy Provider - Emergency Pharmacy Service and Emergency Kits (E-Kits) dated 01/2023, revealed emergency pharmaceutical service was available on a 24-hour basis. Per policy review, emergency needs for medication were met by using the nursing care center's approved emergency medication supply or by special order from the provider pharmacy. Continued review revealed emergency medications were provided by the pharmacy in compliance with applicable state and federal regulations. Further policy review revealed the procedure for obtaining medications from the emergency kits. Observation of the C hall medication cart on 10/04/2024 at 4:17 PM, revealed the presence of an E-kit on the medication cart locked in the narcotic drawer which included Hydrocodone 10 mg/Acetaminophen 325 mg tablets. 1. Review of the medical record for R20 revealed the facility admitted the resident on 03/08/2023, with diagnoses to include osteomyelitis of vertebra, quadriplegia, chronic pain syndrome, and pressure ulcer of the sacral region, stage IV. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R20 to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. Continued review of the MDS, section J, revealed the facility assessed R20 to receive routine pain medication and not to require as needed (PRN) medication, with the resident denying pain at that the time of assessment. Review of the Medication Administration Record (MAR) dated 09/2024, revealed R20 had orders for Hydrocodone 10 mg/Acetaminophen 325 mg one tablet by mouth every four (4) hours routinely and no PRN medication for pain. Review of the MAR Information Key legend revealed parentheses around a person's name administering medications indicated a medication was not administered or not charted, see Reasons/Comments. Continued review of R20's 09/2024 MAR revealed starting on 09/15/2024 at 6:00 AM through 09/16/2024 at 2:00 PM, there was no documented evidence the resident's prescribed scheduled doses of Hydrocodone 10 mg/Acetaminophen 325 mg pain were administered every four hours as ordered, for a total of 28 consecutive hours. Further review of the MAR, of the section for noting reasons/comments, revealed the medication (Hydrocodone 10 mg/Acetaminophen 325 mg, was not administered and had not been available for administration. In an interview with R20 on 10/01/2024 at 3:50 PM, the resident stated he had a splint that was worn on the left upper extremity that helped with pain. He stated he had pain in his butt that was constant and he took pain medication for it. The resident stated he had not talked to anyone about pain management and the pain was worse at night. In a follow up interview with R20 on 10/04/2024 at 9:06 AM, the resident rated his pain at an eight out of 10, on a scale of one to 10, with 10 being the worst pain. R20 further stated he talked with staff about his pain. 2. Review of the medical record for R30 revealed the facility admitted the resident on 12/16/2021, with diagnoses to include Type 2 Diabetes Mellitus with diabetic neuropathy (associated nerve pain), and pain, unspecified. Review of the Quarterly MDS assessment dated [DATE] for R30, revealed the facility assessed the resident to have a BIMS score of nine out of 15, indicating moderate cognitive impairment. Continued review of the MDS, section J, revealed the facility assessed R30 to have received routine pain medication and did not require a PRN pain medication and the resident denied pain at the time of assessment. Review of the active Physician's order printed 10/02/2024 revealed an order dated 07/15/2024, for Tramadol 25 mg revealed R30 was prescribed Tramadol 25 mg to be administered by mouth three times per day with a start date of 07/15/2024. Further review of the Physician's orders printed on 10/02/2024, revealed R30 did not have additional PRN medication ordered for pain management. Review of R30's MAR dated 08/2024, revealed the Physician's order for Tramadol 25 mg. Review of the 08/2024, MAR revealed there was no documented evidence R30's Tramadol 25 mg scheduled doses were administered as ordered on 08/14/2024 at 9:31 PM; or 08/15/2024 at 4:51 PM. Continued MAR review revealed it was noted R30's Tramadol had an asterisk, which per the MAR Information Key legend was other. Per MAR review of the reasons/comments, for the asterisk, documentation revealed it was noted on 08/14/2024 at 4:51 PM, Not Administered: Drug/Item Unavailable and on 08/14/2024 at 9:31 PM, Not Administered: Drug/Item Unavailable Comment: waiting on pharmacy. MAR review revealed no documented evidence R30's Tramadol pain medication was administered: on 08/16/2024 at 12:09 PM and 2:41 PM as there were parentheses around staff's initials indicating the medication was not administered. Per continued review of the 08/16/2024 MAR documentation, under reasons/comments it was noted, Not Administered: Drug/Item Unavailable. Review of the 09/2024 MAR for R30 revealed on 09/17/2024, 12:00 PM to 3:00 PM timeframe, parentheses were around the staff's initials, and in the reasons/comments it was noted as, Not Administered: Drug/Item Unavailable. Review of the 09/18/2024 MAR, revealed for the timeframe of 12:00 AM to 9:00 PM, R30's Tramadol dose had parentheses and an asterisk with the corresponding note documented at 12:51 PM that stated Not Administered: Drug/Item Unavailable. Comment: spoke with pharmacy medication being sent STAT. Further review of the 09/18/2024 MAR documentation revealed a corresponding administration note time stamped at 9:27 PM, that stated, Not Administered: Other Comment: waiting on pharmacy. In an interview with R30 on 10/01/2024 at 10:23 AM, the resident stated he received pain medication; however, continued to have some pain related to his diabetes. 3. Review of the medical record for R59 revealed the facility admitted the resident on 07/09/2021, with diagnoses to include pain, unspecified; cerebral infarction; and cognitive communication deficit. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R59 to have a BIMS score of three out of 15, indicating the resident had severe cognitive impairment. Continued review of the MDS, section J, revealed the facility assessed R59 to have received routine pain medication and did not require a PRN pain medication and a pain assessment conducted revealed the resident had no pain at the time of assessment. Review of the current Physician's orders for R59 revealed an order for Tramadol 25 mg twice a day. Review of R59's MAR, for the month of 08/2024, revealed no documented evidence R59's Tramadol pain medication was administered as ordered on 08/07/2024 at 9:53 PM. Review of R59's MAR for 09/2024, revealed on 09/27/2024 at 8:44 AM, no documented evidence the resident's Tramadol 25 mg was administered as ordered, due to not being available. Further review of the 09/2024 MAR revealed documentation noting (the facility was) waiting for pharmacy documented in the reasons/comments area for 09/27/2024. Observation of the resident on 10/02/2024 at 9:25 AM, revealed R59 sitting up in a wheelchair with no visual signs of pain displayed, such as grimacing. In an interview with R59's Power of Attorney (POA) on 10/02/2024 at 1:43 PM, the POA stated she had no complaints with the care or treatment of the resident at the facility. In an interview on 10/04/2024 at 4:17 PM, with Licensed Practical Nurse (LPN) 7, she stated she was responsible for administering residents' medications for the residents she was assigned to. She stated she hits the resupply button to let the pharmacy know and Physician know if a resident's medication was needed. LPN 7 stated she knew how important it was for residents to receive their pain medication to manage their pain. She said if a medication was not available on the medication cart and was due to be administered, she notified the charge nurse to assist with getting the medication. LPN 7 stated she was aware of the Emergency Drug Kit (EDK) and that some narcotics were available. She stated she was also aware of the process for how to remove medication from the EDK. The LPN further stated if the medication was not available in the EDK, she contacted the Physician for a substitute and possibly administer another analgesic that was ordered. In an interview on 10/04/2024 4:01 PM, with Unit Manager (UM) 2, she stated the nurses assigned to the medication cart managed the stock of medication and should notice if the level was low and notify the UM or Advanced Practice Registered Nurse (APRN) per the binder if a prescription was needed. She stated if the medication was needed, staff could call the (medical) provider and ask for the prescription and get the medication statted over from the pharmacy. UM 2 stated the pharmacy had a four (4) hour window to deliver the requested statted medication. She said if a medication was on order and it was going to be more than four hours from the usual medication delivery time and a dose was due, staff could call the (medical) provider and get a one-time dose order. The UM stated staff could then get the medication from the EDK. Per UM 2 in interview, she expected staff to take the steps to get the medication as ordered and thought staff knew the process for obtaining medication and prescriptions. She stated the facility did not document pain levels except on PRN medication and progress note charting was done only by exception (notes charted only for deviations in a resident's norm or baseline). UM 2 further stated she expected a nurse to assess a resident for pain and address pain as indicated. In an interview with the Staff Development Coordinator (SDC) on 10/04/2024 at 11:21 AM, the SDC stated staff were educated regarding the use of the EDK to obtain medications and on pain management. In an interview with the Assistant Director of Nursing (ADON) on 10/04/2024 at 3:55 PM, she stated the nurse on the hall was responsible for monitoring medication levels and if needed, checking for refills and calling the pharmacy or Physician as indicated. The ADON stated the delivery of medications depended on when the order was placed and she said the facility had an EDK, but she would have to find out what medications were stored and available in the EDK. She further stated she expected nurses to take the steps needed to obtain residents' medications and staff had been educated regarding obtaining medications from the EDK. In an interview with the Director of Nursing (DON) on 10/04/2024 at 3:59 PM, he stated it was his expectation that routine medications were administered as ordered. He stated he expected the nurse assigned to administer medications to call the Physician if a prescription was needed and then call the pharmacy. The DON stated his expectation was for staff to use the reorder process which included faxing the pharmacy requesting a refill. He said if a medication was needed, it might be available in the EDK and he expected nurses to check the EDK for the medication. The DON stated he was not aware of any audits having been done regarding narcotic drug levels for refills. He further stated if staff had a problem or did not know how to utilize the EDK, a nurse was always on call after hours. The DON additionally stated other nurses including the UM's, ADON, and DON were in the facility to assist. In an interview with the Administrator on 10/04/2024 04:40 PM, she stated the nurse and medication technician (med tech) were responsible for monitoring medication stock levels. She stated she expected staff to take the steps needed to get any medication required, including obtaining the medication from the EDK. The Administrator also stated if the needed medication was a pain medication, she expected staff to assess the resident's pain level and notify the Physician. She said the facility had on-call nurses and staff had access to those nurses' phone numbers if there were any questions or concerns. The Administrator stated she was not aware of any problems with the pharmacy sending medications, but said, at times a prior authorization might be needed before the pharmacy would send the medication(s). She further stated the DON or a designee would complete the necessary prior authorizations.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the Power of Attorney (POA) for one (1) of six (6) sampled residents, Resident #1, with laboratory reports, and a need to alter treatment. The findings include: Review of the facility policy and procedure titled, Change of Condition, and dated 11/06/19, revealed Guideline: 7. Notify the resident's representative, consistent with his or her authority, of change and follow through completed by the facility, and document in the Electronic Medical Record (EMR). Review of the Quarterly Minimum Data Set (MDS), dated and signed on 06/25/2020, revealed the facility readmitted Resident #1 on 03/11/2020 with the following Diagnoses: [REDACTED]. Continued review revealed other [DIAGNOSES REDACTED]. Further review of the MDS revealed the facility assessed Resident #1 with a Brief Interview for Mental Status exam score of fourteen (14), and determined the resident was interviewable. Observation of Resident #1, on 07/27/2020 at 1:15 PM, revealed the resident in the process of transferring self from the wheelchair into the bed. The resident appeared alert, and was dressed appropriately for the season. Telephonic interview with Resident #1 on 07/28/2020 at 9:00 AM revealed he/she expected the facility to notify his/her POA anytime changes were made in his/her delivery of care. Telephonic interview with Resident #1's POA, on 07/27/2020 at 10:20 AM, revealed on 07/14/2020 Resident #1 made her aware of recent blood work, and new medications. She stated the facility did not notify her of the medication changes, or the need for lab work. Review of the Medication Administration History, dated 07/01/2020 through 07/27/2020, revealed a provider order for [MEDICATION NAME], forty (40) milligrams (MG) daily for two (2) days, start 07/14/2020, and end 07/15/2020. Review of the progress notes, dated 07/13/2020 at 9:40 AM, and signed by the Assistant Director of Nurses (ADON) #1, revealed labs reviewed from 07/10/2020, new order for [MEDICATION NAME] forty 40 MG for two (2) days, and repeat labs on 07/13/2020. Resident is aware. Telephonic interview with ADON #1, on 07/31/2020 at 1:22 PM, revealed she did not contact Resident #1's POA regarding the new order for [MEDICATION NAME], or the new order for labs. She stated the resident was pretty alert and the resident said he/she would tell the POA. The ADON revealed that normally staff notified the POA of new orders. Review of the Care Plan Conference Summary, dated 01/07/2020 and signed by Resident #1, and the POA as well as Social Services, the Director of Nursing, the Advanced Registered Nurse Practitioner #1, Unit Manager #1, and the Ombudsman, revealed the POA requested to be first and only point of contact. The summary continued the facility explained person centered care but facility would communicate changes with the POA, and Resident #1 at the same time and Responsible Party (RP) and resident in agreement. Telephonic interview with the Director of Nursing 07/28/2020 at 11:40 AM revealed staff should notify Resident #1's POA with any changes in the resident's treatment plan. Telephonic interview with the Administrator, on 07/31/2020 at 12:28 PM, revealed during the previous Care Plan Conference in January 2020, both the resident and the POA concurred the facility would notify both with any changes in the resident's care. She stated her expectation was Resident #1 was to be notified first of changes, and ask the resident if it was okay to also notify the POA. She stated the facility had not done audits related to notification of changes.

Based on interview, record review, and policy review, it was determined the facility failed to implement the individualized plan of care for two (2) of five sampled residents, (Resident #1, and Resident #3) related to medication administration. The findings include: Review of the policy titled, Comprehensive Care Plans, revised on 07/19/2020, revealed the care plan included how the facility assisted the resident to meet their needs, goals, and preference. The resident had the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made .in the case of a resident refusal or declination of care or treatment poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or treatment being declined, the risk the declination poses to the resident, and the efforts made by the Interdisciplinary Team to educate the resident and representative as appropriate. The attempts to find alternative means to address the identified need/risk shall be documented in the care plan. 1. Review of the Quarterly Minimum Data Set (MDS), dated and signed on 06/25/2020, revealed the facility readmitted Resident #1 on 03/11/2020 with the following Diagnoses: [REDACTED]. Other [DIAGNOSES REDACTED]. Continued review of the MDS revealed the facility assessed the resident with a Brief Interview for Mental Status exam score of fourteen (14), and determined the resident was interviewable. Observation of Resident #1, on 07/27/2020 at 1:15 PM, revealed the resident in the process of transferring self from the wheelchair into the bed. The resident appeared alert, and dressed appropriately for the season. Record review of Resident #1's Medication Administration Record [REDACTED]. Staff did not document administration of the medication to Resident #1 on 07/04/2020, 07/05/2020, 07/08/2020, 07/14/2020, and 07/21/2020. Review of the Reasons/Comment documentation stated, Not Administered/Item Unavailable. Review of Resident #1's MAR indicated [REDACTED]. There was no documentation staff administered Resident #1 the medication on July 8th, and July 14th. Review of the document titled House Stock Drug Kit revealed the medication was available to staff, however, it was not administered per providers order. Review of Resident #1's care plan revealed, dated 06/13/2019, the problem, Resident has potential for cardiovascular complications related to [DIAGNOSES REDACTED]. The goal, with target date 10/18/2020, was Resident will remain free of complications related to multiple cardiac [DIAGNOSES REDACTED]. 2. The facility admitted Resident #3 on 10/29/2019. Current [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the MDS, signed and dated on 05/11/2020, revealed the facility assessed Resident #3 with BIMS exam score of 00, and determined the resident was not interviewable. Record review of Resident #3's MAR, dated 07/01/2020 revealed an order for [REDACTED]. The reasons/comments for each missed administration of the medication stated Not Administered: Drug/Item Unavailable. Review of the care plan, dated 11/04/2019, revealed the problem the Resident has a memory/recall problem related to BIMS assessment and [DIAGNOSES REDACTED]. The Long Term Goal was the Resident will not sustain serious injury due to memory/recall deficit, and the approach, dated 07/14/2020, was administer antianxiety medication as ordered. Continued review of Resident #3's MAR indicated [REDACTED]. There was no documentation the medication was administered to the resident on 07/21/2020, 07/22/2020, or 07/23/2020. The reason/comments revealed the Drug/Item was Unavailable. Review of Resident #3's care plan, dated 10/30/2019, revealed the problem the Resident has a [DIAGNOSES REDACTED]. The approach, dated 10/30/2019, was medications as ordered. Telephonic interview with Unit Manager (UM) #1, on 07/29/2020 at 9:27 AM, revealed an individualized care plan was developed for each resident so staff could deliver the appropriate care. Telephonic interview with Registered Nurse (RN)#2, on 07/31/2020 at 10:15 AM, revealed the purpose of the care plan was to guide staff on how to care for each individual resident. She stated the care plan should be followed by staff to avoid a negative outcome to a resident. Telephonic interview with the Director of Nursing (DON), on 07/29/2020 at 2:21 PM, revealed the care plan was an outline of care provided based on a resident's needs, and staff should follow the care plan. Telephonic interview with the Administrator, on 07/31/2020 at 12:28 PM, revealed the plan of care was developed based on resident choices, and needs. She stated she expected staff to review, and follow the care plan in order to provide the best care possible to each resident.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure three (3) of five (5) sampled residents (Resident #1, #2, #3), received treatment and care in accordance with provider orders. Record review and inteview revealed staff failed to follow physician orders. The findings include: Review of the policy titled, Medication Administration General Guidelines, dated 09/2018 revealed medications were administered as prescribed in accordance with manufacturers' specifications, and good nursing practices. Review of the section Medication Administration revealed medications were administered in accordance with written orders of the prescriber; and, if two (2) consecutive doses of a vital medication were withheld or refused, the physician was notified. 1. Review of the Quarterly Minimum Data Set (MDS), dated and signed on 06/25/2020, revealed the facility readmitted Resident #1 on 03/11/2020 with the following Diagnoses: [REDACTED]. Other [DIAGNOSES REDACTED]. Continued review of the MDS revealed the facility assessed the resident with a Brief Interview for Mental Status exam score of fourteen (14) and determined the resident was interviewable. Observation of Resident #1, on 07/27/2020 at 1:15 PM, revealed the resident in the process of transferring self from the wheelchair into the bed. The resident appeared alert, and was dressed appropriately for the season. Record review of Resident #1's Medication Administration Record [REDACTED]. Resident #1 did not receive the medication on 07/04/2020, 07/05/2020, 07/08/2020, 07/14/2020, and 07/21/2020. Review of the Reasons/Comment documentation stated, Not Administered/Item Unavailable. Diagnosis- Essential Primary Hypertension. Continued review of Resident #1's MAR indicated [REDACTED]. Further review revealed staff did not administer the medication to Resident #1 on July 8th, and July 14th. Review of the document titled House Stock Drug Kit revealed the medication was available to staff, however, it was not administered per providers order. Review of Resident #1's care plan dated 06/13/19 revealed Problem the resident has potential for cardiovascular complications related to [DIAGNOSES REDACTED]. Resident will remain free of complications related to multiple cardiac [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]. Start 07/20/2020 and end 07/22/2020. Continued review revealed no administration of the medication on 07/20/2020, nor the morning dosage on 07/21/2020. The resident only received three (3) of the six (6) ordered dosages. Documentation on the MAR indicated [REDACTED]. Review of the House Stock Drug Kit revealed the medication as available to staff, however, it was not administered per order. 2. The facility admitted Resident #2 on 02/19/2020 with the following Diagnoses: [REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Quarterly MDS revealed the facility assessed the resident with a BIMS of ten (10) and determined the resident was moderately cognitively impaired. Record review of the MAR indicated [REDACTED]. Continued review of the House Stock Drug Kit document revealed Aspirin eighty-one (81) MG was available for staff to access however, the medication was not administered. Continued review of the MAR for Resident #2 revealed an order for [REDACTED]. Further review of the MAR indicated [REDACTED]. Continued review of Resident #2's MAR indicated [REDACTED]. Further review revealed the medication was not administered on 07/07/2020 (evening dose), 07/09/2020, 07/10/2020 (evening dose), 07/12/2020 (morning dose), 07/14/2020 (evening dose), 07/17/2020, 07/20/2020 (morning dose), 07/23/2020 (evening dose), 07/24/2020 (evening dose), 07/25/2020 (evening dose), and 07/28/2020 (morning dose) due to,Drug/Item Unavailable. Review of the document House Stock Drug Kit revealed [MEDICATION NAME] sodium 100 MG was available to staff to administer, however, the resident did not receive the medication as prescribed by the provider. 3. The facility admitted Resident #3 on 10/29/2019 and [DIAGNOSES REDACTED]. Review of the MDS, signed and dated on 05/11/2020, revealed the facility assessed Resident #3 with a BIMS exam score of 00, and determined the resident was not interviewable. Record review of Resident #3's MAR, dated 07/01/2020 revealed an order fir [MEDICATION NAME] zero point five (0.5) MG twice a day. Continued review revealed the resident did not receive the medication per provider order on 07/19/2020 (morning dose), 07/20/2020, 07/21/2020 (morning dose), 07/22/2020, 07/23/2020, 07/25/2020, 07/26/2020, 07/27/2020, 07/28/2020, and 07/29/2020 (morning dose). The reasons/comments for each missed administration of the medication stated Not Administered: Drug/Item Unavailable. Review of the care plan, dated 11/04/2019, revealed the problem the Resident has a memory/recall problem related to BIMS assessment and [DIAGNOSES REDACTED]. Long Term Goal- Resident will not sustain serious injury due to memory/recall deficit. Approach, dated 07/14/2020, administer antianxiety medication as ordered. Continued review of the MAR indicated [REDACTED]. Continued review revealed the medication was refused by the resident on 07/09/2020 (refused both doses). Review of Resident #3's MAR indicated [REDACTED]. The resident refused both doses of the medication on 07/09/2020. Continued review of the MAR indicated [REDACTED]. Resident #3 refused both the morning and evening dose on 07/09/2020. Review of the MAR indicated [REDACTED]. Resident #3 refused the medication on 07/09/2020 for a total of two (2) missed doses. Continued review of Resident #3's MAR indicated [REDACTED]. The medication was not administered to the resident on 07/21/2020, 07/22/2020, or 07/23/2020. The reason/comments revealed the Drug/Item was Unavailable. Review of Resident #3's care plan, dated 10/30/2019, stated, Problem- Resident has a [DIAGNOSES REDACTED]. Approach, dated 10/30/2019, was medications as ordered. Telephonic interview with Registered Nurse #1 on 07/29/2020 at 8:37 AM revealed any time staff did not administer a medication to a resident as ordered by the provider, the staff should notify the Advanced Registered Nurse Practitioner (ARNP). Staff should inform the ARNP either the resident refused the medication, the medication was not available in the facility to administer, or a prescription was needed to obtain the medication. He revealed any interventions put into place to obtain medications, as well as notification of the ARNP should be documented in the clinical record. He stated the facility did have an emergency cart from which staff could pull medications and that he has pulled medications from the cart before. Telephonic interview with Certified Medication Technician (CMT) #1, on 07/29/2020 at 9:22 AM revealed anytime a resident refused a medication, or a medication was not available, she notified the resident's nurse. She revealed she was not aware of a House Stock Drug Kit, or what medications were available in the kit. Telephonic interview with Unit Manager (UM) #1, on 07/28/2020 at 9:27 AM, revealed she was unaware [MEDICATION NAME] (Resident #1) was stored in the House Stock Drug Kit because the drug ordered was [MEDICATION NAME], and the House Stock Drug Kit referred to the medication as [MEDICATION NAME] only. She stated she should have researched the drugs name more, or contacted the physician for a possible alternative treatment. She stated the resident was to receive the medication for a Urinary Tract Infection [MEDICAL CONDITION] and this was an important medication that Resident #1 should have not missed. Telephonic interview with CMT #2, on 07/29/2020 at 11:25 AM, revealed she never looked in the House Stock Drug Kit to replace missing medications because it never crossed her mind. Telephonic interview with Licensed Practical Nurse # 1 on 07/29/2020 at 12:20 PM revealed anytime a resident does not get their medications as ordered, the doctor, or the ARNP should be notified immediately because they may give alternative treatment orders. Telephonic interview with the Pharmacy Consultant, on 07/29/2020 at 12:27 PM, revealed she reviewed resident medications once a month for antibiotic use. She revealed she reviewed resident MARs on 07/23/2020 but did not observe that Resident #1 had not received [MEDICATION NAME] as ordered on [DATE] and 07/21/2020. She stated when medications are not administered as ordered, she will email the Director of Nursing as soon as possible so she could address the issue. Telephonic interview with Registered Nurse #2 on 07/31/2020 at 10:15 AM revealed whenever a medication was not available to administer to a resident, staff should call pharmacy, and ask for a re-supply of the medication. She stated staff could also access the House Stock Drug Kit as well. She revealed if a medication had been completely omitted then the doctor or the ARNP should be notified, and an alternative treatment might be ordered. She continued to state if a prescription was needed, the ARNP would fax it within thirty (30) minutes to both the facility and the pharmacy. She stated staff should chart anything relevant to a missed dosage of medication as well as provider notification in the progress notes. Telephonic interview with the ARNP, on 07/29/2020 at 1:00 PM, revealed her expectation was notification from the staff whenever an ordered medication was going to be administered late, or was not available for administration, and the plan of course for treatment might be changed. She revealed she was not aware of Resident #1, Resident #2, or Resident #3's missed medications. Telephonic interview with the DON, on 07/28/2020 at 11:40 AM, revealed whenever medication administration times had to be altered, or a medication was omitted, the nurse should notify the pharmacy, and call the doctor for a possible replacement order. She stated if the medication was in the Emergency Kit staff should go ahead and pull it for administration. She stated the pharmacy delivered medications to the facility twice a day. The DON stated the nurses should document all notifications made to the pharmacy, and the doctor in the event medication times were altered, or a medication was omitted. She revealed the nurses should follow up on any missing or omitted medications, and chart the findings. She stated the facility ran a medication omission report daily for review in the morning meeting. However, she stated the facility did not compare omitted medications with the availability of the medication in the Emergency Kit (eKit). Telephonic interview with the Administrator, on 07/31/2020 at 12:28 PM, revealed her expectation of staff, as the Administrator, was any missing medications be re-ordered through the electronic system, and a call be made to the Pharmacy. If the medication was available in the eKit, staff should pull and give the medication to the resident. She revealed staff were informed and were aware of the eKit and to utilize the kit, as needed. She stated the Provider should be notified of any missed medications, and her expectation was for staff to document the notification. She revealed omitted and missed medications were reviewed in the Clinical Meeting, however, the facility had not performed audits related to missed medications.

Based on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for one (1) resident, Resident #40, out of the forty-six (46) sampled residents. Resident #40 had a significant weight loss and the comprehensive care plan was not updated to reflect the weight loss. The findings include: Record review of the facility policy titled, Comprehensive Care Plans, revised 07/19/18, revealed a person-centered comprehensive care plan would include objectives and timetables to meet the resident nursing, mental, medical and psychological needs. The policy further revealed each comprehensive care plan would incorporate risk factors associated with identified problems and aid in preventing or declines in the residents status. Record review of the clinical record for Resident #40 revealed the facility admitted the resident on 12/1/15 with [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/19, revealed Resident #40 had a Brief Interview of Mental Status (BIMS) score of eleven (11), which indicated the resident was interviewable. Review of the nutrition assessment revealed Resident #40 was sixty-one (61) inches tall and weighed One hundred and thirty-nine (139) pounds. Resident #40 only needed supervision and set up help with eating. Record review of the weight documentation revealed Resident #40 had a sixteen (16) pound weight loss from 06/16/19 to 07/23/19. Review further revealed, on 08/06/19, Resident #40 weighed 125.1 pounds and on 08/31/19 the resident weighed 123 pounds, which was a two pound weight loss. Record review of Resident #40's comprehensive care plan, dated 06/18/19 and a target date of 10/12/19, revealed a problem was listed for nutritional status being at risk as evidenced by less than seventy-five percent (75%) of food was eaten at meals. Review of the interventions revealed weights were to be done as ordered, diet as ordered, and intakes were to be monitored. Record review of the comprehensive care plan revealed there was no mention of the weight loss and no interventions were added to prevent further weight loss. Interview with the MDS staff, on 08/31/19 at 3:00 PM, revealed there was nothing in Resident #40's comprehensive care plan that addressed the resident's weight loss and it should have been addressed. She revealed she was not aware of any significant weight loss for Resident #40. However, after she reviewed the weights for 06/16/19, which was 139 pounds, with the weight for 07/23/19, which was 123 pounds, she stated that was greater than a 5% weight loss in one month and that was considered significant. The MDS staff further revealed a care plan should have been initiated and the physician, dietician, and the Interdisciplinary team (IDT) should have been notified. The MDS staff revealed if interventions were on the care plan she would expect them to be followed Interview with Dietary Manager on 08/31/19 at 10:30 AM, revealed new interventions could have been put into place on the comprehensive care plan if the significant weight loss had been identified. She revealed some of those interventions were fortified foods, magic cup, house supplements, and whole milk. Interview with Signature Care Nurse Consultant on 08/31/19 at 5:09 PM revealed she was not aware of the weight loss for Resident #40 until today and she did not know why it was not brought to the IDT team to review. She further revealed, on 08/31/19 at 7:03 PM, the care plan should be reviewed quarterly, any change, and on admission. The Signature Care Nurse Consultant further revealed if there was an error identified then the care plan should be revised. She revealed if pertinent information on a resident was missed the care of the resident could be affected.

Based on observation, interview, record and policy review, it was determined the facility failed to identify and address residents with a significant weight loss, for one (1) out of the forty-six (46) sampled residents. Resident #40 had a 14.90% weight loss from 01/28/2019 to 08/06/2019. The findings include: Record review of the undated facility policy titled, Weight Monitoring Program, revealed when weights were obtained the results would be given to the Assistant Director of Nursing (ADON)/Designee on that unit. The Designee would review all the weights and compare them to the previous months' weight and give a list of reweights to the person getting weights for any resident with a five (5) pound gain or loss. The Designee would record all weights in the weight book in their unit each month. The Dietary Manager would calculate each resident's weight and determine who had a significant weight loss or gain. The policy further revealed a significant weight loss/gain would be 5% in one month, 7.5% in three(3) months, and 10% in six (6) months. The Assistant Director of Nursing (ADON)/Nurse or Designee would notify the physician, dietician, and responsible party of any weight change. The ADON, Nurse or Designee would note any new orders or recommendations from the physician and dietician and update the clinical records accordingly. The policy further revealed the ADON/RD/Dietary Manager (DM) would update the care plan accordingly. The resident would be placed on weekly weights for four weeks or until the Registered Dietician (RD) determined the weights were stable. Residents that have significant weight loss would be reviewed during the at risk meetings. Observation, on 08/27/19 at 12:15 PM, revealed Resident #40 was sleeping with lunch tray at bedside. Observation at 12:30 PM revealed the tray was still on the overbed table and the resident was still asleep. Interview on, 08/27/19 at 03:51 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #40 did not eat lunch or breakfast and he/she was diabetic. LPN #2 revealed staff have to wake the resident up to get him/her to eat and then she/he can feed herself/himself. Interview with Resident #40, on 08/28/19 at 1:21 PM, revealed the food was pretty good and he/she said he/she would eat it but sometimes he/she was sleepy and did not want to eat much. Resident #40 stated he/she had lost weight, but had not missed it and did not know the reason for the weight loss. Record review of the clinical record for Resident #40 revealed the facility admitted the resident on 12/01/15 with [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/19 revealed Resident #40 had a Brief Interview of Mental Status (BIMS) of eleven (11) which indicated the resident was interviewable. Review of the nutrition assessment revealed Resident #40 was 61 inches tall and weighed 139 pounds. Resident #40 only needed supervision and set up help with eating. Record review of the annual MDS with an ARD of 05/07/19 revealed Resident #40 had a BIMS of ten (10) which indicated the resident was interviewable. The Resident #40 needed supervision and set up help for eating. Record review of the weight documentation revealed Resident #40 on 08/06/19 weighed 125.1 pounds, on 07/30/19 the weight was 125.1 pounds, on 07/23/19 the weight was 123 pounds, on 06/16/19 the weight was 139 pounds, on 03/18/19 the weight was 137 pounds, on 03/11/19 the weight was 140.5 pounds, on 03/04/19 the weight was 141.5 pounds, on 02/18/19 the weight was 140.5 pounds, on 02/11/19 the weight was 143.5 pounds, and on 01/28/19 the weight was 147 pounds. Review revealed there was a sixteen (16) pound weight loss from 06/16/19 to 07/23/19. Review further revealed on 08/06/19 Resident #40 weighed 125.1 pounds and on 08/31/19 the resident weighed 123 pounds, which was a two pound weight loss. Record review of the progress notes for Resident #40, from 06/07/19 to 08/30/19, revealed there was no documentation of the significant weight loss for the resident. Dietary notes written by the Dietary Manager (DM) revealed on 06/07/19, the Interdisciplinary Team ( IDT) team reviewed the resident and Resident #40 was eating meals in the room and the intakes were fair. Record review of the dietary notes on 07/02/19, revealed the IDT team discontinued the resident from being at risk. Interview with the DM, on 08/31/19 at 10:30 AM, revealed she did not know when the IDT team picked Resident #40 up for review but the resident was discharged from nutritionally at risk list in (MONTH) 2019. The DM stated Resident #40 weighed 123 pounds today and had a 14 pound weight loss from 06/16/19. The DM took responsibility for the oversight and stated the dietician should have been notified of the weight loss and she had not notified her. The DM further stated she did not know why she did not realize the weight loss had occurred. The DM revealed when the Certified Nursing Assistants (CNA) did the weights they were not aware of the previous weight so they would not know there was a weight loss. DM reviewed the weight variance report, which usually flagged a weight loss, however there was no weight variances documented for (MONTH) 2019 or (MONTH) 2019. Review revealed the last documentation on the weight variance report was 06/16/19 and that indicated Resident #40 weighed 139 pounds. The DM stated she could not understand why the report did not include the (MONTH) and (MONTH) weights. The DM revealed the dietician reviewed the variance reports for weight loss. Interview further revealed there were no new interventions put in place when the weight loss occurred and there should have been. Interventions such as fortified foods, magic cup, house supplements and whole milk should have been initiated. Interview on, 08/31/19 at 12:15 PM, with the Unit Manager, after she reviewed Resident #40's physician orders, the physician progress notes [REDACTED]. The Unit Manager further revealed the dietician had not been notified either. She revealed if the physician and dietician had been notified they could have made changes to help her gain weight. She revealed she did not know why they had not been notified of the significant weight loss and she was not aware of the weight loss either. The Unit Manager further revealed she was part of the IDT team and did not recall Resident #40 being addressed for weight loss. The Unit Manager stated when the weights were done they get turned in to the Dietary Manager and she would compile the list of reweights and if truly a weight loss then the dietician followed the resident until the weights were stable. Record review of the west weight list given to the Dietary Manager for the month of (MONTH) 2019 and (MONTH) 2019 revealed Resident #40 weighed 125 pounds and 123 pounds and no reweight was done. Record review of the comprehensive care plan, dated 06/18/19 and a target date of 10/12/19 , for Resident #40, revealed a problem was listed for nutritional status being at risk as evidenced by less than 75% of food was eaten at meals. Review of the interventions revealed weights were to be done as ordered, diet as ordered, and intakes were to be monitored. Record review of the comprehensive care plan revealed there was no mention of the weight loss and no interventions were added to prevent further weight loss. Interview with the MDS staff, on 08/31/19 at 3:00 PM, revealed there was nothing in Resident #40's comprehensive care plan that addressed the resident's weight loss and it should have been addressed. She revealed she was not aware of any significant weight loss for Resident #40. However, after she reviewed the weights for 06/16/19, which was 139 pounds, with the weight for 07/23/19, which was 123 pounds, she stated that was greater than a 5% weight loss in one month and that was considered significant. The MDS staff further revealed a care plan should have been initiated and the physician, dietician, and the Interdisciplinary team (IDT) should have been notified. Interview with Signature Care Nurse Consultant on 08/31/19 at 5:09 PM revealed she was not aware of the weight loss for Resident #40 until today and she did not know why it was not brought to the IDT team to review. She revealed to ensure accuracy of weights they have a staff member assigned routinely to perform the weights and would see how that would improve the accuracy of the weights. Interview, on 08/31/19 at 7:01 PM, with the Administrator revealed weights were to be done consistently.

Based on observation, record review, and interview it was determined the facility failed to notify the physician of a change in condition for two (2) of the forty-six (46) sampled residents. Resident #78 had speech therapy recommendations that were not conveyed to the physician. Resident #40 had a significant weight loss and the physician was not notified. The findings include: Record review of the facility policy titled Change of Condition, revised 07/10/18, revealed the facility would evaluate and document changes in resident's status to relay evaluation information to the physician. The physician would be notified if there was a need to alter treatment. The policy stated the physician notification should be documented in the medical record or the communication form would serve as the nursing documentation. Further review of the policy revealed the care plan and Minimum Data Set (MDS) should be updated. Record review of the undated facility policy titled Weight Monitoring Program revealed when weights were obtained the results would be given to the Assistant Director of Nursing (ADON)/Designee on that unit. The Designee would review all the weights and compare them to the previous months' weight and give a list of reweights to the person getting weights for any resident with a five (5) pound gain or loss. The Designee would record all weights in the weight book in their unit each month. The Dietary Manager would calculate each resident's weight and determine who had a significant weight loss or gain. Further review of the policy revealed a significant weight loss/gain would be 5% in one month, 7.5% in three(3) months, and 10% in six (6) months. The ADON/Nurse or Designee would notify the physician, dietician, and responsible party of any weight change. The ADON, Nurse or Designee would note any new orders or recommendations from the physician and dietician and update the clinical records accordingly. 1. Observation, on 08/27/19 at 12:15 PM, revealed Resident #40 was sleeping and no one assisted /himher. Observation at 12:30 PM revealed the tray was still on the overbed table and the resident was still asleep. Interview on, 08/27/19 at 03:51 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #40 did not eat lunch or breakfast and he/she was diabetic. LPN #2 revealed staff have to wake the resident up to get him/her to eat and then she/he can feed herself/himself. Interview with Resident #40, on 08/28/19 at 1:21 PM, revealed the food was pretty good and he/she said he/she would eat it but sometimes he/she was sleepy and did not want to eat much. Resident #40 stated the facility stated he/she had lost weight, but he/she had not missed it. The resident did not know cause of his/her weight loss. Record review of the clinical record for Resident #40 revealed the facility admitted the resident on 12/01/15 with [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/19, revealed Resident #40 had a Brief Interview of Mental Status (BIMS) of eleven (11), which indicated the resident did not have a cognitive deficit and was interviewable. Review of the nutrition assessment revealed Resident #40 was 61 inches tall and weighed 139 pounds. Resident #40 only needed supervision and set up help with eating. Record review of the weight documentation revealed Resident #40, on 08/06/19 weighed 125.1 pounds, on 07/30/19 the weight was 125.1 pounds, on 07/23/19 the weight was 123 pounds, on 06/16/19 the weight was 139 pounds, on 03/18/19 the weight was 137 pounds, on 03/11/19 the weight was 140.5 pounds, on 03/4/19 the weight was 141.5 pounds, on 02/18/19 the weight was 140.5 pounds, on 02/11/19 the weight was 143.5 pounds, and on 01/28/19 the weight was 147 pounds. Review revealed there was a sixteen (16) pound weight loss from 06/16/19 to 07/23/19. Review further revealed on 08/06/19 Resident #40 weighed 125.1 pounds and on 08/31/19 the resident weighed 123 pounds, which was a two pound weight loss. Interview with the Dietary Manager (DM), on 08/31/19 at 10:30 AM, revealed Resident #40 weighed 123 pounds today and had a 14 pound weight loss from 06/16/19. The DM took responsibility for the oversight and stated the dietician should have been notified of the weight loss and she had not notified her. Interview on, 08/31/19 at 12:15 PM, with the Unit Manager, after she reviewed Resident #40's physician orders, the physician progress notes [REDACTED]. The Unit Manager revealed the facilities policy stated the physician and the family should have been notified of the change. The Unit Manager further revealed the dietician had not been notified either. She revealed if the physician and dietician had been notified they could have made changes to help her gain weight. She revealed she did not know why they had not been notified of the significant weight loss and she was not aware of the weight loss either. The Unit Manager further revealed she was part of the IDT team and did not recall Resident #40 being addressed for weight loss. The Unit Manager stated when the weights were done they get turned in to the Dietary Manager and she would compile the list of reweights and if truly a weight loss then the dietician followed the resident until the weights were stable. Interview with the MDS staff, on 08/31/19 at 3:00 PM, revealed there was nothing in Resident #40's comprehensive care plan that addressed the resident's weight loss and it should have been addressed. She revealed she was not aware of any significant weight loss for Resident #40. However, after she reviewed the weights for 06/16/19, which was 139 pounds, with the weight for 07/23/19, which was 123 pounds, she stated that was greater than a 5% weight loss in one month and that was considered significant. The MDS staff further revealed a care plan should have been initiated and the physician, dietician, and the Interdisciplinary team (IDT) should have been notified. Interview with Signature Care Nurse Consultant on 08/31/19 at 4:26 PM revealed she was not aware of the weight loss for Resident #40 until today and she did not know why it was not brought to the Interdisciplinary team to review. She further revealed the physician should have been notified of the significant weight loss and in order for staff to follow the physicians direction for care. 2. Observation during the lunch meal, on 08/27/19 at 12:15 PM, revealed Resident #78 was eating lunch in his/her room and was unassisted by staff. Observation of the meal tray showed he/she had pureed food. Observation, on 08/31/19 at 12:05 PM, during the lunch meal revealed Resident #78 had her/his tray served to her/him in the Residents' room and had tried to feed herself/himself. Observation further revealed there was no staff in the room for supervision. Review of the clinical record revealed Resident #78 was admitted on [DATE] and had [DIAGNOSES REDACTED].#78 had a Brief Interview of Mental Status (BIMS) of four, which indicated the resident had impaired cognition. Review of the functional status showed Resident #78 needed extensive assistance of one for eating. Record review of the comprehensive care plan showed a problem for alteration in nutrition and one of the interventions was to assist as needed for meals and set up. Review of the care plan revealed there was no indication that the resident had to have one on one supervision with meals. Record review of the Speech Therapy (ST) discharge summary, dated 08/15/19, revealed Resident #78 was to continue on the least restrictive diet (thin liquids, pureed solids) with one on one assist. The ST discharge summary stated Resident #78 would alternate liquids and solids and use bolus size modifications to facilitate safety and efficiency. It was also recommended for Resident #78 to have close supervision for oral intakes. Interview with the Speech Therapist, on 08/30/19 at 2:18 PM, revealed Resident #78 was recently discharged from speech therapy. The Speech Therapist stated Resident #78 needed one on one supervision with eating because of the cognitive impairment and the lack of initiation to eat when staff was not present. He revealed he had told nursing that Resident #78 needed one on one supervision however, he could not remember who he told. The Speech Therapist revealed Resident #78 should be encouraged to feed self but staff would sometimes have to assist. He revealed Resident #78 needed someone with /him her because sometimes her/his arms were restricted and he/she can not always hold them up. He stated Resident #78 had oral dysphagia and that was why the resident was on a pureed diet. The Speech Therapist stated that was why staff needed to be in there with her/him to make sure smaller bites were taken. The Speech Therapist further revealed he verbally communicated the recommendation to nursing and did not document who he spoke with. He was not sure if nursing had access to his discharge summaries. Interview with Certified Nursing Assistant (CNA) #3, who was the CNA for Resident #78, on 08/31/19 at 12:15 PM, revealed Resident #78 could feed self and she was not aware that the resident needed one on one supervision. CNA #3 reviewed her CNA care plan sheet and it did not indicate the resident needed one on one supervision with eating. Interview with Licensed Practical Nurse (LPN) #2, on 08/30/19 at 2:25 PM, revealed the speech therapist would tell them verbally a recommendation or a note may be in room to alert them to what the recommendations were. LPN #3 reviewed the physician orders and could not find an order for [REDACTED].#78 had received a pureed diet. LPN #2 reviewed Resident #78 chart and could not find any order for pureed diet or one on one supervision as outlined in the speech therapy discharge summary. Interview with the Minimum Data Set (MDS) staff, on 08/31/19 at 2:38 PM, revealed if speech therapy did not convey the discharge summary recommendation to nursing then the nurses would have no way of knowing what orders to obtain from the physician because speech therapy recommendations have to have a physician order. Interview with Signature Care Nurse Consultant, on 08/31/19 at 4:10 PM revealed the facility did not have a policy regarding communications from therapy to nursing. She revealed when therapy discharged a resident they should have communicated specific instructions and written an order for [REDACTED]. The Signature Care Nurse Consultant further revealed she was not aware of the need for one on one supervision for Resident #78 until that day. She revealed it should have been communicated and she did not know where the breakdown occurred because there was no documentation that nursing had been notified. She also revealed she did not know why the physician orders did not reflect the pureed diet.

Based on observation, interview, record review and review of facility policies it was determined the facility failed to assess and monitor a resident's condition while staff performed [MEDICAL CONDITION] (trach) care consistent with professional standards of practice for three (3) of four (4) sampled [MEDICAL CONDITION] residents, Resident #21 #26 and #66, out of forty-six sampled residents. Observations revealed the facility failed to provide a complete suction set up at the bedside to provide suction care for Resident #21 for three (3) of four (4) days. Observations revealed staff failed to assess Resident #21 [MEDICAL CONDITION] condition, obtain vital signs before the start of the procedure and failed to monitor the resident's oxygen saturation [MEDICAL CONDITION] was provided. Resident #21 was observed to cough secretions through [MEDICAL CONDITIONS] began and staff failed to provide suction to the resident to ensure the airway was clear prior to the start of the procedure. Furthermore, staff was observed to have exited the resident's room and failed to complete the post assessment after [MEDICAL CONDITION] was completed. In addition observations and interview with RN #6 revealed the facility failed to have the appropriate size [MEDICAL CONDITION] Resident #66. Resident #66 was fitted with a number four (4) Shiley and the [MEDICAL CONDITION] was located on a medication cart was a number six (6) Shiley. In addition, observations revealed the facility provided inconsistent [MEDICAL CONDITION] to residents' bedside and the East emergency cart was not equipped [MEDICAL CONDITION]. Observation on 08/29/19 at 4:35 PM, revealed Licensed Practical Nurse (LPN) #8 failed to apply a pulse oximeter during Resident #26's [MEDICAL CONDITION] care per facility policy. The findings include: Review of the facility policy, [MEDICAL CONDITION] Care, revised 09/28/17, revealed the procedure was to be completed by staff to maintain the residents airway and prevent infection. Staff were to have a pulse oximeter to monitor the resident [MEDICAL CONDITION] was performed. Staff were to ensure the suction was available and functional. The pulse oximeter was to be placed by staff for the resident to be monitored. If needed staff were to suction the resident. The staff were to document the residents' respiratory rate, heart rate, oxygen saturation while the procedure was performed and the condition of the stoma and skin integrity. Review of the facility guide, [MEDICAL CONDITION] Care, undated, revealed staff were to ensure equipment was brought to the bedside. However, the necessary equipment was not listed. Staff were to suction the resident prior to the start of the procedure. Staff were to chart the completion of the procedure and was to record the residents' toleration and condition after the procedure. Review of the facility policy, Accidental [MEDICAL CONDITION] Decannulation, reviewed 05/25/19, revealed staff were to replace [MEDICAL CONDITION] when the tube was completely expelled. The staff were to obtain a [MEDICAL CONDITION] of the same size and replace the tube. Review of Perry and Potter Clinical Nursing Skill and Techniques, unknown date, revealed the standards of care for [MEDICAL CONDITION] included to maintain patency with provided suction of the upper airway. Prior to and after completion [MEDICAL CONDITION] staff were to assess the residents' vital signs, oxygen saturation, and the residents' lung sounds. Listed equipment included a pulse oximeter Review of the facility competency, [MEDICAL CONDITION] Care, reviewed 09/28/17, revealed staff were to have a pulse oximeter [MEDICAL CONDITION] was provided. The competency form noted staff were to document after the care was provided which included respiratory and heart rate, breath sounds and oxygen saturation, type and size of the [MEDICAL CONDITION], if suctioned to documents [MEDICAL CONDITION] note color, amount and type of secretions, and the condition of the stoma and skin integrity. Review of the facility policy, Emergency Carts, revised 05/18/18, revealed the suggested stock in the cart included alcohol pads, iv starter pack, variety sizes of intravenous catheters, tubing, tape, twenty (20) milliliter syringe, suction supplies, oxygen supplies, equipment to obtain vital signs, and miscellaneous items which included Ambu bag, covered suction machine completely prepared for use, a full tank of oxygen with regulator, wrench for oxygen tank and a non-rebreather mask. Review of the facility in-service attendance record, dated 03/29/19, revealed the facility provided education [MEDICAL CONDITION]. Review of the facility staff attendance sign in sheet revealed Licensed Practical Nurse (LPN) #2, #5 and #7 signatures were present to verify attendance to the in-service. The facility material included the guideline [MEDICAL CONDITIONS] Care facility policy, and [MEDICAL CONDITION] care competency form. Review of the facility competency check off' s provided by the facility LPN #2, #5 and #7 were not identified with completion of return demonstration competency [MEDICAL CONDITION]. Continued review of the Weekend Supervisor LPN #6 completed the competency on 06/21/19. The facility failed to provide a policy or list of emergency equipment which was to be placed at the bedside of a resident with a [MEDICAL CONDITION]. The facility was unable to provide a service contract for Respiratory Care Services for the facility. Review of the facility's policy titled [MEDICAL CONDITION] Care, last reviewed 5/25/18, revealed the purpose of the procedure was to maintain airway patency, prevent infection and prevent skin breakdown at the stoma site. Further review of the policy revealed the guideline steps include to bring properly functioning equipment to the room and apply pulse oximeter. 1. Review of Resident #26's clinical record revealed the facility readmitted the resident on 12/19/18 with [DIAGNOSES REDACTED]. Review of Resident #26's Physician Order's, dated 05/16/19, revealed the facility was to provide [MEDICAL CONDITION] care every shift including cannula care. Review of Resident #26's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the Resident as severly cognitively impaired. Further review of the MDS revealed [MEDICAL CONDITION] care and Suctioning were performed while he/she resided at the facility. Review of the Comprehensive Care Plan, dated 01/09/19, revealed Resident #26 had a [MEDICAL CONDITION] with interventions to provide [MEDICAL CONDITION] suction and care including cannula care as ordered. Observation on 08/29/19 at 4:35 PM, revealed Resident #26 was in bed with a [MEDICAL CONDITION] present. Licensed Practical Nurse (LPN) #8 entered the resident's room and performed [MEDICAL CONDITION] care following the [MEDICAL CONDITION] Care steps except LPN #8 failed to bring the pulse oximeter in the room and apply it to Resident #26. LPN #8 did not assess Resident #26's oxygen saturation levels until after [MEDICAL CONDITION] care was provided which was 92% (Normal blood oxygen saturation levels in humans are 95-100 percent). Interview with LPN #8, on 08/29/19 at 5:24 PM, revealed he/she assessed Resident #26's oxygen saturation level before and after [MEDICAL CONDITION] care (90% before care and 92% after care). He/she stated the [MEDICAL CONDITION] policy stated to assess oxygen levels prior to and after [MEDICAL CONDITION] care not during care. LPN #8 stated he/she worked at the facility for almost a year and had [MEDICAL CONDITION] training during orientation. 2. Review of Resident #66's clinical record revealed the facility admitted the resident on 04/27/19 with the [DIAGNOSES REDACTED]. Review of Resident #66's Physician Order's (PO), dated 05/09/19, revealed the facility was to keep an obturator, [MEDICAL CONDITION] Ambu Bag at the bedside at all times. Further review revealed Resident #66 was to be suctioned every shift. Review of Resident #66's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility left the section under special procedures [MEDICAL CONDITION] care was unchecked. Review of Resident #66's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #66 [MEDICAL CONDITION] care and services were acquired while a resident of the facility. Observation, on 08/29/2019 at 4:03 PM, revealed Resident #66 was in bed with [MEDICAL CONDITION] to his/her neck. Observation revealed an [MEDICAL CONDITION] not visible in the room near or around Resident #66. Certified Nurse Assistant (CNA) #11 was present in the room and opened the three drawers to Resident #66's bedside table. CNA #11 removed all contents from the three (3) drawers and found an [MEDICAL CONDITION] obturator was not at Resident #66's bedside. Continued observation revealed an Ambu-bag for resuscitation was not present in the resident's room. Further observation revealed LPN #2 entered the resident's room. LPN #2 was observed to have removed all contents of the three (3) drawers and stated the emergency equipment of a trach, obturator, and Ambu-bag were not in the drawers or the room and stated the supplies for [MEDICAL CONDITION] were not in the room. LPN #2 stated Resident #66's [MEDICAL CONDITION] removed from the room and placed on the top drawer of the medication cart. Interview with LPN #2, on 08/29/19 at 4:07 PM, revealed the facility kept Resident #66'[MEDICAL CONDITION] the medication cart for several months. LPN #2 opened the cart drawer to reveal a metal Shiley trach. The facility did not provide identification of which resident [MEDICAL CONDITION] assigned. LPN #2 identified the size of [MEDICAL CONDITION] a number six (6) Shiley. She stated the resident was recently down sized to a size four (4). She stated if an emergency occurred of dislodgement and the staff were required to replace the stoma with the [MEDICAL CONDITION] would be unable to place the number (6) into Resident #66's stoma because the [MEDICAL CONDITION] too big. She stated because it was too big Resident #66 may not be able to breathe and could die. She continued and stated the facility was to provide emergency supplies were for residents and were to be easily accessed. However, [MEDICAL CONDITION] on the cart and the Ambu-bag was on the emergency cart. She stated she would run down the hallway to get the emergency equipment from the carts. She further stated she was a flex nurse for the company which meant she went to different facilities where staff were needed. She stated she received annual education and trained [MEDICAL CONDITION], emergency interventions, and was check off in a skilled lab by a supervisor 3. Review of Resident #21's clinical record revealed the facility admitted the resident, on 5/24/16, with the [DIAGNOSES REDACTED]. Review of Resident #21's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #21 was an extensive assist for care and services and the resident was unable to communicate or vocalize words. Continued review revealed Resident #21 acquired a [MEDICAL CONDITION] while he/she was a resident at the facility and the facility marked respiratory care was provided. Review of Resident #21's Treatment Order's (TO), dated 04/25/19, revealed staff were to [MEDICAL CONDITION] to the cannula every shift. The TO included staff were to suction Resident #21 as needed. The TO reason [MEDICAL CONDITION] and suction was for chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] or hypercapnia. Review of Resident #21's PO, dated (MONTH) 01- (MONTH) 31 2019, revealed the facility resident orders did not remark of required equipment at the bedside and to monitor for equipment. Review of Physician order (PO), dated 4/2/19, revealed the facility physician treated Resident #21 for the diagnosed of Pneumonia on 04/02/19 and review of record on 6/17/19 the facility started intravenous (IV) antibiotics for the [DIAGNOSES REDACTED]. Observation, on 08/27/19 at 10:14 AM, revealed Resident #21 was in bed with his/[MEDICAL CONDITION]. The bed side table contained a blue suction machine with one short tube noted on top of the unit. Further observation revealed the unit was without a canister to receive secretions from the resident, a long tube to reach the resident and suction catheters [MEDICAL CONDITION] of the resident. Continued observations, on 08/27/19 at 12:35, revealed the resident room remained without equipment observed at 10:14 AM. RN #2 entered the room and searched through all three (3) drawers a located a pencil box. The pencil box was not marked as to what items were in the box. RN #2 opened the box which contained a [MEDICAL CONDITION] obturator. RN #2 picked up the short clear tube from the suction machine and stated this was to short and proceeded to leave the room. Continued observation, on 08/27/19 at 12:35 PM, revealed Resident #21's room remained without a suction canister, long tube, suction catheters, a [MEDICATION NAME] suction tip (an oral suction tool), and an Ambu-bag. Observation, on 08/28/19 at 09:39 AM, revealed Resident #21 was in his/her bed with an intact trach. The bedside table remained with a suction unit with one small tube to the top of the unit. No other supplies for suction needs were not observed in the resident's' room. Observation, on 08/29/19 at 10:01 AM, revealed Resident #21 was awake with [MEDICAL CONDITION]. Resident #21 was observed to have coughed phlegm out of his/[MEDICAL CONDITION] the phlegm was on [MEDICAL CONDITION] down the front of his/her gown. Certified Nurse Assistant #2 was observed to have entered the room at this time. CNA #2 stated she was to check the resident'[MEDICAL CONDITION] because if it were dirty it meant the care was not completed and she would wait to provide personal care. Resident #21 was observed to have continued to cough with projected phlegm while CNA #2 observed the resident'[MEDICAL CONDITION]. CNA #2 remarked the dressing was not clean and left the room. Continued observations revealed the suction unit remained on the side table with only the short tube on top. Further observation, on 08/29/19 at 10:01 AM, revealed Resident #21 was awake in his/her room and was forcefully continued to cough. Resident #21 was observed to have audible sounds of bubbling in his/her airway. CNA #2 entered the room and stated she wanted to evaluate the resident'[MEDICAL CONDITION] condition. She stated if it was not clean she would provide care later. While Resident #21 actively coughed CNA #2 leaned over the resident, stated it was not cleaned yet, the resident was observed to have coughed out a large amount of phlegm which landed on his chest area and CNA #2 walked out of the room. The resident's room was observed to remain without suction supplies to provide suction to the resident and an Ambu-bag. The facility Weekend Supervisor was observed to have entered the room while Resident # 21 continued to cough at 08/29/19 at 10:53 AM. Interview with Family #2, on 08/27/19 at 10:00 AM, revealed the facility transferred Resident #21 to the hospital when there was an issue with [MEDICAL CONDITION] included frequent decannulation by the resident. Family #2 stated the staff seem unable to deal with emergency events when it came to Resident #21's care needs for the [MEDICAL CONDITION]. Interview with the RN #6, on 08/29/19 at 10:53 AM, revealed she entered Resident #21's room and was assigned to care for Resident #21. She stated Resident #21 needed to be suctioned. She stated she observed the small tube connected the suction top to the unit. She stated there was to be gloves and another tube to hook the suction up and somewhere there should be saline to help loosen his/her secretions. She stated the suction machine was without a canister and was not set up for use. She stated she was not sure if a canister needed to be at the resident's bedside. She stated she would assume since Resident #21 was a resident with [MEDICAL CONDITION] suction set up was supposed to be at the bedside. She stated if Resident #[MEDICAL CONDITION] with secretions he/she would be unable to breath and she would perform the [MEDICATION NAME] maneuver to the resident and then stated she would not try to pull [MEDICAL CONDITION] out. She further stated she would not be able to help Resident #21 because she would need the suction to be set up and it was not. The RN #6 searched for supplies in Resident #21's drawers and she pulled from the drawer the obturator. She held up the obturator and remarked the device was to clear [MEDICAL CONDITION] it was plugged and this would be accomplished when she pushed the device into the trach. She further stated if [MEDICAL CONDITION] not able to be suctioned and the [MEDICAL CONDITION] the resident would have an emergency resuscitation and staff would obtain the emergency cart. However, she was unsure [MEDICAL CONDITION] were present in the emergency cart. She stated the facility educator was not available when she came to the facility and just followed staff for a couple days after a three (3) day orientation at the corporate office. She stated the facility did not provide education or competencies [MEDICAL CONDITION] to her or request return demonstration. She further stated she was unaware of what supplies were to be at the bedside for an emergency response of a resident with a trach. Observation, on 08/29/2019 at 11:01 AM, revealed the East Unit Manager (EUM) opened the East Unit Emergency Cart which was the unit for Resident #21. She stated the oxygen tank was without a key to access the oxygen in the tank. She stated the oxygen tank was to have a key present to ensure the delivery of oxygen was not delayed. The EUM stated review of the four (4) drawers revealed the cart was not equipped with variable sizes of trach's, an obturator, or vials of saline to help loosen secretions. She stated the facility admitted resident's with [MEDICAL CONDITION] required care. She stated an obturator was to help guide a [MEDICAL CONDITION] not to clear a plug. She stated the staff were provided a check list to ensure supplies for [MEDICAL CONDITION] were at the bedside. She further stated the facility was to provide an [MEDICAL CONDITION] the same size, obturator, suction set up which included a canister, long and short suction tube, suction catheter, [MEDICATION NAME] suction tip, and gloves. She stated there were supplies in the supply room where staff were able to grab in an emergency. However, both supply rooms were not mirror images of each other and the supply room was not checked to ensure supplies were readily available [MEDICAL CONDITION]. She further stated education [MEDICAL CONDITION], supplies and emergencies were provided in orientation at the corporate office. She stated she was unaware of the policies in regards [MEDICAL CONDITION] and services, and unaware of issues with supplies not available at the resident's bedside. She stated the facility was to ensure staff was proficient [MEDICAL CONDITION] and services, and she knew where to find the policy in the computer. She stated the facility did not request and she did not [MEDICAL CONDITION] audits for staff's care and supplies. She further stated the facility [MEDICAL CONDITION] for care and services and the facility was required to properly care for those residents. She stated if supplies were not readily available, if staff were not trained and comfortable [MEDICAL CONDITION] the facility would have to send the resident to the emergency room (ER) or it was possible the facility would have to start resuscitation because of respiratory distress. Observation, on 08/29/19 at 04:23 PM, revealed LPN #5 prepared to [MEDICAL CONDITION] for Resident #21. LPN #5 washed her hands and turned off the faucet with the wet paper towel. LPN #5 was observed to have removed clean gloves from her scrub pocket and proceeded to remove the resident's dirty gauze around his/[MEDICAL CONDITION] the same gloves. LPN #5 was observe to have placed [MEDICAL CONDITION] onto the over bedtable without having cleaned the table prior to have opened and placed the sterile supplies onto a sheet of paper found inside the kit. She continued and donned sterile gloves and opened all the packages contents. LPN #5 removed the inner trach, Resident #21 began to cough with visible phlegm coughed out. The suction machine was observed fully set up at the resident's bedside. LPN #5 proceeded to clean the [MEDICAL CONDITION], took a 4x4 and completely dried the outer cannula, proceeded to dry the inside of [MEDICAL CONDITION], and replaced the tube to the residents base plate with the dry trach. LPN #5 stated she was finished with [MEDICAL CONDITION] procedure and the resident tolerated well. Observations revealed Resident #21 was not monitored for oxygen saturation with the procedure, vitals were not obtained, suction was not provided, and lung sounds were not assess before or after the procedure by LPN #5. Interview with LPN #5, on 08/29/19 at 04:33 PM, revealed staff were to chart the procedure was completed, color of the secretions and condition of [MEDICAL CONDITION]. She stated the facility medication and treatment record for Resident #21 did not provide a list of supplies at the bedside, emergency supplies [MEDICAL CONDITION] or other emergencies, or to monitor oxygen with the procedure. She stated the resident's room was not equipped with oxygen or an Ambu bag. She stated the facility provided education and trained staff [MEDICAL CONDITION] and emergency services. However the last skill check off provided for staff by the facility was over one and a half (1 ½) years ago, and facility observation by staff education, or by administration for staff was two (2) to three (3) years ago. Review of Resident #21's clinical record revealed LPN #5 checked on 08/29/19 [MEDICAL CONDITION]. However, there were no additional notes pertaining to stoma condition, vital signs, oxygen saturation and lung sound pre and post treatment on the nursing notes or on the treatment record. Interview with LPN #7, on 08/30/19 at 02:00 PM, revealed the facility was to have emergency equipment at a residents' bed side. She stated the equipment included a full suction set up, an [MEDICAL CONDITION] the same size, and an obturator at the minimum. She stated staff were to assess resident lung condition, oxygen saturation, and vital signs every shift. She stated staff were to assess the resident before and [MEDICAL CONDITION] was performed to have a baseline for reference, was to monitor residents' oxygen with the procedure for desaturation, and obtain post procedure vital signs. She stated staff were to assess the resident lung condition after the resident was suctioned and after [MEDICAL CONDITION] cleaned. She stated the facility education [MEDICAL CONDITION] and services was provided to staff. However, the facility gave a verbal form of education and not a task check off and observation. She further [MEDICAL CONDITION] were not to be wiped off and dried, rather shook to remove excess water. She stated reinsertion of [MEDICAL CONDITION] causes pain and irritation when it was dry. She stated staff were to document the residents' toleration, condition, color of secretions after the procedure was completed. She further stated residents with an altered respiratory system were subject to an increased potential for infection, respiratory changes, plugged trach, and low oxygen levels which were all examples of harm to the resident. Interview with the Plant Operator, on 08/31/19 at 5:22 PM, revealed the facility did not maintain resident suction machines provided for residents. He stated the facility leased the equipment. Interview with the Nurse Consultant, 08/31/19 07:40 PM, revealed the decannulation policy [MEDICAL CONDITION] was reviewed with staff but the facility did not require care competencies on the skill check of list. Interview with the Medical Director, on 08/31/19 at 4:44 PM, revealed he and the facility previously discussed the provision of education and a systematic system to ensure residents in the facility were given the best care possible. He stated the facility identified the need for education to staff for respiratory and [MEDICAL CONDITION] for residents. He further stated he and the facility previously discussed supply issues, education and procedural education for staff for proficient care of a trach, assessments, and identification of a change in status. He stated the facility was to improve day to day to keep residents from decline. Interview with the Director of Nursing (DON), on 08/29/19 at 3:00 PM, revealed the facility would have to determine the seriousness of the residents' emergency with [MEDICAL CONDITION] would call for emergency services. The DON stated she was unfamiliar with the process [MEDICAL CONDITION], services and emergency in the facility because she was an interim DON. However, she stated she knew where to find the policies in the electronic system. She stated all nurses, flex or regular staff [MEDICAL CONDITION] and were evaluated on the physical skill [MEDICAL CONDITION] and services. The DON stated she would expect a spare trach, suction catheters, a full suction set up and an obturator at the residents' bedside. She stated a resident's [MEDICAL CONDITION] to be the same size. She stated the facility care and services included to ensure supplies were readily available to meet an emergency, provide general care and if the facility could not address the resident's respiratory concerns the resident may experience an emergency and the resident would be sent to the hospital after the activation of nine one one (911). She stated the staff were to suction the resident's with [MEDICAL CONDITION] have a full set up available at the bedside to provide care. She stated the residents could experience harm if the facility was unable to maintain the residents' airway. She stated she was not able to evaluate the competency of the staff [MEDICAL CONDITION] and services. However, she stated she counts on regulations and company to have trained and to have 'readymade staff'. She stated there were no reported issues with equipment or services when she was made aware of the facility residents with trach's. She stated she was not able to complete an audit of [MEDICAL CONDITION] in the facility to ensure care and services were provided per standards of care. She stated the facility followed Lippincott for standards of care. Further interview with the DON, on 08/30/19 at 10:18 AM, revealed the facility did not have a respiratory provider for care and services. She stated staff were trained [MEDICAL CONDITION] at an education center and completed competencies at a sister facility. She stated staff were not audited on respiratory care of a resident with [MEDICAL CONDITION] the facility. She stated facility policy for equipment at the bedside was initiated by corporate authorities. However, at the time the facility did not have one in place for reference or a guide or check list to ensure equipment at the bedside of residents were uniform. She stated staff were to follow the facility policy [MEDICAL CONDITION] and were to provide care as to what they were checked off at the skill portion of the education. She further stated when staff do not follow proper care for policy procedure may not affect the resident and she further stated she would not try to figure out what might happen if the procedure was not followed. She stated the facility did not have suction equipment at Resident #21 bedside. She stated the facility was expected to provide safe and effective care to Resident #21. She stated staff were to know what equipment was to be the bedside of a resident with [MEDICAL CONDITION] or not an order or a care plan intervention included this information because she expected staff to follow policy. Interview with the Administrator, 08/31/19 at 5:30 PM, revealed the facility was concerned over the lack [MEDICAL CONDITION] supplies at residents' bedsides. She stated the corporation was without a policy or procedure for supplies for residents with a [MEDICAL CONDITION] which were to be at the residents' bedside. She stated the facility was to have uniformity with residents for care and services, ensure staff were proficient in care and services, ensures supplies were available for the resident either at the bedside, the supply room or the emergency carts. She further stated the facility did not previously identify issues [MEDICAL CONDITION] and services. She said [MEDICAL CONDITION] were not provided proper support and care the facility would have to call 911 to intervene.

Based on observation, interview and record review, and policy review it was determined the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) for three (3) of forty-six (46) sampled residents, Resident's #21, #66 and #78. Review of Resident #66's Physician Order's (PO), dated [DATE], revealed the facility was to keep an obturator, [MEDICAL CONDITION] Ambu Bag at the bedside at all times. Review of Resident #66's Comprehensive Care Plan (CCP), dated [DATE], revealed Resident #26 CCP identified a problem area of potential for complications related to a [MEDICAL CONDITION]. The CCP interventions directed staff to [MEDICAL CONDITION] as ordered; however, observation revealed not all ordered items were at the bedside. Review of Resident #21's CCP revealed no plan of care for a [MEDICAL CONDITION]. Interview with the RN #6, on [DATE] at 10:53 AM, revealed she determined Resident #21 needed to be suctioned, however, the suction machine was not set up to [MEDICAL CONDITION] and there was also no Ambu bag in the resident's room in case of respiratory distress. She further stated she was unsure what supplies were needed at Resident #21's bedside. Interview with the Minimum Data Set (MDS) staff, on [DATE] at 2:38 PM, revealed after the speech therapy assessment and recommendations were made, a care plan should have been developed, to meet the resident's assessed needs. After she reviewed the speech therapy discharge summary from [DATE], she stated she was not aware of the need for one on one supervision with meals for Resident #78 and the need to alternate liquids and solids. She stated those interventions should be on the care plan and they were not. The findings include: Review of the facility policy, Comprehensive Care Plan, revised [DATE], revealed the CCP was to ensure the facility prevented or reduced decline in a residents functional level and was to be reflective of the standards of practice for problem area's and conditions. The care plan was to have intervention implementation after the residents' problem areas were identified with interventions which were to reflect action, treatment or procedure to meet the objective goal. Review of the facility policy, [MEDICAL CONDITION] (trach) Care, revised [DATE], revealed staff were to ensure suction equipment was available and functional. Review of the facility guide, [MEDICAL CONDITION] Care, undated, revealed staff were to ensure equipment was brought to the bedside. However, the guide did not have the equipment listed. In addition, staff were to suction the resident prior to the start of [MEDICAL CONDITION]. Review of Perry and Potter Clinical Nursing Skill and Techniques, unknown date, revealed the standards of care for [MEDICAL CONDITION] included to maintain patency with provided suction of the upper airway. The facility failed to provide a policy or list of equipment which was to be placed at the bedside of a resident with a [MEDICAL CONDITION]. 1. Review of Resident #66's clinical record revealed the facility admitted the resident on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #66's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #66 [MEDICAL CONDITION] care and services were acquired when he/she was a resident of the facility. Review of Resident #66's Physician Order's (PO), dated [DATE], revealed the facility was to keep an obturator, [MEDICAL CONDITION] Ambu Bag at the bedside at all times. Review of Resident #66's Comprehensive Care Plan (CCP), dated [DATE], revealed Resident #26 CCP identified a problem area of potential for complications related to a [MEDICAL CONDITION]. The CCP included the goal of potential complications related to a [MEDICAL CONDITION]. Continued review of Resident #26's CCP revealed the staff's goal included to successfully ventilate through the residents nose, pharynx, larynx and trachea. The facility approach included staff were to check the residents oxygen level, acquire labs as ordered, administer medications as ordered, Observe for shortness of air and report changes, suction and [MEDICAL CONDITION] as ordered Interview on [DATE] at 4:30 PM, with the MDS Coordinator, revealed the facility developed CCP based on the baseline admission care plan, and MDS triggers with assessments, observations and care needs. She further stated an accurate care plan was to be in place to ensure the resident needs were met. She stated if the care plan was not implemented the resident could have a decline in his/her status. Interview on [DATE] at 10:18 AM, with the Director of Nursing (DON), revealed staff were expected to follow the residents care plans. Interview on [DATE] at 5:53 PM, with the Director of Nursing Care Consultant, revealed care plans were to be followed to provide quality care to the residents of the facility. She stated part of her role was to review charts for facilities and she did not identify issues in the facility. Interview on [DATE] at 5:30 PM, with the Administrator, revealed the facility was to provide a safe and comfortable environment and ensure the resident needs were addressed through the implementation of the plan of care. 2. Review of Physician order's (PO), dated [DATE] to [DATE], and revealed Resident #21 for the diagnosed of Pneumonia upon readmission. Further review of Resident #21's clinical record on [DATE], revealed the facility provided antibiotic treatment for [REDACTED]. Observation, on [DATE] at 10:14 AM, revealed Resident #21 was in bed with his/[MEDICAL CONDITION]. The resident was observed to cough and produced a large amount of phlegm which was observed to have landed on the edge of the resident'[MEDICAL CONDITION] on his/her gown. The bed side table contained a blue suction machine without the setup of a long suction tube to reach the resident, suction catheter and a receptacle container to receive secretions. Observations revealed an Ambu-Bag was not observable in the room. Registered Nurse (RN) #2 entered the resident's room and stated after she searched the drawers, closet and areas around bed stated an Ambu bag was not in the resident's room. RN #2 proceeded to picked up the short clear tube from the top portion of the suction machine and stated the tube was too short to suction the resident and left the room Continued observation, on [DATE] at 12:35 PM, revealed Resident #21's room remained without a suction machine set up readied to suction the resident, and an Ambu-Bag and the box were not available for resident care at the bedside. Observation, on [DATE] at 09:39 AM, revealed Resident #21 was in his/her bed with an intact trach. The bedside table remained with a suction unit, that was not set up and readied for the suction needs of the resident. An Ambu-bag was not observed to be in the resident's room. Observation, on [DATE] at 10:01 AM, revealed Resident #21 was awake with [MEDICAL CONDITION]. Continued observations revealed the suction unit remained on the side table and was not set up to suction the resident, and the Ambu-bag was not observed the room. Resident #21 was observed to have coughed phlegm out of his/[MEDICAL CONDITION] the phlegm was on [MEDICAL CONDITION] down the front of his/her gown. Certified Nurse Assistant #2 was observed to have entered the room at the same time, checked the resident'[MEDICAL CONDITION] status as the resident continued to cough, and left the room. Review of Resident #21's CCP revealed no plan of care for a [MEDICAL CONDITION]. Interview with the RN #6, on [DATE] at 10:53 AM, revealed she entered the room to check on the resident and determined Resident #21 needed to be suctioned. She stated the suction machine was not set up to [MEDICAL CONDITION] and there were no supplies in the resident's room to set up the suction machine to provide care. She further stated she was unable to find an Ambu bag in the resident's room. However, she would go get the emergency cart to provide emergency care to the resident. She also stated the room was without oxygen. She further stated she was unsure what supplies were needed at Resident #21's bedside. She stated she was unable to suction Resident #21 and needed to get supplies. She stated the lack of the availability of all the needed suction equipment for the resident, meant a delay in care could occur; and the resident'[MEDICAL CONDITION] become plugged with phlegm causing the resident to be unable to breath. Interview with the MDS coordinator, on [DATE] at 4:30 PM, revealed the facility developed CCP based on the baseline admission care plan, and MDS triggers with assessments, observations and care needs. She stated the facility care plan was on the electronic computer system and the MDS electronic program provided a care plan template when a [DIAGNOSES REDACTED]. She stated the program allowed the person to check interventions and provide customized care and interventions. She stated the system was used since (MONTH) of 2019. She stated the program provided different areas the coordinator was able to access for interventions. She stated the area the MDS coordinator chose for Resident #21's care plan was the minimum for a [MEDICAL CONDITION] resident. She stated the facility held quarterly care plan reviews and when order's changed or condition changed. She stated CCP's were the care needs for the resident and it was to reflect the residents care needs. She further stated an accurate care plan was to be in place to ensure the resident needs were met and the care appropriate. She stated if the care plan was not reflective of the resident needs the resident could have a decline in his/her status. Interview with the Medical Director, on [DATE] at 4:44 PM, revealed he and the facility administration staff discussed the need for continuity of care regarding the [MEDICAL CONDITION] care needs of all [MEDICAL CONDITION] residents. He further stated the facility goal was to maintain and improve resident's conditions. Interview with the Director of Nursing Care Consultant, on [DATE] at 5:53 PM, revealed care plans were to be reviewed for accuracy. She stated care plans were to be developed and followed to provide quality care to the residents of the facility. She stated part of her role was to review charts for facilities and she did not identify issues in the facility. She further stated staff were to follow resident care plans. Interview with the Director of Nursing (DON), on [DATE] at 10:18 AM, revealed staff were expected to follow the residents care plans. However, if the resident care plans were not complete related to [MEDICAL CONDITION] care she expected staff to follow policy and procedure. She stated the MDS personnel were responsible to ensure the care plans reflected the resident care needs. She stated she would not try to figure out what could occur to the residents if the care plans were not developed or followed. She stated she was not able to audit care plans. She stated Resident #21's care plan was not reflective of the resident needs as well as the residents risk and actual [DIAGNOSES REDACTED]. She stated she expected staff and the facility to provide safe and effective care for [MEDICAL CONDITION] residents as the facility accepted resident with a [MEDICAL CONDITION]. Interview with the Administrator, on [DATE] at 5:30 PM, revealed the resident's care plans were to be reviewed on admission, quarterly, and with a change of condition. She stated when resident care plans lacked information for the residents care the facility missed pertinent information. She stated the omission on the care plan could affect the residents care. She further stated when the facility did not provide an accurate and complete care plan to reflect the resident needs then the resident will have a less than positive outcome. She stated the facility was to provide a safe and comfortable environment and ensure the resident needs were addressed. . Review of the clinical record revealed Resident #78 was admitted on [DATE] and had [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #78 had a Brief Interview of Mental Status (BIMS) of four (4), which indicated the resident had impaired cognition. Review of the functional status showed Resident #78 needed extensive assistance of one for eating. Review of the Range of Motion (ROM) revealed Resident #78 had impairment on one side of the upper and lower extremities. Record review of the comprehensive care plan showed a problem for alteration in nutrition and one of the interventions was to assist as needed for meals and set up. Review of the care plan revealed there was no intervention specifically for handled cups and no indication that the resident had to have one on one supervision with meals. Interview with the Speech Therapist (ST), on [DATE] at 2:18 PM, revealed he/she assessed Resident #78 to need one on one supervision with feeding because of cognitive impairment and initiation to eat meals was reduced if staff not present. The ST stated the resident was encouraged to feed self but staff may have to feed the resident to ensure nutritional intake. The ST stated the resident had restricted arm movement and oral dysphagia which could also affect oral intake. The ST stated the resident was discharged from their care on [DATE], however, did not know if they communicated recommendations/care needs to nursing staff. Observation during the lunch meal, on [DATE] at 12:15 PM, revealed Resident #78 was eating her/his lunch in her/his room and was unassisted by staff. Observation of the meal tray showed he/she had pureed food, milk in a carton, and punch in a regular glass with a straw. Observation of the diet card revealed Resident #78 was to have a handled cup for fluids. Observation during the lunch meal, on [DATE] at 11:59, revealed Resident #78 had a carton of milk and a glass of lemonade and no handled cup. Observation revealed there were no staff in with the resident. Observation on [DATE] at 12:05 PM during the lunch meal revealed Resident #78 had her/his tray served to her/him in the room and the resident had tried to feed herself/himself. Observation further revealed there was no staff in the room for supervision. Interview with Certified Nursing Assistant (CNA) #3, who was the CNA for Resident #78, on [DATE] at 12:15 PM, revealed Resident #78 could feed herself/himself and she was not aware that the resident needed one on one supervision. CNA #3 reviewed her CNA care plan sheet and it did not indicate the resident needed one on one supervision with eating. Interview with the Minimum Data Set (MDS) staff, on [DATE] at 2:38 PM, revealed the speech therapy recommendations should be on the care plan and should be on the CNA care plan sheet. After she reviewed the speech therapy discharge summary from [DATE] she revealed she was not aware of the need for one on one supervision with meals for Resident #78 and the need to alternate liquids and solids. She revealed those interventions should be on the care plan and they were not. After she reviewed the speech therapy notes she revealed Resident #78 had dysphagia which meant he/she had difficulty with swallowing and that placed her/him at risk for aspiration, further decline in function, and at risk for pneumonia. The MDS staff further revealed there should have been an intervention of the need for the handled cup and it was not on the comprehensive care plan Interview with Signature Care Nurse Consultant, on [DATE] at 4:10 PM revealed that during the clinical white board meeting, with the interdisciplinary team, they would discuss therapy recommendations and the manager would communicate the need for the physician order, process the order, update the care plan, and call the family with the changes. The Signature Care Nurse Consultant further revealed she was not aware of the need for one on one supervision for Resident #78 until that day. She revealed it should have been communicated and she did not know where the breakdown occurred because there was no documentation that nursing had been notified. She also revealed she did not know why the physician orders did not reflect the pureed diet. She revealed the pureed diet as a lower level of diet and the safest but Resident #78 might now eat as well since different than mechanical soft. She stated she did not think there was a risk of choking given the consistency of the food.

Based on observation, interview, record review, and review of the facility policy/procedure, it was determined the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for three (3) of ten (10) residents with pressure ulcers out of forty-six (46) sampled residents (Resident #62, #78 and #190). Observation of Resident #190's wound care on 08/29/19, revealed Licensed Practical Nurse (LPN) #3 failed to provide wound care appropriately by not washing hands and changing gloves. Observation of Resident #78's wound care on 08/29/19, revealed LPN #3 failed to provide wound care appropriately by not sanitizing scissors, no changing gloves, and not following physician orders. Observation of Resident #62 wound care on 08/29/19 at 1:53 PM, revealed LPN #3 failed to provide wound care appropriately by not changing/discarding gloves, sanitizing scissors, and hands between tasks. LPN #3 also used a pen and tape from her pocket and did not discard tape or sanitize her pen after wound care. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, with a revised date of (MONTH) (YEAR), revealed an infection prevention control program was established to provide a safe, sanitary environment to prevent the development and spread of infection. Review of the facility policy titled, Pressure Ulcer (Injury) Treatment, with a revised date of 07/24/18, revealed the guidelines purpose was to care for existing pressure ulcer and to prevent additional pressure injuries. The procedure included the application of dressings or ointments according to the physician orders. The policy further revealed pressure ulcer treatment required a comprehensive approach that included managing infections and maximizing the potential for healing. The policy procedure further revealed the staff was to be educated and ensured that the staff adhere to proper technique and procedures. 1. Observation of Resident #78 with the Licensed Practical Nurse (LPN) #3, on 08/29/19 at 10:44 AM, revealed LPN #3 placed the wound supplies on the overbed table without sanitizing it, also did not remove items lying on it, and she did not create a barrier. LPN #3 cut the old dressing off the left foot with her scissors and laid the scissors on the overbed table. Observation further revealed she cleaned the wound, removed her gloves, and washed her hands. She put on new gloves and applied the medication to the gauze and applied zinc oxide without cleansing the area which had zinc oxide already on it. LPN #3 pulled the cover up for the resident, touched the call light, and touched the overbed table without removing her gloves that had been used to apply the zinc oxide. Observation further revealed LPN #3 removed her gloves and did not wash her hands before she gathered her supplies and put the unwashed scissors back into her pocket. Observation revealed LPN #3 went to the treatment cart and gathered supplies for the next resident. The facility admitted Resident #78 on 12/01/15 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 04/30/19, revealed the facility assessed Resident #78's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review further revealed Resident #78 needed extensive assistance of one person for bed mobility and transfers. Review further revealed Resident #78 did not have a pressure area. Review of the Quarterly MDS, dated [DATE], revealed Resident #78 had a Stage two pressure ulcer to the coccyx. Review of the progress notes for 08/09/19 revealed Resident #78 had also had a Stage two pressure ulcer to the left 2nd toe. Review of the Comprehensive Care Plan for Resident #78 revealed a problem was listed for skin breakdown to the coccyx and to the left toe. Review of the most recent Braden Scale revealed Resident #78 was at risk for skin breakdown. Review of the (MONTH) 2019 Physician Orders revealed the treatment for [REDACTED]. Further review of the Physician Orders revealed the left second toe was to be cleaned with normal saline and Iodosorb gel was to be applied and then covered with a dry dressing. Interview with LPN #3, on 08/30/19 at 3:01 PM, revealed you should clean the overbed table if the tray was dirty and use a paper towel for a barrier. LPN #3 stated there was a potential issue for the resident if something was on the table that could make the wound worse. She revealed it did not occur to her to clean the table. LPN #3 revealed she should clean the scissors before putting them in her pocket or using them during wound care because they could be contaminated from whatever they came into contact with in her pocket. Then whatever was on the scissors could be transferred to another resident. LPN #3 revealed it was a risk of cross contamination. LPN #3 reviewed the physician orders and revealed she did not follow the orders for the coccyx as outlined by the physician. LPN #3 further revealed if staff did not follow physician orders it could potentially make the wound worse. 2. Record review revealed the facility admitted Resident #190 on 09/20/17 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 05/31/19 revealed the facility assessed Resident #190's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the Quarterly MDS revealed the resident had two (2) unstageable pressure ulcers that were present upon admission/entry or reentry. Review of a weekly skin assessment, dated 04/01/18, revealed two (2) unstageable pressure ulcers were identified to Resident #190's peri-area and coccyx. Review of the Comprehensive Care Plan for Resident #190 revealed the resident had an unstageable pressure ulcer to the peri-area and coccyx present on admission and at risk for further skin breakdown. Review of the (MONTH) and (MONTH) 2019 Physician Orders revealed an order to apply 50/50 mix of of [MEDICATION NAME]/Zinc to peri wound and cover with ABD pad twice a day. Observation of wound care, on 08/29/19 at 11:08 AM, revealed Licensed Practical Nurse (LPN) #3 washed hands after removing the dressing then applied gloves from her scrub pocket. Further observation revealed after wiping feces from the resident's peri area, she placed the tube feeding on hold, then wiped feces from the resident's coccyx again without washing hands and changing gloves or cleaning the equipment. Interview with LPN #3 on 08/29/19 at 11:38 AM, revealed she should have washed her hands and changed her gloves after placing the tube feeding on hold. She revealed she should have used gloves from the box not from her scrub pocket. She stated she was not aware of what the infection control policy said regarding wound care. 3. Review of Resident #62's clinical record revealed the facility admitted the resident on 06/06/19 with the [DIAGNOSES REDACTED]. Review of Resident #62's Physician Orders, dated 07/30/19 to 08/31/19, revealed the staff were to provide to the left heel the daily a treatment of [REDACTED]. Further review revealed staff were to provide wound care to the sacral area which included to clean with normal saline, apply the medicated gel then pack with a normal saline moist gauze and cover with a pad once a day. Review of Resident #62's Comprehensive Care Plan (CCP), dated 08/07/19, revealed the facility identified the resident with skin integrity as a problem. The goals included the area would be free of infection. Review of Resident #62's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility identified Resident #63's skin condition with an existed pressure ulcer of a stage four (4) upon entry to the facility. Observation, on 08/29/19 at 1:53 PM, revealed Licensed Practical Nurse (LPN) #3 acquired wound care supplies to complete Resident #62's wound care. LPN #3 placed the wound care supplies onto an uncleaned bedside table. The table contained a white crumbly substance and a visible sticky semi dry liquid. LPN #3 washed her hands, turned off the faucet then removed clean gloves from her right pocket, placed the gloves on and proceeded to remove Resident #63's sacral wound dressing which contained drainage. LPN #3 proceeded to remove the dirty gloves then reached into her right pocket and placed a new set of clean gloves without hand hygiene after the soiled dressing was removed. LPN #3 obtained wound dressing material from the packages with gloved hands and then reached into her pocket and removed scissors from her pocket. She proceeded to cut the gauze dressing and placed the scissors back into her pocket. LPN #3 handled the tube of gel for the wound, handled the tube on the outside with both gloved hands and proceeded to place the wound gel onto her gloved hand and proceeded to place the medicated gel directly onto the wound with her gloved hands. Resident #63 produced a large bowel movement during the wound treatment. LPN #3 acquired new gloves from her pocket after she removed the gloves worn with wound care without hand hygiene. LPN #3 proceeded to remove the gloves worn to clean the resident's bowel movement and removed the gloves and placed the gloves directly onto the surface of Resident #63's over the bed table. LPN #3 proceeded to place a new pair of clean gloves which were remove from her pocket and removed a roll of tape from her pocket and placed on the table without the completion of hand hygiene. LPN #3 continued and held the saturated saline filled gauze and proceeded to place the gauze into the wound and used the gloved hands to push the gauze up into areas which were pocketed. LPN #3 continued with the same gloved hands to place a pad over the wound, taped the edges with the tape she removed from her pocket previously, and removed a blue marker from her right pocket with her gloved hands and wrote on the dressing the date and time. Continued observation, on 08/29/19 at 2:11 PM, revealed LPN #3 continued wound care to Resident #62 left heel. LPN #3 removed her scissors from her pocket with clean gloved hands, cut the gauze roll, placed the scissors onto the bare table and proceeded to remove the old gauze dressing. LPN #3 removed the dirty gloves and laid the gloves onto the residents bedding. LPN #3 opened a previously opened and cut foam gauze and proceeded to use the scissors, which she had not sanitized, to cut out the square. She placed the scissors back into her right pocket. LPN #3 covered the wound, taped the gauze, obtained the pen from her pocket and completed the dressing. LPN #3 placed the scissors and pen back into her pocket. LPN #3 removed her gloves, repositioned the resident with assistance, removed the soiled gloves from the resident's bowel movement with bare hands and placed them into the garbage. The tape used for the wounds was observed to fall onto the resident's floor and LPN #3 proceeded to return the tape into her pocket which she picked up off the floor. LPN #3 performed hand hygiene, obtained the bottled gel, package of foam and returned the supplies to the treatment cart. The LPN left the room and stated she was done after the trash was removed from the room. The resident's table was observed to not have been sanitized after treatment. Interview with LPN #3, on 08/29/19 at 2:20 PM, revealed she provided wound treatments for the residents five (5) days a week. LPN #3 stated the wound process included hand hygiene, placement of clean gloves, and she wound clean the wound. She stated she often doubled her gloves with wound care and would especially double glove with excessive wound drainage. She stated she would complete the wound care, take off gloves and date the wound cover. Afterwards, she stated she would gather her supplies and leave. She stated a common infection control technique was to make sure hands were washed after the wound care is completed. She stated staff were to ensure gloves were changed between dirty and clean technique. She continued and stated she kept her gloves in her pocket and she was not told otherwise. She stated she utilized the residents' personal table to use for wound supplies and would ensure not to use another residents table. She stated if the table is dirty, she would clean it. She further stated she would not have a reason to clean the table if she did not see dirt. However, she stated the residents' wound could worsen with infection if the table was not cleaned. She stated she cleaned her scissors between residents but kept her scissors in her pocket. She stated her pockets were contaminated and therefore the resident wounds could worsen. She stated infection control was important with wound care to prevent cross contamination and placed residents in jeopardy of an infection. She continued and stated she was trained for one day at another facility when she followed a wound nurse. She stated she mimicked what she observed with staff at the other facility. She stated the facility was not conducting audits on her knowledge and wound techniques. She stated the facility did not require her to be wound certified, did not offer further training for wound care, and she took it upon herself obtain more education through video. Interview with the Medical Director, on 08/31/19 at 4:38 PM, revealed the facility provided residents with a wound physician who evaluated and ordered treatments for resident with a wound. He stated the facility previously identified concerns with the wound treatment nurse care and techniques. He stated the facility addressed the concerns to the wound nurse several times, provided tutorials, and made adjustments. However, he further stated the recent events were a wake up call for care concerns in the facility. Interview with the East Unit Manager, on 08/31/19 at 5:00 PM, revealed facility audits for wound care and techniques were not completed. She stated the facility completed trends for infections and the staff development person would complete this task. She stated the facility staff and the wound nurse were to ensure hand hygiene and infection control techniques were followed at all times to prevent infection. She stated staff who do not follow infection control techniques would cause infections to the residents wound and the resident could become septic. Interview with the Nurse Consultant, on 08/31/19 at 5:53 PM, revealed the DON was not available for interview. She stated staff were expected to follow the process of wound care, hand hygiene, equipment use, surfaces were to be cleaned, and care techniques were to be provided with the prevention of infection in mind at all times. She stated the residents were at risk for infection of the wound if infection control was not followed during wound care. She stated the DON was expected to audit staff for infection control issues in the facility. Interview with the Administrator, on 08/31/19 at 5:32 PM, revealed the facility identification of infection control issues with wound care were not previously identified. However, she stated the Medical Director discussed concerns on pressure ulcer and wound care in the facility. She stated wound care in the facility was to be provided with good basic infection control care and techniques, at all times, to make sure the residents were not infected from cross contamination. She stated infection control for wounds in the facility was imperative for residents. She further stated she oversaw the daily care the residents received in the facility with the Director of Nursing and it was important to provide a safe environment.

Based on observation, record review, and interview and policy review it was determined the facility failed to maintain one (1) medication room refrigerator on the East hall at acceptable temperatures out of the two (2) medication room refrigerators. In addition, intravenous medication was stored in with oral medications that were being sent back to the pharmacy in the East hall medication room out of the two medications room. The findings include: Record review of the facility policy Medication Storage, Storage of Medication, with a date of 09/18, revealed the medications and biological's were to be stored properly to maintain their integrity and support safe effective drug administration. Review further revealed intravenously administered medications were to be stored separately from orally administered medication and under appropriate temperatures. The policy stated medications that required refrigeration should be kept at temperatures from 36 degrees Fahrenheit to 46 degrees Fahrenheit. Observation of the East hall medication room with Licensed Practical Nurse (LPN) #1, on 08/28/19 at 3:15 PM, revealed the refrigerator had a temperature of htirty-two (32) degrees. The refrigerator had [MEDICATION NAME] liquid, Dronabinol, [MEDICATION NAME] solution, [MEDICATION NAME], Hepatitus B vaccine, and [MEDICATION NAME] vials stored in it. Observation revealed none of the liquids were frozen and did not have visible crystals in them. Observation of the refrigerator log for (MONTH) showed only one day that was out of the acceptable range and it was 34 degrees then. Observation further revealed intravenous (iv) medications and fluids were stored in the same container as the medications being returned to the pharmacy. Interview with Licensed Practical Nurse (LPN) #1, on 08/28/19 at 3:15 PM, revealed she did not know what temperature the refrigerator should be maintained at but after looking at the refrigerator log, stated the temperature should be between 36 and 46 degrees. LPN #1 stated she was not sure if 32 degrees had any effect on the medication. Interview by phone with Pharmacist #1 at Pharmacare, on 08/30/19 at 4:15 PM, revealed the acceptable range of temperatures for the medication room refrigerator should be between 36 to 46 degrees. He stated 32 degrees was too cold and being too cold can be just as bad and too hot. He stated , generally, being too cold can decrease the potency of the medication. Stated he would have to call me back with more specific information. Interview by phone with Pharmacist #2 at Pharmacare, on 08/31/19 at 8:42 AM, revealed since the time frame was relatively short that the medication was in the refrigerator at the 32 degree temperature the medications should be okay. He stated they would come out and have someone look at the refrigerator. Observation of the east hall medication room refrigerator with LPN #7, on 08/31/19 at 10:58 AM, revealed the temperature of the refrigerator was 34 degrees and the log had not been filled out that day. Observation revealed there was an emergency kit that contained Tylenol suppositories, [MEDICATION NAME] suppositories, [MEDICATION NAME] suppositories, [MEDICATION NAME] insulin, and mouthwash in there. Interview with LPN #7, on 08/31/19 at 10:58 AM, revealed she would get a new refrigerator. LPN #7 stated maintenance had looked at the refrigerator yesterday and done something to the door because it was hanging incorrectly. LPN #7 stated 34 degrees was not within the correct parameters of 36 to 46 degrees. Interview with LPN #1, on 08/28/19 at 3:15 PM, revealed normally they have a separate tote for the intravenous supplies that was separate from oral medications that were being returned to the pharmacy. LPN #1 stated she did not know how long they had been stored together. LPN #1 revealed they put the return medications in a separate tote, seal it, and pharmacy was alerted to pick it up. LPN #1 stated oral medications and iv fluids and medications should not be stored together. Interview with LPN #7, on 08/31/19 at 10:58 AM, revealed oral medications should not be stored with iv medication and fluids. She stated they do not belong together. LPN #7 further revealed no one of her staff will own up to placing them together. Interview with the Signature Care Nurse Consultant, on 08/31/19 at 4:00 PM, revealed they had maintenance look at the refrigerator and he adjusted the temperature. She revealed the temperature range should be between 36 degrees and 46 degrees. She stated if the temperatures were not in that range there would be a potential that medication cold be frozen and could not be used. The consultant stated she was not sure about how being too cold would affect the potency of the medication or if it would alter the medication. Interview with Signature Care Nurse Consultant further revealed intravenous fluids and medication returned to the pharmacy should be stored separate because they were medications that were administered via different routes.

Based on observation, record review, and interview it was determined the facility failed to provide an assistive device for one (1)resident out of the forty-six (46) sampled residents. Resident #78 was to utilize a handled cup and it was not provided consistently. In addition Resident #78 was to have one on one supervision with eating as outline in the speech therapy discharge summary. The findings include: Record review of the facility policy Adaptive Equipment - Feeding Device with a date of 08/2019, revealed adaptive feeding equipment was used by the residents to improve their ability to feed themselves and improve their eating functions. Record review of the communication from therapy to staff policy revealed there wasn't a policy. Observation during the lunch meal, on 08/27/19 at 12:15 PM, revealed Resident #78 was eating his/her lunch in his/her room and was unassisted by staff. Observation of the meal tray showed he/she had pureed food, milk in a carton, and punch in a regular glass with a straw. Observation of the diet care revealed Resident #78 was to have a handled cup for fluids. Observation during the lunch meal, on 08/27/19 at 11:59, revealed Resident #78 had a carton of milk and a glass of lemonade and no handled cup. Observation revealed there were no staff in with the resident. Observation on 08/31/19 at 12:05 PM during the lunch meal revealed Resident #78 had her/his tray served to her/him in the room. Observation revealed Resident #78 was in her/his room and had tried to feed herself. Observation further revealed there was no staff in the room for supervision. Review of the clinical record revealed Resident #78 was admitted on [DATE] and had [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/19 revealed Resident #78 had a Brief Interview of Mental Status (BIMS) of four, which indicated the resident had impaired cognition. Review of the functional status showed Resident #78 needed extensive assistance of one for eating. Review of the Range of Motion (ROM) revealed Resident #78 had impairment on one side of the upper and lower extremities. Record review of the comprehensive care plan showed a problem for alteration in nutrition and one of the interventions was to assist as needed for meals and set up. Review of the care plan revealed there was no intervention specifically for handled cups and no indication that the resident had to have one on one supervision with meals. Interview with Special Projects Coordinator, on 08/27/19 at 12:00 PM revealed she had delivered the tray to the resident and stated Resident #78 liked to feed herself and staff just monitored her/him. Interview further revealed she usually checked the diet card before setting it up but she had not checked the diet card for Resident #78. After reviewing the diet card the Special Projects Coordinator revealed she did not know why Resident #78 needed handled cups but it may be because of her/his grasp. She revealed the handled cup should have come from the kitchen on the tray. Interview with the Dietary Manager (DM), on 08/30/19 at 8:53 AM, revealed the adaptive utensils needed for each resident were listed on the tray card and they read it at the beginning of the tray line and the items were placed on the tray . The DM further revealed Resident #78 needed the handled cups because he/she spills things and he/she did better with cups that had handles. The DM revealed she did not know why Resident #78 did not receive the handled cups as outlined on the diet card. Record review of the Speech Therapy (ST) discharge summary, dated 8/15/19, revealed Resident #78 was to continue on the least restrictive diet (thin liquids, pureed solids) with one on one assist. The ST discharge summary stated Resident #78 would alternate liquids and solids and use bolus size modifications to facilitate safety and efficiency. It was also recommended for Resident #78 to have close supervision for oral intakes. Interview with the Speech Therapist, on 08/30/19 at 2:18 PM, revealed Resident #78 was recently discharged from speech therapy. The Speech Therapist stated Resident #78 needed one on one supervision with eating because of the cognitive impairment and the lack of initiation to eat when staff was not present. He revealed he had told nursing that Resident #78 needed one on one supervision however, he could not remember who he told. The Speech Therapist revealed Resident #78 should be encouraged to feed herself but staff would sometimes have to assist her. He revealed Resident #78 needed someone with her because sometimes her/his arms were restricted and he/she can't always hold them up. He stated Resident #78 had oral dysphagia and that was why the resident was on a pureed diet. The Speech Therapist stated that was why staff needed to be in there with her/him to make sure smaller bites were taken. The Speech Therapist further revealed he verbally communicated the recommendation to nursing and did not document who he spoke with. He was not sure if nursing had access to his discharge summaries. Interview with Medical Record staff, on 08/31/19 at 12:15 PM, revealed she had taken the tray into Resident #78's room and set it up. She revealed Resident #78 was okay to eat by herself/himself as far as she knew. Interview with Certified Nursing Assistant (CNA) #3, who was the CNA for Resident #78, on 08/31/19 at 12:15 PM, revealed Resident #78 could feed self and she was not aware that the resident needed one on one supervision. CNA #3 reviewed her CNA care plan sheet and it did not indicate the resident needed one on one supervision with eating. Interview with Licensed Practical Nurse (LPN) #2, on 08/30/19 at 2:25 PM, revealed the speech therapist would tell them verbally a recommendation or a note may be in room to alert them to what the recommendations were. LPN #3 reviewed the physician orders and could not find an order for [REDACTED].#78 had received a pureed diet. LPN #2 reviewed Resident #78 chart and could not find any order for pureed diet or one on one supervision as outlined in the speech therapy discharge summary. Interview with the Minimum Data Set (MDS) staff, 08/31/19 at 2:38 PM, revealed the speech therapy recommendations should be on the care plan and should be on the CNA care plan sheet. After she reviewed the speech therapy discharge summary from 08/15/19 she revealed she was not aware of the need for one on one supervision with meals for Resident #78 and the need to alternate liquids and solids. She revealed those interventions should be on the care plan and they were not. After she reviewed the speech therapy notes she revealed Resident #78 had dysphagia which meant he/she had difficulty with swallowing and that placed her/him at risk for aspiration, further decline in function, and at risk for pneumonia. The MDS staff further revealed if speech therapy did not convey the discharge summary recommendation to nursing then the nurses would have no way of knowing what orders to obtain from the physician because speech therapy recommendations have to have a physician order. Interview with Signature Care Nurse Consultant, on 08/31/19 at 4:10 PM, revealed the facility did not have a policy regarding communications from therapy to nursing. She revealed when therapy discharged a resident they should communicate specific instructions and write an order for [REDACTED]. The Signature Care Nurse Consultant further revealed she was not aware of the need for one on one supervision for Resident #78 until that day. She revealed it should have been communicated and she did not know where the breakdown occurred because there was no documentation that nursing had been notified. She also revealed she did not know why the physician orders did not reflect the pureed diet. She revealed the pureed diet as a lower level of diet and the safest but Resident #78 might now eat as well since different than mechanical soft. She stated she did not think there was a risk of choking given the consistency of the food.

Based on observation, interview, and record review, it was determined the facility failed to ensure there was sufficient nursing staff to provide showers for one (1) of three (3) sampled residents, Resident #2, and two (2) unsampled residents, Unsampled Residents A and B. In addition, call lights were not answered timely. The findings include: The facility did not provide a policy regarding staffing or Activities of Daily Living (ADL). Review of Resident Council monthly meeting minutes from (MONTH) (YEAR) through (MONTH) (YEAR), revealed residents voiced concerns related to staff response to call lights in May, June, and August. Review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident was totally dependent on staff for bathing. Observation of Resident #2, on 09/02/18 at 9:25 AM, 11:57 AM, and 2:42 PM, revealed the resident was in bed on his/her back in the same position with the head of bed elevated. Interview with Resident #2, on 09/02/18 at 9:31 AM, 11:57 AM, and 2:37 PM, revealed sometimes staff entered his/her room and turned the call light off without providing assistance, especially when staff was about to go home. The resident stated he/she asked to get a shower and was supposed to get two (2) a week, Tuesday and Friday, but only got one (1) shower last month. The resident stated the Certified Nursing Assistants (CNA) gave him/her a bed bath instead of showers. Observation and interview with Resident #2, on 09/03/18 at 8:31 AM, revealed the resident in bed and stated he/she told nursing staff he/she wanted to get up and in the wheelchair, but he/she was still in bed and bored. Review of Unsampled Resident A's clinical record revealed the facility assessed the resident on 08/28/18 with a BIMS score of fifteen (15) of fifteen (15) and determined the resident interviewable. The facility assessed the resident was totally dependent on staff for bathing. Observation and interview of Unsampled Resident A, on 09/25/18 at 3:15 PM, revealed the resident sitting up in a wheelchair in the doorway to the resident's room. The resident stated he/she had not had a shower in days and had not seen the CNA for his/her unit. Unsampled Resident A further stated the facility did not have enough help to assist the residents but did not specify further. Review of Unsampled Resident B's clinical record revealed the facility assessed the resident on 08/02/18 with a BIMS score of eleven (11) of fifteen (15) and determined the resident was interviewable. The facility determined the resident was totally dependent on staff for bathing. Observation and interview of Unsampled Resident B, on 09/26/18 at 9:18 AM, revealed the resident sitting up in a wheelchair in the resident's room. The resident stated he/she received a shower yesterday after about a week with no showers. Review of Resident #3's Admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eight (8) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for bed mobility. Observation of Resident #3, on 09/02/18 at 10:02 AM and 09/03/18 at 8:52 AM, revealed the resident was in bed on his/her back. There was tubing for a [MEDICAL CONDITION], gastrostomy, as well as a urinary catheter, and the resident stated staff did not check on him/her when needing assistance. Interview with Resident #3, on 09/02/18 at 10:05 AM, and 12:11 PM, revealed the CNAs would not check to see if he/she needed any assistance when he/she used the call light. The resident stated it was hard to turn with all the tubes and if staff came when he/she used the call light, he/she would not have a problem, but staff took to long and did not help him/her. He/she stated sometimes it seemed like the call light did not work. Interview with Family #1, on 09/03/18 at 8:58 AM, revealed the response to Resident #3's call light was forty (40) minutes last night. He further stated multiple call lights were going off because there was not enough staff to assist residents. Interview with CNA #2, on 09/03/18 at 3:48 PM, revealed the facility did not have enough staff and she dreaded going to work. She stated she had thirteen (13) high acuity residents on the rehabilitation hall. Besides that, two (2) residents were in isolation, which she stated took more time because she had to apply Personal Protective Equipment (PPE) to assist the residents. She stated she spoke to the Director of Nursing (DON) about her concerns; however, the facility thought the staffing was sufficient. She stated when she had to give showers, she relied on the nurse to assist her with call lights, but the nurse was not always able to cover for her. She spoke to the Staffing Coordinator about being short staffed, but there were no changes. She was concerned resident care suffered without having enough staff. Interview with CNA #3, on 09/03/18 at 4:17 PM, revealed two (2) CNAs could not do everything that was expected of them. She stated there was twenty-seven (27) residents on the C Hall, plus thirteen (13) on the rehabilitation hall, for a total of forty (40) residents. She stated when she had to give showers to residents who required a mechanical lift, sometimes she had to give a bed bath. She stated today she had four (4) showers assigned and she had to drop one and give a bad bath instead of the shower. She stated there was not enough staff to give showers the way residents were supposed to get them. Interview with Licensed Practical Nurse #1, on 09/03/18 at 5:19 PM, revealed there was not always enough CNAs, especially on Fridays and Saturdays. She stated most times it was the weekends when there was insufficient staffing. Interview with DON #1, on 09/03/18 at 6:31 PM, revealed the facility conducted staffing in respect to acuity of the resident population. She expected all staff to answer call lights timely to take care of the residents.

Based on interview, record review, and facility policy review, it was determined the facility failed to maintain accurate and complete clinical records for one (1) of three (3) sampled residents, Resident #2. The Medication Administration Record (MAR) contained multiple blank spaces for ordered wound treatments. The findings include: Review of facility's policy, Charting and Documentation, last reviewed 07/02/18, revealed any services provided to the resident or any changes in the resident's medical or mental condition would be documented in the resident's medical record. In addition, documentation included the date and time of a procedure/treatment provided, name and title of staff providing the care, assessment data/unusual findings, how the resident tolerated the procedure, resident refusal of the procedure, notification to parties if indicated, and the signature and title of the individual documenting the procedure. Review of the clinical record for Resident #2 revealed a physician order, dated 06/06/18, for [MEDICATION NAME]-iodine ([MEDICATION NAME]) 10% solution, apply [MEDICATION NAME] moist gauze to right ischial and sacral wound twice daily. In addition, complete weekly skin assessments on Wednesday. Review of the MAR for (MONTH) (YEAR), revealed an order for [REDACTED]. There was no documentation the treatment was administered on day shift on 06/16/18, 06/19/18, 06/23/18, and 06/28/18; or night shift on 06/14/18, 06/15/18, 06/16/18, 06/19/18, 06/25/18, 06/26/19, 06/27/18, 06/28/18, and 06/30/18. There was no documentation the resident refused the treatment on those dates. Review of the MAR for (MONTH) (YEAR), revealed no documentation the [MEDICATION NAME] treatment was administered on day shift on 07/31/18; or night shift on 07/02/18, 07/03/18, 07/06/18, 07/08/18, 07/11/18, 07/17/18, 07/29/18, and 07/31/18. There was no documentation the resident refused the treatment on those dates. In addition, there was no documentation the weekly skin assessment was completed on 07/11/18. Review of the MAR for (MONTH) (YEAR), revealed no documentation the [MEDICATION NAME] treatment was administered on day shift on 08/02/18, 08/06/18, 08/10/18, 08/21/18, 08/25/18, 08/28/08, 08/30/18, and 08/31/18; or night shift on 08/01/18, 08/12/18, 08/22/18, and 08/27/18. There was no documentation the resident refused the treatment on those dates. In addition, there was no documentation the weekly skin assessment was completed on 08/01/18, 08/22/18, and 08/29/18. Review of the MAR for (MONTH) (YEAR), revealed no documentation the [MEDICATION NAME] treatment was administered on day shift on 09/01/18, 09/02/18, 09/06/18, 09/10/18, and 09/13/18; or night shift on 09/01/18, 09/02/18, and 09/03/18. Interview with Licensed Practical Nurse (LPN) #1, on 09/03/18 at 4:51 PM, revealed staff documented completion of treatments in the MAR and she considered an undocumented treatment as not done. LPN #1 stated staff documented resident refusals of treatment in the MAR also. Interview with Registered Nurse (RN) #1, on 09/03/18 at 5:23 PM, revealed if staff did not document treatment was done; it meant staff did not execute the treatment as ordered. RN #1 stated if staff did not provide wound treatment as ordered, it could cause the wound not to heal or infection to develop. Interview with the Staff Development Coordinator (SDC), on 09/02/18 at 2:19 PM, revealed staff documented completion of treatments in the MAR, including any appropriate notes. The SDC stated if staff did not document treatment, then staff did not complete the treatment and did not follow the physician order. The SDC stated following physician wound order treatments promoted wound healing and implications from incomplete treatment included worsening wounds and infections to the resident. Interview with Director of Nursing (DON) #1, on 09/03/18 at 6:06 PM, revealed she was aware the facility had issues with clinical record documentation. The DON stated incomplete documentation reflected an inaccurate clinical record. Interview with the DON #2, on 09/26/18 at 11:22 AM, revealed a blank space on the MAR indicated staff omitted a treatment. DON #2 stated he was aware of a documentation issue with staff but was unsure why blanks continued to exist on the MAR. He stated the blanks on a MAR resulted in an incomplete record.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were accurately labeled with the date opened on two (2) of four (4) medication carts. In addition, the facility failed to ensure bottles of nutritional feeding were not expired. The findings include: Review of the facility's policy, Medication Storage, revised (MONTH) (YEAR), revealed medications and biologicals were stored properly following the manufacturer or pharmacy recommendations to maintain their integrity and to support safe effective drug administration. In addition, the policy stated to note the date of first use on the label for insulin vials and pens. Observation of the B Wing Medication Cart, on [DATE] at 8:30 AM, revealed one (1) [MEDICATION NAME]flex pen and one Toujeo insulin flex pen were opened and not labeled with the dates opened. Observation of the D Wing Medication Cart, on [DATE] at 8:45 AM, revealed one (1) opened [MEDICATION NAME] flex pen and one (1) opened [MEDICATION NAME] flex pen not labeled with the dates opened. In addition, three (3) packages of solution for nebulization were opened and not labeled with date opened. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed she did not see a date written on either flex pen from the medication cart on the B Wing and stated the flex pens should have been labeled with the dates they were opened. RN #3 did not know why the insulin flex pens were not dated when opened but stated it was facility policy to date insulin when first opened. Interview with RN #1, on [DATE] at 8:45 AM, revealed all items should be labeled when opened for any type of insulin, and the nebulizer treatments had stickers on them so she thought those should be dated as well. RN #1 did not know why the insulin flex pens or nebulizer solutions were not dated when opened. Interview with the Unit Manager (UM), on [DATE] at 9:15 AM, revealed it was facility policy to date insulin when opened and she did not know why the insulin flex pens observed were not dated. In addition, she stated she was not aware the nebulizer solutions had stickers on them so they could be dated when opened. The UM stated it was her responsibility to do an audit of all medication carts to ensure expired and undated medications were removed from the carts. The last audit was completed [DATE]; however, the results were not documented. The UM did not state whether staff received education on removing expired medication or ensuring opened medication were labeled. Observation of the Central Supply Room and interview with Unit Manager, on [DATE] at 9:30 AM, revealed eight (8) bottles of Two Cal-HN Nutritional Feeding with an expiration date of [DATE]. The UM stated she did not know who audited the central supply room, and did not know when the last audit was completed or why the expired bottles of nutritional feeding were not removed. In addition, she stated no resident was currently on Two Cal-HN. Interview with the Interim Director of Nursing (DON), on [DATE] at 1:15 PM, revealed she was not aware of the eight (8) expired bottles of nutritional feeding or four (4) insulin flex pens and three (3) nebulizer solutions opened, used, and not labeled with the dates opened. The DON stated education had been done with the nurses but not documented. In addition, she stated it was the responsibility of the UM and night shift supervisor to audit medication carts for expired or un-dated medication and remove them. However, she stated the audits were not documented and there was no specific schedule regarding the audits.

Based on observation, interview, record review, and facility job description review, it was determined the facility failed to provide adequate supervision for one (1) of twenty (20) sampled residents, Resident #37. Observation revealed Resident #37 fell from his/her wheelchair onto the parking lot pavement when taken to a transport van. The findings include: Observation, on 06/07/18 at 10:12 AM, revealed Resident #37 laying on the facility parking lot pavement. The resident was semi-reclining on his/her right elbow, awake and alert. A transport driver was supporting the resident from behind and the resident's wheelchair was facing the resident on his/her left side. The right wheel of the chair was unlocked and the left wheel was locked. At 10:14 AM the facility's Escort came out and spoke with the resident and transport driver, and then went back into the facility. At 10:15 AM, the Interim Director of Nursing (DON) came out and assessed the resident. Interview with Resident #37, on 06/07/18 at 10:13 AM, and prior to the Escort coming out of the facility, revealed he/she did not know what happened but that he/she was fine and not hurt. In addition, the resident stated he/she did not hit his/her head. Review of Resident #37's clinical record revealed the facility admitted Resident #37 on 10/26/17, with [DIAGNOSES REDACTED]. The facility assessed Resident #37 on 05/18/18 with a Brief Interview for Mental Status score of eleven (11) out of fifteen (15) and determined the resident was interviewable. Review of the Comprehensive Care Plan for Resident #37, dated 04/12/18, revealed the facility assessed the resident was at risk for a fall related injury due to a history of unsafe transfer attempts. Interview with the Escort, on 06/07/18 at 12:59 PM, revealed her job was to escort residents to physician or hospital appointments, take facility information to the appointments, and bring information back to the facility from the appointments. She stated the transport driver took Resident #37 out of the facility that morning, 06/07/18, after she told the driver she was going to the restroom, otherwise usually she would be with the resident and transport driver when they left the facility. She further stated she had no orientation to the role of Escort and there were no specific directions on her job description as Hospitality Aide about what she should do as an Escort. The Escort stated she should have been with Resident #37 when the resident left the building and the fall could have been avoided. Review of the facility's Hospitality Aide Job Description, dated (MONTH) 2011, (provided as a job description for the Escort) revealed no direction for the Hospitality Aide when acting as a resident Escort. Interview with the Staff Development Coordinator, on 06/07/18 at 1:30 PM, revealed there was no evidence the facility trained the Escort regarding that role. Interview with the Unit Manager, on 06/07/18 at 2:20 PM, revealed it was her understanding the Escort went to physician or hospital appointments with residents if a family member could not go. She stated the Escort worked as necessary when a Unit Manager called her to assist a resident to an appointment. She further stated it was her understanding the Escort would stay with the resident from the time the resident left his/her room, to out of the facility and into the transport van. According to the Unit Manager, Resident #37, or any resident, could have a serious injury from a fall onto pavement and the fall might have been avoided if the Escort had been with the resident. Interview with the Interim DON, on 06/07/18 at 2:35 PM, revealed she assessed Resident #37 after the resident fell and found him/her to be without injury. She stated after the assessment, Resident #37 went to the previously arranged hospital visit with the Escort and the transport driver. She stated the transport driver told her he had locked Resident #37's wheelchair and had turned to lower the wheelchair lift when he heard a noise, and turned and saw the resident on the pavement. According to the Interim DON, the Escort should stay with residents when being transported from the facility to avoid accidents and serious harm to residents. The Interim DON stated the Escort was a nursing service employee but she had not given the Escort any specific directions in the short time she had been Interim DON. Interview with the Administrator, on 06/07/18 at 5:00 PM, revealed the transport driver was responsible for a resident once the transport driver took the resident out of the facility, as some of the residents did not need an Escort even if family were not present. However, she stated the Escort should have been with Resident #37 that morning. She further stated Resident #37 could have been seriously harmed when he/she fell from the wheelchair onto the pavement and she stated the facility was ultimately responsible for all the residents.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician of abnormal laboratory results for one (1) of four (4) sampled residents, Resident #2. The findings include: Review of the facility's policy, Laboratory Protocol-Diagnostic Testing, not dated, revealed the facility provided laboratory, radiological, and diagnostic services as necessary and assured that the results were reported to the resident's Attending Physician/NP (Nurse Practitioner)/PA (Physician Assistant) or clinical Nurse Specialist as necessary. Review of the facility's policy, Change in Condition, updated 05/12/17, revealed the facility documented changes in a resident's health status in an efficient and effective manner and relayed the evaluation information to the physician, then documented actions that included, but not limited to the following: a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment; a decision to transfer or discharge the resident from the facility; refusals of compliance with prescribed plan of care; and accidents with injuries. Review of Resident #2's clinical record revealed the facility readmitted the resident on 12/08/17, with [DIAGNOSES REDACTED]. Review of Resident #2's Progress Notes, dated 04/10/18, revealed the physician saw the resident and ordered a urine analysis, and culture and sensitivity laboratory test to rule out a Urinary Tract Infection [MEDICAL CONDITION]. Review of Resident #2's Laboratory Results, dated 04/13/18 at 10:53 AM, revealed the resident had a UTI. Review of Resident #2's Progress Notes, dated 04/16/18, revealed the resident's abnormal laboratory results were called to the Advanced Practiced Registered Nurse (APRN) three (3) days after the facility received the results. The APRN ordered an antibiotic for seven (7) days. Review of Resident #2's Physician Order, dated 04/16/18, revealed the APRN ordered Bactrim DS (antibiotic), one (1) tablet, twice a day, for seven (7) days. Interview with the Unit Manager of the A and B Halls, on 04/19/18 at 10:23 AM, revealed as soon as laboratory results were available, staff was to notify the physician of the results. She stated calling the physician three (3) days later was not effective because Resident #2's infection could have gotten worse, which could have been detrimental to the resident. Interview with the Director of Nursing, on 04/20/18 at 3:28 PM, revealed the laboratory policy and change in condition policy required nurses to notify the physician in a timely manner, which had not happened for Resident #2. Interview with the Administrator, on 04/20/18 at 3:25 PM, revealed although she was not a clinician, she expected clinical staff to notify the physician regarding abnormal laboratory results immediately.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of four (4) sampled residents, Resident #1. The findings include: Review of the facility's policy, Care Plans-Comprehensive, dated 10/31/17, revealed a person-centered comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs and included how the facility met the needs, goals, and preferences of a resident. The comprehensive care plan was based on a thorough assessment and enhanced the optimal functioning of the resident by incorporating identified problem areas, built on the resident's strength and focused on a rehabilitative program. Review of Resident #1's clinical record revealed the facility readmitted the resident on 02/03/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) and determined the resident interviewable. The facility determined the resident required extensive assistance of one (1) person with locomotion on the unit and the resident had no upper or lower extremity impairment. Review of Resident #1's Care Plan, dated 01/21/18, revealed the resident had a self-care deficit for Activities of Daily Living (ADL) with a goal for the resident to maintain his/her ADL self-performance levels. The approach was for Certified Nursing Assistants (CNA) to ambulate the resident to the dining room daily for all meals, which equaled fifteen (15) minutes of ambulation for each meal. Observation of Resident #1, on 04/17/18 at 8:25 AM, revealed the resident was dressed and groomed and seated in his/her wheelchair outside the resident's room. Staff arrived and pushed the resident in the wheelchair to the C Hall dining room for breakfast without encouraging Resident #1 to ambulate. Review of Resident #1's CNA Care Report, not dated, revealed a restorative intervention to assist the resident to ambulate to the dining room for meals daily with gait belt and rolling walker, pulling the wheelchair behind the resident in case of fatigue, which equaled fifteen (15) minutes. Review of Resident #1's Restorative Nursing Report, dated 02/21/18 to 04/17/18, revealed the resident ambulated fifteen (15) times in fifty-six (56) days. Review of Resident #2's Progress Notes, dated 03/14/18, revealed the resident continued with the restorative program for ambulation and Active Range of Motion and tolerated the program well as he/she continued to be monitored. Interview with Resident #1, on 04/17/18 at 11:20 AM, revealed walking was hard; however, he/she did not get many chances to walk and was not given the opportunity to ambulate as often as he/she would have liked. Interview with CNA #4, on 04/18/18 at 4:16 PM, revealed Resident #1 was supposed to walk to meals; however, she stated the last few weeks the resident had a problem with pivoting. She stated second shift did not have a restorative program that she knew of. Interview with the Unit Manager of the C and D Halls, on 04/19/18 at 11:18 AM, revealed although Resident #1 was to walk routinely every morning, ambulating was not offered consistently to the resident. She further stated walking made the resident feel like he/she was not losing his/her abilities because Resident #1's mind was good. Interview with the MDS Nurse, on 04/19/18 at 3:12 PM, revealed he implemented the restorative program on the care plan for Resident #1. He stated the resident wanted to walk to meals and CNAs on the unit were to assist the resident with ambulation. The MDS nurse stated to the best of his knowledge, the care plan was implemented for the most part. However, he did not work on the unit because he completed the MDS'. Interview with the Director of Nursing, on 04/19/18 at 12:31 PM, revealed she did not know about the resident's restorative program. However, she stated the care plan was not implemented if staff did not offer to walk the resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident with limited mobility received appropriate services to maintain or improve mobility for one (1) of four (4) sampled residents, Resident #1. Resident #1 was discharged from Physical Therapy services with recommendations for restorative nursing services to continue the Functional Maintenance Program for transfers and ambulation. However, the facility failed to provide consistent restorative nursing services for Resident #1. The findings include: Review of the facility's Restorative Nursing Policy and Procedure Manual, not dated, revealed the program focused on transfers, use of assistive devices such as walkers, canes, and wheelchairs, and increased independent ambulation for all residents. Ambulation was provided in accordance with the Restorative Plan of Care. Review of Resident #1's clinical record revealed the facility readmitted the resident on 02/03/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 01/21/18, revealed the resident had a self-care deficit for Activities of Daily Living (ADL) with a goal for the resident to maintain his/her ADL self-performance levels. The approach was for Certified Nursing Assistants (CNA) to ambulate the resident to the dining room daily for all meals, which equaled fifteen (15) minutes of ambulation for each meal. Review of Resident #1's CNA Care Report, not dated, revealed a restorative intervention to assist the resident to ambulate to the dining room for meals daily with gait belt and rolling walker, pulling the wheelchair behind the resident in case of fatigue, which equaled fifteen (15) minutes. Observation of Resident #1, on 04/17/18 at 8:25 AM, revealed the resident seated in his/her wheelchair outside the resident's room. Staff arrived and took the resident in his/her wheelchair to the dining room for breakfast without offering Resident #1 to ambulate. Observation of Resident #1, on 04/17/18 at 11:47 AM, revealed the resident was able to stand, hold on to the rail in the bathroom, and pivot during wound care. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) and determined the resident interviewable. The facility determined the resident required extensive assistance of one (1) person with locomotion on the unit and the resident had no upper or lower extremity impairment. The resident was able to move from a sitting to a standing position and complete surface-to-surface transfers with one (1) person assistance. Interview with Resident #1, on 04/17/18 at 11:20 AM, revealed walking was hard; however, he/she did not get many chances to walk, and was not given the opportunity to ambulate as frequently as he/she would have liked. Review of a Physical Therapy (PT) Discharge Summary, dated 01/19/18, revealed Resident #1 was discharged with recommendations for restorative nursing to include transfers and ambulation as a continued Functional Maintenance Program. The prognosis to maintain the current level of functioning was good, according to the PT note. Review of the Nursing Progress Notes, dated 03/14/18, revealed Resident #1 continued with his/her restorative program for ambulation and Active Range of Motion and tolerated the program well. Review of Resident #1's Restorative Nursing Report, dated 02/21/18 to 04/17/18, revealed the resident ambulated fifteen (15) times in fifty-six (56) days. Interview with the Physical Therapist, on 04/19/18 at 12:49 PM, revealed Resident #1 was able to walk between fifty (50) to one hundred and ninety-nine (199) feet. She stated the resident should be on the restorative program for walking. Interview with CNA #4, on 04/18/18 at 4:16 PM, revealed Resident #1 was supposed to walk to meals; however, she stated the last few weeks the resident had a problem with pivoting. She stated second shift did not have a restorative program that she knew of. Interview with the Unit Manager of the C and D Halls, on 04/19/18 at 11:18 AM, revealed although Resident #1 was to walk routinely every morning, ambulating was not offered consistently to the resident and made the resident feel like he/she lost his/her functional abilities since Resident #1's mind was good. Interview with the MDS Nurse, on 04/19/18 at 3:12 PM, revealed he implemented the restorative program on the care plan for Resident #1. He stated the resident wanted to walk to meals and CNAs on the unit assisted the resident with ambulation. Interview with the Director of Nursing, on 04/19/18 at 12:31 PM, revealed she was not informed about the resident's restorative program.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure staff performed proper hand hygiene during wound care for one (1) of four (4) sampled residents, Resident #1. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, revised (MONTH) (YEAR), revealed hand hygiene was to be performed before and after direct contact with residents, before handling clean or soiled dressings, after handling used dressings, and after removing gloves. Handwashing was described as vigorously lathering hands with soap and water, creating friction to all surfaces for a minimum of twenty (20) seconds at a comfortable water temperature. Observation of Resident #1's wound care, on 04/17/18 at 11:47 AM, revealed the resident had a wound to his/her coccyx and the dressing was soiled with pink to red exudate. Licensed Practical Nurse (LPN) #1 washed her hands, took the resident's dressing off and disposed of it, took her gloves off and washed her hands for seven (7) seconds. Next, the LPN donned clean gloves and used normal saline to cleanse the wound. However, prior to packing the wound with Dakins Solution, LPN #1 failed to wash her hands and completed the dressing change by applying Santyl around the wound and affixing an abdominal pad. Then LPN #1 washed her hands for ten (10) seconds, grabbed the garbage bag containing the disposed dressing, and exited Resident #1's room. Interview with LPN #1, on 04/17/18 at 11:55 AM, revealed she did not wash her hands long enough. She stated she was supposed to sing happy birthday twice in her head but got nervous. LPN #1 further stated handwashing was done to prevent infections and since she left Resident #1's room, she could have taken the infection with her and spread it to other residents. Interview with the Director of Nursing, on 04/19/18 at 11:56 AM, revealed she expected nurses to wash hands appropriately then don gloves and wash hands after the removal of a dressing and when the treatment was completed. If staff did not wash hands effectively, it contributed to an infection control issue and there was a chance LPN #1 could have contaminated other things. Interview with the Administrator, on 04/20/18 at 3:22 PM, revealed she expected clinical staff to follow the infection control protocol and wash hands for twenty (20) seconds or longer. She stated nursing staff was responsible to assure adequate handwashing.

Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicare Services Resident Assessment Instrument User's Manual, Version 3.0, it was determined the facility facility failed to revise the Comprehensive Care Plan based on the assessment to meet the physical needs of one (1) of four (4) sampled residents (Resident #1). Resident #1 was identified in the Quarterly Minimum Data Set (MDS) assessment dated [DATE], as requiring extensive assistance of two (2) persons for bed mobility; however, the Comprehensive Care Plan was not individualized with specific interventions to state how many persons were required to assist with bed mobility. On 09/19/16 one (1) staff member was attempting to provide perineal care to Resident #1 and assisted with bed mobility by turning the resident to his/her left side, when the resident reached out and grabbed an overbed table which rolled away, causing the resident to roll out of bed. Resident #1 sustained injuries including a Right Distal Radius Fracture, a Right Index Finger Fracture, a Laceration to the Right Forehead, and Skin Tears to the Right Elbow and Left Index Finger. The findings include: Review of the Centers for Medicare and Medicare Services Resident Assessment Instrument User's Manual, Version 3.0, revealed regulations require facilities to complete at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs. The results of the assessment, which must accurately reflect the resident's status and needs, were to be used to develop, review, and revise each resident's Comprehensive Care Plan. Review of the facility Care Plans-Comprehensive Policy, undated, revealed the Comprehensive Care Plan was based on a thorough assessment. Each residents' Comprehensive Care Plan was designed to incorporate identified problem areas; incorporate risk factors for the identified areas; and aide in preventing or reducing declines in the resident's functional status and/or functional levels. Care Plans were to be revised as information about the resident and the residents' condition changed and the Nurse/Interdisciplinary Team was responsible for the review and updating of Care Plans. Per Policy, the Care Plan should reflect the current status of the resident and be updated when there was a significant change in the residents' condition, when the desired outcome was not met, when the resident was readmitted from a hospital stay and at least quarterly. Review of Resident #1's clinical record revealed the facility admitted the resident on 06/14/16 with [DIAGNOSES REDACTED]. Interview with MDS Nurse #1, on 12/21/16 at 10:01 AM, revealed the MDS Detail Form was the form the State Registered Nurse Aides (SRNA) completed to indicate how much assistance was required for functional status for residents during the look back period for the MDS. Review of the seven (7) day look back period as outlined on the facility MDS Detail Form under Section G, for Resident #1's Quarterly MDS dated [DATE], revealed Resident #1 required two (2) assist with bed mobility a total of seven (7) out of thirty-one (31) documented instances which occurred on days and evenings with three (3) different SRNAs. Review of the Quarterly MDS Assessment, dated 09/07/16, revealed the facility assessed Resident #1 as having both short and long term memory loss and as requiring extensive assist of two (2) persons for bed mobility. Review of the Comprehensive Care Plan dated 06/24/16, and revised September 2016, revealed Resident #1 was a fall risk related to his/her unsteady balance and a history of falls. The goal stated the resident would not sustain a fall related injury by utilizing fall precautions through the next review date. The interventions included the following: monitoring by nursing staff for side effects of medications; keeping the call light in reach; and ensuring the resident had appropriate footwear. However, the Care Plan was not specific and individualized to include interventions stating the number of staff required for assistance with Activities of Daily Living (ADL's) performance including bed mobility. Further review of the Comprehensive Care Plan dated 06/24/16, and revised September 2016, revealed the resident had a problem of Activities of Daily Living (ADL) Self Care Deficit and was at risk for complications related to the deficit requiring assist in all ADL's, which may fluctuate related to lethargy and motivation. The goal stated the resident would participate with care and would be clean, groomed and dressed by resident's choice through next review. The interventions included the need for two (2) staff to assist with transfers, and provide only the amount of assistance/supervision to meet Resident's needs for all ADLs. However, the Care Plan was not specific and individualized to include interventions stating the number of staff required for assistance with bed mobility. Review of the Weekly Note dated 09/11/16 written by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was coded total dependence for bed mobility. However, review of the Daily Skilled Nursing Note dated 09/15/16 completed by LPN #1, revealed staff assessed Resident #1 as dependent on one (1) staff for bed mobility. Post survey interview with LPN #1 on 01/09/17 at 4:14 PM, related to the difference in the required assistance with bed mobility per the Weekly Note dated 09/11/16,and the Daily Skilled Note dated 09/15/16, revealed she was not sure why there was the discrepancy and didn't remember what was going on with Resident #1 at the time. Review of Resident #1's Nurse Aide Care Plan, undated, revealed no interventions related to the number of staff needed to assist the resident with bed mobility. Interview with MDS Nurse #1, on 12/21/16 at 10:01 AM, revealed the Nurse Aide Care Plan was updated daily as needed, and provided to SRNAs at the start of their shift. She revealed Nurse Aide Care Plans were a tool for the SRNAs to use. Review of the facility Investigation for Resident #1, revealed on 09/19/16 at 10:00 PM, Resident #1 rolled out of bed during routine care being provided by SRNA #1. Continued review revealed the resident sustained [REDACTED]. Further review of the Investigation, revealed the resident was transferred to the hospital on [DATE] at 10:45 PM due to injuries. Interview with State Registered Nurse Aide (SRNA) #1, on 12/20/16 at 12:45 PM, revealed she didn't know Resident #1 very well and had only worked with Resident #1 a few times prior to being assigned to care for the resident on 09/19/16. She stated she worked second shift from 2:30 PM until 10:30 PM, on 09/19/16, and had received a copy of the Nurse Aide Care Plan at the beginning of her shift which indicated Resident #1 required assistance of one (1) for bed mobility. SRNA #1 further revealed at 10:00 PM, she turned Resident #1 over on his/her left side to provide perineal care when Resident #1 reached out and grabbed an overbed table which rolled away, causing the resident to roll out of bed. SRNA #1 confirmed there was no other staff present in the room when she attempted to turn the resident in the bed to provide perineal care. Post survey interview with LPN #1, on 01/09/17 at 4:14 PM, revealed she was the nurse assigned to Resident #1 on the night of 09/19/16 at the time the resident sustained [REDACTED]. She stated on the night of 09/19/16 SRNA #1 rushed to the desk and informed her Resident #1 had sustained a fall. She revealed she immediately assessed Resident #1, who had a laceration above the eyebrow, was bleeding from a finger, and was holding his/her right arm. She stated nursing staff was responsible for ensuring SRNAs followed resident care needs as documented on the Plans. She further revealed she wasn't certain at the time of the interview the amount of assistance Resident #1 required with bed mobility, but believed SRNA #1 had been following the Nurse Aide Care Plan. Review of the Hospital Operative Procedure, dated 09/24/16, revealed the resident underwent [REDACTED]. on ulnar side of fingertip. Review of the Hospital After Visit Summary, dated 09/24/16, revealed Resident #1 was admitted on [DATE] and during the hospital stay received the following procedure: Right Wrist Open Reduction Internal Fixation (ORIF) (surgical procedure to fix a severe bone fracture or break) for Distal Radius Fracture and Right Index Finger ORIF for Distal Phalanx Fracture and Repair of Skin Laceration. Further interview with MDS Nurse #1, on 12/21/16 at 10:01 AM, revealed the MDS Nurses developed and revised the Comprehensive Care Plan, along with nursing staff and other members of the interdisciplinary team, and the MDS Nurses used the Comprehensive Care Plan as a basis for developing and revising the Nurse Aide Care Plans. She further stated the Comprehensive Care Plans and SRNA Care Plans were updated as needed based on information obtained from staff and from new physician's orders [REDACTED].#1 revealed she completed the Quarterly MDS for Resident #1 dated 09/07/16, and reviewed and revised the Comprehensive Care Plan after completing the MDS. She revealed she reviewed Nurse's Notes, interviewed SRNAs, and reviewed the MDS Detail Form under Section G, for the look back period as part of care planning. She stated she did not care plan Resident #1 to be a two (2) person assist with bed mobility and would not necessarily care plan a resident as a two (2) person assist, unless he/she required a two (2) person assist with bed mobility fifty (50) percent or more of the time on the seven (7) day look back period. However, she further acknowledged the MDS assessment was to be utilized in guiding the Comprehensive Care Plan related to the care required for the residents. Interview with the Director of Nursing (DON), on 12/21/16 at 11:42 AM, and post survey interview on 01/09/17 at 3:13 PM, revealed she took the position as DON at the facility on 10/31/16. She stated based on review of the Quarterly MDS Detail Section G, dated 09/07/16, Resident #1 required assistance of two (2) for bed mobility three (3) times, and she would expect MDS Nurses to make the determination of the assistance required based on all the available information. The DON further revealed she did not know if having the assist of two (2) staff with bed mobility would have prevented Resident #1's fall on 09/19/16. Interview with the Administrator, on 12/21/16 at 11:58 AM, revealed it was her expectation that the facility meet the regulatory requirements in order to determine and provide the level of care needed. She further acknowledged care planning was not her area of expertise, but stated she expected the MDS staff to know based on their expertise what a residents' needs were and to Care Plan accordingly.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of four (4) sampled residents (Resident #1). Resident #1 was assessed by the facility to require the assist of two (2) persons for bed mobility per the Admission Minimum Data Set (MDS) assessment dated [DATE], and the Quarterly MDS Assessment, dated 09/07/16. According to the Comprehensive Care Plan dated 06/24/16, and revised September 2016, there was no intervention to indicate how many staff were required to assist the resident with bed mobility. On 09/19/16 one (1) staff member was attempting to assist the resident with bed mobility by turning Resident #1 to his/her left side to perform pericare, when the resident reached out and grabbed an overbed table which rolled away, causing the resident to roll out of bed. Resident #1 was admitted to the hospital on [DATE] with a Right Distal Radius Fracture, a Right Index Finger Fracture, a Laceration to the Right Forehead and Skin Tears to the Right Elbow and Left Index Finger. The findings include: Review of the facility Falls Policy, review date 06/01/15, revealed it was the intent of the facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. Further review, revealed all residents would have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition and appropriate care plan interventions implemented and evaluated based on falls risk assessment, with goals and interventions individualized and specific to each resident. Review of Resident #1's medical record revealed the facility admitted the resident on 06/14/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Fall Risk Evaluation, dated 06/14/16 revealed the resident was a fall risk, was able to ambulate without problem and with devices, and was not able to balance without physical help. Further review revealed a total score of seventeen (17), due to fall risk factors and according to the scale a score of ten (10) or higher indicated the resident was a high fall risk. Review of the Nursing Admission Information Form, dated 06/14/16, revealed staff assessed Resident #1 as dependent on two (2) persons for assist with bed mobility. Review of the Daily Skilled Nursing Note dated 06/21/16, revealed Resident #1 was coded as requiring extensive assistance of two (2) for bed mobility. Interview with MDS Nurse #1 on 12/21/16 at 10:01 AM, revealed the MDS Detail Form was the form the State Registered Nurse Aides (SRNA) completed to state how much assistance was required for functional status needed for residents during the look back period for the MDS. Review of the seven (7) day look back period as outlined on the facility MDS Detail Form under Section G for Resident #1's Admission MDS, dated [DATE], revealed Resident #1 required assistance of two (2) staff for bed mobility a total of twelve (12) of thirty-four (34) documented instances. This was over thirty-five (35) percent of the time. These twelve (12) instances occurred during different shifts and involved four (4) different SRNAs. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having both short term and long term memory loss, and as requiring extensive assist of two (2) persons with bed mobility. Review of the Care Area Assessment (CAA) dated 06/21/16, revealed Resident #1 was a new admission, and was at the facility receiving Physical Therapy (PT) and Occupational Therapy (OT) for muscle weakness, history of falling, and lack of coordination. The CAA further stated Resident #1 required extensive assist with bed mobility. Review of the Comprehensive Care Plan dated 06/24/16, and revised September 2016, revealed Resident #1 was a fall risk related to unsteady balance and a history of fall. The goal stated the resident would not sustain a fall related injury by utilizing fall precautions through next review date. The interventions included monitoring by nursing staff for side effects of medications; keeping the call light in reach; and ensuring resident had appropriate footwear. However, the interventions listed did not state the number of staff required for assistance with Activities of Daily Living (ADL's) performance including bed mobility. Further review of the Comprehensive Care Plan dated 06/24/16, and revised September 2016, revealed the resident had an Activities of Daily Living (ADL) Self Care Deficit and was at risk for complications related to the deficit requiring assist in all ADL's which may fluctuate related to lethargy and motivation. The goal stated the resident would participate with care and be clean, groomed and dressed by resident's choice through next review. The interventions included staff assist of two (2) with transfers, and provide only the amount of assistance/supervision to meet Resident's needs for all ADLs. There was no mention of the number of staff required for bed mobility. Review of the Physical Therapy Discharge Summary, dated 06/24/16, revealed Resident #1 had achieved maximum potential from therapy, and at the time of discharge under the section titled, bed mobility, revealed total dependence with attempts to initiate. Interview with Physical Therapist #1, on 12/21/16 at 11:14 AM, revealed Resident #1 was seventy-six (76) to ninety-nine (99) percent dependent on staff for assistance at the time of discharge on 06/24/16, and she (Physical Therapist #1) was able to assist Resident #1 with bed mobility without assistance. When asked if her results were indicative of what should be expected of other staff, she revealed they were not, as the amount of assistance a resident would require could change and could also be affected by the experience, comfort level, and capability of the staff in question. Further interview revealed she did not teach staff related to instructions for bed mobility regarding Resident #1 at time of discharge from therapy. She revealed therapy staff only educated SRNAs on the use of new equipment when provided for residents, and also when there were changes noted in therapy regarding resident care needs. Review of the seven (7) day look back period as outlined on the facility MDS Detail Form under Section G for Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 required two (2) assist with bed mobility a total of seven (7) out of thirty-one (31) documented instances which occurred on days and evenings by three (3) different SRNAs. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having both short and long term memory loss and as requiring extensive assist of two (2) persons for bed mobility. Review of the Weekly Note dated 09/11/16 written by Licensed Practical Nurse (LPN) #1, revealed the resident was coded total dependence for bed mobility. Review of the Daily Skilled Nursing Note dated 09/15/16 completed by LPN #1, revealed staff assessed Resident #1 as dependent on one (1) staff for bed mobility. Post survey interview with LPN #1 on 01/09/17 at 4:14 PM, regarding the discrepancy related to the required assistance with bed mobility for Resident #1 per the Weekly Note dated 09/11/16,and the Daily Skilled Note dated 09/15/16, revealed she was not sure why there was the discrepancy. She stated she didn't remember what was going on with Resident #1 at the time, but if she did not observe something she used report given by SRNAs to guide her documentation. Review of Resident #1's Nurse Aide Care Plan, undated, revealed no instructions related to the number of staff needed to assist the resident with bed mobility. Additional interview with MDS Nurse #1, on 12/21/16 at 10:01 AM, revealed the Nurse Aide Care Plan was updated daily as needed, and provided to nurse aides at the start of their shift. She revealed Nurse Aide Care Plans were a tool for SRNAs. Review of the facility Investigation for Resident #1, revealed on 09/19/16 at 10:00 PM, Resident #1 rolled out of bed during routine care provided by SRNA #1. Further review revealed the resident sustained [REDACTED]. Per the investigation, the resident was transferred to the hospital on [DATE] at 10:45 PM due to injuries. Interview with State Registered Nurse Aide (SRNA) #1, on 12/20/16 at 12:45 PM, revealed she didn't know Resident #1 very well and had only worked with Resident #1 a few times prior to caring for the resident on 09/19/16. She revealed she worked second shift from 2:30 PM until 10:30 PM, on 09/19/16, and had received a copy of the Nurse Aide Care Plan at the beginning of her shift which indicated Resident #1 required assistance of one (1) for bed mobility. SRNA #1 further stated at 10:00 PM, she turned Resident #1 over on his/her left side to provide perineal care when Resident #1 reached out and grabbed an overbed table which rolled away, causing Resident #1 to roll out of bed. SRNA #1 revealed there was no other staff present in the room when she attempted to turn the resident in the bed to provide perineal care. Interview with SRNA #2, on 12/20/16 at 2:41 PM, revealed she had worked with Resident #1 on occasion prior to the fall on 09/19/16, and described Resident #1 as totally dependent on staff for care, with the resident being combative at times. She further stated Resident #1 was a one (1) person assist with bed mobility prior to hospitalization , according to the information which was available on the Nurse Aide Care Plan which was in place prior to the fall. Interview with SRNA #4, on 12/20/16 at 3:01 PM, revealed she worked with Resident #1, and revealed Resident #1 was a one (1) person assist with bed mobility prior to the fall on 09/19/16, and could hold himself/herself over to the side during care. She stated resident care needs were outlined on the Nurse Aide Care Plans, which were reviewed by the SRNAs at the beginning of each shift. Post survey interview with LPN #1, on 01/09/17 at 4:14 PM, revealed she was the nurse assigned to Resident #1 on the night of 09/19/16 at the time the fall occurred. She revealed SRNAs received care sheets which were the Nurse Aide Care Plans at the beginning of their shift which informed them of a resident's care needs, and nursing staff was responsible for ensuring SRNAs followed resident care needs as documented on the Plans. She stated on the night of 09/19/16 she had just returned to her desk when SRNA #1 rushed to the desk and informed her Resident #1 had sustained a fall. She revealed she assessed Resident #1, who had a laceration above the eyebrow, was bleeding from a finger, and was holding his/her right arm. She further revealed she wasn't certain at the time of the interview the amount of assistance Resident #1 required with bed mobility, but believed SRNA #1 had been following the Nurse Aide Care Plan. Review of the Hospital Operative Procedure, dated 09/24/16, revealed Resident #1 accidentally fell out of bed on the night of 09/19/16. Further review revealed the preoperative [DIAGNOSES REDACTED]. The operative procedure included right wrist open reduction (reduction of a fracture after incision into the fracture site) of the intraarticular distal radius fracture, three (3) fragments, and internal fixation (the surgical implementation of implants for the purpose of repairing a bone) with plate; and right index finger open reduction and internal fixation with K-wire (stainless steel pins) for phalangeal base open fracture with displacement, and repair skin laceration wound on ulnar side of fingertip. Review of the Hospital After Visit Summary, dated 09/24/16, revealed the resident was admitted on [DATE] and during the hospital stay received the following procedure: Right Wrist Open Reduction Internal Fixation (ORIF) for Distal Radius Fracture and Right Index Finger ORIF for Distal Phalanx Fracture and Repair of Skin Laceration. Continued interview with MDS Nurse #1, on 12/21/16 at 10:01 AM, revealed the MDS Nurses developed and revised the Comprehensive Care Plan, along with nursing staff and other members of the interdisciplinary team, and MDS staff used the Comprehensive Care Plan as a basis for developing and revising the Nurse Aide Care Plans. She further stated the Comprehensive Care Plans and SRNA Care Plans were updated as needed based on information obtained from staff and from new physician's orders [REDACTED].#1 stated she completed the Quarterly MDS for Resident #1 dated 09/07/16, and reviewed and revised the Comprehensive Care Plan with the MDS. She stated she did not care plan Resident #1 as a two (2) person assist and would not necessarily care plan a resident as a two (2) person assist, unless he/she required a two (2) person assist with bed mobility fifty (50) percent or more of the time on the seven (7) day look back period. However, MDS Nurse #1 further acknowledged the MDS assessments were to be utilized in guiding the Comprehensive Care Plan related to the care required for the residents. Interview with the Director of Nursing (DON), on 12/21/16 at 11:42 AM, and post survey interview on 01/09/17 at 3:13 PM, revealed she had only been at the facility since 10/31/16. She stated her expectation was that MDS staff would look at the seven (7) day look back period, along with staff interviews and Nurse's Notes, and would base a resident care plan on the information obtained as well as observation of the resident. She stated, based on review of the MDS Detail Section G for the Admission MDS dated [DATE] for Resident #1, it was her expectation that Resident #1 would have been care planned as requiring two (2) assist with bed mobility. She further stated based on review of the Quarterly MDS Detail Section G dated 09/07/16, Resident #1 required assistance of two (2) for bed mobility fewer times, and she would expect MDS nurses to make the determination of the assistance required based on all the available information. The DON stated she did not know if having the assist of two (2) staff with bed mobility would have prevented Resident #1's fall. Interview with the Administrator, on 12/21/16 at 11:58 AM, revealed it was her expectation that the facility meet the regulatory requirements in order to determine and provide the level of care needed and the level of care should be documented on the care plan. She further acknowledged care planning was not her area of expertise but she expected the MDS staff to know based on their expertise what a residents' needs were.