Every finding on record at Signature Healthcare of Bowling Green

Based on interview, record review, and review of facility policy, the facility failed to ensure confidentiality of medical records for one (Resident (R) 83) of 11 residents sampled during medication pass. Facility staff failed to ensure that R83's medical information was secured when unattended, so as to prevent unauthorized access to the record. The findings include:Review of a facility policy, titled Resident Rights, last revised 01/31/2025, revealed residents have the right to privacy and confidentiality. Further review of the policy revealed the unauthorized release, access, or disclosure of resident information is prohibited.Review of a Face Sheet revealed the facility admitted R83 on 07/16/2020 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and depression.Observation of medication pass, on 09/02/2025 at 7:20 PM with Certified Nurse Aide (CNA)1, revealed the computer screen on the medication cart was left open, displaying R83's medical information, while CNA1 was in a resident room and the medication cart and computer was unattended. During the time that the resident's medical information was visible on the unattended computer, at least two persons were noted walking in the hall.In an interview with CNA1 on 09/02/2025 at 7:35 PM, she stated she normally closes the computer fully when it is unattended. CNA1 added that leaving the computer open was inappropriate, because anyone walking by could read the information displayed on it.In an interview with the Administrator on 09/05/2025 at 3:30 PM, she stated her expectation was that all nurses and medication technicians would close the computer when stepping away from the medication cart so as to protect residents' privacy (confidentiality of personal information).

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two (R68 and R83) of eight residents reviewed for infection control. Staff failed to use personal protective equipment (PPE) for R68, who was on contact precautions. In addition, staff failed to perform hand hygiene when indicated, including before and after resident contact/care for R83. The findings include: 1. Review of a facility policy titled, Infection Control, revised 01/31/2025, revealed the facility intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of a facility policy titled, Transmission Based Precautions (TBP), revised 01/31/2025, revealed TBP were initiated when a resident developed signs and symptoms of a transmissible infection or had a laboratory confirmed infections; and was at risk of transmitting the infection to other residents. Per the policy, TBP were used only when the spread of infection could not be reasonably prevented by less restrictive measures. Further review of the policy revealed that it did not specify the specific PPE that was to be used for residents who were on Contact Precautions (measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). Review of a Face Sheet revealed the facility admitted R68 on 08/09/2025 with diagnoses including chronic kidney disease (CKD), pyuria, and klebsiella pneumoniae/ ESBL (extended-spectrum beta-lactamase, a bacteria found in urine). Review of a urine culture laboratory result, dated 08/31/2025, revealed the organism klebsiella pneumoniae/ ESBL was found in R68's urine. Review of a physician order, dated 09/02/2025, revealed R68 was placed into contact precautions, related to the ESBL in her urine. Review of R68's Comprehensive Care Plan for a problem of Infection Control, created 09/02/2025, revealed the resident was placed on contact precautions related to ESBL in her urine. Per the care plan, interventions included the use of PPE as indicated. Observation on 09/03/2025 at 11:09 AM revealed a PPE Contact Precautions sign posted on R68's door, which stated that a gown and gloves were to be donned prior to entering the resident room. A PPE cart was present in the hallway with PPE available for use. Further observation at this time revealed the admission Director, who was inside R68's room, was not wearing any PPE. During this observation, the admission Director was observed to give R68 a beverage and adjust the resident's pillow. Interview with the Admissions Director (AD) on 09/03/2025 at 11:23 AM, revealed she had stepped in R68's room to check on the resident. The AD stated she did not provide any direct care, and therefore, did not think the PPE was necessary. Further interview with the AD revealed she should have put on a gown and gloves prior to entering R68's room, The AD noted that it was important to wear the required PPE so that staff did not bring something (i.e. infection/communicable disease) out to other residents. During an interview with the Infection Prevention (IP) nurse on 09/04/2025 at 3:45 PM, she stated staff was educated on the importance of wearing the proper PPE when a resident was placed in isolation. She stated she thought the AD was confused, as she was not providing direct care to R68. The IP stated that she expected staff to pause and take into consideration why the resident was on precautions to begin with; however, sometimes staff lacked understanding. Further interview with the IP revealed that there could always be a negative outcome to other residents or staff such as the spread of something (infection/communicable disease) to other residents. During an interview with the Director of Nursing (DON) on 09/05/2025 at 3:00 PM, she stated she expected everyone to wear the proper PPE. She stated you could potentially spread whatever was going on with the resident to other residents. She stated management did try to communicate well through team chats as to why the residents were in isolation. She stated she tried to be up front with her staff, especially direct care staff on her expectations, why the resident was in isolation, and what a worst-case scenario could be. During an interview with the Administrator on 09/05/2025 at 3:19 PM, she stated she expected that, when a staff observed an isolation sign outside a resident's room, they would wear the appropriate PPE. 2. Review of a facility policy, titled Infection Control. last revised 01/31/2025, revealed all personnel will be trained on the infection control policies and practices upon hire and periodically thereafter. Review of a facility policy, titled Medication Administration General Guidelines, dated 09/2018, revealed hands are to be washed with soap and water after administration and with any resident contact. Per the policy, antimicrobial sanitizer may be used in place of soap and water Observation of medication pass on 09/02/2025 at 7:20 PM revealed Certified Nurse Aide (CNA) 1 exited room [ROOM NUMBER] without performing hand hygiene after passing medication to a resident. CNA1 next proceeded to the medication cart in the hallway, where she prepared R83's medication. CNA1 then entered R83's room, administered medications, and exited R83's room. CNA1 failed to perform hand hygiene at any time during this observation of R83's medication pass. After exiting R83's room, CNA1 then entered another resident's room to wash her hands. In an interview with CNA1 on 09/02/2025 at 7:35 PM, she confirmed that she did not perform hand hygiene prior to preparing and/or administering R83's medications. She added that she did not immediately perform hand hygiene after leaving R83's room because it was easier to wash her hands in the next room since those residents were asleep, and it was close to where she left the med cart. She stated she saw no problem with exiting one resident's room and then entering another resident room without washing or sanitizing her hands. In an interview with the DON on 09/05/2025 at 3:00 PM, she stated hand hygiene is extremely important and should be performed between each resident. She stated you could potentially spread whatever was going on with one resident (i.e. communicable disease/infection) to other residents. The DON added that she tried to be up front with her staff, especially direct care staff on her expectations, as well as what a worst-case scenario could be. In an interview with the Administrator on 09/05/2025 at 3:30 PM, she stated hand hygiene should be completed any time you leave a room and after any interaction with a resident.

Based on interview, and record review, the facility failed to ensure three of three residents (R) reviewed out of a sample size of 42 for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, (R381, R71, and R95) whose Medicare therapy services were terminated, received an estimated cost for services if they chose to pay for the services themselves. This had the potential for residents not to be able to make an informed decision as to whether to continue therapy services. The findings include: The State Survey Agency (SSA) Contractor Surveyor asked the Administrator for the facility's Beneficiary Notice of Medicare Non-Coverage policy; however, such policy was not provided prior to exiting the survey. 1. Review of the undated Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab for R381, revealed the facility admitted the resident on 01/11/2024. Review of the information provided by the facility for R381 revealed the resident was discontinued from skilled therapy services on 01/30/2024, due to having exhausted the Medicare benefit days. Review of R381'sSkilled Nursing Facility Advance Beneficiary Notification of Non-coverage (SNF ABN) Form CMS-10055 revealed under the heading (Estimated Cost), no cost was listed. Therefore, R381 was not allowed the right to make an informed decision about continuing skilled services. 2. Review of the undated Resident Face Sheet located in the EMR under the Face Sheet tab for R71 revealed the facility admitted the resident on 06/26/2023. Review of the EMR revealed R71 had Medicare benefits and had been discontinued from skilled therapy services on 01/19/2024, due to exhausting the Medicare benefit days. Further review of R71's SNF ABN Form CMS-10055 revealed under the heading (Estimated Cost), no cost was listed. Therefore, R71 was not allowed to make an informed decision about continuing skilled services. 3. Review of the undated Resident Face Sheet located in the EMR under the Face Sheet tab for R95 revealed the facility admitted the resident on 02/28/2024. Continued review of the EMR revealed R95 had Medicare benefits and had been discontinued from skilled therapy services on 04/26/2024, related to exhausting the Medicare benefit days. Further review of R95's SNF ABN Form CMS-10055 revealed under the heading (Estimated Cost), no cost was listed. Therefore, R95 was not allowed to make an informed decision about continuing skilled services. During an interview on 06/25/2024 at 11:20 AM, the Business Office Manager (BOM), asked if she knew the estimated cost had to be filled in on the SNF ABN Form CMS-10055 document so residents would know the cost if they wanted to continue services. The BOM stated, I did not know that it had to be filled in with the cost. They all chose Option 3 where they are not responsible for paying and I can't appeal to see if Medicare would pay. I do not think that I have ever filled in the cost.

Based on interview and record review, the facility failed to ensure two residents of 42 sampled residents' (R) Resident Assessment Instruments ([NAME]) accurately reflected the resident's hospice designation for R88 and ability to communicate for R58. This failure could result in the residents' needs, strengths, and areas of decline not being addressed appropriately for R 88 and R58. The findings include: During an interview with the Director of Nursing (DON) on 06/27/2024 at 10:32 AM, she stated she would check for a specific policy related to accurate Minimum Data Set (MDS) Assessments; however, further stated the facility followed the Centers for Medicare and Medicaid Services (CMS) RAI Manual for MDS instructions. No additional policy was provided. 1. Review of R88's undated Admission Record located in the electronic medical record (EMR) under the Census tab revealed the facility admitted the resident on 04/16/2021, with diagnoses including advanced dementia, depressive disorder, and anxiety disorder. Review of R88's IDG Hospice Report dated 08/02/2023, located in the resident's EMR under the Resident Documents: Hospice/Palliative tab revealed R88 was admitted to [Hosparus] Care for hospice/comfort care on 05/20/2023. Review of R88's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/20/2024, located in the resident's EMR under the MDS tab, revealed the MDS did not accurately reflect R88's hospice designation. Continued review revealed the facility also failed to identify R88's hospice status on the Annual MDS Assessment with the ARD of 05/22/2024. During an interview on 06/27/2024 at 9:08 AM, MDS 1 and MDS 2 stated, When a resident is on hospice, Section O should be coded for hospice services. It looks like we missed that for her (R88) . 2. Review of R58's undated Admission Record located in the resident's EMR revealed he was admitted to the facility on [DATE], with diagnoses including cerebral palsy and communication deficits (deaf and nonverbal). Review of R58's Annual MDS Assessment with an ARD of 08/22/2023, located in the resident's EMR under the MDS tab revealed the MDS Section B indicated R58 had no speech. Review of the Quarterly MDS Assessment with an ARD of 05/14/2024, revealed Section B indicated R58 had no speech. In interview on 06/27/2024 at 9:08 AM, MDS 1 and MDS 2 stated R58 communicated with others through use of his iPad; however, they failed to capture that information in the communication section (Section B) of the MDS Assessments. They stated that tool was how R58 made his needs known to staff. MDS 1 and MDS 2 concurred that R58's two MDS Assessments had been coded as the resident had no speech, however, the resident was able to make himself understood with the tools provided by the facility.

Based on observations, interview, record review and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development of communicable diseases and infections for one (1) of one-hundred and thirty-one (131) facility residents. Observation on 09/28/2021 at 12:52 PM, revealed Certified Nursing Assistant entered Resident #1's isolation room, without wearing the designated Personal Protective Equipment (PPE). The findings revealed: Review of the facility's policy, Isolation-Categories of Transmission Based Precautions: Droplet Precaution, with revised date of 10/2018, revealed; Transmission -based precautions were initiated when a resident developed signs and symptoms of a transmissible infection. If a resident arrived for admission with symptoms of an infection or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. Contact Precautions: implemented for residents known or a suspected infection with microorganisms with potential transmission by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff would wear gloves, disposable gowns upon entering. Droplet Precautions: implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets [larger than 5 microns in size] that could be generated by the individual coughing, sneezing, talking, or by the performance of procedures. Gloves, gown, and goggles were to be donned if there was a risk of spraying respiratory secretions. Review of the facility's policy, Policies and Practices-Infection Control revised on 10/2018, revealed, facility's infection control policies and practices intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and general-public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payer source. Objectives of the IFC policies and practices: to prevent, detect, investigate, and control infections in the facility, establish guidelines for implementation of isolation precautions, including standard and transmission-based precautions. Review of the facility's policy, Novel Coronavirus (COVID-19) with last revision on 06/02/2021, revealed instructional signage would be posted throughout facility on infection control precautions and staff would utilize the appropriate PPE. Continued review revealed unvaccinated residents would be placed in droplet isolation precautions for (14) fourteen days. Review of 09/28/2021 documentation, provided by Infection Control Nurse, revealed the facility had (4) four residents on Droplet precautions, which included Resident #1. Review of 09/28/2021 door signage, going into Resident #1's room revealed: Special Droplet/Contact Precautions were implemented. In addition to standard precautions-only essential personnel should enter the room and everyone must clean their hands when entering/leaving room, wear face mask, wear eye protection, (face shield and goggles), gown and glove at the door. Additional Special Droplet/Contact Precaution signage revealed a display outside of the door for use with respiratory viruses including COVID-19. Continued review revealed PPE should be put on in this order: 1. Wash or gel hands (even if gloves were used), 2. Gown, 3. Mask and eye cover and 4. Gloves. Record review revealed the facility admitted Resident #1 on 09/21/2021, with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Kentucky Immunization Record revealed Resident #1 was without a COVID-19 vaccination. Further review revealed Resident #1 discharged on [DATE]. Observation of Resident #1's room, on 09/28/2021 at 12:52 PM, revealed signage to indicate the resident was on isolation precautions. Continued observation revealed Certified Nursing Assistant (CAN) #1 entered Resident #1's isolation room without donning appropriate PPE for contact/droplet isolation (gown, gloves and N95 mask), per the facility's policies. Further observation revealed Resident #1 was sitting just inside the doorway in his/her wheelchair. CNA #1 maneuvered around the seated resident to retrieved Resident #1's lunch tray from within the residents room. Further observation revealed after retrieving the food tray, CNA #1 exit the resident's room and placed lunch tray on the kitchen cart in the hallway without donning and doffing appropriate PPE or hand hygiene. Interview with Resident #1, on 09/28/2021 at 12:47 PM, revealed, he/she was on special droplet/contact precautions and had been since admitted by the facility a week ago. Continued interview revealed he/she had not had the COVID-19 vaccine that was why he/she was on isolation precautions. Interview with Certified Nursing Assistant (CNA) #1, on 09/28/2021 at 12:55 PM, revealed she was supposed to wear appropriate PPE to include a gown, gloves, mask, and shield/goggles per the signage on the door to Resident #1's room and the facility's policies. Continued interview revealed, she had forgotten to put it on. Interview with Unit Manager (UM) #1, on 09/28/2021 at 1:05 PM, revealed she had spoken with CNA #1 after she observed the CNA enter an isolation room without utilizing the appropriate PPE. UM #1 stated she had informed CNA #1 that goggles/shield, gown, gloves and an N95 mask should be worn in the isolation room. Interview with Infection Control Nurse/ Staff Development Coordinator (IFCN/ SDC), on 09/30/2021 at 12:51 PM and 1:16 PM, revealed her expectation for staff was if a resident was on precautions with the signs on the door, and for resident not vaccinated; the expectation was for staff to don a gown, N95 mask, goggles/face shield and gloves before entering the room and doff before exiting the room. Additionally, IFCN/SDC stated she would have expected the staff to follow the sign, and to follow the guidelines of the facility. Interview with Director of Nursing (DON), on 09/30/2021 at 11:08 AM, revealed she would expect personal protective equipment (PPE) to be donned upon entrance to an isolation room and doffed when exiting an isolation room. The DON further stated although a resident may be tested prior to admission, the precautions were in place, because a resident(s) may have had an exposure and the facility implemented the precautions for the protection of all and it was maintained for fourteen (14) days. Interview with the Administrator, on 09/30/2021 at 9:30 AM, revealed he expected staff to wear PPE in isolation rooms to prevent the transmission of infection/COVID and transmitting it to other residents, staff or home.

Based on observation, interview, record review, dietary slip review, and facility policy review, it was determined the facility failed to honor one (1) of three sampled residents meal preferences (Resident #1). The facility identified Resident #1 disliked rice; however, served the resident rice on on 08/05/2020. The findings include: Review of the facility policy titled, Resident Food Preferences, last reviewed 07/11/18, revealed the Dietician or Nursing staff will identified a resident's food preferences. The residents clinical record (orders, care plan, or other appropriate location location) will contain documentation of the resident's likes and dislikes. Record review revealed the facility readmitted Resident #1 on 12/06/18 with diagnoses which included Dysphagia, and [CONDITION(S)], and [CONDITION(S)]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/02/2020, revealed the facility assessed the resident's cognition as moderately impaired. Observation of a Lunch meal on 08/05/2020 at 12:05 PM revealed Resident #1 was served his/her meal in his/her room. The meal consisted of Pork Jambalaya, white rice, green beans and ice cream. Further observation revealed Licensed Practical Nurse (LPN) #1 was feeding the resident and the first time she fed the resident a bite of rice, the resident scrunched up his/her nose and moved his/her mouth as though he/she did not want the rice. LPN #1 then fed the resident a bite of green beans and the resident ate it, The next time the LPN gave the resident another bite of rice, the resident had the same response as before. Surveyor asked to see the resident's meal ticket which was dated 08/05/2020, and it listed rice as a dislike. Surveyor pointed this out to the LPN and she asked the resident if she liked rice and the resident shook his/her head no. The LPN proceeded to go get the resident another tray that consisted of soup and a pimento sandwich. Interview with LPN #1, 08/06/2020 at 10:45 AM, revealed Dietary is supposed to ensure trays are accurate and honor likes and dislikes and nursing is supposed to also check prior to delivering tray to resident. She stated looked at the slip to ensure the resident received the appropriate food consistency but did not identify the resident disliked rice. Interview with the Dietician on 08/06/2020 at 8:47 AM, revealed she assesses the resident's food likes and dislikes and this information is listed on each resident's dietary slip. She stated the Cook is supposed to ensure the food placed on the plate is according to the dietary slip and if the food is listed as a dislike, then a substitute should be placed on the tray. She further revealed nursing staff are also supposed to ensure the tray is accurate according to the dietary slip prior to serving the meal. She stated this was important to ensure the residents will eat as much of their meal as possible.

Based on interview, record review, review of facility policy, and review of the facility's investigation, it was determined the facility failed to ensure one (1) of three (3) sampled residents was free from physical abuse (Resident #1). On 04/22/2020 at 6:30 PM, two (2) staff members witnessed Certified Nurse Aide (CNA) #1 slap Resident #1 on the left side of the cheek in the dining room. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, last revised May 2019, revealed the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further review of the policy revealed verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability. Physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonably related to the appropriate provision of ordered care and services. Record review revealed the facility admitted Resident #1 on 07/29/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed Resident #1 has been on the Special Care Transitional Unit since 09/12/2019, due to wandering, exit seeking, aggression, agitation and intrusive behaviors. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/26/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was unable to complete an assessment interview. Further review of the Quarterly MDS revealed Resident #1 required extensive assistance of two (2) staff with bed mobility and physical assistance of one (1) staff for transfers and toileting and required set up only for eating. Review of the facility's Initial Report to the State Survey Agency, dated 04/22/2020, revealed a nurse reported to Administrator that CNA #1 had slapped Resident #1 in the face. CNA #1 was suspended pending investigation. A skin assessment was completed on Resident #1 with no injuries noted and neuro-checks were initiated. Further review of the report revealed interviews with other staff members and assessment of all other residents on unit; had been initiated. Notifications had been sent to physician, family member, Department of Community Based Services, local law enforcement, Attorney General, and Ombudsman. Review of Event Report dated 04/22/2020 at 8:44 PM revealed there were no concerns with Resident #1's vital signs or any pain. CNA #1 was removed from unit immediately and Resident #1 de-escalated quickly with another caregiver. Further review of event report revealed Resident #1 did not recall incident. An attempt to interview CNA #1 by phone was made on 04/24/2020 at approximately 11:22 AM but the phone had been disconnected. Review of a statement written by CNA #1, dated 04/22/20 revealed she stated when she pulled her arm from Resident #1 it could have caused her hand to come in contact with part of the resident's face, but she in no way meant to touch or slap the resident. Phone interview with CNA #2 on 04/24/2020 at 9:25 AM revealed she worked the 3-11 shift on 04/22/2020. CNA #2 stated around 6:30 PM, Resident #1 was in the dining room and picked up a spoon and started to eat off another resident's meal tray. CNA #2 revealed she observed CNA #1 try to get the spoon away from Resident #1 but the resident refused to release the spoon. CNA #2 heard CNA #1 tell Resident #1, Either give up the spoon or I will take it from you. CNA #2 revealed Resident #1 refused and when CNA #1 reached for the spoon, the resident turned, then grabbed and scratched CNA #1. CNA #2 stated she then observed CNA #1 slap Resident #1 on left side of face leaving a small red mark on cheek towards the jaw bone and chin. CNA #2 stated the resident then asked CNA #1, What did you hit me with? CNA #2 stated she reported the abuse to the nurse immediately. Phone interview with CNA #3 on 04/24/2020 at 10:38 AM revealed she worked the 3-11 shift on 04/22/2020 and the incident happened around 6:30 PM in the dining room. CNA #3 stated she observed Resident #1 come into the dining room, sit at the table, and start to eat off another resident's tray. CNA #3 stated CNA #1 walked in and she heard CNA #1 ask Resident #1 to release the spoon. Resident #1 refused and the CNA #1 repeated the request to release the spoon. CNA #3 stated she then observed CNA #1 reach across Resident #1 to get the spoon from the resident's left hand. CNA #3 revealed she started to walk over to help with the situation and noticed that Resident #1 had dug his/her nails in the back of CNA #1's right arm and then observed CNA #1 slap Resident #1 on the left cheek. She stated she then heard Resident #1 ask CNA #1, What did you hit me with? and the resident started pointing to his/her own face, and the resident's facial expression appeared shocked. CNA #3 stated she and CNA #2 reported the incident to the nurse immediately and CNA #3 stood with Resident #1 while the nurse called the Administrator in office to report incident and ask for assistance on the unit. Phone interview with Licensed Practical Nurse (LPN) #1 on 04/24/2020 at 9:25 AM, revealed she had worked the 7AM-7PM shift on 04/22/2020. LPN #1 stated she had just finished passing her medication when she heard a commotion in the dining room around 6:30 PM. LPN #1 revealed she observed Resident #1 holding his/her own face and CNA #1 (alleged perpetrator ) holding her own arm. LPN #1 stated she made sure Resident #1 was safe with CNA #3 and she noted a small red mark on Resident #1's left cheek. LPN #1 further revealed CNA #1 walked around the corner to the empty shower room which was in her view while she called the Administrator to the unit. LPN #1 reported that the Administrator escorted CNA #1 off the unit. LPN #1 stated she did not see the incident but the two (2) other CNA's reported the incident to her immediately. Phone interview with the Director of Nursing (DON) on 02/24/2020 at 11:32 AM, revealed she was notified via phone about the incident between 6:40 and 6:45 PM on 04/22/2020. The DON stated when she arrived at the facility, CNA #1 was in the Administrator's office. The DON revealed she requested vitals and skin assessment of Resident #1 from the nursing staff, however she did not see a red mark or swelling on Resident #1's face or cheek. The DON requested the Assistant Director of Nursing (ADON) to begin skin assessments on all resident's in unit and to begin staff training and development on abuse and neglect on 04/23/2020. She stated in addition, social services was following up on affects of Resident's wellbeing and completing interviews of residents and staff as appropriate according to facility protocol for investigation guidelines and protection. The DON reported that CNA #1 (alleged perpetrator) had worked at the facility as a CNA for over a year and did not have any reports of misconduct at this facility. The DON further stated CNA #1 had passed all background checks and had sufficiently completed all facility trainings. The DON revealed she also requested staff to initiate neuro-checks on Resident #1 for extra precautions and emotional well-being due to Resident #1 having dementia. Phone interview with the Administrator on 04/24/2020 at 11:05 AM, revealed he received call from LPN #1 at around 6:30 PM on 04/22/2020, reporting the incident and requesting immediate assistance on the unit. He told LPN #1 to remove CNA #1 from floor and that he was on the way to unit. The Administrator stated he met CNA #1 right outside the doorway of unit and escorted her to the office and away from resident care areas. The Administrator revealed he started abuse protocols immediately and an investigation of incident after securing safety of resident's and facility. The Administrator stated he terminated CNA #1 from employment that night because his initial investigation indicated her actions constituted abuse by facility policy. He said he terminated CNA #1 that night because she admitted that it was possible she made contact with the resident's head, even if she hadn't meant to touch or slap the resident.

Based on observation, interview and review of facility policy it was determined the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations of the kitchen on 02/19/19 and 02/20/19, revealed during lunch tray-line, Cook #1 inserted the thermometer into the foods past the stem to the handle, which was not sanitized, was the handle was coming in contact with the foods. In addition, dishes were stored improperly. Review of the Census and Condition, dated 02/19/19, revealed one-hundred twenty-five (125) of one-hundred twenty-nine residents received their meals from the kitchen. The findings include: 1. Review of facility policy titled, Food Temperatures, last revised 01/04/19, revealed staff are to wash, rinse, sanitize a dial face, metal probe-type thermometer with an alcohol wipe and re-sanitize after each use and staff are to insert thermometer into center of product. Observation of Cook #1 on 02/19/19 at 11:28 AM, revealed Cook #1 checked the temperature of foods on tray-line and inserted the thermometer into the foods in a manner in which the thermometer stem was inserted all the way until the handle was making contact with the foods, even though the handle had not been sanitized. Interview with Dietary Manager on 02/19/19 at 11:52 AM, revealed she expected the cooks to not insert the thermometer deep enough into the foods that the handle was down in the foods. She further stated she expected the thermometer handle to not be down in the food when staff are checking temperature of foods. Interview with facility's Registered Dietician on 02/19/19 at 11:53 AM, revealed she expected the staff to keep the handle of the thermometer out of the foods that are being checked for temperature. 2. Review of facility policy titled, Dry Storage-Dishes and Utensils, last revised 02/01/12, revealed enclosed storage should be provided for clean and sanitized dishes and utensils. It further stated dish storage areas should be kept closed or covered when not in use. Observation of the kitchen on 02/20/19 at 9:40 AM, revealed a open wired rack storing pots and pans, with pans stored uncovered and not inverted with dust and white material collecting in the pans. Interview with Dietary Manager on 02/20/19 at 9:46 AM, revealed she expected all dishes, pots and pans to be stored either covered or inverted so they do not collect dust or other material.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure they developed and/or implemented a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for six (6) of thirty-three (33) sampled residents (Residents #30, #76, #79, #83, #110 and #374). The facility failed to implement care plans for Residents #30, #76, #79, #83, and #374 related to ADL assistance and failed to develop person centered interventions for falls related to Resident #110's severely impaired cognition. The findings include: Review of the facility Policy titled Comprehensive Care Plans , dated 07/19/18, revealed the following: A person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. The Minimum Data Set (MDS) will be used to assess the resident's clinical condition, cognitive and functional status and use of services. 1. Record review revealed the facility admitted Resident #30 on 09/23/16 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 12/18/18, revealed facility coded the Brief Interview for Mental Status (BIMS) score as ninety-nine (99), indicating the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed Resident #30 as totally dependent with assist of two for bathing. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL's), self care deficit, initiated 10/03/16, revealed the resident had a stroke with paralysis of one (1) side. Further review revealed an intervention for two (2) person lift for transfers, and extensive assist with all areas of care, grooming, and bathing with no indication of how many staff to assist. Review of an ADL Certified Nurse Aide (CNA) Care Plan, dated 02/06/19, revealed the resident was to be a total assist of two (2) persons for bathing. However, review of a bathing sheet revealed the resident was charted as a one (1) person physical assist on 01/22/19, 01/23/19, 01/24/19, 01/27/19, 01/28/19, 02/01/19, 02/02/19, 02/04/19, 02/11/19, 02/12/19, 02/13/19, 02/15/19, 02/17/19, and 02/19/19 (total of fourteen (14) days). Observation of Resident #30, on 02/19/19 at 9:11 AM, revealed the resident was lying in bed on his/her back on an air mattress with Oxygen at two (2) liters per minute (LPM). 2. Record review revealed the facility admitted Resident #76 on 11/06/18 with [DIAGNOSES REDACTED]. Review of an Admission MDS assessment, dated 11/13/18, revealed the facility assessed Resident #76's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. In addition, further review of the MDS assessment revealed the facility assessed the resident required extensive assistance of two (2) for bathing. Review of a Comprehensive Care Plan for self care deficit, initiated on 01/28/19, revealed an intervention for staff to provide the amount of assistance/supervision that is needed: Extensive assist; however, the intervention did not indicate the amount of staff needed. Review of the CNA Care Plan dated (MONTH) 2019 revealed the resident was listed as Dependent with no type (one or two person) of assistance indicated for bathing or dressing. However, review of a Bathing sheet revealed the resident was charted as one person physical assist and total dependence on 01/22/19, 01/23/19, 01/24/19, 01/28/19, 01/29/19, 01/30/19, 02/01/19, 02/02/19, 02/03/19, 02/04/19, 02/13/19, 02/15/19, 02/17/19, 02/18/19 and 02/19/19. Observation of Resident #76 on 02/19/19 at 10:51 AM revealed the resident was in wheel chair in his/her room. Interview with CNA #4 on 02/21/19 at 2:30 PM revealed if her care plan did not address the amount of staff needed for bathing or stated one to two, she would ask her nurse. CNA #4 stated if the care plan indicated extensive assist/dependent, then the resident needs two (2) assist. Interview with CNA #1 on 02/21/19 at 2:32 PM revealed if the CNA Care Plan did not address the amount of staff needed she would ask the nurse. She stated if it indicated one-two assist, she would take another person with her, just to be on safe side. 3. Record review revealed the facility admitted Resident #83 on 03/02/18 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 01/28/19, revealed the facility assessed the resident's BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL's), self-care deficit, initiated 03/14/18, revealed the resident had a stroke with paralysis on one (1) side. Further review of the Care Plan revealed an intervention to include physical assist of one (1) person with all areas of care, grooming, and bathing. Review of the ADL Certified Nurse Aide (CNA) Care Plan, no date, revealed the resident was to be a total assist of one (1) person for bathing. However, review of a bathing sheet revealed the resident was charted as independent on 01/23/19, 01/26/19, 02/06/19, 02/09/19, 02/10/19, 02/11/19, 02/14/19, 02/15/19, and 02/18/19. 4. Record review revealed the facility admitted Resident #374 on 12/28/18 with [DIAGNOSES REDACTED]. Review of the five (5) day PPS MDS assessment, dated 12/28/18, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of a Comprehensive Care Plan for ADL's, self-care deficit, initiated 01/07/19, revealed the resident required extensive assistance of two (2) persons for transfer and mobility. Further review of the care plan did not specify the amount of assistance required for areas such as care, grooming, and bathing. Review of the ADL CNA Care Plan, no date, revealed the resident was extensive assist of two (2) persons for bathing. However, review of a bathing sheet revealed the resident was charted as one (1) person physical assist on 01/21/19, 01/23/19, 01/24/19, 01/25/19, 01/28/19, 01/29/19, 01/30/19, 02/01/19, 02/02/19, 02/04/19, 02/05/19, 02/06/19, 02/07/19, 02/08/19, 02/09/19, and 02/18/19. 5. Record review revealed the facility admitted Resident #79 on 07/26/14 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 01/05/19, revealed the facility assessed the resident's BIMS score as three (3), which indicated the resident was cognitively intact and interviewable. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL's), self-care deficit, initiated 08/4/14, revealed the resident Resident #79 requires assist in Transfer, mobility and total care. had a stroke with paralysis on one (1) side. Further review of the Care Plan revealed an intervention to include physical assist of two (2) person with bathing. Review of the ADL Certified Nurse Aide (CNA) Care Plan, no date, revealed the resident was to be a total assist of two (2) person for bathing. However, review of a bathing sheet revealed the resident was charted as One person physical assist on 01/22/19, 01/24/19, 01/26/19, 01/29/19, 01/31/19, 02/02/19, 02/05/19, 02/07/19, 02/09/19, 02/12/19, 02/14/2019, 2/16/19 and 02/19/19. Interview with CNA #7, on 02/20/19 at 2:14 PM, revealed CNA staff all receive assignment sheets daily indicating which residents needed to receive a shower or bath that day. CNA #7 stated staff filled out the sheet daily, signed their name on the sheet, and then turned it in at the end of the shift to the nurse in charge on that hall. CNA #7 revealed the CNA care plans revealed the required assistance each resident required with ADL's. CNA #7 stated she assisted Resident #83 with a shower on 02/19/19. Interview with the Director of Nursing (DON), on 02/21/19 at 1:40 PM, revealed she expected staff to follow the Comprehensive Care Plan and CNA Care Plan, and offer the required assistance for the residents, and document accurately. The DON stated the Unit Managers were responsible for reviewing the documentation turned in by CNA staff, with periodic checks done weekly to ensure the documentation turned in by CNA staff accurately reflected the care and assistance provided for the residents. 3. Record review revealed the facility admitted Resident #110 on 05/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/11/19 , revealed the facility assessed the resident's BIMS score as three (3), which indicated the resident was cognitively impaired and not interviewable. Review of a Comprehensive Care Plan for Risk for fall related injury and history of falls due to cognitive and physical deficits, initiated 05/22/17, revealed falls interventions included to remind the resident when rising from a lying position to sitting up on the side of the bed a few minutes before transferring or standing, and to educate/remind him/her to request assistance prior to ambulation, and/or transfers. Further review of the Care Plan revealed updated interventions on 02/08/19 to educate the resident to call for assistance, remind him/her to call for assistance prior to attempting ambulation, educate him/her to stand before starting to walk to ensure steadiness before ambulation, and remind him/her to use an assistive device for ambulation. However, these interventions are not person centered for this resident per facility policy due to the facility assessing Resident #110's cognition as severely impaired. Interview (Post Survey) with DON on 03/08/19 at approximately 11:50 AM revealed she did not feel the interventions put in place were appropiate for Resident #110 due to his/her cognitive deficits. The DON stated she expected the interventions to be specific to Resident #110's needs and limitations in order to prevent future falls and keep him/her safe.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of thirty-three sampled residents who were unable to carry out activities of daily living received the necessary services to maintain personal and oral hygiene (Residents #38, #76, #83, #86, and #427). The facility failed to provide oral hygiene to Resident #427, failed to ensure two (2) staff provided bathing for Resident #76, and failed to provide bathing every three (3) times a week for Residents #38, #83 and #86. The findings include: Review of Facility Policy titled Certified Nursing Assistant Job Description, dated 12/2011, revealed the following: Perform direct care duties under the supervision of licensed nursing personnel, provide personal care such as grooming, bathing, dressing, and oral care of residents daily and as needed. Review of the facility policy titled, Certified Nursing Assistant Job Description, dated (MONTH) 2011, revealed the following: Perform direct care duties under the supervision of licensed nursing personnel, provide personal care such as grooming, bathing, dressing, and oral care of residents daily and as needed. 1. Record review revealed the facility admitted Resident #427 on 02/16/19 with [DIAGNOSES REDACTED]. Review of an Admission Baseline Care Plan initiated on 02/16/19 revealed the resident was Care Planned for being NPO (nothing to eat by mouth), tube feeding, weakness, decreased mobility with intervention to provide Activities of Daily Living (ADL) care to ensure daily needs are met. In addition, the resident was a Hydration risk with goal that resident will remain adequately hydrated as evidenced by good skin turgor; and, pink and moist mucous membranes. Review of the CNA Care Plan dated 02/16/19 revealed Resident #427 was listed as Independent for oral care. Observation of Resident #427 on 02/19/19 at 10:34 AM revealed the resident had Oxygen on at two (2) liters per minute (LPM) with no no humidification. The resident's lips were observed to be very dry, and teeth and lips had a red material that resembled dried blood. Further observation at this time revealed seven (7) oral swabs lying on the over the bed table in unopened packages. The resident was also observed to have an abdominal feeding tube. Resident #427 stated, They (staff) brought the things in to clean my mouth and never did it . Observation on 02/19/19 at 1:40 PM revealed Resident #427 kept licking his/her lips, and his/her lips were very dry with peeling skin and a red looking material on teeth and lips. There were still seven (7) oral swabs on the over bed table in unopened packages. Observation of Resident #427 on 02/20/19 at 4:40 PM and 5:55 PM, the resident's lips were still very dry with peeling skin and there were two (2) oral swabs on over bed table in unopened packages. At 5:55 PM, the resident stated his/her lips were sore. Interview with Resident #427 on 02/20/19 at 4:45 PM revealed he/she would be able to use swabs per self but Someone would have to moisten the swabs for me. When asked if staff ever put anything like chap stick or other lubricant on lips resident stated, They said they couldn't because of the oxygen. The resident further stated no one had used any swabs on his/her mouth recently. Observation on 02/21/19 at 8:57 AM revealed Resident #427 was licking his/her lips, lips were dry with peeling skin, and there were no oral swabs in sight. The resident stated at this time he/she could use swabs per self but someone would have to wet them for me. Asked if anyone had been in room to use swabs and resident stated well, they just used a wet wash cloth on my lips. Interview with Resident #427's cousin, on 02/20/19 at 4:40 PM revealed he came by last week and the resident's lips were very dry, bad looking, skin peeling off lips. Interview with CNA #2 on 02/21/19 at 9:15 AM revealed the first day she took care of Resident #427 (Tuesday {02/19/19} she wet the oral swabs for the resident and the resident did oral care his/herself. CNA #2 stated she did this care twice that Tuesday and she worked from 7:00 AM-3:00 PM. She further revealed she usually does oral care every two (2) hours on tube feeding residents but, this resident was listed as independent on her care plan sheet. Interview with CNA #3 on 02/21/19 at 9:30 AM revealed she provides oral care for residents with tube feeding every two (2) hours and she looks at mouth and lips when she does rounds, and will put something like chap stick to moisten lips if it is available. Interview with Licensed Practical Nurse (LPN) #1 on 02/21/19 at 9:03 AM revealed she did the admission assessment on Resident #427 and put resident as Independent for oral care as the resident had used oral swab one time. She stated she had not observed the resident using oral swab since admission and she had not done any oral care as the CNA's did that. LPN #1 revealed nothing was being put on the resident's lips such as chap stick as That was an over sight on my part. She stated the swabs would have to be moistened by staff for resident to use and if the CNA's were not doing oral care every two (2) hours it would be because the resident was listed as independent for oral care on the CNA care sheets. Interview with the Director of Nursing (DON) on 02/21/19 at 3:12 PM revealed she expected oral care to be completed on residents with tube feedings at a minimum every shift and as needed. She stated the CNA's do the oral care and nurses are responsible for making sure it is done. She stated she expected oral care to be included on the baseline care plans and the admission nurse was responsible for putting it on the Care Plan to ensure the CNA's do the oral care. 2. Record review revealed the facility admitted Resident #76 on 11/06/18 with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment, dated 11/13/18, revealed the facility assessed Resident #76'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 MDS assessment revealed the facility assessed the resident needed extensive assistance of two (2) staff for bathing. Review of a Comprehensive Care Plan for self care deficit initiated on 01/28/19 revealed an interventions of staff to provide the amount of assistance/supervision that was needed: Extensive assist. The care plan did not indicate there amount of staff that was needed to provide bathing. Review of the a CNA Care Plan dated (MONTH) 2019 revealed the resident was listed as Dependent with no amount (one or two person) assistance listed. Review of a Bathing sheet revealed the resident was charted as one (1) person physical assist and total dependence on 01/22/19, 01/23/19, 01/24/19, 01/28/19, 01/29/19, 01/30/19, 02/01/19, 02/02/19, 02/03/19, 02/04/19, 02/13/19, 02/15/19,02/17/19,02/18/19 and 02/19/19. Observation of Resident #76 on 02/19/19 at 10:51 AM revealed the resident to be up in a wheel chair in his/her room with a urinary catheter in a dignity bag. Interview with CNA #4 on 02/21/19 at 2:30 PM revealed if there was nothing on her care plan about the amount of assistance required for a resident or listed as one (1) to two (2) assist, she would ask her nurse. She stated if a resident was care planned for extensive assist/dependent then the resident needs two (2) assist. Interview with CNA #1 on 02/21/19 at 2:32 PM revealed if the CNA Care Plan sheet did not list the amount of assistance needed for bathing, she would ask the nurse. She stated if the care plan stated one (1) to two (2) assist, she would take another person with her, just to be on the safe side. 3. Record review, revealed the facility admitted Resident #38 on 07/04/18 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 12/26/18, revealed the facility assessed Resident #38's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of Resident #38's CNA Care Plan under the section ADL's revealed Resident #38 was scheduled to receive a bath/shower on Wednesday, Friday and Sundays during the 7:00 AM to 3:00 PM shift. Review of Resident #38's Bathing Report for the last thirty (30) days revealed Resident #38 did not receive a bath for six (6) days as the report revealed the resident was not bathed from 01/20/19 until 01/26/19. Further review revealed Resident #38 did not receive a bath for a seven (7) day period from 01/29/19 until 02/07/19, and did not receive another one until 02/12/19 four (4) days later. Further review of the report also showed the last time Resident #38 received a bath was on 02/16/19 and had not received another one as of the day the report was printed on 02/20/19. Interview with Resident #38 on 02/19/19 at approximately 10:20 AM revealed there was never a lot of help during the night shift and he/she had issues getting assistance from certain aides. Resident #38 stated he/she had issues getting baths regularly, and he/she did not get his/her bath three (3) times a week like he/she was scheduled. The resident revealed he/she informed staff but the problem has not been corrected. 4. Record review revealed the facility admitted Resident #83 on 03/02/18 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 01/28/19, revealed the facility assessed the resident's BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of Resident #83's CNA Care Plan under the section ADL's revealed Resident #83 was scheduled to receive a bath/shower on Tuesday, Friday, and Sundays during the 7:00 AM to 3:00 PM shift. Review of Resident #83's Bathing Report for the last thirty (30) days revealed Resident #83 did not receive a bath for seven (7) days, and the report revealed the resident was not bathed from 01/19/19 until 01/26/19 (seven {7} days). Further review revealed Resident #83 did not receive a bath for another seven (7) day period from 01/29/19 until 02/06/19. Interview with Resident #83 on 02/19/19 at approximately 9:58 AM revealed he/she was disappointed in the staff at the facility because he/she feels there was no consistency in the care provided. Resident #83 stated he/she cannot get a bath/shower on a regular basis and it has been two (2) weeks since the last time he/she received one. Resident #83 stated he/she has told staff but things do not ever change and get better. Interview with Resident #83's Family Member #1 on 02/20/19 at approximately 4:30 PM revealed that Family Member #1 was upset that Resident #83 had not received a bath/shower for almost two (2) weeks. Family Member #1 stated she went to the nurse's station yesterday and reported it to staff and Resident #83 finally received a bath/shower. Family Member #1 did not remember the name of the staff member she spoke with as she was just happy that it got Resident #83 a bath/shower. Interview with CNA #7 on 02/20/19 at approximately 2:14 PM revealed she worked both North and South Wings in the facility and each resident received a bath or shower three (3) times a week. CNA #7 stated all CNA staff receive assignment sheets daily which indicate which residents need to receive a shower or bath for that day. CNA #7 revealed the sheets were filled out daily and signed by the CNA staff member and it was turned in at the end of shift to the nurse in charge on the hall. CNA #7 stated she did assist Resident #83 with a shower on 02/19/19 and that Resident #83 reported to her that it had been a few days since he/she had received a shower. She stated Resident #83 was very glad that he/she was finally receiving one. CNA #7 revealed she did not report that information to anyone. 5. Record review revealed the facility admitted Resident #86 on 10/06/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 01/29/19, revealed the facility assessed Resident #86's cognition as severely impaired with a BIMS score of six (6), which indicated the resident was not interviewable. Review of Resident #86's CNA Care Plan under the section ADL's revealed Resident #86 was scheduled to receive a bath/shower three (3) times weekly but no specific days were listed. Review of Resident #86's Bathing Report for the last thirty (30) days revealed Resident #86 did not receive a bath for seven (7) days, and the report revealed the resident was not bathed from 01/19/19 until 01/26/19 (seven {7}days). Further review of the report revealed Resident #86 did not receive a bath for another seven {7} day period from 01/29/19 until 02/06/19. Interview with Unit Manager Registered Nurse (RN) #4 on 02/20/19 at approximately 2:20 PM revealed Resident #86 refused to allow staff to provide him/her a bath/shower and that is why there was a long lapse in time between his/her bath/showers. RN #4 stated there was documentation to support this but RN #4 was unable to provide anything documented to show that Resident #86 ever refused a bath/shower when staff tried to provide this care. Interview with the Director of Nursing (DON) on 02/20/19 at approximately 5:27 PM revealed she expected staff to immediately and properly document refusals of any ADL assistance by residents and report the refusal to the charge nurse/unit manager. The DON stated she expected CNA's to follow the Comprehensive and CNA Care Plans for each resident and provide the required amount of assistance the resident was care planned for. The DON revealed she expected the Unit Manager to investigate refusals by residents and bring the information to IDT for administrative staff to explore possible interventions. The DON stated the Unit Manager was responsible for conducting reviews and periodic checks weekly and to monitor CNA documentation. The DON stated it was the Unit Manager's failure not to follow up during the month timeframe to catch these failures by staff not providing ADL's to residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and changes in conditions for three (3) of thirty-three (33) sampled residents (Residents #37, #44, and #110). Resident #37 sustained a fall on 09/12/18 and Resident #44 sustained falls on 08/19/18 and 02/07/19, however, the comprehensive care plans were not updated to reflect new interventions after the therapy department determined physical therapy was not indicated. In addition, Resident #110 sustained falls on 12/31/18, 01/03/19, 01/07/19 and 02/08/19; however, the comprehensive care plans was not updated to reflect new interventions. The findings include: Review of facility policy titled Falls, last revised 08/16/18, revealed it is 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. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. The Interdisciplinary Team (IDT)/Minimum Data Set (MDS) / Assistant Director of Nursing (ADON) reviews and revises the care plan as appropriate quarterly and as needed. Review of the facility policy titled Comprehensive Care Plans, last revised 07/19/18, revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying sources of the problem areas, rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Care plans are ongoing and revised as information about the resident and the resident's condition change. The nurse/interdisciplinary team is responsible for the review and updating of care plans. The care plans should reflect the current status of the resident and be updated with changes in the resident's status includes when there has been a significant change in the resident's condition and when the desired outcome is not met. 1. Record review revealed the facility admitted Resident #37 on 04/09/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #37's cognition as severely impaired as the resident was unable to complete the Brief Interview of Mental Status (BIMS) exam due to long-term and short-term memory impairment indicating the resident was not interviewable. Further review revealed the resident required extensive assistance of two (2) staff for transfers. Review of the facility provided fall investigation dated 09/12/18 revealed Resident #37 fell at 3:15 PM with no injury noted. The resident was found sitting on the floor at bedside as a result of an attempt to transfer unassisted. Implemented interventions were Physical Therapy (PT) / Occupational Therapy (OT) to evaluate and treat; neuro checks per policy; X-ray of right shoulder; and monitor for latent bruising and pain. Review of the Request for Therapy Evaluation, dated 09/12/18, revealed Resident #37 was evaluated due to a recent fall. It was noted the resident had not had a change in physical ability and the fall was not related to a decline; PT not indicated at this time. Review of Resident #37's Comprehensive Care Plan initiated 04/17/15 for At risk for fall related injury revealed an intervention dated 09/12/18 for OT and PT to evaluate as needed. However, further review revealed there was no intervention to address tthe root cause of the fall put in place after therapy evaluated the resident and determined therapy was not indicated. 2. Record review revealed the facility admitted Resident #44 on 04/06/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE] revealed Resident #44's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. However, after interviewing the resident, it was determined the at resident provided information that was not reliable. Further review of the Quarterly MDS revealed Resident #44 required extensive assistance of one (1) for transfers. Review of the facility provided fall investigation dated 08/19/18 revealed Resdient #44 sustained a fall while picking out clothes to wear in his/her closet. Intervention for staff to assist resident to pick out clothes the night before and place on bed was developed. Review of the facility provided fall investigation dated 02/07/19 at 10:15 PM revealed Resident #44 sustained a fall with no injury noted. The resident was found lying beside bed on his/her right side. Behaviors contributing to falls were listed as impulsivity, poor safety awareness, and non-compliance. Further review revealed interventions put in place were for a therapy referral, and to monitor for signs and symptoms of latent bruising and pain related to fall. Review of the Request for Therapy Evaluation, dated 02/08/19, revealed Resident #44 was evaluated due to a recent fall. It was noted the resident did not have a change in physical ability and the fall was not related to a decline but the resident attempting to transfer without assistance in which he/she is not suppose to do. Review of Resident #44's Comprehensive Care Plan, initiated 04/14/17, revealed the resident was at risk for fall related injury related to right spastic [MEDICAL CONDITIONS], and history of falls. Interventions listed under Approaches included OT, PT, Speech Therapy (ST) evaluate and Medications as ordered, dated 02/07/18. However, further review revealed there was no intervention put in place to address the root cause of the fall after therapy evaluated the resident and determined therapy was not indicated. Further review revealed the intervention for assistance with picking out clothes listed on the 08/19/18. Interview with LPN #2, Unit Manager, on 02/20/19 at 5:34 PM and on 02/21/19 at 8:11 AM revealed the IDT discusses interventions that are working or not, and decides if there should be an intervention added. LPN #2 stated she did not implement a new intervention once therapy evaluated the residents, nor was the care plan updated for the 08/19/18 fall. Interview with the Director of Nursing (DON) on 02/21/19 at 2:49 PM revealed once therapy communicated they were not picking up the residents for therapy, the fall is brought back to IDT for a new intervention to be implemented. She stated it was the unit supervisor's responsibility to implement the new intervention. She revealed she expected the care plans to be updated with any new interventions after a fall and per policy. 3. Record review revealed the facility admitted Resident #110 on 05/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 2/11/19 , revealed the facility assessed the resident's BIMS score as three (3), which indicated the resident was cognitively impaired and not interviewable. Review of the Comprehensive Care Plan, dated 05/22/17, revealed Resident #110 was at risk for injury related to falls due to cognitive and physical deficits and a history of recurrent falls. Additional review of the care plan revealed there had been no updates or revisions to the care plan after falls that occurred in the facility on 12/31/18, 01/03/2019, 01/07/19 until after the last fall on 02/08/2019. Interview with LPN #2, Unit Manager, on 02/20/19 at 5:34 PM and on 02/21/19 at 8:11 AM revealed the IDT discusses interventions that are working or not, and decides if there should be an intervention added. Interview with the Director of Nursing (DON) on 02/21/19 at 2:49 PM revealed it is the unit supervisor's responsibility to implement new interventions. Additionally, the DON expected the care plans to be updated with any new interventions after a fall per policy.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and ensure care was provided in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for two (2) of thirty-three (33) sampled residents (Residents #38 and #67). The findings include: Review of the facility's policy, Resident Rights, revised 08/16/18, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. Further review of the policy revealed when providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. 1. Record review revealed the facility admitted Resident #38 on 07/04/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/26/18, revealed the facility assessed Resident #38's cogntion as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resdient was interviewable. Interview with Resident #38, on 02/19/19 at approximately 10:20 AM, revealed there was not a lot of help during the night shift and he/she had issues receiving assistance from Certified Nurse Aide (CNA) #5. He/she stated every night when CNA #5 worked, it was always a bad night for me. Resident #38 stated CNA #5 does not want to provide assistance to him/her and made the resident feel guilty for asking for assistance or needing help. Resident #38 stated the other night when CNA #5 provided incontinent care for him/her, the CNA left him/her on the bedpan for over an hour. Resident #38 stated he/she got himself/herself off the bedpan without assistance and accidentally spilled urine on the bed. He/she stated when CNA #5 came into the room and observed the bedpan spilled, the CNA told Resident #38 he/she spilled it on purpose so the CNA would have to clean it up. Resident #38 stated when CNA #5 told her/him that, it made him/her feel belittled. Resident #38 stated CNA #5 never asked him/her if he/she needed assistance and never offered to help either. 2. Record review revealed the facility admitted Resident #67 on 09/07/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/27/18, revealed the facility assessed Resident #67's cognition as intact with a BIMS score of fifteen (15), which indicated the resdient was interviewable. Interview with Resident #67, on 02/19/19 at approximately 10:40 AM, revealed staff do not provide her/him any incontinent care during the night shift. Resident #67 stated last night, on 02/18/19 during the night shift, CNA #5 and CNA #6 came into the resident's room and brought Registered Nurse (RN) #3 as a witness. Resident #67 stated CNA #5 and CNA #6 removed his/her incontinent brief and laid it on the bed. Resident #67 stated CNA #5 then took the brief and rubbed her finger around the edges of the brief, and stated to RN #3 the brief was not wet. CNA #5 told RN #3 the resident did not need any care provided. Resident #67 stated RN #3 left the room and CNA #5 told him/her that she would not come back into the resident's room for the remainder of the evening shift or answer his/her call light. Resident #67 stated RN #3 never said anything to CNA #5 during this incident, and the RN was no longer present when the CNA said she would not answer the call light. Resident #67 stated he/she had an ongoing issue with CNA #5 and had reported her/his concerns to RN #2; however, there continued to be issues. Resident #67 stated he/she felt humiliated when CNA #5 removed his/her incontinent brief in front of CNA #6 and RN #3, in an attempt to show the resident did not need any care to be provided. Attempted interviews on 02/21/19 with CNA #6, at 1:15 PM; RN #3 at 1:16 PM, RN #2 at 1:18 PM, and CNA #5 at 3:00 PM with messages left; however, CNA #6, RN #3, RN #2, and CNA #5 did not return the Surveyor's call. Interview with the Director of Nursing (DON), on 02/21/19 at approximately 2:32 PM, revealed she was unaware of the allegations by both residents. The DON stated her expectation was for all staff to provide care to all residents in a respectful and dignified manner. The DON also expressed her apologies due to her staff not returning the Surveyor's calls to discuss the allegations.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process, for two (2) of thirty-three (33) sampled residents (Residents #86 and #87). The findings include: Review of the facility's policy, MDS Assessment Completion, revised 02/16, revealed the facility will conduct and submit resident assessments in accordance with the RAI Manual including deferral and state submission timeframes. Further review revealed a Significant Change in Status assessment will be completed on the fourteenth (14th) calendar day after determination of a Significant Change in status. 1. Record review revealed the facility admitted Resident #86 on 10/06/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/29/19, revealed the facility assessed Resident #86's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of (6), which indicated the resident was not interviewable. Review of a Quarterly MDS, dated [DATE], Section G, revealed his/her Activities of Daily Living (ADL's) were coded as follows: Bed: 2/2, Transfer: 1/1, Eating: 1/1, and Toileting: 1/1. Additionally, review of the Quarterly MDS, dated [DATE], Section G, revealed his/her ADL's were coded as Bed: 2/2, Transfer: 2/2, Eating: 1/2, and Toileting: 2/2. Record review revealed Resident #86 went from requiring set-up assistance by staff to requiring limited assistance in two (2) of the care areas (Transferring and Toileting); however, there was no evidence a Significant Change MDS was completed. 2. Record review revealed the facility admitted Resident #87 on 02/18/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 01/30/19, revealed the facility assessed Resident #87's cognition as severely impaired as the BIMS was coded as ninety-nine (99), which indicated the resident was not interviewable. Review of an Annual MDS, dated [DATE], Section G, revealed his/her ADL's were coded as follows: Bed: 3/3, Transfer: 8/8, Eating: 2/2, and Toileting: 3/3. Further review of the Quarterly MDS, dated [DATE], Section G, revealed his/her ADL's were coded as Bed: 4/3, Transfer: 4/3, Eating: 1/1, and Toileting: 4/3. Record review revealed Resident #87 went from requiring extensive assistance by staff to not participating anymore in two (2) of the care areas (Bed and Toileting); however, there was no evidence a Significant Change MDS was completed. Interview with the MDS Coordinator, on 02/21/19 at approximately 1:30 PM, revealed Resident #86 wanted to be left alone and she felt [MEDICAL CONDITION] in the lower extremity was the cause of Resident #86's ADL decline. She stated staff discussed doing a physical therapy referral for Resident #86; however, a referral was not completed. She stated Resident #86 was referred to Restorative on 01/16/19 prior to the MDS being completed on 01/29/19; however, there had been no additional follow-up, or additional referrals completed since the MDS was completed on 01/29/19. She confirmed a Significant Change MDS was not completed showing an ADL decline in two (2) of the care areas. Interview with the Assistant Director of Nursing (ADON), on 02/21/19 at approximately 1:45 PM, revealed the facility should have monitored Resident #87 for two (2) weeks after the MDS showed a decline in ADL's; however, that did not occur. The ADON stated the Interdisciplinary Team (IDT) should have been made aware in order for them to try to address the cause of the decline, so interventions could be put in to place to prevent further decline. She stated the IDT team was never made aware of the decline. The ADON stated a Significant Change MDS should have been completed; however, the MDS never triggered for a Significant Change MDS to be completed. Interview with the Director of Nursing (DON), on 02/21/19 at approximately 2:00 PM, revealed her expectations were that a Significant Change MDS should have been completed for Resident #86 and Resident #87 when the most recent MDS showed two (2) ADL declines in two (2) care areas. She stated the IDT team should have been made aware of the change/decline to put interventions in place to prevent any further decline, and attempt to restore residents back to their baseline.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for two (2) of thirty-three sampled residents (Residents #37 and #44). Residents #37 and #44 had falls for which interventions were implemented to consult Physical Therapy (PT)/Occupational Therapy (OT). When therapy evaluated the residents, it was determined the falls were not related to the residents' decline and therapy was not indicated. However, another intervention was not implemented to prevent future falls. The findings include: Review of facility policy titled Falls, last revised 08/16/18, revealed it is 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. Interdisciplinary Team (IDT)/Director of Nursing (DON)/or designee reviews during At Risk Meeting to identify additional referrals, consults, and interventions. 1. Record review revealed the facility admitted Resident #37 on 04/09/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #37's cognition as severely impaired as the resident was unable to complete the Brief Interview of Mental Status (BIMS) exam due to long-term and short-term memory impairment indicating the resident was not interviewable. Further review revealed the resident required extensive assistance of two (2) staff for transfers. Review of the facility provided fall investigation dated 09/12/18 and completed by Licensed Practical Nurse (LPN) #3 revealed Resident #37 fell at 3:15 PM with no injury noted. The resident was found sitting on the floor at bedside as a result of an attempt to transfer unassisted. Implemented interventions were Physical Therapy (PT)/Occupational Therapy (OT) to evaluate and treat; neuro checks per policy; X-ray of right shoulder; and monitor for latent bruising and pain. Review of the Request for Therapy Evaluation, dated 09/12/18, revealed Resident #37 was evaluated due to a recent fall. It was noted the resident had not had a change in physical ability and the fall was not related to a decline; PT not indicated at this time. Review of Resident #37's Comprehensive Care Plan initiated 04/17/15 for At risk for fall related injury revealed an intervention dated 09/12/18 for OT and PT to evaluate as needed. However, there was no intervention put in place to address the root cause of the fall after therapy evaluated the resident and determined therapy was not indicated. Review of the Progress Note, dated 09/13/18 at 4:53 PM, revealed an At-Risk meeting was held with IDT members related to Resident #37's fall of 09/12/18. The progress note revealed attributing factors to the fall included decreased safety awareness with impaired vision and an intervention of PT/OT evaluation reviewed and agreed to continue with plan of care. However, there was no documented evidence that the IDT revisited the fall information to determine the root cause of the fall and put an intervention in place to address the root cause. Interview with LPN #3 on 02/20/19 at 4:53 PM revealed the root cause of Resident #37's fall was poor safety awareness. She stated the initial intervention for PT / OT evaluation was implemented because she thought therapy would make the resident stronger to help prevent falls. Additionally, LPN #3 stated the nurse completing the fall investigation is responsible for updating the care plans with the interventions implemented at that time. She stated the fall information is forwarded to the IDT for post fall investigation and additional interventions may be added or the initial intervention may be changed. 2. Record review revealed the facility admitted Resident #44 on 04/06/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 01/05/19 revealed Resident #44's cognition as intact with a BIMS score of fifteen (15) indicating the resident was interviewable. However, after interviewing the resident, it was determined the resident provided information that was not reliable. Further review of the Quarterly MDS revealed Resident #44 required extensive assistance of one (1) for transfers. Review of the facility provided fall investigation dated 02/07/19 and completed by LPN #4 revealed Resident #44 fell at 10:15 PM with no injury noted. The resident was found lying beside bed on his/her right side. Behaviors contributing to falls were listed as impulsivity, poor safety awareness, non-compliance. Implemented interventions were therapy referral, monitor for signs and symptoms of latent bruising and pain related to this fall. Review of the Request for Therapy Evaluation, dated 02/08/19, revealed Resident #44 was evaluated due to a recent fall. It was noted the resident did not have a change in physical ability and the fall was not related to a decline but the resident attempting to transfer without assistance in which he/she is not suppose to do. Review of Resident #44's Comprehensive Care Plan, initiated 04/14/17, revealed the resident was at risk for fall related injury related to right spastic [MEDICAL CONDITIONS], and history of falls. Interventions listed under Approaches included OT, PT, Speech Therapy (ST) evaluate and Medications as ordered, dated 02/07/18. However, there was no intervention to address the root cause of the fall after therapy evaluated the resident and determined therapy was not indicated. Interview with LPN #4 on 02/20/19 at 5:19 PM revealed Resident #44 had attempted to transfer independently from the wheel chair to the bed and was found lying beside the bed on his/her right side. She stated the immediate intervention was to refer the resident for therapy evaluation for stengthening to help prevent future falls. LPN #4 stated it is the responsibility of the nurse completing the investigation report to update the care plans with the immediate interventions put in place. Interview with LPN #2, Unit Manager, on 02/20/19 at 5:34 PM and on 02/21/19 at 8:11 AM revealed PT/OT was consulted for strengthening to prevent falls. LPN #2 stated the IDT discusses interventions that are working or not, and decides if there should be an intervention added. LPN #2 stated she did not implement a new intervention once therapy evaluated the residents, nor was the care plan updated. Interview with the Director of Nursing (DON) on 02/21/19 at 2:49 PM revealed once therapy communicated they were not picking up the residents for therapy, the fall is brought back to IDT for a new intervention to be implemented. She stated the Unit Supervisor was responsible for implementing new interventions

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for two (2) of thirty-three (33) sampled residents (Residents #86 and #110). The facility failed to assess Resident #110 and Resident #86 for possible interventions to improve the resident's noted decline in bowel and bladder continence. The Findings Include: Review of the Facility Policy titled Bowel and Bladder Management, dated 04/27/16, revised 7/19/18 revealed the Facility will evaluate, monitor and track resident's bowel and bladder patterns and will identify the need for early intervention. Further review revealed facility will evaluate Bowel and Bladder status upon admission, readmission, quarterly and annual and with significant change. The IDT team will review bowel and bladder data to determine if retraining is an option or a pattern has been identified. If retraining is indicated the resident's care plan will be updated to reflect results and the interventions. If pattern is identified, the IDT team will implement a voiding plan based on times indicated, cognition, functional ability and habits. 1. Record review revealed the facility admitted Resident #110 on 05/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 2/11/2019 , revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as three (03), which indicated the resident was cognitively impaired and not interviewable. Review of Resident #110 Quarterly MDS dated [DATE], revealed the facility coded the resident as occasionally incontinent of bowel and bladder. Review of the 90 Day Quarterly MDS Assessment, dated 01/17/19, revealed the facility coded the resident as frequently incontinent of bowel and bladder. The IDT team did not review bowel & bladder data to determine if retraining was an option or try to identify a pattern per facility policy. 2. Record review, revealed the facility admitted Resident #86 on 10/06/17 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment, dated 1/29/19, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a six (06), which indicated this resident was not cognitively intact and not interviewable. Review of Resident #110 Annual MDS dated [DATE], revealed the facility coded the resident as always continent of bowel and bladder. Review of the 90 Day Quarterly MDS Assessment, dated 11/02/18, revealed the facility coded the resident as occasionally incontinent of bowel and bladder. The IDT team did not review bowel & bladder data to determine if retraining was an option or try to identify a pattern per facility policy. Interview with MDS Coordinator on 2/21/19 at approximately 1:30 PM revealed MDS coordinator stated Resident #86's bladder decline may have been a result if the medication [MEDICATION NAME] that was prescribed on 10/17/18 but that she could not be certain that was the reason since there was no tracking method put in place to identify the decline and potentially restore back to Resident #86's baseline. MDS Coordinator stated the decline should have been addressed and interventions should have been put in place. Interview with ADON on 2/21/19 at approximately 3:15 PM revealed that once Resident #110's decline was observed it should have been brought to the attention of the IDT team to address the decline and identify interventions to prevent further decline and try to restore back to baseline. ADON stated there was no tracking of any kind put in place to identify bowel & bladder decline and possibly restore.

Based on interview, record review and review of facility policy, it was determined the facility failed to maintain medical records on each resident that are accurately documented for one (1) of thirty-three (33) sampled residents (Resident #65). The findings include: Review of the facility policy titled, Charting and Documentation, dated 07/02/18, revealed the following: Services provided to the resident, or any changes in the resident's medical condition or mental condition, shall be documented in the resident's medical record. Guidelines: For all skilled residents, documentation will occur at least daily. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum the date and time treatment was provided, name and title of individual who provided care, assessment data and/or any unusual findings obtained during the procedure/treatment, signature and title of the individual documenting. Record Review revealed the facility admitted Resident #65 on 12/21/18 with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #65's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated the resident was interviewable. Review of Physician's Orders dated 12/21/18 revealed an order to monitor the Permacath right upper chest site every shift and monitor Fistula site to right forearm for thrill, bruit and any sign of infection every shift. Review of the (MONTH) and (MONTH) 01-20, 2019 Medication Administration Record(MAR)/Treatment Administration Record (TAR) revealed on the 11:00 PM-7:00 AM shift checking of the right upper chest [MEDICAL TREATMENT] site and Right forearm fistula site was charted as eleven on 01/01/19, 01/03/19, 01/06/19-01/08/19, 01/10/19, 01/12/19-01/15/19, 01/17/19, 01/20/19, 01/22/19, 01/24/19, 01/26/19-01/27/19, 02/05/19, 02/07/19, 02/09/19-02/11/19, 02/14/19, and 02/16/19-02/17/19. The coding interpretation indicated the number eleven meant No behavior. Interview with Director of Nursing (DON) on 02/21/19 at 8:27 AM in relation to staff charting for inspection of the [MEDICAL TREATMENT] site No behaviors revealed nurses have been clicking the wrong button. When asked how one is to determine if the site was monitored, the DON replied Well, they (staff) acknowledge they have been putting incorrect information, hitting the wrong button in the computer system. Further interview with the DON on 02/21/19 at 3:15 PM revealed she would expect the nursing staff to do accurate documentation on [MEDICAL TREATMENT] residents when checking the [MEDICAL TREATMENT] port site and would expect staff to put the correct coding. .

Based on observation, interview and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-five (25) residents (Resident #71). Observation revealed CNA #1 failed to remove soiled gloves and wash hands after providing incontinent care , prior to touching personal belongings for Resident #71. The findings include: Review of the facility's procedure titled, Perineal Care Male/Female Competency, last reviewed 11/21/17, revealed to maintain standard precautions for prevention of cross-contamination and spread of infection during the procedure, remove and discard gloves, wash and dry hands thoroughly, and reposition patient comfortably. Record review revealed the facility admitted Resident #71 on 11/16/17 with [DIAGNOSES REDACTED]. Observation of Certified Nurse Aide (CNA) #1 providing peri-care/incontinent care for Resident #71, on 02/14/18 at 2:23 PM, revealed CNA #1 failed to remove her gloves and wash her hands after providing catheter/peri-care/incontinent care, then proceeded to reposition the resident, and placed a pillow behind the residents back, without washing hands and putting on clean gloves. Interview with CNA #1 on 02/14/18 at 2:30 PM, revealed she should have removed the soiled gloves and washed her hands, and put on a clean pair of gloves before repositioning and touching Resident #71's personal belongings, in order to prevent the spread of infection. Interview with the Director of Nursing (DON) on 02/15/18 at 8:26 AM, revealed she would have expected the staff to have changed their gloves and washed their hands after providing catheter/peri-care/incontinent care, before proceeding to provide care for Resident #71, in order to prevent the spread of infection.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide or arrange services by qualified persons in accordance with two (2) of three (3) sampled residents' written plan of care (Resident #2 and #3). Resident #2 was care planned for a bed alarm; however, observations on 08/23/17 and 08/24/17, revealed facility staff failed to ensure a bed alarm was in place. In addition, Resident #3 was care planned for a chair alarm, a sensor alarm to bed, and a fall mat beside bed. However, observations on 08/23/17 revealed facility staff failed to ensure the sensor alarm and fall mat were in place when the resident was in bed and observation on 08/24/17 revealed the facility staff failed to ensure a chair alarm was in place when the resident was up in his/her wheelchair. The findings include: Review of the policy titled Care Plans-Comprehensive, not dated, revealed the nurse/Interdisciplinary Team develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan will be developed with the participation from the resident, resident's family and/or responsible party as indicated. The policy further reveals the nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the residents status when there has been a significant change in the resident's condition, the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly. 1. Record review revealed the facility admitted Resident #1 on 09/04/14 and readmitted him/her on 08/07/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of two (2) which indicated the resident was no interviewable. Further review revealed the facility assessed the resident required assistance of two (2) for transfer, hygiene, bathing, and toileting. Review of Resident #2's History and Physical, dated 08/03/17, revealed he/she fell face first from the wheel chair after trying to reach for something and fell from the chair. It further stated he/she lost consciousness for a short period and had a change in mental state and confusion. The report revealed Resident #2 received a large left Supraorbital hematoma to the face and also a fracture through the odontoid process just beneath the anterior arch of the cervical (C)-1 and a grade one (1) anterolistheis at C-2 and C-3. Review of Resident #2's Comprehensive Care Plan for falls, dated 11/17/15, revealed on 08/03/17 the care plan was updated to include fall with fracture with an intervention added to use a bed alarm and a chair alarm. Review of the Certified Nurse Aide (CNA) Care Report, not dated, revealed under the category for safety/positioning-bed and chair alarm. However, observations on 08/23/17 at 6:30 PM, and on 08/24/17 at 8:30 AM and 11:00 AM, revealed Resident #2 was lying in bed with no bed alarm noted. Interview with Certified Nurse Aide (CNA) #1 who was caring for Resident #3, on 08/24/17 at 10:00 AM, revealed the resident did not use an alarm to the wheelchair, he/she only falls out of the bed. She was not aware a safety alarm had been added on 08/20/17, and had not been told about the alarm from another staff member. 2. Record review revealed the facility admitted Resident #3 on 04/19/16 and readmitted him/her on 03/14/17 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 08/15/17, revealed the facility assessed Resident #3's cognition as severely impaired with a BIMS score of three (3) which indicated he/she was not interviewable. Further review revealed the facility assessed the resident required assistance of two (2) with transfer, Hygiene, Bathing and toileting. Record review titled History and Physical revealed Resident #3 had a right [MEDICAL CONDITION] on 03/21/17 that required surgical repair. On 08/05/17, he/she was sent to the hospital after a fall that resulted in an acute right femoral subtrochanteric fracture. On 08/20/17, he/she was again sent to the ER after a fall. Review of Resident #3's Comprehensive Care Plan for at risk for falls, dated 05/02/17, revealed an interventions for a chair alarm not dated, a pressure sensor to the bed dated 07/21/17, and a fall mat dated 08/03/17. Review of the CNA Care Plan, not dated, revealed a chair alarm was added on 08/20/17, the floor fall matt was not added until 08/24/17, and the sensor alarm was not listed. However, observation on 08/23/17 at 6:49 PM revealed Resident #3 lying in bed and attempting to get up. There was no alarm sounding or observed, and also no fall matt was noted to the floor. Observation on 08/24/17 at 8:40 AM revealed Resident #3 sitting up in the wheel chair at the bedside of his/her spouse with no alarm noted to the chair. On 08/24/17 at 11:00 AM, he/she was observed propelling him/her self in the hallway without an alarm to the chair. At 12:00 PM, he/she was observed in the dining room, participating in activities and an alarm had been added. Interview with Certified Nurse Aide (CNA) #1 who was caring for Resident #3, on 08/24/17 at 10:00 AM, revealed the resident did not use an alarm to the wheelchair, he/she only falls out of the bed. She stated she was not aware a safety alarm had been added on 08/20/17. She revealed she failed to look at the care plan prior to the care of Resident #3 because this was her routine unit and she knew the residents. Interview with CNA #2 on 08/24/17 at 3:10 revealed since she only worked as needed (PRN), she always looked at the CNA care plan prior to caring for the residents. Interview with CNA #3, on 08/25/17 at 9:00 AM revealed he always tried to get a quick look at the resident's care plan and would also get any new information from the nurse or the off going CNA. He stated that was how they were trained to do the job. Interview with the acting Director of Nursing (DON)/Staff Development Educator (SDE), on 08/25/17 at 9:15 AM, revealed she felt the facility needed a deep care plan audit, and she expected all items that were care planned to be used and be in place. She stated the unit managers started educating the staff the night before and would be educating all CNA's, related to checking the care plan each shift prior to caring for a resident. She further stated they did a care plan audit to ensure all interventions were in place. She stated she expected all staff to check the care plan prior to giving care, and also to do walking rounds with the off going staff, and if any questions, ask the charge nurse.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure five (5) of eight (8) sampled residents were provided the necessary care and services to attain/maintain the highest practicable physical, mental, and psychosocial well being related to an outbreak of possible scabies (Residents #1, #3, #4, #5, and #6). In addition, the facility failed to educate staff on caring for residents with possible scabies. The findings include: Review of the policy titled, Skin Assessment Competency dated 06/01/15, revealed each resident will have a weekly skin assessment completed by a Licensed Nurse. The skin assessment will include a physical head to toe with emphasis placed on the following areas: Head, Ears, Face, Neck, Abdomen, Genital Area, Extremities, Back, Buttocks, Shoulders, Hips. They are to document: pink, warm, dry scaling, peeling, clammy, wet and cold. The skin assessment will be documented on a weekly skin assessment form noting any changes in the skin condition. The policy related to skin assessments did not specify documentation of a rash but interview with the acting Director of Nursing (DON) and Educator, on 08/11/17 at 8:40 AM, revealed she expected the staff to document every change noted to the skin integrity, and that is how they are trained when completing a proper skin assessment. She stated if the rash is still present the next week, then it should be documented again. 1. Record review revealed the facility readmitted Resident #1 on 06/27/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 07/04/17, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. Review of Weekly Skin Assessments, dated 06/27/17, 07/03/17 and 07/10/17 revealed a rash was noted to the Pelvic region but no other areas were documented to have a rash. However, review of a Physician's Progress Note, dated 07/01/17, revealed Resident #1 reported an itchy rash mostly on his/her legs. In addition, review of Weekly Skin Assessments revealed no rash was documented from 07/17/17 through 08/01/17, only two (2) scars and a pressure area. However, review of the Nursing Progress Report, dated 07/24/17, revealed a skin scraping was collected and sent for Pathology and was positive for Scabies. There was no documented evidence the staff were monitoring the rash to identify if the rash was worsening or spreading. Review of the July 2017 Medication Administration Record [REDACTED]. However, further review of the Progress Notes Report and Weekly Skin assessments revealed there was no documented evidence staff was monitoring the rash to identify if the treatments were effective. Observation of a full skin assessment for Resident #1 on 08/09/17 at 2:00 PM revealed a rash was noted to the lower back, behind the bilateral knees, on the shoulders. abdomen, and skin folds with open abraded areas related to scratching. Interview with Resident #1 revealed he/she itched all over for several months. 2. Record review revealed the facility readmitted Resident #3 on 03/27/17 with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/21/17, revealed the facility assessed Resident #3's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Review of Resident #3's June, July and August 2017 Weekly Skin Assessments revealed there was no documented evidence the resident had a rash. However, review of a Situation Background Assessment Recommendation (SBAR) Communication Form was sent to the Physician on 06/17/17 which stated red itching rash to the entire body with scratching. There was no documented evidence the staff were monitoring the rash to identify if the rash was worsening or spreading. Review of the July 2017 MAR indicated [REDACTED]. However, further review of the Progress Notes Report And Skin Assessments revealed there was no documented evidence staff was monitoring the rash to identify if the treatments were effective. 3. Record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/12/17 revealed the facility assessed Resident #4's cognition as severely impaired with a BIMS score of five (5), which indicated he/she was not interviewable. Review of Resident#4's July and August 2017 Weekly Skin Assessments revealed there was no documented evidence the resident had a rash. However, review of the physician progress notes [REDACTED]. Patient's right lower arm has two (2) areas that have scant amount of bloody discharge from patient's admission of scratching. We will start the patient on an oral antibiotic for cellulite of the right arm. There was no documented evidence the staff were monitoring the rash to identify if the rash was worsening or spreading. Observation of a full skin assessment on 08/09/17 at 10:15 AM completed by Registered Nurse (RN) #1 and RN #2 revealed a rash to the entire body with abraded areas from scratching and a complaint of severe itching. Review of the June and July 2017 MAR indicated [REDACTED]. Further review revealed on 07/27/17 he/she was treated with Ivermivtin 0.2 mg then repeat in two (2) weeks. However, review of Progress Notes Report and Weekly Skin Assessments revealed there was no documented evidence staff was monitoring the rash to identify if the treatments were effective. 4. Record review revealed the facility readmitted Resident #5 on 05/13/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/20/17, revealed the facility assessed Resident #5's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of Resident #5's July, and August 2017 Weekly Skin Assessments revealed there was no documented evidence the resident had a rash or that the rash has spread and worsened. However, review of the July 2017 MAR indicated [REDACTED]. In addition, observation of a full skin assessment dated [DATE] at 9:50 AM performed by RN #1 and RN #2 revealed a rash to the entire body. However, review of the Progress Notes Report and Weekly Skin assessments revealed there was no documented evidence the staff were monitoring the rash to identify if the rash was worsening or spreading, and if the treatment was effective. 5. Record review revealed the facility readmitted Resident #6 on 04/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 07/31/17, revealed the facility assessed Resident #5's cognition as intact with a BIMs score of fifteen (15) which indicated the resident was interviewable. Review of Resident #6's June, July, and August 2017 Weekly Skin Assessments revealed there was no documented evidence the resident had a rash. However, observation of a complete skin assessment completed by RN #1 and RN #2, on 08/09/17 at 10:30 AM, revealed areas of rash noted to the upper chest, under the bilateral arms to the trunk area and behind the bilateral knees. Resident #6 stated during the assessment that he/she had a rash with severe itching for approximately five (5) weeks, and had lost at least two (2) hours of sleep many nights because of the itching. He/she further stated even his/her family had been bringing things to him/her to help with the itch. There was no documented evidence the staff were monitoring the rash to identify if the rash was worsening or spreading. Review of the July 2017 MAR indicated [REDACTED]. Review of the Progress Notes Reports and Weekly Skin Assessments revealed there was no documented evidence the staff were monitoring the rash to identify if the treatments were effective. In addition, review of a Communication Form, dated 08/08/17, revealed Please review the attached policies regarding Infection Control (pay special attention to contact isolation), Hand washings, and Scabies. If you have any questions regarding these policies, please see your supervisor. Please sign, acknowledging you have read and understand the above. However, further review revealed only nine (9) staff had signed the form indicating they had read the policies. No other documentation of staff education was provided related to scabies. Interview with Licensed Practical Nurse (LPN) #1, who had performed skin assessments on Resident #3 and #4 revealed, since the residents were being treated for [REDACTED]. Interview with the Registered Nurse (RN) #2 on 08/11/17 at 10:00 AM, also the treatment nurse, revealed she noted a rash on all the residents during the full skin assessment but she was only responsible for documenting the wounds, nothing else. Interview with the Unit Manager for North Hall on 08/11/17 at 4:20 PM, who had completed skin assessments on Resident #1, #3, #4, and #6 revealed, I did a head to toe skin assessment on all the residents and did not see a rash, if my name was signed to it, I did it even though there was documented evidence rashes were present by the Physician and Nurse Practitioner, and treatment for [REDACTED]. Interview with Registered Nurse (RN) #3, on 08/10/17 at 9:45 AM revealed they used Wound Sense, a computer program when doing skin assessments. She stated any change should be noted on the assessment including bruises, skin tears, rashes, new open areas or breaks in the skin related to scratching. Interview with Nurse Aide #5 on 08/08/17 at 3:15 PM revealed she had noticed a rash on Resident #6 but had never been educated on scabies outbreak. She further stated she didn't even know what the rash was. Interview with Hospitality Aide (HA) #6 on 08/08/17 at 4:00 PM revealed she had only been inserviced during orientation on standard precautions for everyone. Interview with Nurse Aide (NA) #2, on 08/09/17 at 10:10 AM revealed she was told about the rash a few weeks ago by housekeeping. She stated no one had educated her on contact precautions, she stated I would ask but was not told. Interview with Certified Nurse Aide #4 on 08/09/17 at 12:00 PM revealed she had worked at the facility for about two (2) weeks and about a week ago was inserviced on hand hygiene but did not remember if she had signed anything. She further stated she had not been through all the inservices. Interview with the Unit Manager for South Hall on 08/09/17 at 2:12 PM revealed they had noticed a few rashes on her hall so had decided to treat for scabies on all that had rashes. No contact precautions were put in place, and there was not any inservices related to the outbreak until last night, 08/08/17, which a read and sign was placed at the nurses station related to scabies and contact precautions. Interview with the Nurse Practitioner on 08/10/17 at 10:00 AM revealed she suspected the resident's had scabies. She stated, If they have the signs and symptoms, and use the appropriate treatment, then that is the [DIAGNOSES REDACTED]. Interview with the acting Director of Nursing (DON), Staff Development Coordinator (SDC) on 08/11/17 at 8:40 AM, revealed she realizes they had a problem and education needed to be done on how to do a proper skin assessment, and infectious diseases, and she expected all staff completing skin assessments to document what was observed on the day of the assessment, per policy, and also to receive the needed education. She further stated she felt all the resident's that received the [MEDICATION NAME] Cream and/or the Ivermectin should have been documented on every shift for possible side effects or adverse reactions to the treatment for [REDACTED]. On 08/11/17 at 10:20 PM, it was revealed by the DON that she was put in the position of interim DON only a few months ago so was not there when all the rashes started, and also she knew there was training available but due to the fact of not being there, did not know if it was provided or not.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain clinical records for five (5) of eight (8) sampled residents in accordance with accepted professional standards and practices that are complete and accurately documented (Resident #1, #3, #4, #5, and #6). Staff failed to document rashes that were identifed during weekly skin assessments for Resident #1, #3, #4, #5, and #6. The findings include: Review of the policy titled Skin Assessment Competency dated 06/01/15, revealed each resident will have a weekly skin assessment completed by a Licensed Nurse. The skin assessment will include a physical head to toe with emphasis placed on the following areas: Head, Ears, Face, Neck, Abdomen, Genital Area, Extremities, Back, Buttocks, Shoulders, Hips. They are to document: pink, warm, dry scaling, peeling, clammy, wet and cold. The skin assessment will be documented on a weekly skin assessment form noting any changes in the skin condition. The policy related to skin assessments did not specify documentation of a rash but interview with the acting Director of Nursing (DON) and Educator, on 08/11/17 at 8:40 AM, revealed she expected the staff to document every change noted to the resident's skin integrity, and staff are trained to do so. She stated if the rash is still present the following week it should be documented again. Review of the policy titled Charting and Documentation, not dated, revealed services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical chart. 1. Record review revealed the facility admitted Resident #1 on 04/19/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes Reports revealed Review of the Physician's Progress Note, dated 06/13/17 revealed Resident #1 reported a diffuse itchy rash and that [MEDICATION NAME] and [MEDICATION NAME] helps a little but still having itchy rash on legs, abdomen, and lower back. Further review of the Progress Notes Report revealed Resident #1 was started on an Antifungal for itching on 06/14/17. On 07/01/17 Resident #1 received an order for [REDACTED]. Review of a Progress Note dated 07/01/17 revealed Patient reports diffuse itchy rash. Patient reports that the rash is mostly on his/her legs, it is better but is starting to bother him/her again. On 07/24/17, documentation revealed a skin scraping was collected and sent for Pathology and was positive for Scabies. In addition, observation and full skin assessment for Resident #1 on 08/09/17 at 2:00 PM revealed a rash was noted to to the lower back, behind the bilateral knees, on the shoulders. abdomen, and skin folds with open abraded areas. However, review of Resident #1s Weekly Skin Assessments revealed a rash was noted to the Pelvic region, for the month of June 2017, and no other areas were documented to have a rash. Further review of the Weekly Skin Assessments revealed the rash continued to the Pelvic region through 07/10/17 but no rash was documented from 07/17/17 through 08/01/17. 2. Record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Situational Background Assessment Recomendation (SBAR) Communication Form which was sent to the Physician on 06/17/17 revealed red itching rash to the entire body with scratching. Review of the July 2017 Medication Administration Record [REDACTED]. However, review of the Resident Weekly Skin Assessment for June, July and August 2017 revealed no documented evidence the resident had a rash on his/her entire body. 3. Record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the June and July 2017 MAR indicated [REDACTED]. Review of the physician progress notes [REDACTED]. Patient's right lower arm has two areas that have scant amount of bloodie discharge from patient's admission of scratching. We will start the patient on an oral antibiotic for cellulite of the right arm. Review of the July 3017 MAR indicated [REDACTED]. In addition, observation and full skin assessment on 08/09/17 at 10:15 AM completed by RN #1 and RN #2 revealed a rash to the entire body with abraded areas from scratching and a complaint of severe itching. However, review of Resident#4's weekly skin assessment for the months of May, June, July, and August 2017 revealed no documentation a rash was present. 4. Record review of Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's MAR indicated [REDACTED]. On 07/06/17 an order for [REDACTED].#5 was treated with Premethin cream and on 07/28/17 was treated with Ivermivtin 0.2 mg then repeat in two (2) weeks. In addition, observation of a full skin assessment dated [DATE] at 9:50 AM performed by RN #1 and RN #2 revealed a rash to the entire body with a complaint of severe itching. However, review of the Weekly Skin Assessments for the months of May, June, July, and August 2017 revealed no rash was present at any time. 5. Record review of Resident #6 revealed he/she was admitted to the facility on [DATE] then again on 04/12/17 with [DIAGNOSES REDACTED]. Review of the July 2017 MAR, revealed on 07/06/17 Resident #6 was treated with Premethrin Cream, then with Ivermictin 0.2 mg on 07/26/17, to be repeated in two weeks. Observation and complete skin assessment dated [DATE] at 10:30 AM completed by RN #1 and RN #2, revealed areas of rash noted to the upper chest, under the bilateral arms to the trunk area and behind the bilateral knees. In addition, interview with Resident #6 during the assessment revealed he/she had a rash with severe itching for five (5) weeks, and had lost at least two (2) hours of sleep many nights because of the itching. He/she further stated even his/her family had been bringing things to him/her to help with the itching. However, review of Resident #6's Weekly Skin Assessments revealed no rash was noted from May through August 2017. Interview with the Unit Manager on South Hall, on 08/11/17 at 9:30 AM revealed any changes to the resident's skin should be noted on the weekly skin assessment, and if still present the next week, should be noted and described for that week as well. The majority of the rashes had been the North Unit but a few was noted on the South Hall and documentation revealed the rashes were present on the skin assessments. Had she completed any of the skin. Interview with Licensed Practical Nurse (LPN) #1, who had performed skin assessments on Resident #3 and #4 reveale, since the residents were being treated for [REDACTED]. Interview with the Registered Nurse (RN) #2 on 08/11/17 at 10:00 AM, also the treatment nurse, revealed she noted a rash on all the residents during the full skin assessment but she was only responsible for documenting the wounds, nothing else. Interview with the Unit Manager for North Hall on 08/11/17 at 4:20 PM, which had completed skin assessments on Resident #1, #3, #4, and #6 revealed, I did a head to toe skin assessment on all the residents and did not see a rash, if my name was signed to it, I did it even though there was documented evidence rashes were present by the Physician anf Nurse Practioner, and treatment for [REDACTED]. Interview with the Director of Nursing (DON) on 08/11/17 at 8:40 AM revealed she realizes they have a problem on how to document a proper skin assessment. She stated she was concerned maybe there was a problem with computerized documentation but she expected staff to document any skin integrity issues that are observed per policy.

Based on interview, record review, review of the facility's policy, and review of the Resident Assessment Instrument (RAI) Manual 3.0 Version, it was determined the facility failed to ensure a comprehensive care plan was developed for each resident that included measurable objectives and timetables to meet the resident's medical and nursing needs that were identified in the comprehensive assessment for one (1) of five (5) sampled residents (Resident #3). Resident #3's Comprehensive Care Plan was not developed related to toilet use, although the Minimum Data Set (MDS) triggered for that area. Resident #3 was assessed by staff as a high fall's risk, and required two (2) staff for transfers. The resident also utilized a chair alarm due to unassisted transfers; however, the resident was not care plan related to toileting. On 09/29/14, Resident #3 was left on the commode in his/her bathroom unattended by Licensed Practical Nurse (LPN) #1. Resident #3 fell off the commode and sustained a left distal radius fracture, left boxer's fracture and comminuted intertrochanteric [MEDICAL CONDITION] hip. Resident #3 required surgical intervention to repair the fractures on 09/30/14. The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive", last revised October 2010, revealed the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS. Each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems; and, aid in preventing or reducing declines in the resident's functional status and/or functional levels. Review of the RAI Version 3.0 Manual (section 4.1) revealed the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Further review of the RAI Manual (section 4.4) revealed facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs. The process focuses on evaluating the triggered care areas using the (Care Area Assessments) CAAs, but does not provide exact detail on how to select pertinent intervention for care planning. Interventions must be individualized and based on applying effective problem solving and decision-making approaches to all of the information available for each resident. Section 4.7 states, in selecting interventions and planning care, the key task would be to identify specific symptomatic and cause specific interventions for physical, functional, and psychosocial needs. Record review revealed the facility admitted Resident #3 on 04/03/14 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 09/08/14, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Further review revealed the facility assessed Resident #3's balance during transitions and walking as not steady, only able to stabilize with staff assistance. In addition, the facility assessed Resident #3's toilet use and transfer as the resident required extensive assistance with two (2) plus persons physical assist. Review of Resident #3's Comprehensive Care Plan, dated 05/06/14, and the Certified Nurse Aide (CNA) Assignment Sheet, printed 09/14/14, revealed the resident was at risk for complications related to self-care deficit; and required staff assist of one (1) with transfers even though the MDS assessment indicated the resident required the extensive assistance of two (2) staff for transfers. Further review revealed no documented evidence to address the amount of staff assistance needed for the resident's toilet use even though the MDS assessment identified Resident #3's balance during transitions and walking was not steady, and the resident was only able to stabilize with staff assistance. In addition, the Care Plan revealed the resident required a chair alarm when up in the chair due to unassisted transfers. Review of a Situation, Background, Assessment, Response (SBAR) Communication Form, dated 09/29/14 at 6:50 PM, revealed Resident #3 was found sitting on the floor, legs straight, leaning against the door frame by LPN #1. Further review revealed a head to toe assessment was completed by LPN #1 with no injuries identified. Resident #3 complained of left hip pain and was sent to the local emergency room for evaluation and treatment at 7:10 PM. Further review of the SBAR revealed the facility was notified at 10:50 PM that the resident had sustained a left femur fracture; the greater trochanter was broken into the socket; and, the resident was being admitted to the hospital. Review of an Operative Report, dated 09/30/14, revealed Resident #3 sustained a comminuted intertrochanteric [MEDICAL CONDITION] hip, an angulated [MEDICAL CONDITION] metacarpal neck on the left hand with a nondisplaced [MEDICAL CONDITION] radius requiring surgical repair. The resident required trochanteric nailing of the left hip along with closed reduction and casting of the left boxer's fracture and distal radius. Interview with LPN #1, on 10/08/14 at 3:15 PM, revealed on 09/29/14, she assisted Resident #3 to the bathroom and placed him/her on the commode, and left him/her unattended and went back to the Nurses' Station. She stated she was giving the resident some privacy and gave him/her the call light to call when he/she was ready to get up. LPN #1 stated approximately five (5) minutes later, the resident's call light came on and she found the resident on the floor. She stated she thought the resident had fallen in the past but she was not sure if he/she was care planned as high risk for falls. Interview, on 10/08/14 at 3:30 PM, with Certified Nursing Assistant (CNA) #2, who was responsible for Resident #3 the day of the fall, revealed on the evening of 09/29/14, the South Unit staff consisted of five (5) CNAs, two (2) LPNs and one (1) Certified Medication Aide (CMA). She stated she was assisting in the dining room during mealtime at the time of the fall. CNA #2 stated the other South Unit staff helped with her assignment while she was in the dining room. She stated Resident #3 had already fallen off the toilet when she arrived in the room. CNA #2 stated Resident #3 had a history of [REDACTED]. She stated the resident used a chair and bed alarm because he/she would attempt to get up unassisted. She stated she would never leave Resident #3 unattended on the toilet. Interview with CNA #4, on 10/09/14 at 2:20 PM, revealed if a resident has an alarm they should not be left unattended on the commode. Interview with CNA #5, on 10/09/14 at 3:35 PM, revealed Resident #3 had a care plan in place with interventions which included the assistance of one (1) staff member with transfers. CNA #5 stated Resident #3 self-propelled in the wheelchair. CNA #5 revealed she stayed with the residents when she assisted them to the bathroom if they had a bed or chair alarm in place. Interview with the MDS Coordinator, on 10/09/14 at 9:00 AM, revealed she completed MDS assessments based on information from staff and direct observations. She stated the completion of the MDS generated the comprehensive care plan and the Unit Manager was expected to update care plans and create CNA care plans based on observation of the resident's needs. The MDS Coordinator stated the care plan and MDS assessment were not always the same. She stated the MDS was a snap shot of the seven (7) day look back period, and she used the information the nurses gave her, and made observations to make sure the information was accurate. She stated if the resident required the assistance of two (2) for transfer for only one episode during the look back period, she was required to code it as requiring the assistance of (two). Interview with the Unit Manager (UM) of the South and Reflections Units, on 10/08/14 at 5:00 PM, revealed the MDS Coordinator generated the care plan. The UM stated she no longer had MDS access, as the MDSs were stored in a file cabinet. She stated it was her responsibility to modify the care plan when changes occurred. The UM stated unless the plan of care was specific about restrictions nursing staff could use their own judgement if it was safe to leave a resident alone in the bathroom. She stated her expectation was that if two (2) staff were required to assist with transfers and the resident was considered a fall's risk and had chair alarms, staff should stay with the resident during toileting. Interview with the Director of Nursing (DON), on 10/09/14 at 3:05 PM, revealed she expected nurses to use their judgment to determine if it was safe for the resident to be left alone in the bathroom. She stated residents should have toilet use as part of the care plan. The DON stated staff should use the transfer assist care plan which stated the resident required the assistance of one (1) for transfers if there was not a toilet use care plan because the resident could change from day to day. The DON stated that resident fall risk was noted on the CNA assignment form and she expected nurses to tell the CNAs which residents were cognitively impaired. The DON stated they should know the resident's behavior. If they have a bed or chair alarm they should go with what they have as a guide in toileting. She also stated the nurses were responsible to inform the nurse aides during shift report about each resident's cognitive status and make that decision each shift. She stated the residents were not care planned on whether to leave unattended on the toilet or not because the residents' needs could change daily. She revealed she had not really considered if residents who had been assessed as needing an alarm to alert staff of unassisted transfers should be left on the commode with no supervision.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents related to a fall with injuries for one (1) of five (5) sampled residents (Resident #3). Record review revealed the facility assessed the resident as a high fall risk and required a chair and bed alarm due to unassisted transfers. On 09/29/14, Resident #3 was left on the commode in his/her bathroom unattended by Licensed Practical Nurse (LPN) #1. The resident fell off the commode and sustained a left distal radius fracture, left boxer's fracture and comminuted intertrochanteric fracture of the left hip. Resident #3 required surgical intervention to repair the fractures on 09/30/14. The findings include: Review of the facility's Fall Policy, dated 04/2012, 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. All residents should have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition. Appropriate care plan interventions would be implemented and evaluated as indicated by the assessment. A comprehensive care plan should be implemented based on the fall risk evaluation score with an individualized goal and interventions specific to each patient. The care plan should be reviewed following each fall, quarterly, annually, and with each significant change. Interventions should be revised as indicated by the assessment. Review of the facility's Resident Alarms policy, dated 12/2010, revealed resident alarms may be used for residents as a non-restraining device which alerts staff to a resident rising from a bed or chair without assistance. An alarm assists in providing mobility and ease of movement while promoting quality of life, dignity, and safety with emphasis on quality of care. The procedure to identify residents at risk for falls and those who would benefit from the use of an alarm device (frequent falls, confused residents, unsteady or weak in ambulation and/or bed rail climber). Record review revealed the facility admitted Resident #3 on 04/03/14 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 09/08/14, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) indicating the resident was not interviewable. Further record review revealed Resident #3's balance during transitions and walking was unsteady, and the resident was only able to stabilize with staff assistance. In addition, Resident #3 required the extensive assistance of two (2) staff for transfers and toileting. Review of Resident #3's Fall Risk Assessment, dated 09/08/14, revealed the resident scored sixteen (16) which indicated the resident was at high risk for falls. Review of Resident #3's Comprehensive Care Plan, dated 05/06/14, revealed he/she was at risk for complications related to self-care deficit and required staff assist of one (1) with transfers even though the resident was assessed as needing two (2) staff assist for transfers. Further review revealed no interventions to address the amount of supervision needed for toileting. In addition, the Care Plan revealed the resident required a chair alarm when up in the chair due to unassisted transfers. Review of the Certified Nurse Aide (CNA) assignment sheet, printed 09/14/14 by Unit Manager (UM) of South Unit and the Reflections Unit, revealed documentation which included interventions for fall risk, one (1) assist transfer, alarm to the bed and wheelchair, non-skid socks while in the bed and raised toilet seat. However, there was no intervention to address supervision related to toileting even though the resident required a chair alarm and was assessed as unsteady for transfers and walking. Interview with LPN #1, on 10/08/14 at 3:15 PM, revealed on 09/29/14, she assisted Resident #3 to the bathroom and placed him/her on the commode, and left him/her unattended and went back to the Nurse's Station. She stated she was giving the resident some privacy and gave him/her the call light to call when he/she was ready to get up. LPN #1 stated approximately five (5) minutes later, the resident's call light came on and she found the resident on the floor. She stated she was not sure the resident was care planned for falls, but she knew the resident had fallen in the past. Review of the Communication Form, dated 09/29/14 at 6:50 PM, revealed Resident #3 was found sitting on the floor, legs straight and leaning against the door frame. A head to toe assessment was completed by LPN #1, with no injuries noted. The resident complained of left hip pain and was sent to the local emergency room for an evaluation and treatment at 7:10 PM. Review of an Situation, Background, Assessment, Response (SBAR), dated 09/29/14, revealed the facility was notified at 10:50 PM that the resident had sustained a left femur fracture and the greater trochanter was broken into the socket. Resident #3 was admitted to the hospital. Review of an Operative Report, dated 09/30/14, revealed Resident #3 sustained a comminuted intertrochanteric fracture of the left hip, and an angulated fracture of the small metacarpal neck on the left hand with a nondisplaced fracture of the distal radius requiring surgical repair. The resident required trochanteric nailing of the left hip along with closed reduction and casting left boxer's fracture and distal radius. Interview with CNA #2, who was responsible for Resident #3, on 10/08/14 at 3:30 PM, revealed when she entered the room, Resident #3 had already fallen off the toilet. She stated the resident was care planned for falls and required the assistance of two (2) staff for transfers and a bed and chair alarm due to unassisted transfers. Interview with CNA #4, on 10/09/14 at 2:20 PM, revealed if a resident had an alarm they should not be left unsupervised on the commode. Interview with CNA #5, on 10/09/14 at 3:35 PM, revealed she stayed with the residents when she assisted them to the bathroom if they had a bed or chair alarm in place. Interview with LPN #3, on 10/08/14 at 4:10 PM revealed Resident #3's mobility had decreased since the fall. Interview with the Physical Therapist (PT) on 10/09/14 at 9:10 AM, revealed Resident #3's mobility had declined and pain had increased since the fall. He stated Resident #3's plan of care included non-weight bearing and he/she required assistance of two (2) staff. The current PT goal for Resident #3 was to assist him/her to sit on the bedside. Interview with the Unit Manager (UM), on 10/09/14 at 11:15 AM, revealed she expected nursing staff to use their judgment when deciding if a resident required supervision while toileting. She stated if a resident was a high risk for falls then staff should not leave the resident unsupervised in the bathroom. Interview with the MDS Coordinator, on 10/09/14 at 9:00 AM, revealed she completed MDS assessments based on information from staff and direct observations. Upon MDS completion, the comprehensive care plan was generated and the UM was responsible for the CNA care plans and added updates to the comprehensive care plans based on observation of the resident needs. The MDS Coordinator stated the care plan and MDS assessment were not always the same. She stated she reviewed the MDS Supplemental Charting sheets completed by staff during the seven (7) day look back period and also made observations to ensure the information was accurate before documenting the information on the MDS. She stated she completed the assessments and generated the care plan for Resident #3. Interview with the Director of Nursing (DON), on 10/09/14 at 3:05 PM, revealed she expected nurses to use their judgment to determine if it was safe for the resident to be left alone in the bathroom. She stated residents should have toilet use as part of the care plan. The DON said staff should use the transfer assist care plan if there was not a toilet use care plan. Further interview with the DON revealed a resident's fall risk was noted on the CNA assignment form and she expected nurses to tell the CNAs which residents were cognitively impaired. The DON stated they should know the resident's behavior and if they had a bed or chair alarm they should go with what they had as a guide in toileting. She also stated the nurses were responsible to inform the nurse aides during shift report about each resident's cognitive status and make that decision each shift. She revealed she had not considered if residents who had been assessed as needing an alarm to alert staff of unassisted transfers should be left unsupervised on the commode. Interview with the Administrator, on 10/09/14 at 8:30 AM, revealed that staff should not leave residents unsupervised on the commode if they had a BIMS of eight (8) or below. She stated privacy should be provided by staff standing at the door rather than going to the nurse's station.

Based on observation, interview, record review and review of the facility's policy and procedure it was determined the facility failed to provide services in accordance with the care plans for two (2) of five (5) sampled residents (Resident #1 and Resident #5). Resident #1 was care planned for staff to report changes in the resident's skin status and administer medications as ordered due to a tumor to the resident's right hand. However, the facility failed to monitor the wound to identify any changes and failed to administer treatment to the wound as ordered. Maggots were identified in the wound on 09/05/14. In addition, Resident #5's heels were not floated according to the resident's care plan. The findings include: Record review revealed the facility admitted Resident #1 on 08/02/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/20/14, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status score of "3"; and, the resident required extensive assistance with activities of daily living. Review of the Comprehensive Care Plan, "Resident has actual skin breakdown", dated 08/21/14, revealed the resident had a right hand tumor and interventions included for staff to report changes in the resident's skin status (i.e.: s/s of infection, non-healing, new areas) to physician. Review of the Non-pressure Skin Condition Record Assessments revealed the date the wound was first observed was on 12/18/13. The wound was on the back of the resident's right hand and was described as "a growth". Further review of the Non-pressure Skin Condition Record Assessments revealed the wound was measured and described on 05/12/14, as 7.1 cm x 7.0 cm with a small amount of serosanguineous drainage, no change; on 05/19/14 as 7.0 cm x 7.2 cm with small amount of serosanguineous drainage, no change; on 05/26/14 as 7.0 cm x 7.0 cm, no drainage, no change; on 06/02/14 as 7.0 cm x 7.1 cm with small amount of serosanguineous drainage, no change; and, on 06/09/14 as 7.0 x 6.9 with foul odor and serosanguineous drainage, no change. There was no documented evidence any further wound assessments were completed of the wound until 09/12/14 when the wound measured 12.5 x 15.8 x 2.5 cm and bloody drainage was noted. Interview on 09/16/14 at 8:08 AM; and, on 09/17/14 at 10:44 AM with Assistant Director of Nursing (ADON) #1, revealed the resident's right hand tumor was measured up until 06/09/14, but was not measured after that time. She stated the measurements were started back up on 09/12/14 because the new DON wanted staff to measure the resident's right hand. The ADON revealed it was her responsibility to make sure that the Non-pressure Skin Condition Records were completed, but the previous DON did not want to measure areas like Resident #1's right hand, and further stated if they thought it did not need to be done we did not do it. Interview, on 09/17/14 at 5:16 PM with Registered Nurse (RN) #2, revealed maggots were found in the wound of Resident #1's right hand between 11:30 PM and 1:00 AM on 09/05/14. Interview, on 09/16/14 at 10:03 PM with Licensed Practical Nurse (LPN) #4, revealed maggots were found on the dressing of the resident's right hand and in the wound on his/her right hand on 09/05/14. Review of the Comprehensive Care Plan for Infection, dated 09/05/14, revealed the resident had active infection in his/her wound. Interventions included to administer medications as ordered and assess the wound bed during dressing changes for any additional abnormalities. Review of a telephone Physician Order, dated 09/05/14, revealed to discontinue order to cleanse right hand with normal saline, apply dry dressing wrap with kerlix twice a day; and, a new order to cleanse the resident's right hand growth with normal saline, apply dry dressing then wrap with kerlix every shift. Review of the September 2014 Treatment Administration Record (TAR) revealed the new order received on 09/05/14, for treatment every shift was not placed on the TAR until 09/10/14. Record review revealed no documented evidence Resident #1 received the treatments to his/her right hand wound every shift from 09/05/14 through 09/10/14; and, on 09/12/14, and 09/15/14. Interview on 09/18/14 at 9:24 AM and 3:19 PM with the Assistant Director of Nursing (ADON) #1 revealed she had taken the order on 09/05/14 for Resident #1 to change the treatment for [REDACTED]. She stated the order would have to be put in the computer system to ensure it was printed on the TAR. She was unable to give an explanation as to why the order was not on the TAR prior to 09/10/14. Interview on 09/17/14 at 9:20 AM with the Director of Nursing, revealed the ADONs were supposed to measure pressure and non-pressure wounds. The DON further stated she instructed staff that anything on the non- pressure sheet should have had a measurement to it, and the ADONs were aware they were supposed to measure the pressure and non-pressure areas, and care plans should be specific to the resident. Interview, on 09/18/14 at 7:53 AM and 2:02 PM with Resident #1's Physician revealed he did not expect maggots to be in residents' wound and if dressings were not changed they could get dirty and infected. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 08/18/14, revealed the facility assessed Resident #5's cognition as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Resident #5 required the extensive assistance with activities of daily living. Review of the Interim Care Plan for Actual Alteration in Skin Integrity, dated 09/10/14, revealed an intervention to use heel floating devices. Observation, on 09/19/14 at 8:20 AM, 8:57 AM, and 11:00 AM revealed Resident #5's feet were uncovered and not elevated. Interview on 09/18/14 with LPN #1 at 11:00 AM and LPN #2 at 10:58 AM, revealed the care plans were for staff to know how to take care of the resident and were to be specific to the resident. Interview with ADON #1, on 09/22/18 at 11:08 AM, revealed staff used pillows and blankets to elevate Resident #5's feet. Interview on 10/01/14 at 3:50 PM and 4:08 PM with the DON revealed she did not have a care plan policy that addressed following the care plan.

Based on observation, interview, record review, facility policy and procedure review, and Hospital Admission Record review it was determined the facility failed to provide services to maintain/attain the highest practicable physical, mental and psychosocial well-being for two (2) of five (5) sampled residents (Resident #1 and Resident #3). Resident #1's was identified with a cyst to the back of the right hand on admission on 12/18/13. Staff completed wound assessments on the wound through 06/09/14 when the wound measured 7.0 centimeters (cm) x 6.9 cm. and was identified as having a foul odor and serosanguineous drainage. There was no documented evidence of further wound assessments until maggots were identified in the wound on 09/05/14. A physician's orders [REDACTED]. A wound assessment was completed on 09/12/14 with the wound measuring 12.5 cm x 15.8 cm x 2.5 cm and bloody drainage was noted. In addition, Resident #3's abdominal wound began to have increased drainage and odor and the facility failed to notify the physician to determine if additional treatment was necessary. The findings include: Review of the facility's policy titled, "Skin Management and Prevention At-A-Glance", last revised August 2013, revealed the "Weekly Skin Rounds Sheet" would be utilized to determine if any new skin alterations had developed. Clinical nurses, or nurse designee, on the unit were responsible for the weekly completion of these Sheets. It is the responsibility of the clinical team (DON, ADON, Nurse Managers) to determine compliance. Any new skin condition(s) found during the weekly skin rounds will be documented in the appropriate form (Pressure or Non-pressure, and Skin Ulcer Change of Condition Evaluation if appropriate). Responsible party for completing this form is the nurse who finds the skin alteration. Documentation of new sites must have physician and family notification with documentation of this communication with the medical record. The responsible party for completing this form is the nurse finding the skin alteration. Record review revealed the facility admitted Resident #1 on 08/02/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/20/14, revealed the facility assessed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status score of three (3); Resident #1 required extensive assistance with activities of daily living. Review of the Comprehensive Care Plan for Actual Skin Breakdown, dated 08/21/14 due to a right hand tumor; with a goal, dated 11/19/14, stating resident will have intact skin, free of redness, blisters, or discoloration over a bony prominence through next review date. Review of the interventions revealed to report changes in skin status (i.e.: s/s of infection, non-healing, new areas ) to physician, complete weekly skin check, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. There were no interventions to address the right hand tumor on the resident's hand. Review of Physician Order, dated 08/28/14, revealed to cleanse right hand "growth" (tumor) with normal saline, apply dry dressing, wrap with kerlix twice daily with [DIAGNOSES REDACTED]. Review of the Non-pressure Skin Condition Record Assessments revealed the date the wound was first observed was on 12/18/13 The wound was on the back of the resident's right hand and was described as a "growth". Further review of the Non-pressure Skin Condition Record Assessments revealed the wound was measured and described on 05/12/14, as 7.1 cm x 7.0 cm with a small amount of serosanguineous drainage, no change; on 05/19/14 as 7.0 cm x 7.2 cm with a small amount of serosanguineous drainage, no change; on 05/26/14 as 7.0 cm x 7.0 cm, no drainage, no change; on 06/02/14 as 7.0 cm x 7.1 cm with small amount of serosanguineous drainage, no change; and, on 06/09/14 as 7.0 x 6.9 with a foul odor and serosanguineous drainage, no change. There was no documented evidence any further wound assessments were completed until 09/12/14 when the wound measured 12.5 x 15.8 x 2.5 cm and bloody drainage was noted. Interview on 09/16/14 at 8:08 AM; and, on 09/17/14 at 10:44 AM with the Assistant Director of Nursing (ADON) #1, revealed the right hand tumor was measured up until 06/09/14 but it was not measured after that time. ADON #1 further stated the measurements were started back up on 09/12/14 because the new DON wanted staff to measure the resident's right hand. The ADON revealed it was her responsibility to make sure that non-pressure skin condition records were completed, but the previous DON did not want to measure areas like Resident #1's right hand. ADON #1 further stated if the DON did not want the non pressure wounds measured then we did not do it. Interview, on 09/17/14 at 5:16 PM with Registered Nurse (RN) #2, revealed maggots were found in the wound of Resident #1's right hand between 11:30 PM and 1:00 AM on 09/05/14. Interview, on 09/16/14 at 10:03 PM with Licensed Practical Nurse (LPN) #4, revealed maggots were found on the dressing on the resident's right hand and in the wound of Resident #1's right hand on 09/05/14. Further interview revealed the treatment for [REDACTED]. Review of Telephone Physician Order, and Nursing Notes, dated 09/05/14, revealed Resident #1 was sent to the emergency room for wound determination to the right hand, and returned on 09/05/14 with an order for [REDACTED]. Review of the Comprehensive Care Plan for Infection, dated 09/05/14, revealed the resident had active infection in wound with interventions to administer medications as ordered and assess wound bed during dressing changes for any additional abnormalities. Review of Telephone Physician Order, dated 09/05/14, revealed to discontinue order to cleanse right hand with normal saline, apply dry dressing wrap with kerlix twice a day; and a new order to cleanse right hand growth with normal saline, apply dry dressing then wrap with kerlix every shift. However, review of the September 2014 Treatment Administration Record (TAR) revealed the new order for treatment every shift was not placed on the TAR until 09/10/14 and there was no documented evidence Resident #1 received the treatments to the right hand wound every shift from 09/05/14 through 09/10/14, on 09/12/14, and on 09/15/14. Interview on 09/18/14 at 9:24 AM and 3:19 PM with the Assistant Director of Nursing (ADON) #1 revealed she had taken the order on 09/05/14 for Resident #1 to change the treatment from twice a day to every shift. She stated the order would have to be put in the computer system to ensure it was printed on the TAR. She was unable to give an explanation as to why the order was not on the TAR prior to 09/10/14. Interview with the Director of Nursing (DON), on 09/16/14 at 8:06 AM, revealed she did not know why the wound was not measured because it had to be open to attract flies, and she had seen some skin assessments missing and some wounds were not measured. Further interview with the DON, on 09/17/14 at 9:20 AM, revealed the ADONs were supposed to measure pressure and non-pressure wounds. The DON further revealed she instructed staff that anything on the non-pressure sheet should have had a measurement. She stated the ADONs were aware they were supposed to measure the pressure and non-pressure areas. The DON further revealed the area on the resident's right hand was only 3 cm x 3 cm upon admission, and had been noted as a cyst. The DON stated she was trying to figure out how it got from a cyst to present day. She stated she could not have made it clearer to staff that if they did not complete the admission assessment and non-pressure skin condition and pressure condition records there would be consequences. Interview, on 09/18/14 at 7:53 AM and 2:02 PM with Resident #1's Physician revealed he did not expect maggots to be in the resident's wound and if dressings are not changed they can get dirty and could become infected. 2. Record review revealed the facility admitted Resident #3 on 08/15/14 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) Assessment, dated 08/22/14, revealed the facility assessed the resident's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Resident #3 revealed on 08/25/14 the problem was addressed as, "Resident has disruption of surface, not related to pressure, has abdominal surgical wound". The goal stated, "the resident's disruption of skin surface will remain free from infection and show evidence of healing by: (no date was entered) "The intervention stated as of 08/25/14: Report changes in skin status to physician, provide diet as ordered and monitor nutritional status and dietary needs; consult dietician PRN, monitor for pain and medicate PRN per physician orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of Resident #3's August and September Treatment Administration Record (TAR) revealed staff should cleanse wound to abdomen with normal saline, apply normal saline wet to dry dressing and cover with dry dressing twice daily. Interview with Resident #3, on 09/17/14 at 8:07 AM, revealed nurses occasionally administered more dressing changes in addition to the physician ordered twice daily treatments to the abdomen wound. Resident #3 stated that he/she was receiving three to four dressing changes a day due to more drainage from the abdominal wound. The resident stated that drainage had increased and was more excessive when ambulatory. Interview on 09/17/14 at 5:01 PM with Registered Nurse (RN) #1 revealed she provided care to Resident #3 and had changed the dressing more than ordered because of the dressing being saturated. RN #1 further revealed she knew the order was for twice a day, but if the dressing was dirty she would change it no matter what. She stated she had to change it more because it would be saturated, especially if Resident #3 was up and ambulating. Interview on 09/18/14 at 8:26 AM with Licensed Practical Nurse (LPN) #3 revealed she usually did three (3) dressing changes for Resident #3 because of the drainage. She stated dressings were supposed to be done every shift, and she knew she had to do it more than once and she did not know if the order said every shift or as needed. LPN #3 further revealed she had not spoken with the physician related to the dressing changes, she just did what the computer told her to do according to the treatment. She stated the treatment was every shift and had been as long as resident had been there. Interview on 09/18/14 at 10:48 AM with RN #2 revealed she was not assigned to change Resident #3 dressing but she did so if it was soiled or she was asked to change it by the resident. RN #2 could not recall the orders for the resident. She stated she had not called the physician about changing the dressings, but she had passed the information to the oncoming shift. Further record review revealed there was no documented evidence of wound dressing treatments administered other than the twice daily on August and September TARs. In addition, there was no documented evidence the physician had been notified of the additional needed dressing changes due to the increased drainage. Interview on 09/18/14 at 10:17 AM with Resident #3's Physician revealed he would expect to be notified if the resident was having additional dressing changes related to increased drainage.

Based on interview, record review and facility policy, it was determined the facility failed to ensure services provided were in accordance with written plan of care for one (1) resident (#1) in a sample of fifteen (15). RN #1 on 04/07/12 misread a physician order, dated 04/06/12, and inaccurately transcribed the order no change to [MEDICATION NAME] (anticoagulant); to discontinue the [MEDICATION NAME]. RN #1 inaccurately updated the care plan on 04/07/12; however, it was dated 04/05/12 to discontinue [MEDICATION NAME] as ordered. These failures resulted in the resident not getting the prescribed medication. The facility failed to administer [MEDICATION NAME] ten (10) milligrams (mg) Tuesday through Sunday and seven and one half (7.5) milligrams (mg) on Monday for thirteen (13) days. The physician stated this failure placed Resident #1 who had a history of [REDACTED]. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interviews and record reviews, it was determined Immediate Jeopardy was identified 07/11/12 and determined to exist on 04/07/12 an is on going. (Refer to F333 and F514.) Findings include: A review of the facility's policy/procedure "Comprehensive Plan of care" dated 05/28/12 revealed the Interdisciplinary team, MDS Coordinator/Designee is to review and update the care plan as needed. A review of a closed record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed resident #1 as severely cognitively impaired. A review of the physicians orders, dated 04/03/12, revealed Resident #1 received [MEDICATION NAME] therapy of ten (10) milligrams (mg) on Tuesday through Sunday and seven and one half (7.5) milligrams (mg) on Mondays. A review of the facility's comprehensive care plan, dated 04/04/12, revealed the facility assessed and determined resident #1 was at risk for abnormal bleeding/anticoagulation with an approach to administer anticoagulant "as prescribed by the physician". A [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test was performed on 04/05/12 for therapeutic monitoring of the [MEDICATION NAME] therapy. On 04/06/12 the resident's physician reviewed the PT/INR results and ordered no change in [MEDICATION NAME] therapy. A review of the physician order [REDACTED]. The physician's orders [REDACTED]. Interview with RN #1, on 07/09/12 at 10:25 AM, revealed he reviewed the order on 04/07/12 and misread the order to say "no [MEDICATION NAME]". RN #1 discontinued the [MEDICATION NAME] on the resident's Medication Administration Record [REDACTED]. The facility did not administer 13 doses of [MEDICATION NAME] during this time period to resident #1, thus not following the physician's orders [REDACTED]. Furthermore continued interview with RN#1 and review of the care plan revealed he updated the care plan inaccurately to reflect his transcription error that [MEDICATION NAME] had been discontinued. An interview with Resident #1's physician, on 07/09/12 at 1:20 PM, revealed Resident #1 would have been at an increased risk of stroke for about seven of the thirteen days [MEDICATION NAME] was not administered as prescribed. An interview with the DON, on 07/09/12 at 3:30 PM, revealed that medication orders were supposed to be reviewed by unit managers and in morning meetings. She stated that she had no way to verify the checks were being completed. The DON revealed that there was no written policy she was aware of to address a system to check/verify orders or care plans and that the unit managers didn't sign anywhere to validate orders have been checked and or verified for accuracy. The DON revealed she did not know if the unit managers had checked orders.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 07/11/12, had been removed related to transcription of physician's orders [REDACTED]. [REDACTED]. Findings include: Review of the acceptable Allegation of Compliance (AoC), dated 07/23/12, revealed, on 07/17/12, Nursing Administration consisted of the Director of Nursing Services, Assistant Director of Nursing Services, Unit Managers, Minimum Data Set Coordinators, Registered Nurses and Licensed Practical Nurses who audited all in-house residents from June 1, 2012, forward to ensure the orders were accurately transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Individual physician's orders [REDACTED].[REDACTED]. If a medication variance was identified through the auditing process, the resident's attending physician and family were notified and the resident was placed on 72 hour condition change monitoring. Orders were also clarified with the resident's physician by the Unit Manager or Licensed Nurse. There were no transcription errors related to abbreviations, symbols, or acronyms identified. On 04/29/12, Registered Nurse (RN) #1, who incorrectly transcribed the physician's orders [REDACTED]. On 07/20/12, the Director of Nursing provided education to the RN who incorrectly transcribed the physician's orders [REDACTED]. Effective 07/20/12, the Director of Nursing, Assistant Director of Nursing and/or the Weekend Supervisor will provide direct supervision of the RN through observation and record review. Direct observation of transcription of physician's orders [REDACTED]. Also, a review of this RN's documentation was being completed prior to the end of each shift worked. The direct observation of the transcription of physician's orders [REDACTED]. The documentation included the observer's initials, date, time, and name of the resident. The Executive Director and Director of Nursing will review the documentation weekly to identify any areas of improvement needed. The Director of Nursing and/or the Assistant Director of Nursing will review all physician's orders [REDACTED]. A review of documented education revealed all Licensed Nurses were educated related to the Medical Doctor's order transcription. All current facility licensed staff had been provided the education by 07/17/12 except for one that was active military and that nurse will have the education prior to return to the facility. The education consisted of facility, Procedure physician's orders [REDACTED]. Interview with RN #1, on 07/26/12 at 12:20 PM, revealed he had received education and training by the Director of Nursing related to transcribing physician's orders [REDACTED]. Interviews on 07/26/12 and 07/27/12 with facility licensed staff revealed they had received education from facility administrative staff related to physician's orders [REDACTED]. Medication error education was provided related to the definition of medication error, significant medication error, error rate, drug adverse drug reaction, and the individual steps the licensed nurse was required to take for each. The interviews confirmed Unit Managers were double checking orders daily and initialing the pink copy of the orders. The Executive Director, the Director of Nursing and/or the Assistant Director of Nursing were validating the monitoring and evaluation of the Medical Doctor Transcription audits daily. Performance Improvement meetings were verified conducted on 07/11/12, 07/17/12 and 07/20/12. An interview with the Administrator and Director of Nursing (DON) on 07/27/12 at 12:00 PM revealed RN #1 was inserviced on clinical abbreviations, [MEDICATION NAME] medication regimen, physician order [REDACTED]. A review of this RN's documentation was being completed prior to the end of each shift worked. They stated that the facility was still in the process of conducting audits i.e. the Executive Director and Director of Nursing will review the documentation weekly to identify any areas of improvement needed and all physician orders [REDACTED]. They revealed the PI Committee would continue to audit all findings for three months and then quarterly ongoing. Record review revealed the facility had not had an opportunity to complete their Performance Improvement Committee reviews of all audit findings to ensure compliance with the regulation would be achieved and sustained. Additionally, the facility had not submitted their plan of correction, related to this deficient practice, to the State Agency prior to the 07/27/12 visit.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 07/11/12, had been removed related to accurate transcription of physician's orders [REDACTED]. [REDACTED]. Findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 07/23/12, revealed on 07/17/12, Nursing Administration to consist of the Director of Nursing Services, Assistant Director of Nursing Services, Unit Managers, Minimum Data Set Coordinators, Registered Nurses and Licensed practical Nurses audited all in-house residents from June 1, 2012, forward to ensure the orders were accurately transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Individual physician orders [REDACTED].[REDACTED]. If a medication variance was identified through the auditing process, the resident's attending physician and family were notified and the resident placed on 72 hour condition change monitoring. Orders were also clarified with the resident's physician by the Unit Manager or Licensed Nurse. There were no transcription errors related to abbreviations, symbols or acronyms identified. Registered Nurse (RN) #1, who had incorrectly transcribed a physician's orders [REDACTED]. The education included clinical abbreviations, including the triangle symbols which indicates change, [MEDICATION NAME] medication regimen and physician order [REDACTED]. A review of documented education revealed all Licensed Nurses were educated related to the Medical Doctor's order transcription, developing an initial care plan within 24 hours that addressed the resident's initial individual and immediate needs until the interdisciplinary team finalized the comprehensive care plan. The education included appropriate and timely administration of medications as indicated as an intervention in resident's plan of care. Also included in the education, was the utilization and review of pre-printed care plans to ensure interventions were appropriate and implemented as well as revision of the care plan, as indicated, through utilization of the Care Plan Update form which included the Problem, Goal and Intervention. Education related to definition of standing orders, routine orders, orders upon admission, treatment orders and performance improvement was provided. The education also included appropriate steps and timeliness of transcription of physician's medication and treatment orders. It was verified all facility licensed staff had been provided the education by 07/17/12. Interview with RN #1, on 07/26/12 at 12:20 PM, revealed he had received education and training by the Director of Nursing related to transcribing physician orders [REDACTED]. Interviews on 07/26/12 and 07/27/12 with facility licensed staff revealed they had received education from facility administrative staff related to physician order [REDACTED]. Medication error education was provided related to the definition of medication error, significant medication error, error rate, drug adverse drug reaction, and the individual steps the licensed nurse was required to take for each. The interviews confirmed Unit Managers were double checking orders daily and initialing the pink copy of the orders. Unit Managers and /or Registered Nurse Weekend Supervisor were reviewing all new physician's orders [REDACTED]. Audits were being documented on a Medical Doctor Transcription audit and the Unit Manager and/or Weekend Supervisor will date and initial the pink copy of the physician's orders [REDACTED]. The Executive Director, the Director of Nursing and the Assistant Director of nursing were validating the monitoring and evaluation of the Medical Doctor Transcription audits daily. Performance Improvement meetings were verified conducted on 07/11/12, 07/17/12 and 07/20/12. An interview with the Administrator and Director of Nursing (DON) on 07/27/12 at 12:00 PM revealed Registered Nurse (RN) #1, who had incorrectly transcribed a physician's orders [REDACTED]. RN #1 was being directly monitored related to transcribing transcription orders. All licensed staff except one received inservicing related to transcribing physician orders. They revealed audits were still be conducted by Unit Managers and Weekend Supervisors related to all physician orders [REDACTED]. Record review revealed the facility had not had an opportunity to complete their Performance Improvement Committee reviews of all audit findings to ensure compliance with the regulation would be achieved and sustained. Additionally, the facility had not submitted their plan of correction, related to this deficient practice, to the State Agency prior to the 07/27/12 visit.

Based on interview, record review and facility policy, it was determined the facility failed to ensure the medical record was accurately maintained for one (1) resident (#1) in a sample of fifteen (15) residents. The facility failed to follow policies and procedures related to physician orders [REDACTED]. On 04/07/12, RN #1 inaccurately transcribed a physician's orders [REDACTED].#1's [MEDICATION NAME]. This error resulted in the facility discontinuing [MEDICATION NAME] administration to Resident #1 for thirteen (13) days. Furthermore, RN #1 inaccurately revised the care plan to reflect that the [MEDICATION NAME] was discontinued. The facility system failed to identify the significant medication error for thirteen (13) days. The facility failed to administer [MEDICATION NAME] ten (10) milligrams (mg) Tuesday through Sunday and seven and one half (7.5) milligrams (mg) on Monday for thirteen (13) days. Interview with the physician revealed this failure placed Resident #1, who had a history of [REDACTED]. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interviews and record reviews, it was determined Immediate Jeopardy was identified on 07/11/12 and determined to exist on 04/07/12 and is ongoing. (Refer to F333, F282) Findings include: A review of the facility's policy/procedure, dated 05/28/08, revealed the Interdisciplinary team, MDS Coordinator/Designee is to review and update the care plan as needed. A review of the facility's policy/procedure "Physicians's Orders", dated 10/31/09, revealed to double check physicians orders to ensure there were no transcription errors. A review of a closed record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physicians orders, dated 04/03/12, revealed Resident #1 received [MEDICATION NAME] therapy of ten (10) milligrams (mg) on Tuesday through Sunday and seven and one half (7.5) mg on Mondays. The facility's comprehensive care plan, dated 04/04/12, revealed the facility determined Resident #1 was at risk for abnormal bleeding/anticoagulation with an approach to administer anticoagulant as prescribed by the physician. On 04/06/12, the resident's physician ordered no change in [MEDICATION NAME] therapy. A review of the physician order [REDACTED]. An interview with RN #1, on 07/09/12 at 10:25 AM, revealed he reviewed the order on 04/07/12 and misread the order to say "no [MEDICATION NAME]". RN #1 discontinued the [MEDICATION NAME] on the resident's Medication Administration Record [REDACTED]. A review of the MAR for April 2012 revealed the facility discontinued administering [MEDICATION NAME] to Resident #1 on 04/07/12 and restarted on 04/20/12, resulting in the facility not administering thirteen (13) doses of [MEDICATION NAME] for thirteen (13) days. An interview with Resident #1's physician, on 07/09/12 at 1:20 PM, revealed Resident #1 would have been at an increased risk of stroke for about seven of the thirteen days [MEDICATION NAME] was not administered as prescribed. Continued interview with RN #1 on 07/09/12 revealed he had misread the physician's orders [REDACTED]. He said it was not unusual to change or discontinue [MEDICATION NAME]. He stated orders are written on a three section form which include the condition change, order and the care plan update. The resident's chart was in the rolling rack which meant it needed attention and he did not get to review the chart until noon on 04/07/12 after performing routine work. He stated he did not know the process in which orders are checked to ensure transcription/care plan accuracy. An observation, on 07/10/12 at 3:35 PM and 4:00 PM after shift change on South and North Hall's nursing stations, revealed a total of 16 charts in the rolling rack with documents strapped to the front of the charts. Interviews with RN#1 on 07/09/12 at 12:10 PM, RN#2 on 07/10/12 at 12:30 AM, and RN#3 on 07/10/12 at 12:05 PM revealed these documents were to be addressed and had been left over from day shift. An interview with RN #2, on 07/10/12 at 10:30 AM, revealed she was shown during orientation how to transcribe physician orders. She stated this order wasn't taken off until the next day which was Saturday 04/07/12. She stated sometimes we don't get it done and second and third shifts do it. We pass it on in report that we haven't had time to transcribe all the order's. An interview with RN #3, on 07/10/12 at 3:05 PM, revealed no one ever double checked orders. admission orders [REDACTED]. An interview with the DON, on 07/09/12 at 11:05 AM, 07/09/12 at 3:30 PM and 07/11/12 at 1:50 PM, revealed she was made aware on 04/20/12 that an error had occurred and RN #1 had misread the order. She revealed that unit managers were supposed to review medications orders. The new orders were to be reviewed in morning meetings. She stated the facility had no system to verify that orders were checked for accuracy. The order should have been addressed on 04/06/12 when it was received and not delayed until the next day. Orders that need to be addressed are placed on the front of the chart and placed in the rolling rack at the nurses station. The DON revealed that there was no policy she was aware of to address a system to check/verify orders and that the unit managers didn't sign anywhere to validate orders have been checked/verified. The DON revealed she could not verify the unit managers had checked orders and she had no documentation to verify checks had been completed to ensure accuracy of the medical record. She stated she had not initiated any additional investigations, audits or tracking of medication order transcriptions or care plan updates to identify other potential errors leaving other residents at risk. Therefore, the facility failed to ensure Resident #1's medical record was accurate to ensure he/she was free from a significant medication error. On 04/06/12, after reviewing laboratory results, Resident #1's physician wrote an order to not change the resident's [MEDICATION NAME] which was 10 mg Tuesday through Sunday and 7.5 mg on Monday. The physician's orders [REDACTED].#1 and the [MEDICATION NAME] was discontinued based on the transcription error. Resident #1 did not receive the prescribed [MEDICATION NAME] for thirteen days. On 04/20/12 the transcription error was identified and the resident's physician ordered the [MEDICATION NAME] to be restarted as previously prescribed. The physician revealed Resident #1 was at an increased risk for a stroke for at least seven of the thirteen days the [MEDICATION NAME] was not administered. The facility failed to have an effective system in place to verify accuracy of orders, to identify transcription errors and to ensure care plans were accurately updated. There were no additional audits of medication order transcriptions to identify other potential errors, leaving others at risk. Thus immediate jeopardy is ongoing.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 07/11/12, had been removed related to implementation of resident care plans. However, non-compliance continued to exist at a S/S of a "D" as the Quality Assessment and Assurance (QAA) Committee had not completed monitoring, analysis of information and the facility had not had an opportunity to develop and implement a Plan of Correction (POC), related to implementation of resident care plans. Findings include: Review of the Acceptable Allegation of Compliance (AoC), dated 07/23/12, revealed the facility audited all in-house resident care plan interventions related to medications to ensure the interventions were appropriate and implemented in accordance with the care plan on 07/17/12. The Staff Development Coordinator and Director of Nursing Services initiated education with all Licensed Nurses and Certified Medication Technicians on Care Plan Implementation related to medications which included the pre-printed and Care Plan Review and Revision. Review of the documented inservice which was provided to the Certified Medication Technicians revealed the education included appropriate and timely administration of medications as indicated, and as an intervention in the resident's plan of care and in accordance with Certified Medication Technician scope of practice. The Licensed Nurses were educated about the facility Procedure Initial Plan of Care. The procedure included, but was not limited to, developing an initial care plan within twenty-four hours of admission and addressed the resident's initial individual and immediate needs until the interdisciplinary team finalized the comprehensive care plan. The education also included Procedure , Comprehensive Plan of Care, which addressed implementation of the care plan, appropriate and timely administration of medications as indicated. Utilization and review of a pre-printed care plan to ensure appropriate interventions were appropriate and implemented was addressed in the education. The education included revision of the care plan, as indicated, through utilization of the Care Plan Update form to reflect current status. The Care Plan Update form covered the problem, goal and intervention. Administration of medications in accordance with the physician orders [REDACTED]. Unit Managers and Registered Nurse Weekend Supervisors reviewed all new physician orders [REDACTED]. Audit findings were documented on a Medical Doctor Transcription audit and the Unit Manager and/or Weekend Supervisor dated and initialed the pink copy of the Physician Telephone Order sheet. All audit findings were being reviewed at the weekly Performance Improvement Committee. Interviews conducted with Medication Technicians and Licensed Nurses on 07/26-27/12 confirmed this education had been completed. Review of the documented inservices completed on 07/17/12, and interview with the RN Corporate Compliance Nurse on 07/27/12, revealed only one licensed staff had not received the inservice due to military service and that staff would receive the education upon return to the facility. An interview with the Administrator and Director of Nursing (DON) on 07/27/12 at 12:00 PM revealed the Staff Development Coordinator and Director of Nursing Services initiated education with all Licensed Nurses and Certified Medication Technicians on Care Plan Implementation related to medications which included the pre-printed and Care Plan Review and Revision. Administration of medications in accordance with the physician orders [REDACTED]. Unit Managers and Weekend Supervisors were auditing all physician orders [REDACTED]. The PI Committee had met on 07/11/12 and 07/17/12, 07/20/12 to review the all audit findings; however, scheduled to continue to meet for three months and then quarterly to evaluate their process to ensure compliance. Record review revealed the facility had not had an opportunity to complete their Performance Improvement Committee reviews of all audit findings to ensure compliance with the regulation would be achieved and sustained. Additionally, the facility had not submitted their plan of correction, related to this deficient practice, to the State Agency prior to the 07/27/12 visit.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure one (1) resident (#1) out of a sample fifteen (15), was free from a significant medication error. The facility failed to ensure physician's orders were accurately transcribed and followed. On 04/06/12 the physician ordered no change to [MEDICATION NAME] (anticoagulant - blood thinner); however, RN #1 on 04/07/12 transcribed the order as discontinue the [MEDICATION NAME]. The facility failed to administer [MEDICATION NAME] ten (10) milligrams (mg) Tuesday through Sunday and seven and one half (7.5) mg on Monday for thirteen (13) days failing to administer thirteen (13) doses. The physician stated this failure placed Resident #1 who had a history of [REDACTED]. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Based on interviews and record reviews, it was determined Immediate Jeopardy and Substandard Quality of Care was identified 07/11/12 and determined to exist on 04/07/12 and is ongoing. (Refer to F282 and F514) Findings include: A review of the facility's policy/procedure "Physicians's Orders" dated 10/31/09 revealed to double check physicians orders to ensure there were no transcription errors. An interview with the Director of Nursing (DON) on, 07/09/12 at 3:30 PM, revealed she would expect orders to be reviewed by unit managers and in morning meetings orders were to be checked and compared for accuracy. A review of a closed record revealed the facility admitted Resident #1 on 04/03/12 with [DIAGNOSES REDACTED]. A review of the physicians orders, dated 04/03/12, revealed Resident received [MEDICATION NAME] therapy of ten (10) milligrams (mg) on Tuesday through Sunday and seven and one half (7.5) mg on Mondays. A review of the facility's comprehensive care plan, dated 04/04/12, revealed the facility assessed and care planned Resident #1 as at risk for abnormal bleeding/anticoagulation with an approach to administer anticoagulant as prescribed by the physician. On 04/05/12, a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory test was performed for therapeutic monitoring of the [MEDICATION NAME] therapy. On 04/06/12, the physician reviewed resident #1's PT/INR results and ordered no change in [MEDICATION NAME] therapy. A review of the physician order dated 04/06/12, written by the physician, revealed no, triangle shaped symbol (change) [MEDICATION NAME]. There was no documented evidence the facility had addressed and/or transcribed the physician's order until 04/07/12; however, review of the Comprehensive care plan update by RN #1, dated 04/05/12, revealed to discontinue (D/C) [MEDICATION NAME] as ordered and review of the April 2012 Medication Administration Record (MAR) revealed the facility discontinued administering [MEDICATION NAME] to Resident #1 on 04/07/12. Interview with RN #1, on 07/09/12 at 10:25 AM, revealed he reviewed the order on 04/07/12 and misread the order to say no [MEDICATION NAME]. RN #1 discontinued the [MEDICATION NAME] on the resident's MAR and implemented a care plan update to "discontinue [MEDICATION NAME] as ordered". An interview with RN #2, on 07/10/12 at 10:30 AM, revealed Resident #1 was assigned to her on 04/06/12 and that she did remember the order "it said no change [MEDICATION NAME]" and that she did not know who discontinued the [MEDICATION NAME]. The resident had a history of [REDACTED]. A Certified Medication Assistant (CMA) had probably told her the resident's [MEDICATION NAME] had been stopped. RN #2 had called the physician and informed him the resident had not been receiving [MEDICATION NAME] for a matter of time (couldn't remember the exact time). RN #2 asked for a PT/INR to get a baseline and the physician declined and gave the order to restart [MEDICATION NAME] at the previous dosage. Review of the physician's orders and condition change form dated 04/20/12 revealed "physician spoke to regarding [MEDICATION NAME] D/C (discontinued) and asked if wanted a stat PT/INR and to restart [MEDICATION NAME] as before, physician stated no stat PT/INR just restart [MEDICATION NAME] as before". The physician ordered, on 04/20/12, to restart the [MEDICATION NAME] therapy at the previous dosage "[MEDICATION NAME] 10 mg by mouth (po) on Sunday, Tuesday, Wednesday, Thursday, Friday and Saturday related to (R/T) [MEDICAL CONDITION], [MEDICATION NAME] 7.5 mg po on Monday R/T [MEDICAL CONDITION]". A review of the Comprehensive care plan update by RN #2 dated 04/20/12 revealed "Omission of medication with a goal to restart [MEDICATION NAME] as before and approaches [MEDICATION NAME] 10 mg po on Sunday, Tuesday, Wednesday, Thursday, Friday and Saturday R/[MEDICAL CONDITION] 7.5 mg po on Mondays". Further review of the April 2012 MAR revealed the facility did not administer the physician's ordered [MEDICATION NAME] to Resident #1 from 04/07/12 until 04/20/12, missing thirteen (13) doses in thirteen (13) days. An interview with Resident #1's physician, on 07/09/12 at 1:20 PM, revealed Resident #1 would have been at an increased risk of stroke for about seven of the thirteen days [MEDICATION NAME] was not administered as prescribed. An interview with RN #1, on 07/09/12 at 10:25 AM, revealed there was a medication variance, the order had a symbol on the order that stood for change that he was not familiar with, the symbol (triangle) looked like it was a zero (0) meaning "no" [MEDICATION NAME], written by the physician and that the resident's chart was in the rolling rack which meant it needed attention. He stated he did not get to review the chart until noon on 04/07/12 after performing routine work. He revealed he had misread the physician's order that was written as " No, triangle symbol (change) [MEDICATION NAME] to read as "No zero (0) [MEDICATION NAME]. He said it was not unusual to change or discontinue [MEDICATION NAME] and was not sure how the medication error was found. He stated that physician orders are written on a three section form; however, he was unaware of the facility's system to check to ensure accurate transcription. An interview with RN #3, on 07/10/12 at 3:05 PM, revealed no one ever double checked orders to ensure accuracy of transcription. An interview with the DON, on 07/09/12 at 11:05 AM, 07/09/12 at 3:30 PM and 07/11/12 at 1:50 PM, revealed she was made aware on 04/20/12 that a medication error had occurred; however, knew that RN #1 had misread the order and that a medication variance had been completed. She was unable to provide verification of an investigation of the medication error incident. She state she doesn't conduct a full investigation. She stated sometimes the unit managers or ADON do the investigation and they look at them in Performance Improvement (PI) meetings where they ask for details. She does not dig down into them, she just looks at them to see if there's a trend or a need of education. Review of the facility summary, undated, revealed action the facility had taken related to the significant medication error was a performance improvement conducted with RN #1. The DON detailed that medication orders were supposed to be reviewed by unit managers and in morning meetings. She stated that she had no way to verify the checks were being completed. She stated also that the order should have been addressed on 04/06/12 when it was received and not the next day. The DON revealed that there was no written policy she was aware of to address a system to check/verify orders and that the unit managers didn't sign anywhere to validate orders have been checked and or verified for accuracy. The DON revealed she did not know if the unit managers had checked orders. The DON confirmed that RN #1 had received a performance improvement addressing the incident and that ward conferences for the nurses had been completed which addressed that orders were to be handled on the shift they were received. She stated she had not initiated any additional investigation, audit or tracking of medication order transcriptions in order to identify and verify other potential errors that may have occurred leaving other residents at risk. She further detailed that the facility initiated seventy two hour monitoring of the resident once the medication error was identified. The DON was unable to provide the ward conference description or list of staff who attended. Therefore, the facility failed to ensure Resident #1 was free from a significant medication error. On 04/06/12, after reviewing laboratory results, Resident #1's physician wrote an order to not change the resident's [MEDICATION NAME] which was 10 mg Tuesday through Sunday and 7.5 mg on Monday. The physician's order was not transcribed until the next day 04/07/12, was misread by RN #1 and the [MEDICATION NAME] was discontinued based on the transcription error. Resident #1 did not receive the prescribed [MEDICATION NAME] for thirteen days. On 04/20/12 the transcription error was identified and the resident's physician ordered the [MEDICATION NAME] to be restarted as previously prescribed. The physician revealed Resident #1 was at an increased risk for a stroke for at least seven of the thirteen days the [MEDICATION NAME] was not administered. The facility failed to have an effective system in place to verify accuracy of orders or to identify transcription errors. There was no evidence the facility had conducted additional audits of medication order transcriptions or reviewed other medication errors having occurred to identify other potential errors leaving other residents at risk for significant medication errors prior to exit, therefore immediate jeopardy is ongoing.

Based on interviews and record review it, was determined the facility failed to use the results of the assessment to develop the Comprehensive Care Plan, for one resident (#1) in the selected sample of six. The facility assessed Resident #1 to need extensive assistance of staff for bed mobility and was knowledgeable of the resident's history and recent falls from the bed; however, review of the Comprehensive Care Plan revealed no interventions to address the need for the extensive assistance of two staff for bed mobility. The facility failed to ensure staff was knowledgeable of the number of staff required to assist Resident #1 with bed mobility to prevent accidents. On 09/29/10, Certified Nurse Aide (CNA) #1 assisted Resident #1 with bed mobility and hygiene needs, and after turning to retrieve a washcloth, the resident fell out of the bed and sustained a subdural hematoma. Findings include: The facility failed to provide adequate supervision and assistive devices to prevent accidents for Resident #2. Refer to F323 A record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Reviews of Post Fall Evaluations, dated 02/20/10 at 5:30 AM, 03/03/10 at 5:05 AM, 03/03/10 at 7:20 PM, revealed Resident #1 had falls from a low bed to a mat on the floor beside the bed. A review of the initial Minimum Data Set (MDS) assessment, dated 03/01/10, revealed the facility assessed Resident #1's cognitive skills as severely impaired and the resident required extensive assistance of two staff for bed mobility. A review of the Resident Assessment Protocol for falls and Activities of Daily Living (ADL) Functional/Rehab function, dated 03/01/10, revealed the resident had a history of [REDACTED]. A review of the quarterly MDS assessment, dated 08/13/10, revealed the facility assessed the resident as needing the extensive assistance of two staff for bed mobility. A review of a bed safety evaluation and falls risk assessment, dated 08/14/10, revealed the facility assessed the resident as having no awareness of the proximity of the edge of the bed while moving or rolling in the bed and as a high risk for falls. In addition, reviews of Post Fall Evaluations, dated 09/10/10 at 2:30 PM and 09/10/10 at 4:30 PM, revealed Resident #1 had falls from a low bed to a mat on the floor beside the bed. Interviews with CNAs #2 and #3, on 10/08/10 at 12:15 PM and 12:25 PM respectively, revealed Resident #1 was able to throw his/her legs over the scoop/wing mattress and then pull him/herself over the scoop/wing mattress. They stated one staff was required to assist Resident #1 with bed mobility. A review of the Comprehensive Care Plan, dated 08/18/10, revealed the facility did not address the assessed need for the extensive assistance of two staff for bed mobility. A review of the CNA Care Plan, no date, revealed the facility developed an intervention for the resident to have the assistance of one staff for ADLs; even though, the facility's assessment had determined the resident required the extensive assistance of two staff for bed mobility. A review of the nursing progress notes, dated 09/29/10, and an interview with CNA #1, on 10/07/10 at 9:20 AM, revealed Resident #1 was in bed and had vomited. CNA #1 stated she entered the room and obtained washcloths from the wheelchair. She stated she observed the resident had vomited on the sheet, so she rolled the resident toward the wall (resident's right side) to roll up the dirty sheet and place a clean sheet on the mattress. She then rolled the resident towards her (resident's left side) to remove the dirty sheet and pull the clean sheet around the rest of the mattress. She stated before she stretched the clean sheet over the mattress, she observed vomit on the mattress. The CNA stated she either rolled the resident to his/her back or the resident rolled on to his/her back when she let go of the resident. The CNA stated she told the resident "just a minute", turned her back and walked (three steps) over to the wheelchair to obtain another washcloth. She stated when she turned back around, the resident was falling from the bed. She stated she rushed to the resident and was able to grab the resident's leg, but the resident's head hit the floor. She stated when she bent down to check on the resident, she observed the resident was bleeding from his/her head and called for the nurse. The CNA stated she was aware Resident #1 would roll out of the bed. She stated she did not think to press the call light for assistance or place the bed back in the low position and put the mattress back in place before turning her back on the resident and taking the three steps to the wheelchair to obtain another washcloth. She stated one staff was needed to provide care to Resident #1 when in the bed. An interview with Registered Nurse (RN) #1, on 10/06/10 at 4:40 PM, revealed he assessed the resident and noted a large hematoma on the left forehead with bleeding. He called for an ambulance to transfer the resident to the hospital. A review of the history and physical from the hospital, dated 09/29/10, revealed the resident was diagnosed with [REDACTED]. An interview with the Director of Nursing, on 10/07/10 at 4:10 PM, revealed the CNA should have used the call light to call for assistance or she should have lowered the bed and put the mattress back in place before walking away from the resident.

Based on interviews and record review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one resident (#1) in the selected sample of six. The facility failed to follow the Accident and Supervision to Prevent Accident policy and procedure. The facility failed to ensure staff was knowledgeable to the number of staff required to assist Resident #1 with bed mobility to prevent accidents. The facility assessed Resident #1 as requiring two staff to assist with bed mobility; however, the Comprehensive Care Plan failed to detail the number of staff necessary. Furthermore, the facility was knowledgeable of the resident's recent history of falls from the bed. On 09/29/10, Certified Nurse Aide (CNA) #1 assisted Resident #1 with bed mobility and hygiene needs, after turning to retrieve a washcloth, the resident fell out of the bed and sustained a subdural hematoma. Findings include: A review of the facility's Accidents and Supervision to Prevent Accident policy and procedure, dated 08/06/07, revealed the center should provide supervision and assistive devices for each resident to prevent avoidable accidents. The center should evaluate accident risk data, analyze potential causes of the accident risk and design interventions based on the immediacy of the risks. The center should communicate the interventions to relevant staff, assign responsibility to appropriately trained individuals, implement and document interventions. The center should implement interventions correctly and consistently, including adequate supervision. If the RAP for falls was triggered, the center should assess the need for assistive devices and care plan and implement preventive measures for the resident at risk for falls. A review of the facility's Accidents and Supervision to Prevent Accidents Definitions, dated 08/06/07, revealed Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. An avoidable accident means that a resident had an accident and the facility failed to implement interventions, including adequate supervision, consistent with the resident's needs, goals, plan of care, and recognized standards of practice in order to reduce the risk of an accident. A lack of supervision occurs when the center has determined supervision of the resident or resident's environment was necessary, but failed to provide it. A record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Post Fall Evaluation, dated 02/20/10 at 5:30 AM, revealed the resident was found lying on the floor on his/her side beside the bed. The resident was in a low bed and had a sensor alarm on the bed. The facility investigated the incident and assessed the need for a landing strip beside the bed, therapy to evaluate the resident and the continued use of the sensor alarm and a low bed. A review of the initial Minimum Data Set (MDS) assessment, dated 03/01/10, revealed the facility assessed the resident as needing extensive assistance of two staff for bed mobility and the resident had a fall in the past 31-180 days. A review of the Resident Assessment Protocol (RAP) for falls and Activities of Daily Living (ADL) Functional/Rehab Potential, dated 03/01/10, revealed the resident had a history of [REDACTED]. The resident required total assistance of two staff for bed mobility. The facility had the resident in a low bed with a sensor pad alarm and a landing strip at the bedside for safety. A review of a Post Fall Evaluation, dated 03/03/10 at 5:05 AM, revealed a CNA heard Resident #1's alarm sounding. When the CNA entered the room, the CNA witnessed the resident had scooted off the side of the bed and onto the mat on the floor at the bedside. The facility investigated the incident and assessed the need to offer the resident a snack during the night hours, if the resident woke up and to continue the current interventions. A review of a Post Fall Assessment, dated 03/03/10 at 7:20 PM, revealed the resident's bed alarm was sounding. Staff entered the room and found Resident #1 lying on the mat on the floor at the bedside. The facility investigated the incident and assessed the need to place the resident in bed at 8:00 PM, to get the resident up at 5:00 AM and place the resident in the bed for a nap at 12:00 Noon. A review of the quarterly MDS assessment, dated 08/13/10, revealed the facility assessed Resident #1's cognitive skills as severely impaired. The facility assessed the resident as requiring extensive assistance of two staff for bed mobility. The resident had a fall in the last 31-180 days. A review of a bed safety evaluation and falls risk assessment, dated 08/14/10, revealed the facility assessed the resident as having no awareness of the proximity of the edge of the bed while moving or rolling in bed and as a high risk for falls. The facility assessed the need to place a scoop/wing mattress on the bed. A review of the Comprehensive Care Plan for at risk for falls and Self-Care Deficit, dated 08/18/10, revealed interventions for staff to keep the adjustable bed in the low position, place a mattress on the floor beside the bed at night, for the resident to be up at 5:00 AM, placed back in the bed at 12 Noon and bedtime at 8:00 PM, to offer the resident snacks if awake in the late night hours, to apply a bed sensor alarm when in the bed and to provide total care for bathing, dressing and hygiene needs. There was no documented evidence the facility updated the Comprehensive Care Plan to address the assessed need for extensive assistance of two staff for bed mobility. A review of the CNA Care Plan, undated, revealed the resident required the assistance of one staff for ADL care; even though, the facility had assessed the resident as needing the extensive assistance of two staff for bed mobility. A review of a Post Fall Assessment, dated 09/10/10 at 2:30 PM, revealed staff entered Resident #1's room and observed the resident lying on his/her left side on the mat. The resident's alarm did not sound. The facility investigated the incident and referred the resident for a therapy screen. In addition, the facility discontinued the bed sensor alarm and initiated a motion detector to the outer aspect of the bed. Further review of the Comprehensive Care Plan, dated 08/18/10, revealed no documented evidence the facility updated the Comprehensive Care Plan to address the discontinuation of the bed sensor alarm and the initiation of the motion detector. A review of a Post Fall Assessment, on 09/10/10 at 4:30 PM, revealed the resident was observed lying on the landing strip on the floor. The facility investigated the incident and determined the landing strip needed to be replaced with a mattress on the floor at the bedside. Interviews with two CNAs (#2 and #3) on 10/08/10 at 12:15 PM and 12:25 PM respectively revealed, Resident #1 was able to throw his/her legs over the scoop/wing mattress and then pull him/herself over the scoop/wing mattress. A review of the nursing progress notes, dated 09/29/10, and an interview with CNA #1, on 10/07/10 at 9:20 AM, revealed Resident #1 was in bed and had vomited. CNA #1 stated she entered the room and obtained washcloths from the wheelchair, that was beside the wall opposite from the bed. She wet the washcloths in the sink and placed them on the foot of the bed. The CNA revealed she removed the soft mattress from the floor beside the bed and raised the bed so she could provide care to the resident. She stated she observed the resident had vomited on the sheet, so she rolled the resident toward the wall (resident's right side) to roll up the dirty sheet and place a clean sheet on the mattress. She then rolled the resident towards her (resident's left side) to remove the dirty sheet and pull the clean sheet around the rest of the mattress. She stated before she stretched the clean sheet over the mattress, she observed vomit on the mattress. The CNA stated she either rolled the resident to his/her back or the resident rolled onto his/her back when she let go of the resident. The CNA stated she told the resident "just a minute", turned her back and walked (three steps) over to the wheelchair to obtain another washcloth. She stated when she turned back around, the resident was falling from the bed. She stated she rushed to the resident and was able to grab the resident's leg, but the resident's head hit the floor. She stated when she bent down to check on the resident, she observed the resident was bleeding from his/her head. The CNA stated she went to the door and called for the nurse. The CNA stated she was aware Resident #1 would roll out of the bed. She stated she did not think to press the call light for assistance or place the bed back in the low position and put the mattress back in place before turning her back on the resident and taking the three steps to the wheelchair to obtain another washcloth. She stated one staff was needed to provide care to Resident #1 when in the bed. An interview with Registered Nurse (RN) #1, on 10/06/10 at 4:40 PM, revealed he assessed the resident and noted a large hematoma on the left forehead with bleeding. He applied pressure to the injury and the bleeding stopped. He called for an ambulance to transfer the resident to the hospital. A review of the history and physical from the hospital, dated 09/29/10, revealed the resident was diagnosed with [REDACTED]. An interview with the Director of Nursing, on 10/07/10 at 4:10 PM, revealed the CNA should have used the call light to call for assistance or she should have lowered the bed and put the mattress back in place before walking away from the resident.

Based on observations, interviews and record review, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented, with sufficient information regarding resident assessments related to problem behaviors and development and implementation of care plan interventions needed for adequate supervision for five residents (#1, #4, #5, #6 and #7), in the selected sample of five. Additionally, the facility failed to follow its' established policy and procedures related to documentation of the information for each resident. Staff interviews and record review revealed Resident #1 was identified by the facility as at risk for choking and received a specialized diet consistency. However, the facility staff was aware Resident #1 had exhibited behaviors of grabbing food and fluids from other residents or from the dining table, which was not the consistency ordered for the resident. There was no evidence the known behaviors had been documented or included in the resident's care plan with interventions developed and implemented to ensure Resident #1 was adequately supervised during eating. On [DATE], Resident #1 choked on bread the resident obtained from a plate placed on the table by staff. The resident stopped breathing and had no pulse. Staff were unable to revive the resident at the facility and Emergency Medical Services responded and had to insert a Laryngoscope (instrument inserted into the resident's airway to remove the bread with forceps.) The resident was transported to the hospital. Interviews and record reviews revealed after the incident, the facility failed to correct the lack of documentation of behaviors for Residents #1, #4, #5, #6 and #7. The facility's failure to maintain clinical records that were complete and accurate for residents at risk for choking, represented a situation that had caused and was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and was found to exist on [DATE] and was on-going. Substandard Quality of Care was identified at 483.25 Quality of Care. The facility was notified on [DATE]. Findings include: A review of the facility's policy and procedure for Documenting in a Resident's Medical Record, dated [DATE], revealed the medical record should serve as a planning tool for resident care, to record the course of the resident's treatment and changes in medical condition and to document communication between the healthcare members. 1. Record review revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Interviews with the Activity Director on [DATE] at 3:50 PM, Registered Nurse (RN) #1 on [DATE] at 2:40 PM, RN #2 on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #1 on [DATE] at 5:20 PM, LPN #2 on [DATE] at 1:40 PM, LPN #3 on [DATE] at 10:55 AM, LPN #4 on [DATE] at 3:00 PM, Certified Nurse Aide (CNA) #1 on [DATE] at 2:55 PM, CNA #2 on [DATE] at 3:20 PM, CNA #3 on [DATE] at 3:10 PM, CNA #4 on [DATE] at 3:10 PM, CNA #5 on [DATE] at 5:05 PM, CNA #6 on [DATE] at 5:15 PM, CNA #7 on [DATE] at 5:35 PM, CNA #8 on [DATE] at 5:50 PM, CNA #9 on [DATE] at 2:40 PM and CNA #10 on [DATE] at 4:05 PM, revealed Resident #1 had behaviors of grabbing food and/or fluids off of residents' trays and from the dining room table prior to [DATE]. The staff stated they immediately took the food/fluid away from the resident. The staff revealed they tried to keep an eye on the resident because of the resident's behaviors of grabbing food and drinks from tables and other residents' trays. They stated everyone was aware that Resident #1 had this behavior because the resident did it all the time. However, review of the Comprehensive Care Plan revealed there was no revision to the care plan to address the resident's behavior of grabbing other resident's food off the trays or from the table. Interviews on [DATE] at 3:00 PM and on [DATE] at 10:50 AM, with the Minimum Data Set (MDS) Supervisor, RN Supervisor and Social Worker #1 (who participated in the resident's care plan meetings), revealed they were not aware Resident #1 had behaviors of grabbing food from the table and other residents' trays. They stated the behavior should have been documented in the record or brought up by staff in the care plan meeting so the behavior could have been addressed in the resident's care plan. Interviews with RN #3 on [DATE] at 10:40 AM, LPN #5 on [DATE] at 10:20 AM, LPN #6 on [DATE] at 3:40 PM, CNA #1 on [DATE] at 2:55 PM, CNA #2 on [DATE] at 3:20 PM, CNA #3 on [DATE] at 3:10 PM, CNA #4 on [DATE] at 3:10 PM, CNA #9 on [DATE] at 2:40 PM and CNA #10 on [DATE] at 4:05 PM, revealed Resident #1 was seated at a table on the third row in the dining room with other residents for the noon meal on [DATE]. The staff had placed sliced fresh baked bread on saucers and passed it out to the residents who were on regular diets. The staff revealed they started passing out trays to the residents at the first row of tables. CNA #9 revealed as she turned around to pass a tray, she observed Resident #1 with a slice of bread in his/her hand. CNA #9 stated Resident #1 had taken the bread from a resident sitting at the table with him/her. CNA #9 stated she walked over to the resident and removed the bread from his/her hand and from the table. She resumed passing out trays. The staff revealed the next thing they knew CNA #4 shouted Resident #1 was turning blue. The staff stated they immediately called a Code, grabbed a crash cart and lowered the resident to the floor. The licensed staff responded to the code and attempted the [MEDICATION NAME] Maneuver with finger sweeps three times with no success. They stated the resident was not breathing and they could not detect a pulse. EMS was called and Cardiopulmonary Resuscitation (CPR) was started. A review of the EMS report, dated [DATE], revealed a Laryngoscope was inserted into the resident's throat and the lodged bread was removed with forceps. The resident's pulse and breathing returned. The resident was sent out to the hospital. Observation of the noon meal, on [DATE] at 12:15 PM, revealed Resident #1 was seated at a table with a resident with the same kind of diet. A licensed staff was in the dining room. Staff began passing fluids to the residents. A CNA sat with Resident #1 when his/her glass of fluid was served and stayed with the resident through the resident's tray being served and then fed the resident his/her meal. The remaining staff began passing out the residents' trays. The staff had their backs to the residents in the dining room while passing the trays and the surveyor observed a resident to take and consume another resident's fluids. A review of the comprehensive care plan, for Resident #1 revealed the resident's care plan was revised for the resident to sit with residents with the same diet consistency on [DATE]; however, there were no revisions to the care plan to address adequate supervision/monitoring of the resident due to the behavior of grabbing of food/drinks and the increased risk of the resident choking and there were no interventions to monitor and document the resident's behavior of grabbing food/drinks. 2. A record review revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Interviews with RN #2 on [DATE] at 5:40 PM, RN #1 on [DATE] at 2:40 PM, LPN #1 on [DATE] at 5:20 PM, CNA #5 on [DATE] at 5:05 PM, CNA #6 on [DATE] at 5:15 PM, CNA #7 on [DATE] at 5:35 PM and CNA #8 on [DATE] at 5:50 PM, revealed Resident #4 grabbed other residents' food/drinks or pulled the tablecloth to pull items within his/her reach. However, further review of the medical record revealed there was no documentation of the resident's behaviors of grabbing food/drinks and pulling the tablecloth to pull items within reach. Observation of the noon meal on [DATE] at 12:15 PM, revealed Resident #4 was seated at a table with a resident with the same kind of diet. A licensed staff was in the dining room. A CNA sat with Resident #4 when his/her tray was served. A review of the comprehensive care plan for potential for alteration in nutrition/hydration related to mechanically altered diet, end stage Alzheimer's and potential for aspiration, dated [DATE], revealed interventions to provide a mechanical soft diet with nectar thick liquids, fed per staff in dining room and encourage to eat slowly. Further review revealed the care plan did not address adequate supervision/monitoring of the resident's behaviors of grabbing food/drinks and pulling the tablecloth to pull items within his/her reach. Additionally, there were no interventions to monitor and document the resident's behavior of grabbing food/drinks. 3. A record review revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An interview with CNA #5 on [DATE] at 5:05 PM, revealed Resident #5 was blind in one eye and saw objects with the other eye and grabbed for them. She stated the resident had grabbed food/drinks belonging to another resident in the dining room. However, further review of the record revealed no documentation of the resident's behavior of grabbing for food/drinks in the dining room. A review of the comprehensive care plan for alteration in nutrition/hydration related to mechanically altered diet and swallowing problems, dated [DATE], revealed an intervention to provide assistance with meals. Further review revealed the care plan did not address adequate supervision/monitoring of the resident's behavior of grabbing food/drinks and there were no interventions to monitor and document the resident's behavior of grabbing food/drinks. 4. A record review revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. An interview with CNA #7 on [DATE] at 5:35 PM, revealed Resident #6 grabbed other residents' food/drinks at times when he/she ate in the dining room. However, further review of the medical record revealed there was no documentation of the resident's behavior of grabbing for food/drinks. A review of the comprehensive care plan for impaired swallowing related to the resident ate too fast causing him/her to choke revealed interventions to provide a pureed diet with regular liquids and to encourage the resident to slow down and take small bites to decrease the risk of choking. Further review revealed the care plan did not address adequate supervision/monitoring of the resident's behavior of grabbing for food/drinks and there were no interventions to monitor and document the resident's behavior of grabbing food/drinks. 5. A record review revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. An interview with LPN #1 on [DATE] at 5:20 PM, revealed Resident #7 grabbed other residents' food/drinks at times and tried to eat inedible objects. However, further review of the medical record revealed there was no documentation of the resident's behavior of grabbing for food/drinks. A review of the comprehensive care plan for at risk for altered nutrition/hydration related to Alzheimer's and wandering, dated [DATE], revealed an intervention to provide a mechanical soft diet with pureed meat and regular liquids. Further review revealed the care plan did not address adequate supervision/monitoring of the resident's behavior of grabbing for food/drinks and there were no interventions to monitor and document the resident's behavior of grabbing for food/drinks. An interview with the DON on [DATE] at 1:25 PM, revealed during the investigation of Resident #1's incident, she did not identify that there were four other residents (#4, #5, #6 and #7), who also had behaviors of grabbing for other residents' food/drinks. She had not identified that there was no documentation in the residents' medical records identifying the behaviors of grabbing for food/drinks, no care plans to address the behaviors and no interventions to monitor and document the residents' behaviors of grabbing food/drinks. An acceptable credible allegation of correction for the removal of the Immediate Jeopardy was received on [DATE]. The Immediate Jeopardy was verified removed on [DATE], prior to exit. The alleged date of removal was [DATE]. Based on observations, interviews and record reviews, verification was made the Immediate Jeopardy was removed on [DATE]. The AOC revealed: Affected residents: On [DATE], the ARNP communicated to all direct care staff, licensed nurses State Registered Nurse Aides, that Resident #1 would be seated in the dining room at a table with other residents who received the same type of mechanically altered diet. On [DATE], the care plan was updated to reflect dining room seating arrangement for Resident #1. On [DATE], the care plan was updated to reflect a problem of At risk for Choking Possible Aspiration related to Dementia with Impulsive Behavior , Past Behavior of Grabbing food and/or liquids, with interventions to include, but not limited to: provide LCS pureed diet with honey thick liquids by small spoon per staff; encourage po intake and po fluids, fed per staff; encourage dining room attendance each meal and sit with resident with same texture diet; supervise all po intake and meal times. On [DATE], the care plan was updated, with a problem of no safety awareness as resident grabs out for people and items, with interventions to include, but not limited to: keep resident in supervised area when out of bed; notify nurse of any abnormal behavior; be attentive to resident when reaching; and encourage resident to attend activities. In addition, the Executive Director (ED), Director of Nursing Services (DNS), the District Director of Operations (DO), and the District Director of Clinical Operations, (DDCO), conducted further investigation for Resident #1 on [DATE]. This investigation consisted of staff interviews and medical record review, to include but not limited to: the comprehensive Minimum Data Set (MDS) Assessment, Resident Assessment Protocols (RAPs), Comprehensive Care Plan, Behavior and Mood Logs and Resident Progress Notes. The 24-hour report, the Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. The SRNA Assignment Sheet and the Dining Room Seating Arrangement Diagram were updated for Resident #1. The care plan for Resident #4 was revised on [DATE] with a problem of Inappropriate Behaviors of grabbing at items on dining room tables, including food, with interventions to include, but not limited to: place at table with residents with same diet; table cloth will be removed; center piece removed; staff will monitor during meals/activities; will not be seated within reach of other residents' food at meals; psych services as indicated for management of behaviors. On [DATE], the care plan was updated with an intervention to notify nurse of any new abnormal behaviors. The care plan for Resident #5 was revised on [DATE] with a problem of Inappropriate Behaviors of grabbing objects, food on dining table, and at persons, with interventions to include, but not limited to: sitting at table with others who have same diet; have snacks available when hungry, needs assistance; reassure resident; remove objects from table/tablecloth. On [DATE], the care plan was updated with an intervention to notify nurse of any new abnormal behaviors. The care plan for Resident #6 was revised on [DATE] with a problem of Repetitive Movements, Oral Fixation, does not currently, but in past, has taken food from others rooms or trays and over eating, with interventions to include, but not limited to: monitor all po intake; set up and episodic chewing during meals; feed assist if stops feeding self at meals; have resident slow down if eating fast; notify nurse of any new onset of abnormal behaviors and document. The care plan for Resident #7 was revised on [DATE] with a problem of Socially Inappropriate Behaviors, at time unable to tell the difference from edible and non-edible item, history of taking food off others' trays, with interventions to include, but not limited to: place at table without centerpieces; staff to monitor during meals; will not be seated within reach of other residents' food at meals. Homemade bread would continue to be served during meal service as appropriate and in accordance with MD order for diet consistency. For residents with mechanically altered diets, bread would be altered accordingly and served with the meal service. Effective [DATE], residents who have known behaviors of reaching for and obtaining items that are not on their meal tray or that are inedible, have been arranged to be seated at tables with same MD ordered mechanically altered diet. This is reflected on the Dining Room Seating Assignment Chart, effective [DATE]. Effective [DATE], each meal service will be monitored by a licensed nurse for the duration of the meal service. SRNAs are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse are responsible to conduct observations of all residents during the meal service to identify behaviors or concerns. The licensed nurse are responsible to document any behaviors or identified concerns on the Meal Supervision Log, the 24-hour report and will report the behaviors or identified concerns to the Director of Nursing Services and/or the Social Worker. The DNS and CM will also review the Meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns are identified and addressed on the care plan and that supervision is appropriate. In addition, the DNS and CM participate in the licensed staff dining room observation to validate appropriate supervision. Effective [DATE], each activity with meal service is monitored by the Activities Staff for the duration of the meal service. Activities Staff are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse is responsible to document any behaviors or identified concerns on the 24-hour Report and to report the behaviors or identified concerns to the DNS and/or Social Worker(SW). Effective [DATE], Administrative Licensed Nurses (DNS, Assistant Director of Nursing Services (ADNS), Unit Manager (UM), Minimum Data Set Coordinator (MDSC), Case Manager (CM), Weekend Supervisor (WS) and Staff Development Coordinator (SDC) participate in the licensed staff dining room observation. Administrative nurses through direct observation will validate that all behaviors and/or concerns have been identified, documented on the 24-Hour Report and report to the DNS and SW. Meal Supervision, behaviors and/or concerns will be documented at each meal on the Meal Supervision Log. The Meal Supervision Log will be reviewed daily in the Stand-Up meeting and on weekends by the WS to identify any concerns and to validate that appropriate corrective action has been taken. Any concerns identified will be documented on the Meal Supervision Log at the time of the review. All direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food, and to document on the 24-Hour Report and to address in care plan. Other Facility Residents with the Potential to be Affected: The DNS, UM, Registered Dietician (RD) and Assistant Dietary Services Manager (ADSM) reviewed the medical records of all other facility residents on mechanically altered diets on [DATE]. Record reviews included, but not limited to, the comprehensive MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs, and Resident Progress Notes. The 24-Hour Report, The Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. Record review was conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The Comprehensive Care Plan, the State Registered Nurse Aide Assignment Sheet and the Dining Room Seating Arrangement Diagram were updated as indicated, based on record review and staff interviews. To ensure the safety of all mobile residents on mechanically altered diets with behaviors, all direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food. Licensed nurses were educated to document on the 24-Hour Report, the Resident Progress Notes and on the Behavior Log and to address on the care plan. The SRNAs were educated to document on the Behavior Log and report to the licensed nurse. The DNS and CM will conduct 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plan. The DNS, UM, Minimum Data Set Coordinator (MDSC), Case Manager (CM), and Advanced Register Nurse Practitioner (ARNP) reviewed the medical records of all facility residents on [DATE]. Record reviews included but were not limited to: the MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs and Resident Progress Notes for the previous 30-day period. Record review was conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The comprehensive care plan, SRNA Assignment Sheet and Dining Room Seating Arrangement Diagram were updated, as indicated, based on record review and staff interviews. In addition, on [DATE], all SRNA Assignment Sheets were updated to reflect the intervention for staff to report any and all new behaviors to the licensed nurse. Systemic Changes to Prevent Reoccurrence of Deficient Practice: The DNS, UMS and Weekend Supervisor initiated in-servicing to all direct care staff, to include licensed nurses and SRNAs on [DATE]. In-service content included Care plans and Care plan Meeting and Assigned Seating Designations. In addition, all direct care staff, including Activities, were educated on the Dining Room Seating Assignment Chart and on how the chart was designed. All staff were educated that activity seating groups will be the same as the Dining Room Seating Assignment Chart. The DO and DDCO initiated Investigative Training in-servicing on [DATE] with the ED and DNS. The DDCO completed in-servicing to all Administrative Staff (ED, DNS, CM, MDSC, Social Worker, UM, RD, Activity Director, Housekeeping Supervisor, Rehab Manager, Program Director, Nutrition Services Manager, ARNP and Respiratory Therapist) on [DATE]. In-service content included Documentation of Resident Health Status, Needs and Services; Documenting in a Resident's Medical Record; 24-Hour Report and Investigative Protocol. The DNS and UM initiated additional in-servicing on [DATE] with all direct care staff to include licensed nurses, SRNAs, and Activities staff related to meal supervision. In-servicing was initiated on [DATE] and [DATE] and will continue until all appropriate staff have attended the appropriate in-service. Staff will not be allowed to work until having attended the appropriate in-service. The in-service will be included in New Employee Orientation for all new hires. The facility does not utilize Agency Staff. If the facility should employ Agency Staff, they will receive the in-service prior to working. The ED and DNS will be responsible to validate that staff do not work prior to receiving the in-service. A sign is posted at the time clock to notify staff they are not to work or provide care to any resident prior to reporting to a charge nurse to receive the in-service. If the staff in need of in-service is a charge nurse, they are to report to a charge nurse on a different unit. Facility Monitoring: An ad hoc Performance Improvement Committee was held on [DATE]. Members in attendance included the ED, DNS, UM and RD. The Medical Director was notified of the Facility Action Plan on [DATE]. The ED, DNS, RD and WS will audit residents on mechanically altered diets through staff interviews, direct observations of dining services and through record reviews of Behavior and Mood Logs and Resident Progress Notes. The review will also include the Meal Supervision Log and Dietary Communication Book. The ED, DNS, RD and WS will each conduct one audit per week for four weeks. The audit will validate that all behaviors have been appropriately identified and addressed. The DNS and CM will audit four random records (two per unit) per week for any new behaviors exhibited and to validate that all behaviors have been appropriately addressed on the comprehensive care plan. The audit will include but will not be limited to: the MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs and Resident Progress Notes for the previous 7-day period. The DNS and CM will also review the meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns have been identified and addressed. In addition, the DNS and CM participate in the licensed staff dining room observation. In addition, the audit will include 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plan. The DNS will be responsible to report all audit (residents on mechanically altered diets, behaviors, and the Meal Supervision Logs) findings at the weekly PIC meeting. The PIC will meet weekly (Tuesday) for four weeks to review audit findings to determine the need for additional action steps. If no concerns are identified during the weekly (Tuesday) PIC meetings, the audits on a monthly basis for two months, and on an as needed basis thereafter. The DNS will be responsible to report all audit findings at the monthly PIC meeting. All monthly findings will be reviewed at the monthly PIC to validate that any identified concerns were immediately corrected. Findings will be tracked and trended at the PIC for additional action steps, if indicated. The Interdisciplinary Team, to include but not limited to: ED, DNS, UM, RD, Social Worker, DM, Activities Director, will review all resident events during morning Stand-Ups by reviewing Event Reports, 24-Hour Reports, hospitalization s, Dietary Communications Book to ensure that all events are investigated to ensure the health, safety and overall well-being is met and maintained for the affected resident, other facility residents with the potential to be affected, to identify the need for systemic changes and to validate that the PI process is effective. The ED is responsible for overall compliance through attendance at the Stand -Up Meeting and by reviewing audits to ensure conducted. The ED will assume overall responsibility for the Performance Improvement Program at the Facility. The ED will utilize weekly (Wednesday) IDT recommendations to validate one medical record (from resident identified in the IDT Meeting) to ensure implementation of the Credible Allegation of Compliance. The ED/Administrator will then return to routine monitoring, of the facility systems each month as specified in the Facility Performance Improvement policy and procedure, when substantial compliance is achieved. In addition, the DDCO will conduct weekly calls with the facility to review events from the previous week to validate that all events are thoroughly investigated, to include care plan revision. Interviews conducted on [DATE], during the extended survey, with the DON and direct care staff (SW #2, RN #1, RN #3, LPN #2, LPN #6, LPN #7, LPN #8, CNA #3, CNA #5, CNA #6, CNA #11, CNA #13, CNA #14 and CNA #15 ), revealed there was now a seating chart for the dining room. Residents were seated with residents on the same diet consistency. Licensed staff were present in the dining room for all meals and Administrative staff participated in the dining room service. They revealed if any behaviors were noted, the staff reported the behavior to the licensed staff in the dining room. The licensed staff then documented it on the behavior log in the dining room and reported it to the Charge nurse and documented on the 24 hour report and in the resident's record. Observation of the noon meal on [DATE] revealed Resident #1 was seated at a table by him/herself. No food was placed on the table until Resident #1's tray was served. The CNA immediately sat down next to the resident when the tray was served. Residents #4, #5, #6 and #7 were seated with residents with like diets and were seated according to the dining room seating chart. A licensed staff was present during the entire meal. Staff were reporting observations of behaviors to the licensed staff during the meal. A review of the Dining Room behavior observation sheets for [DATE], revealed each resident's name was documented with the behaviors that were observed. Observations of Resident #,1 on [DATE] at 2:20 PM, revealed the resident was in a wheelchair seated in the area across from the nurse's station in view of staff. A review of Resident #1's comprehensive care plan revisions, dated [DATE], [DATE], [DATE] and [DATE], revealed the care plan had been revised to include interventions to seat the resident at a table with same texture diets, supervise all po intake and meal times, keep the resident in a supervised area when out of bed, notify the nurse of any abnormal behavior and be attentive to the resident when reaching. A review of Residents' #1, #4, #5, #6 and #7 comprehensive care plans, revealed the care plans were updated to include individual interventions to provide supervision for the residents related to their behaviors of grabbing for food/drinks. A review of the in-service trainings provided to all direct care staff, dated [DATE], [DATE], [DATE] and [DATE], revealed all staff received training on care plans and care plan meetings, assigned seating charts, dining/meal service supervision, activity seating groups, to report any and all behaviors (to include wandering or reaching for objects to include food/drink) and documentation. In addition, Administrative Staff were in-serviced on [DATE], on Documentation, Documenting Residents' Health Status, Needs and Services, and Documenting in a Resident's Medical Record and on the 24- Hour Report. The Executive Director and Director of Nursing received in-servicing on [DATE] related to conducting investigations. Although it was determined the Immediate Jeopardy was removed on [DATE], non-compliance continued with the scope and severity of a "D", based on the facility's need to monitor for the on-going effectiveness of the corrective actions taken and to ensure evaluation through the facility's Quality Assurance process.

Based on observations, interviews and record review, it was determined the Administration failed to ensure the facility was administered in a manner that enabled it to use its' resources effectively to attain or maintain the highest practicable physical, mental and psychosocial well-being of five residents (#1, #4, #5, #6 and #7) in the selected sample of five. The Administration failed to ensure staff followed the facility's Accident and Supervision to Prevent Accidents policy and procedure related to identifying resident risks, implementing interventions to prevent accidents and the staff's failure to conduct a thorough investigation to identify residents' risks, ensuring care plan revisions were made and adequate supervision was provided for Residents #1, #4, #5, #6 and #7 related to their behaviors of grabbing food/drinks. On 09/01/10, staff placed bread (regular consistency) at the table accessible to Resident #1. Staff did not provide supervision to ensure Resident #1 did not gain access to the bread despite having knowledge of this resident's history of attempts to obtain food of a different consistency. Staff observed Resident #1 with bread in his/her hand and removed it; however, the resident began to choke. Staff initiated the [MEDICATION NAME] Maneuver; however, this method was not successful. The resident stopped breathing and had no pulse. Emergency Medical Services had to insert a Laryngoscope (instrument inserted into the airway to provide visual access) into the resident's throat to remove the bread with forceps. The resident was sent out to the hospital. The Administrator's failure to ensure adequate supervision was provided for residents' at risk for choking, represented a situation that had caused and was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/21/10 and found to exist on 09/01/10 and was ongoing. Substandard Quality of Care was identified at 483.25 Quality of Care. The facility was notified on 09/21/10. The findings Include: Based on observations, interviews and record reviews, it was determined the facility failed to revise the care plans for five residents (#1, #4, #5, #6 and #7), in the selected sample of five. Interviews with staff revealed the residents had behaviors of grabbing food off of dining room tables and other residents' trays that was not the right consistency food for these residents. The residents' care plans were not revised to address the residents' behaviors of grabbing food/drinks and the need for adequate monitoring and supervision to prevent choking. Refer to F280 Based on observations, interviews and record reviews, it was determined the facility failed to provide adequate supervision to prevent accidents for five residents (#1, #4, #5, #6 and #7), in the selected sample of five. The facility failed to supervise and monitor residents who required supervision due to choking risks while eating. Facility staff was aware of Residents' #1, #4, #5, #6 and #7 history of attempts to obtain food of a different consistency than their diets, but failed to develop and implement interventions to prevent the residents from obtaining the food/fluids. Refer to F323 Based on observations, interviews and record review, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented, with sufficient information regarding resident assessments related to problem behaviors and development and implementation of care plan interventions needed for adequate supervision for five residents (#1, #4, #5, #6 and #7), in the selected sample of five. Additionally, the facility failed to follow its' established policy and procedures related to documentation of the information for each resident. Refer to F514. A review of the facility's Accidents and Supervision to Prevent Accidents policy and procedure, dated 08/06/07, revealed the center provided supervision to each resident to prevent avoidable accidents. This included systems to identify and evaluate hazards and risks, implement interventions to reduce hazards and risks and to monitor the effectiveness and modify approaches when necessary. The center identified hazards and the risks of the resident having an unavoidable accident through Quality Assurance activities, medical history, physical exam and individual observation. Staff was involved in observing and identifying potential hazards. The Center investigated accidents and developed a plan of action to prevent the accident from reoccurring. A review of the Accidents and Supervision to Prevent Accidents Definitions revealed an avoidable accident was when the facility failed to identify: 1. environmental hazards and individual resident risk of an accident, including supervision, 2. evaluate the hazards and risks and 3. implement interventions, including adequate supervision, consistent with the resident's needs, resident's goals, resident's plan of care, and current standards of practice in order to reduce the risk of an accident. Lack of Supervision was the lack of adequate supervision to prevent accidents occurred when the center failed to accurately assess a resident to determine whether supervision to avoid an accident or injury was necessary. Refer to F323 An interview with the Administrator, on 09/21/10 at 10:45 AM, revealed she made rounds every morning, talked to residents, reviewed 24 hour reports, monitored staff answering call lights, talked with staff and come in on different shifts to try to ensure staff were providing adequate supervision for the residents. She stated she participated in daily stand-up meetings and Quality Assurance activities. She revealed she was not aware Residents #1, #4, #5, #6 and #7 had behaviors of grabbing other residents' food/drinks and that the information was not documented in each resident's clinical record. A credible allegation of correction for removal of the Immediate Jeopardy was received on 09/22/10. The Immediate Jeopardy was verified removed on 09/22/10, prior to exit. The alleged date of removal was 09/22/10. Based on observations, interviews and record reviews, verification was made the Immediate Jeopardy was removed on 09/22/10. The AOC revealed: Affected residents: On 09/02/10, the ARNP communicated to all direct care staff, licensed nurses, State Registered Nurse Aides, that Resident #1 would be seated in the dining room at a table with other residents who received the same type of mechanically altered diet. On 09/07/10, the care plan was updated to reflect dining room seating arrangements for Resident #1. On 09/16/10, the care plan was updated to reflect a problem of At risk for Choking Possible Aspiration related to Dementia with Impulsive Behavior , Past Behavior of Grabbing food and/or liquids, with interventions to include but not limited to: provide LCS pureed diet with honey thick liquids by small spoon per staff; encourage po intake and po fluids, fed per staff; encourage dining room attendance each meal and sit with residents with same texture diet; supervise all po intake and meal times. On 09/21/10, the care plan was updated, with a problem of no safety awareness as the resident grabs out for people and items, with interventions to include but not limited to: keep the resident in a supervised area when out of the bed; notify the nurse of any abnormal behavior. be attentive to the resident when reaching; and encourage the resident to attend activities. In addition, the Executive Director (ED), Director of Nursing Services (DNS), the District Director of Operations (DO), and the District Director of Clinical Operations, (DDCO), conducted further investigation for Resident #1 on 09/19/10. This investigation consisted of staff interviews and medical record reviews, to include but not limited to: the comprehensive Minimum Data Set (MDS) Assessments, Resident Assessment Protocols (RAPs), Comprehensive Care Plans, Behavior and Mood Logs and Resident Progress Notes. The 24-hour report, the Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. The SRNA Assignment Sheets and the Dining Room Seating Arrangement Diagram were updated for Resident #1. The care plan for Resident #4 was revised on 09/17/10 with a problem of Inappropriate Behaviors of grabbing at items on dining room tables, including food, with interventions to include but not limited to: place at a table with residents with same diet; tablecloth will be removed; center piece removed; staff will monitor during meals/activities; will not be seated within reach of other residents' food at meals; psych services as indicated for management of behaviors. On 09/21/10, the care plan was updated with an intervention to notify the nurse of any new abnormal behaviors. The care plan for Resident #5 was revised on 09/17/10 with a problem of Inappropriate Behaviors of grabbing objects, food on dining table, and at persons, with interventions to include but not limited to: seat at table with others who have same diet; have snacks available when hungry, needs assistance; reassure resident; remove objects from table/tablecloth. On 09/21/10, the care plan was updated with an intervention to notify the nurse of any new abnormal behaviors. The care plan for Resident #6 was revised on 09/20/10 with a problem of Repetitive Movements, Oral Fixation, does not currently, but in past, had taken food from others rooms or trays and over eating, with interventions to include but not limited to: monitor all po intake; set up and episodic chewing during meals; feed assist if stops feeding self at meals; have resident slow down if eating fast; notify nurse of any new onset of abnormal behaviors and document. The care plan for Resident #7 was revised on 09/16/10 with a problem of Socially Inappropriate Behaviors, at time unable to tell the difference from edible and non-edible item, history of taking food off others' trays, with interventions to include but not limited to: place at table without centerpieces; staff to monitor during meals; will not be seated within reach of other residents' food at meals. Homemade bread will continue to be served during meal service as appropriate and in accordance with MD order for diet consistency. For residents with mechanically altered diets, bread will be altered accordingly and served with the meal service. Effective 09/17/10, residents who have known behaviors of reaching for and obtaining items that are not on their meal trays or that are inedible, have been arranged to be seated at tables with residents with the same MD ordered mechanically altered diet. This is reflected on the Dining Room Seating Assignment Chart, effective 09/17/10. Effective 09/02/10, each meal service is monitored by a licensed nurse for the duration of the meal service. SRNAs are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse is responsible to conduct observations of all residents during the meal service to identify behaviors or concerns. The licensed nurse is responsible to document any behaviors or identified concerns on the Meal Supervision Log, the 24-hour report and to report the behaviors or identified concerns to the Director of Nursing Services and/or the Social Worker. The DNS and CM will also review the Meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns have been identified and addressed on the care plans and that supervision is appropriate. On addition, the DNS and CM participate in the licensed staff dining room observations to validate appropriate supervision. Effective 09/17/10, each activity with meal service is monitored by the Activities Staff for the duration of the meal service. Activities Staff are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse is responsible to document any behaviors or identified concerns on the 24-hour Report and to report the behaviors or identified concerns to the DNS and/or Social Worker(SW). Effective 09/17/10, Administrative Licensed Nurses (DNS), Assistant Director of Nursing Services (ADNS), Unit Manager (UM), Minimum Data Set Coordinator (MDSC), Case Manager (CM), Weekend Supervisor (WS) and Staff Development Coordinator (SDC), participate in the licensed staff dining room observations. Administrative nurses through direct observations will validate that all behaviors and/or concerns have been identified, documented on the 24-Hour Reports and report to the DNS and SW. Meal Supervision, behaviors and/or concerns will be documented at each meal on the Meal Supervision Logs. The Meal Supervision Logs will be reviewed daily in the Stand-Up meeting and on weekends by the WS to identify any concerns and to validate that appropriate corrective actions have been taken. Any concerns identified will be documented on the Meal Supervision Logs at the time of the review. All direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food, and to document on the 24-Hour Reports and to address in care plans. Other Facility Residents with the Potential to be Affected: The DNS, UM, Registered Dietician (RD) and Assistant Dietary Services Manager (ADSM) reviewed the medical records of all other facility residents on mechanically altered diets on 09/19/10. Record reviews included but were not limited to: the comprehensive MDS Assessments, Comprehensive Care Plans, Behavior and Mood Logs, and Resident Progress Notes. The 24-Hour Report, The Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. Record reviews were conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The Comprehensive Care Plans, the State Registered Nurse Aide Assignment Sheets and the Dining Room Seating Arrangement Diagram were updated as indicated, based on record reviews and staff interviews. To ensure the safety of all mobile residents on mechanically altered diets with behaviors, all direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food. Licensed nurses were educated to document on the 24-Hour Reports, the Resident Progress Notes and on the Behavior Logs and to address on the care plans. The SRNAs were educated to document on the Behavior Logs and report to the licensed nurse. The DNS and CM will conduct 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plans. The DNS, UM, MDSC, Case Manager (CM), and Advanced Register Nurse Practitioner (ARNP) reviewed the medical records of all facility residents on 09/21/10. Record reviews included but no limited to: the MDS Assessments, Comprehensive Care Plans, Behavior and Mood Logs and Resident Progress Notes for the previous 30-day period. Record reviews were conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The comprehensive care plans, SRNA Assignment Sheets and Dining Room Seating Arrangement Diagram were updated, as indicated, based on record reviews and staff interviews. In addition, on 09/21/10, all SRNA Assignment Sheets were updated to reflect the intervention for staff for report any and all new behaviors to the licensed nurse. Systemic Changes to Prevent Reoccurrence of Deficient Practice: The DNS, UMS and Weekend Supervisor initiated in-servicing to all direct care staff, to include licensed nurses and SRNAs on 09/17/10. In-service content included care plans and care plan meetings and Assigned Seating Designations. In addition, all direct care staff, including Activities, were educated on the Dining Room Seating Assignment Chart and on how the chart was designed. All staff were educated that activity seating groups will be the same as the Dining Room Seating Assignment Chart. The DO and DDCO initiated Investigative Training in-servicing on 09/18/10 with the ED and DNS. The DDCO completed in-servicing to all Administrative Staff (ED, DNS, CM, MDSC, Social Worker, UM, RD, Activity Director, Housekeeping Supervisor, Rehab Manager, Program Director, Nutrition Services Manager, ARNP and Respiratory Therapist) on 09/20/10. In-service content included Documentation of Resident Health Status, Needs and Services; Documenting in a Resident's Medical Record; 24-Hour Reports and Investigative Protocol. The DNS and UM initiated additional in-servicing on 09/21/10 with all direct care staff to include licensed nurses, SRNAs, and Activities staff related to meal supervision. In-servicing was initiated on 09/17/10 and 09/20/10 and will continue until all appropriate staff have attended the appropriate in-service. Staff will not be allowed to work until having attended the appropriate in-service. The in-service will be included in New Employee Orientation for all new hires. The facility does not utilize Agency Staff. If the facility should employ Agency Staff, they will receive the in-service prior to working. The ED and DNS will be responsible to validate that staff do not work prior to receiving the in-service. A sign is posted at the time clock to notify staff they are not to work or provide care to any resident prior to reporting to a charge nurse to receive the in-service. If the staff in need of in-service is a charge nurse, they are to report to a charge nurse on a different unit. Facility Monitoring: An ad hoc Performance Improvement Committee was held on 09/17/10. Members in attendance included the ED, DNS, UM and RD. The Medical Director was notified of the Facility Action Plan on 09/20/10. The ED, DNS, RD and WS will audit residents on mechanically altered diets through staff interviews, direct observations of dining services and through record reviews of Behavior and Mood Logs and Resident Progress Notes. The reviews will also include the Meal Supervision Logs and Dietary Communication Book. The ED, DNS, RD and WS will each conduct one audit per week for four weeks. The audits will validate that all behaviors have been appropriately identified and addressed. The DNS and CM will audit four random records (two per unit) per week for any new behaviors exhibited and to validate that all behavior have been appropriately addressed on the comprehensive care plans. The audits will include but not be limited to: the MDS Assessments, Comprehensive Care Plans, Behavior and Mood Logs and Resident Progress Notes for the previous 7-day period. The DNS and CM will also review the meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns have been identified and addressed. In addition, the DNS and CM participate in the licensed staff dining room observations. In addition, the audits will include 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plans. The DNS will be responsible to report all audit (residents on mechanically altered diets, behaviors, and the Meal Supervision Logs) findings at the weekly PIC meeting. The PIC will meet weekly (Tuesday) for four weeks to review audit findings to determine need for additional action steps. If no concerns are identified during the weekly (Tuesday) PIC meetings, the audits will take place on a monthly basis for two months, and on an as needed basis thereafter. The DNS will be responsible to report all audit findings at the monthly PIC meeting. All monthly findings will be reviewed at the monthly PIC to validate that any identified concerns were immediately corrected. Findings will be tracked and trended at the PIC for additional action steps, if indicated. The Interdisciplinary Team, to include but not limited to, (ED, DNS, UM, RD, Social Worker, DM, Activities Director, will review all resident events during morning Stand-Ups by reviewing Event Reports, 24-Hour Reports, hospitalization s, Dietary Communications Book to ensure that all events are investigated to ensure the health, safety and overall well-being is met and maintained for the affected resident, other facility residents with the potential to be affected, to identify the need for systemic changes and to validate that the PI process is effective. The ED is responsible for overall compliance through attendance at the Stand -Up Meetings and by reviewing audits to ensure they were conducted. The ED will assume overall responsibility for the Performance Improvement Program at the Facility. The ED will utilize weekly (Wednesday) IDT recommendations to validate one medical record (from resident identified in the IDT Meeting) to ensure implementation of the Credible Allegation of Compliance. The ED/Administrator will then return to routine monitoring, of the facility systems each month as specified in the Facility Performance Improvement policy and procedure, when substantial compliance is achieved. In addition, the DDCO will conduct weekly calls with the facility to review events from the previous week to validate that all events are thoroughly investigated, to include care plan revisions. Interviews conducted on 09/22/10, during the extended survey, with the DON and direct care staff (Social Worker #2, RN #1, RN #3, LPN #2, LPN #6, LPN #7, LPN #8, CNA #3, CNA #5, CNA #6, CNA #11, CNA #13, CNA #14 and CNA #15 ), revealed there was now seating chart for the dining room. Residents were seated with residents on the same diet consistency. Licensed staff were present in the dining room for all meals and Administrative staff participated in the dining room services. They revealed if any behaviors were noted, the staff reported the behavior to the licensed staff in the dining room. The licensed staff then documented them on the behavior logs in the dining room and reported them to the charge nurse and documented them on the 24 hour reports and in the residents' records. Observation of the noon meal, on 09/22/10, revealed Resident #1 was seated at a table by him/herself. No food was placed on the table until Resident #1's tray was served. The CNA immediately sat down next to the resident when the tray was served. Residents #4, #5, #6 and #7 were seated with residents with like diets and were seated according to the dining room seating chart. A licensed staff was present during the entire meal. Staff were reporting observations of behaviors to the licensed staff during the meal. A review of the Dining Room behavior observation sheet for 09/22/10 revealed each resident's name was documented with the behaviors that was observed. Observations of Resident #1 on 09/22/10 (throughout the day) revealed the resident was in a wheelchair sitting in the area across from the nurse's station, in view of staff. A review of Residents' #1, #4, #5, #6 and #7 comprehensive care plan revisions, revealed the care plans had been revised to include individualized interventions for each resident, to include supervision, related to the residents' behaviors of grabbing food/drinks. Reviews of the in-service training provided to all direct care staff, dated 09/17/10, 09/18/10, 09/19/10 and 09/21/10, revealed all staff received training on care plans and care plan meetings, assigned seating charts, dining/meal service supervision, activity seating groups, to report any and all behaviors (to include wandering or reaching for objects to include food/drink) and documentation. In addition, Administrative Staff were in-serviced on Documentation, Documenting the Residents' Health Status, Needs and Services, Documenting in a Resident's Medical Record and on the 24- Hour Reports on 09/20/10. The Executive Director and DON received in-servicing on 09/18/10 related to conducting investigations. Although it was determined the Immediate Jeopardy was removed on 09/22/10, non-compliance continued with the scope and severity of a "D", based on the facility's need to monitor for the on-going effectiveness of the corrective actions taken and to ensure evaluation through the facility's Quality Assurance process.

Based on observations, interviews and record reviews, it was determined the facility failed to provide adequate supervision to prevent accidents for five residents (#1, #4, #5, #6 and #7), in the selected sample of five. The facility failed to supervise and monitor residents who required supervision due to choking risk while eating. Facility staff was aware of Residents #1, #4. #5, #6 and #7 history of attempts to obtain food of a different consistency than their diets, but failed to develop and implement interventions to prevent the residents from obtaining the food/fluids. On [DATE], staff placed bread (regular consistency) at the table accessible to Resident #1. Staff did not provide supervision to ensure Resident #1 did not gain access to the bread despite having knowledge of this resident's history of attempts to obtain food of a different consistency. Staff observed Resident #1 with bread in his/her hand and removed it; however, the resident began to choke. Staff initiated the Heimlich Maneuver; however, this method was not successful. The resident stopped breathing and had no pulse. Emergency Medical Services had to insert a Laryngoscope (instrument inserted into the airway to provide visual access) into the resident's throat to remove the bread with forceps. The resident was sent out to the hospital. Additionally, the facility failed to follow its' accidents and supervision to prevent accidents policy and procedure as it related to implementing interventions after staff had identified the residents' risk. The facility's investigation failed to identify individual residents' risks including supervision, resulting in the failure to implement interventions for supervision. The facility's failure to provide adequate supervision for residents' at risk for choking, represented a situation that had caused and was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and found to exist on [DATE] and was ongoing. Substandard Quality of Care was identified at 483.25 Quality of Care. The facility was notified on [DATE]. Findings include: A review of the facility's Accidents and Supervision to Prevent Accidents policy and procedure, dated [DATE], revealed the center provided supervision to each resident to prevent avoidable accidents. This included systems to identify and evaluate hazards and risks, implement interventions to reduce hazards and risks and to monitor the effectiveness and modify approaches when necessary. The center identified hazards and the risks of the resident having an unavoidable accident through Quality Assurance activities, medical history, physical exam and individual observation. Staff were involved in observing and identifying potential hazards. The Center investigates accidents and develops a plan of action to prevent the accident from reoccurring. A review of the Accidents and Supervision to Prevent Accidents Definitions revealed an avoidable accident was when the facility failed to identify: 1. environmental hazards and individual resident risks of an accident, including supervision, 2. evaluate the hazards and risks and 3. implement interventions, including adequate supervision, consistent with the resident's needs, resident's goals, resident's plan of care, and current standards of practice in order to reduce the risks of an accident. Lack of Supervision was the lack of adequate supervision to prevent accidents occurred when the center failed to accurately assess a resident to determine whether supervision to avoid an accident or injury was necessary. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Reviews of the Dysphagia Discharge Summary, dated [DATE], a Speech Therapy Recommendation, dated [DATE], and an interview with the Speech Therapist, on [DATE] at 9:55 AM, revealed Resident #1 was admitted to the facility on [DATE], status [REDACTED]. She stated the resident returned on a pureed diet with thin liquids. Strategies were put in place to take the resident's spoon away after each bite and provide hand over hand feeding with a small spoon to include the resident's liquids. She stated the resident was very impulsive and grabbed the food or fluids off the tray and ate and drank them very fast. An intervention was put in place for staff to sit with the resident immediately when the resident's tray was served. In March/[DATE], a modified swallow was completed and the resident's diet was changed to a pureed diet with honey thick liquids, however, the same strategies were kept in place. She stated she knew of another time the resident had grabbed macaroni off either another resident's tray or from a table. She revealed staff was very aware of the resident's behavior of trying to grab food and fluids, so they tried to keep a close eye on the resident. A review of the comprehensive care plan for Alteration in Nutrition/Hydration related to swallowing and chewing problems and risk of aspiration pneumonia, dated [DATE], revealed interventions to totally assist with meals, feed per staff ,[DATE] teaspoon at a time, remind resident to clear throat in between bites, follow each bite with honey thick liquids with spoon. A review of the comprehensive care plan, dated [DATE], revealed there were no changes to the care plan despite staff's knowledge of the resident's behavior of grabbing food, according to speech therapy. A review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 as severely impaired cognitively and the resident never or rarely made decisions. Resident #1 was also assessed as having chewing and swallowing problems. Interviews with Registered Nurse (RN) #3 on [DATE] at 10:40 AM, Licensed Practical Nurse (LPN) #5 on [DATE] at 10:20 AM, LPN #6 on [DATE] at 3:40 PM, Certified Nurse Aide (CNA) #1 on [DATE] at 2:55 PM, CNA #2 on [DATE] at 3:20 PM, CNA #3 on [DATE] at 3:10 PM, CNA #4 on [DATE] at 3:10 PM, CNA #9 on [DATE] at 2:40 PM and CNA #10 on [DATE] at 4:05 PM, revealed Resident #1 was seated at a table on the third row in the dining room with other residents for the noon meal, on [DATE]. The staff had placed sliced fresh baked bread on saucers and passed it out to the residents who were on regular diets. The staff revealed they started passing out trays to the residents at the first row of tables. CNA #9 revealed as she turned around to pass a tray, she observed Resident #1 with a slice of bread in his/her hand. CNA #9 stated Resident #1 had taken the bread from a resident sitting at the table with him/her. CNA #9 stated she walked over to the resident and removed the bread from Resident #1's hand and from the table. She resumed passing out trays. The staff revealed the next thing they knew CNA #4 shouted Resident #1 is turning blue. The staff stated they immediately called a Code, grabbed a crash cart and lowered the resident to the floor. The licensed staff responded to the code and attempted the Heimlich Maneuver with finger sweeps three times with no success. They stated the resident was not breathing and they could not detect a pulse. EMS was called and Cardiopulmonary Resuscitation (CPR) was started. A review of the EMS report, dated [DATE], revealed a Laryngoscope was inserted into the resident's throat and the lodged bread was removed with forceps. The resident's pulse and breathing returned. The resident was sent out to the hospital. Interviews with the Activity Director on [DATE] at 3:50 PM, RN #1 on [DATE] at 2:40 PM, RN #2 on [DATE] at 2:40 PM, LPN #1 on [DATE] at 5:20 PM, LPN #2 on [DATE] at 1:40 PM, LPN #3 on [DATE] at 10:55 AM, LPN #4 on [DATE] at 3:00 PM, CNA #1 on [DATE] at 2:55 PM, CNA #2 on [DATE] at 3:20 PM, CNA #3 on [DATE] at 3:10 PM, CNA #4 on [DATE] at 3:10 PM, CNA #5 on [DATE] at 5:05 PM, CNA #6 on [DATE] at 5:15 PM, CNA #7 on [DATE] at 5:35 PM, CNA #8 on [DATE] at 5:50 PM, CNA #9 on [DATE] at 2:40 PM and CNA #10 on [DATE] at 4:05 PM, revealed Resident #1 had behaviors of grabbing food and/or fluids off other residents' trays and from the dining room table prior to the resident's choking on [DATE]. The staff stated they immediately took the food/fluid away from the resident. The staff revealed they tried to keep an eye on the resident because of the resident's behaviors of grabbing food and drinks of other residents. They stated everyone was aware that Resident #1 had this behavior because the resident did it all the time. Although the interviews revealed the staff were aware of the resident's behavior of grabbing for food/drinks prior to [DATE], there was no evidence the facility implemented any interventions after identifying this risk to avoid an accident. An interview with the Director of Nursing (DON) on [DATE] at 1:25 PM, revealed she immediately completed an investigation of the incident. She stated she determined the resident had grabbed the bread from a resident seated at the same table, who was on a regular diet. Based on the investigation, she stated staff was told that Resident #1 was to be seated at a table with residents with like diets and licensed nurses would be present in the dining room for all meals. The DON revealed during her investigation, she did not identify that Resident #1 had displayed behaviors of grabbing for other residents' food and/or drinks numerous times prior to this incident. She did not identify the need for increased supervision for Resident #1 due to this behavior. She stated she had not asked staff if Resident #1 had tried to grab food/drinks before. She revealed she had not identified that there was no documentation in Resident #1's record related to this behavior. The DON failed to follow the facility's policy and procedure related to developing a plan or action to prevent the accident from reoccurring and failed to identify individual resident's risks so interventions could be implemented, including adequate supervision, in order to reduce the risk of an accident. Observation of the noon meal on [DATE] at 12:15 PM, revealed Resident #1 was seated at a table with a resident with the same kind of diet. A licensed staff was in the dining room. Staff began passing fluids to the residents. A CNA sat with Resident #1 when his/her glass of fluid was served and remained with the resident through the resident's tray being served and then fed the resident. The remaining staff began passing out the residents' trays. During this time staff had their backs to the residents in the dining room and a resident was observed, by the surveyor, to reach out and take and consume another resident's fluids. Further review of Resident #1's care plan, dated [DATE], revealed the resident's care plan was updated for the resident to sit with residents with the same diet consistency; however, there were no interventions to address supervision or monitoring of the resident related to grabbing of food/drinks. 2. A record review revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Speech Therapy's recommendations, dated [DATE], revealed the resident was on a Dysphasia II diet with nectar thick liquids and required 1:1 feeding, small bites and sips and cue to double swallow with each bite. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #4 as severely impaired cognitively and never/rarely made decisions. Interviews with RN #2 on [DATE] at 5:40 PM, RN #1 on [DATE] at 2:40 PM, LPN #1 on [DATE] at 5:20 PM, CNA #5 on [DATE] at 5:05 PM, CNA #6 on [DATE] at 5:15 PM, CNA #7 on [DATE] at 5:35 PM and CNA #8 on [DATE] at 5:50 PM, revealed Resident #4 grabbed other residents' food/drinks or pulled the tablecloth to pull items within his/her reach prior to [DATE]. Further review of Resident #4's clinical record revealed no documentation related to the resident's grabbing at food/drinks and pulling the table cloth to get items within reach. A review of the comprehensive care plan for potential for alteration in nutrition/hydration related to mechanically altered diet, end stage Alzheimer's and potential for aspiration, dated [DATE], revealed interventions to provide a mechanical soft diet with nectar thick liquids, to feed per staff in dining room and to encourage to eat slowly. A review of the resident's dietary slip revealed food was to be served in bowls. However, further review of the comprehensive care plan revealed there were no interventions to provide supervision/monitoring of the resident related to the behaviors of grabbing food/drinks and of pulling the tablecloth to pull items within reach. Observation of the noon meal on [DATE] at 12:15 PM, revealed Resident #4 was seated at a table with a resident with the same kind of diet. A licensed staff was in the dining room. Staff began passing fluids to the residents. Staff began passing out the residents' trays. During this time staff had their backs to the residents and a resident was observed, by the surveyor, to reach out and take and consume another resident's fluids. A CNA sat with Resident #4 when his/her tray was served. 3. A record review revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the comprehensive care plan for alteration in nutrition/hydration related to mechanically altered diet and swallowing problems, dated [DATE], revealed an intervention to provide assistance with meals. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #5 as severely impaired cognitively and never or rarely made decisions. Resident #5 was also assessed as having swallowing problems. An interview with CNA #5 on [DATE] at 5:05 PM, revealed Resident #5 was blind in one eye; however, could see objects with the other eye and grabbed for food/drink. She stated the resident had a history of [REDACTED]. However, a reviews of the clinical record and the care plan for Resident #5, revealed no documentation of the resident's behavior of grabbing for food/drink in the dining room and no interventions to address supervision/monitoring of the resident related to the resident's behavior of grabbing food/drinks. 4. A record review revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the annual MDS assessment, dated [DATE], revealed the facility assessed Resident #6 as severely impaired cognitively and rarely/never made decisions. Resident #6 was also assessed as having chewing and swallowing problems. A review of the comprehensive care plan, dated [DATE], for impaired swallowing related to ate too fast, which caused the resident to choke, revealed interventions to provide a pureed diet with regular liquids and to encourage the resident to slow down and take small bites to decrease the risk of choking. An interview with CNA #7, on [DATE] at 5:35 PM, revealed Resident #6 grabbed other residents' food/drink at times when he/she ate in the dining room. However, reviews of the clinical record and care plan for Resident #6, revealed there was no documentation of the resident's behavior of grabbing food/drinks or interventions to address supervision/monitoring of the resident related to the resident's behavior of grabbing for food/drinks. 5. A record review revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #7 as severely impaired cognitively and the resident rarely/never made decisions. Resident #7 was assessed as having chewing problems. An interview with LPN #1 on [DATE] at 5:20 PM, revealed Resident #7 grabbed other residents' food/drink at times and tried to eat inedible objects. A review of the clinical record for Resident #7, revealed there was no documentation of the resident's behavior of grabbing food/drinks or trying to eat inedible objects. A review of the comprehensive care plan for at risk for altered nutrition/hydration related to Alzheimer's and wandering, dated [DATE], revealed an intervention to provide a mechanical soft diet with pureed meat and regular liquids. However, further review revealed there were no interventions to address supervision/monitoring of the resident related to the resident's behaviors of grabbing for food/drinks and trying to eat inedible objects. An interview with the DON, on [DATE] at 1:25 PM, revealed during the investigation of Resident #1's incident she did not identify that there were four other residents (#4, #5, #6 and #7), who also had behaviors of grabbing for other residents' food/drink, with no care plans in place to address the needed supervision/monitoring of the residents to prevent choking. The DON stated she had not asked staff if there were any other residents in the facility, who grabbed foods/drinks. The facility's investigation failed to identify individual residents' risks including supervision, resulting in the failure to implement interventions for supervision. A credible allegation of correction for removal of the Immediate Jeopardy was received on [DATE]. The Immediate Jeopardy was verified removed on [DATE], prior to exit. The alleged date of removal was [DATE]. Based on observations, interviews and record reviews, verification was made the Immediate Jeopardy was removed on [DATE]. The AOC revealed: On [DATE], the ARNP communicated to all direct care staff, licensed nurses State Registered Nurse Aides, that Resident #1 would be seated in the dining room at a table with other residents who received the same type of mechanically altered diet. On [DATE], the care plan was updated to reflect the dining room seating arrangement for Resident #1. On [DATE], the care plan was updated to reflect a problem of At risk for Choking Possible Aspiration related to Dementia with Impulsive Behavior, Past Behavior of Grabbing food and/or liquids, with interventions to include but not limited to: provide LCS pureed diet with honey thick liquids by small spoon per staff; encourage po intake and po fluids, fed per staff; encourage dining room attendance each meal and sit with resident with same texture diet; supervise all po intake and meal times. On [DATE], the care plan was updated, with a problem of no safety awareness as resident grabs out for people and items, with interventions to include but not limited to: keep resident in supervised area when out of bed; notify nurse of any abnormal behaviors; be attentive to resident when reaching; and encourage resident to attend activities. In addition, the Executive Director (ED), Director of Nursing Services (DNS), the District Director of Operations (DO), and the District Director of Clinical Operations, (DDCO), conducted further investigation for Resident #1 on [DATE]. This investigation consisted of staff interviews and medical record reviews, to include but not limited to, the comprehensive MDS Assessment, Resident Assessment Protocols (RAPs), Comprehensive Care Plans, , Behavior and Mood Logs and Resident Progress Notes. The 24-hour report, the Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. The SRNA Assignment Sheet and the Dining Room Seating Arrangement Diagram were updated for Resident #1. The care plan for Resident #4 was revised on [DATE] with a problem of Inappropriate Behaviors of grabbing at items on dining room tables, including food, with interventions to include but not limited to: place at table with residents with same diet; table cloth will be removed; center piece removed; staff will monitor during meals/activities; will not be seated within reach of other residents' food at meals; psych services as indicated for management of behaviors. On [DATE], the care plan was updated with an intervention to notify the nurse of any new abnormal behaviors. The care plan for Resident #5 was revised on [DATE] with a problem of Inappropriate Behaviors of grabbing objects, food on dining table, and at persons, with interventions to include but not limited to: sitting at table with others who have same diet; have snacks available when hungry, needs assistance; reassure resident; remove objects from table/tablecloth. On [DATE], the care plan was updated with an intervention to notify the nurse of any new abnormal behaviors. The care plan for Resident #6 was revised on [DATE] with a problem of Repetitive Movements, Oral Fixation, does not currently, but in past, had taken food from others' rooms or trays and over eating, with interventions to include but not limited to: monitor all po intake; set up and episodic chewing during meals; feed assist if stops feeding self at meals; have resident slow down if eating fast; notify nurse of any new onset of abnormal behaviors and document. The care plan for Resident #7 was revised on [DATE] with a problem of Socially Inappropriate Behaviors, at time unable to tell the difference from edible and non-edible item, history of taking food off others' trays, with interventions to include, but not limited to: place at table without centerpieces; staff to monitor during meals; will not be seated within reach of other residents' food at meals. Homemade bread will continue to be served during meal service as appropriate and in accordance with MD order for diet consistency. For residents with mechanically altered diets, bread will be altered accordingly and served with the meal service. Effective [DATE], residents who have known behaviors of reaching for and obtaining items that are not on their meal tray or that are inedible, have been arranged to be seated at tables with same MD ordered mechanically altered diet. This is reflected on the Dining Room Seating Assignment Chart, effective [DATE]. Effective [DATE], each meal service is monitored by a licensed nurse for the duration of the meal service. SRNAs are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse is responsible to conduct observations of all residents during the meal service to identify behaviors or concerns. The licensed nurse is responsible to document any behaviors or identified concerns on the Meal Supervision Log, the 24-hour report and to report the behaviors or identified concerns to the Director of Nursing Services and/or the Social Worker. The DNS and CM will also review the Meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns have been identified and addressed on the care plan and that supervision is appropriate. On addition, the DNS and CM participate in the licensed staff dining room observation to validate appropriate supervision. Effective [DATE], each activity with meal service is monitored by the Activities Staff for the duration of the meal service. Activities Staff are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse is responsible to document any behaviors or identified concerns on the 24-hour Report and to report the behaviors or identified concerns to the DNS and/or Social Worker(SW). Effective [DATE], Administrative Licensed Nurses (DNS), Assistant Director of Nursing Services (ADNS), Unit Manager (UM), Minimum Data Set Coordinator (MDSC), Case Manager (CM), Weekend Supervisor (WS) and Staff Development Coordinator (SDC) participate in the licensed staff dining room observation. Administrative nurses through direct observation will validate that all behaviors and/or concerns have been identified, documented on the 24-Hour Report and report to the DNS and SW. Meal Supervision, behaviors and/or concerns will be documented at each meal on the Meal Supervision Log. The Meal Supervision Log will be reviewed daily in the Stand-Up meeting and on weekends by the WS to identify any concerns and to validate that appropriate corrective actions had been taken. Any concerns identified will be documented on the Meal Supervision Log at the time of the review. All direct care staff, licensed nurses, and SRNAs have been inserviced to report any and all behaviors, to include wandering or reaching for objects, to include food, and to document on the 24-Hour Report and to address in care plan. Other Facility Residents with the Potential to be Affected: The DNS, UM, Registered Dietician (RD) and Assistant Dietary Services Manager (ADSM) reviewed the medical records of all other facility residents on mechanically altered diets on [DATE]. Record reviews included but were not limited to: the comprehensive MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs, and Resident Progress Notes. The 24-Hour Report, The Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. Record reviews were conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The Comprehensive Care Plan, the State Registered Nurse Aide Assignment Sheets and the Dining Room Seating Arrangement Diagram were updated as indicated, based on record reviews and staff interviews. To ensure the safety of all mobile residents on mechanically altered diets with behaviors, all direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food. Licensed nurses were educated to document on the 24-Hour Report, the Resident Progress Notes and on the Behavior Logs and to address on the care plans. The SRNAs were educated to document on the Behavior Logs and report to the licensed nurse. The DNS and CM will conduct 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plans. The DNS, UM, MDS Coordinator (MDSC), Case Manager (CM), and Advanced Register Nurse Practitioner (ARNP) reviewed the medical records of all facility residents on [DATE]. Record reviews included but were not limited to: the MDS Assessments, Comprehensive Care Plans, Behavior and Mood Logs and Resident Progress Notes for the previous 30-day period. Record reviews were conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The comprehensive care plans, SRNA Assignment Sheets and Dining Room Seating Arrangement Diagram were updated, as indicated, based on record reviews and staff interviews. In addition, on [DATE], all SRNA Assignment Sheets were updated to reflect the interventions for staff to report any and all new behaviors to the licensed nurse. Systemic Changes to Prevent Reoccurrence of Deficient Practice: The DNS, UMS and Weekend Supervisor initiated in-servicing to all direct care staff, to include licensed nurses and SRNAs on [DATE]. In-service content included care plans and care plan meetings and Assigned Seating Designations. In addition, all direct care staff, including Activities, were educated on the Dining Room Seating Assignment Chart and on how the chart was designed. All staff were educated that activity seating groups will be the same as the Dining Room Seating Assignment Chart. The DO and DDCO initiated Investigative Training in-servicing on [DATE] with the ED and DNS. The DDCO completed in-servicing to all Administrative Staff (ED, DNS, CM, MDSC, Social Worker, UM, RD, Activity Director, Housekeeping Supervisor, Rehab Manager, Program Director, Nutrition Services Manager, ARNP and Respiratory Therapist) on [DATE]. In-service content included Documentation of Resident Health Status, Needs and Services; Documenting in a Resident's Medical Record; 24-Hour Report and Investigative Protocol. The DNS and UM initiated additional in-servicing on [DATE] with all direct care staff to include licensed nurses, SRNAs, and Activities staff related to meal supervision. In-servicing was initiated on [DATE] and [DATE] and will continue until all appropriate staff have attended the appropriate in-service. Staff will not be allowed to work until having attended the appropriate in-service. The in-service will be included in New Employee Orientation for all new hires. The facility does not utilize Agency Staff. If the facility should employ Agency Staff, they will receive the in-service prior to working. The ED and DNS will be responsible to validate that staff do not work prior to receiving the in-service. A sign is posted at the time clock to notify staff they are not to work or provide care to any resident prior to reporting to a charge nurse to receive the in-service. If the staff in need of in-service is a charge nurse, they are to report to a charge nurse on a different unit. Facility Monitoring: An ad hoc Performance Improvement Committee was held on [DATE]. Members in attendance included the ED, DNS, UM and RD. The Medical Director was notified of the Facility Action Plan on [DATE]. The ED, DNS, RD and WS will audit residents on mechanically altered diets through staff interviews, direct observation of dining service and through reviews of Behavior and Mood Logs and Resident Progress Notes. The review will also include the Meal Supervision Logs and Dietary Communication Book. The ED, DNS, RD and WS will each conduct one audit per week for four weeks. The audit will validate that all behaviors have been appropriately identified and addressed. The DNS and CM will audit four random records (two per unit) per week for any new behaviors exhibited and to validate that all behavior have been appropriately addressed on the comprehensive care plans. The audit will include but will not be limited to: the MDS Assessments, Comprehensive Care Plans, Behavior and Mood Logs and Resident Progress Notes for the previous 7-day period. The DNS and CM will also review the meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns have been identified and addressed. In addition, the DNS and CM participate in the licensed staff dining room observations. In addition, the audit will include 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plans. The DNS will be responsible to report all audit (residents on mechanically altered diets, behaviors, and the Meal Supervision Logs) findings at the weekly PIC meeting. The PIC will meet weekly (Tuesday) for four weeks to review audit findings to determine the need for additional action steps. If no concerns are identified during the weekly (Tuesday) PIC meetings, the audits will take place on a monthly basis for two months, and on an as needed basis thereafter. The DNS will be responsible to report all audit findings at the monthly PIC meeting. All monthly findings will be reviewed at the monthly PIC to validate that any identified concerns were immediately corrected. Findings will be tracked and trended at the PIC for additional action steps, if indicated. The Interdisciplinary Team to include, but not limited to: ED, DNS, UM, RD, Social Worker, DM, Activities Director, will review all resident events during morning Stand-Up by reviewing Event Reports, 24-Hour Reports, hospitalization s, Dietary Communications Book to ensure that all events are investigated to ensure the health, safety and overall well-being is met and maintained for the affected resident, other facility residents with the potential to be affected, to identify the need for systemic changes and to validate that the PI process is effective. The ED is responsible for overall compliance through attendance at the St

Based on observations, interviews and record reviews, it was determined the facility failed to revise the care plans for five residents (#1, #4, #5, #6 and #7) in the selected sample of five. Interviews with staff revealed the residents had behaviors of grabbing food from dining room tables and other residents' trays, that was not the right consistency food for these residents. The residents' care plans were not revised to address the residents' behaviors of grabbing food/drinks and the need for adequate monitoring and supervision to prevent choking. On [DATE], staff placed bread (regular consistency) at the table accessible to Resident #1. Staff did not provide supervision to ensure Resident #1 did not gain access to the bread despite having knowledge of this resident's history of attempts to obtain food of a different consistency. Staff observed Resident #1 with bread in his/her hand and removed it; however, the resident began to choke. Staff initiated the [MEDICATION NAME] Maneuver; however, this method was not successful. The resident stopped breathing and had no pulse. Emergency Medical Services had to insert a Laryngoscope (instrument inserted into the airway to provide visual access) into the resident's throat to remove the bread with forceps. The resident was sent out to the hospital. The facility's failure to revise the care plans related to the residents' behaviors of grabbing food/drinks that was not the right consistency to ensure adequate monitoring/supervision was provided for these residents resulted in a situation that caused and was likely to cause serious injury, harm, impairment or death to a resident, at risk for choking. Immediate Jeopardy was identified on [DATE] and found to exist on [DATE] and was ongoing. The facility was notified on [DATE]. Findings include: 1. Record review revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the comprehensive care plan for Alteration in Nutrition/Hydration related to swallowing and chewing problems and risk of aspiration pneumonia, dated [DATE], revealed interventions that staff would totally assist with meals, feed per staff ,[DATE] teaspoon at a time, remind the resident to clear his/her throat in between bites, and follow each bite with honey thick liquids with a spoon. Interviews with the Activity Director on [DATE] at 3:50 PM, Registered Nurse (RN) #1 on [DATE] at 2:40 PM, RN #2 on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #1 on [DATE] at 5:20 PM, LPN #2 on [DATE] at 1:40 PM, LPN #3 on [DATE] at 10:55 AM, LPN #4 on [DATE] at 3:00 PM, Certified Nurse Aide (CNA) #1 on [DATE] at 2:55 PM, CNA #2 on [DATE] at 3:20 PM, CNA #3 on [DATE] at 3:10 PM, CNA #4 on [DATE] at 3:10 PM, CNA #5 on [DATE] at 5:05 PM, CNA #6 on [DATE] at 5:15 PM, CNA #7 on [DATE] at 5:35 PM, CNA #8 on [DATE] at 5:50 PM, CNA #9 on [DATE] at 2:40 PM and CNA #10 on [DATE] at 4:05 PM, revealed Resident #1 had behaviors of grabbing food and/or fluids off of residents' trays and from the dining room table prior to [DATE]. The staff stated they immediately took the food/fluid away from the resident. The staff revealed they tried to keep an eye on the resident because of the resident's behaviors of grabbing food and drinks from tables and other residents' trays. They stated everyone was aware that Resident #1 had this behavior because the resident did it all the time. However, review of the Comprehensive Care Plan revealed there was no revision to the care plan to address the resident's behavior of grabbing other resident's food off the trays or from the table. Interviews on [DATE] at 3:00 PM and on [DATE] at 10:50 AM, with the Minimum Data Set (MDS) Supervisor, RN Supervisor and Social Worker #1 (who participated in the resident's care plan meetings), revealed they were not aware Resident #1 had behaviors of grabbing food from the table and other residents' trays. They stated the behavior should have been documented in the record or brought up by staff in the care plan meeting so the behavior could have been addressed in the resident's care plan. A record review to include nurse's notes, behavior assessments and behavior logs revealed there was no documentation Resident #1 had behaviors of grabbing food/drinks from the table or other residents' trays. Interviews with RN #3 on [DATE] at 10:40 AM, LPN #5 on [DATE] at 10:20 AM, LPN #6 on [DATE] at 3:40 PM, CNA #1 on [DATE] at 2:55 PM, CNA #2 on [DATE] at 3:20 PM, CNA #3 on [DATE] at 3:10 PM, CNA #4 on [DATE] at 3:10 PM, CNA #9 on [DATE] at 2:40 PM and CNA #10 on [DATE] at 4:05 PM, revealed Resident #1 was seated at a table on the third row in the dining room with other residents for the noon meal on [DATE]. The staff had placed sliced fresh baked bread on saucers and passed it out to the residents who were on regular diets. The staff revealed they started passing out trays to the residents at the first row of tables. CNA #9 revealed as she turned around to pass a tray, she observed Resident #1 with a slice of bread in his/her hand. CNA #9 stated Resident #1 had taken the bread from a resident sitting at the table with him/her. CNA #9 stated she walked over to the resident and removed the bread from his/her hand and from the table. She resumed passing out trays. The staff revealed the next thing they knew CNA #4 shouted Resident #1 was turning blue. The staff stated they immediately called a Code, grabbed a crash cart and lowered the resident to the floor. The licensed staff responded to the code and attempted the [MEDICATION NAME] Maneuver with finger sweeps three times with no success. They stated the resident was not breathing and they could not detect a pulse. EMS was called and Cardiopulmonary Resuscitation (CPR) was started. A review of the EMS report, dated [DATE], revealed a Laryngoscope was inserted into the resident's throat and the lodged bread was removed with forceps. The resident's pulse and breathing returned. The resident was sent out to the hospital. An interview with the Director of Nursing (DON) on [DATE] at 1:25 PM, revealed she was not aware Resident #1 grabbed other residents' food/fluids prior to this incident. She stated she immediately completed an investigation of the incident. She stated she determined the resident grabbed the bread from a resident at the same table, who was on a regular diet. She stated staff was told that Resident #1 was to be seated at a table with residents with like diets and a licensed nurse would be present in the dining room for all meals. Observation of the noon meal, on [DATE] at 12:15 PM, revealed Resident #1 was seated at a table with a resident with the same kind of diet. A licensed staff was in the dining room. Staff began passing fluids to the residents. A CNA sat with Resident #1 when his/her glass of fluid was served and stayed with the resident through the resident's tray being served and then fed the resident his/her meal. The remaining staff began passing out the residents' trays. The staff had their backs to the residents in the dining room while passing the trays and the surveyor observed a resident to take and consume another resident's fluids. A review of the comprehensive care plan, for Resident #1 revealed the resident's care plan was revised for the resident to sit with residents with the same diet consistency on [DATE]; however, there were no revisions to the care plan to address adequate supervision/monitoring of the resident due to the behavior of grabbing of food/drinks and the increased risk of the resident choking. 2. A record review revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the comprehensive care plan for potential for alteration in nutrition/hydration related to mechanically altered diet, end stage Alzheimer's and potential for aspiration, dated [DATE], revealed interventions to provide a mechanical soft diet with nectar thick liquids, fed per staff in dining room and encourage to eat slowly. A review of the resident's dietary slip revealed food was to be served in bowls. Interviews with RN #2 on [DATE] at 5:40 PM, RN #1 on [DATE] at 2:40 PM, LPN #1 on [DATE] at 5:20 PM, CNA #5 on [DATE] at 5:05 PM, CNA #6 on [DATE] at 5:15 PM, CNA #7 on [DATE] at 5:35 PM and CNA #8 on [DATE] at 5:50 PM, revealed Resident #4 grabbed other residents' food/drinks or pulled the tablecloth to pull items within his/her reach. However, further review of the comprehensive care plan revealed there was no revision to the care plan to address adequate supervision/monitoring related to the resident's behaviors of grabbing food/drinks, pulling the tablecloth to pull items within reach and the risk of the resident choking. Observation of the noon meal on [DATE] at 12:15 PM, revealed Resident #4 was seated at a table with a resident with the same kind of diet. A licensed staff was in the dining room. Staff began passing fluids to the residents. Staff began passing out the residents' trays. During this time staff had their backs to the residents and a resident was observed, by the surveyor, to reach out and take and consume another resident's fluids. A CNA sat with Resident #4 when his/her tray was served. A review of Resident #4's clinical record revealed no documentation related to the resident's grabbing at food/drinks and pulling the table cloth to get items within reach. 3. A record review revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the comprehensive care plan for alteration in nutrition/hydration related to mechanically altered diet and swallowing problems, dated [DATE], revealed an intervention to provide assistance with meals. An interview with CNA #5 on [DATE] at 5:05 PM, revealed Resident #5 was blind in one eye and saw objects with the other eye and grabbed for them. She stated the resident had grabbed food/drink belonging to another resident in the dining room. However, further review of the care plan revealed there were no revisions to the care plan to address the resident's behavior of grabbing food/drinks and the increased risk of the resident choking. A review of the clinical record for Resident #5 revealed no documentation of the resident's behavior of grabbing for food/drink in the dining room. 4. A record review revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the comprehensive care plan for impaired swallowing related to the resident ate too fast causing him/her to choke revealed interventions to provide a pureed diet with regular liquids and to encourage the resident to slow down and take small bites to decrease the risk of choking. An interview with CNA #7 on [DATE] at 5:35 PM, revealed Resident #6 grabbed other residents' food/drink at times when he/she ate in the dining room. However, further review of the care plan revealed there were no revisions to the care plan to address the resident's behavior of grabbing for food/drinks and the increased risk of the resident choking. A review of the clinical record for Resident #6 revealed there was no documentation of the resident's behavior of grabbing food/drinks. 5. A record review revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the comprehensive care plan for at risk for altered nutrition/hydration related to Alzheimer's and wandering, dated [DATE], revealed an intervention to provide a mechanical soft diet with pureed meat and regular liquids. An interview with LPN #1 on [DATE] at 5:20 PM. revealed Resident #7 grabbed other residents' food/drink at times and tried to eat inedible objects. However, further review of the care plan revealed there were no revisions to the care plan to address the resident's behavior of grabbing for food/drinks, trying to eat inedible objects and the increased risk for choking. A review of the clinical record for Resident #7 revealed there was no documentation of the resident's behavior of grabbing food/drinks or trying to eat inedible objects. An interview with the DON on [DATE] at 1:25 PM, revealed during the investigation of Resident #1's incident, she did not identify that there were four other residents (#4, #5, #6 and #7), who also had behaviors of grabbing for other residents' food/drink, with no care plan in place to address the needed supervision/monitoring of the residents to prevent choking. The DON stated she had not asked staff if there were any other residents in the facility who grabbed food/drinks. The facility's investigation failed to identify individual residents' risks including supervision, resulting in the failure to implement interventions for supervision. An acceptable credible allegation of correction for the removal of the Immediate Jeopardy was received on [DATE]. The Immediate Jeopardy was verified removed on [DATE], prior to exit. The alleged date of removal was [DATE]. Based on observations, interviews and record reviews, verification was made the Immediate Jeopardy was removed on [DATE]. The AOC revealed: Affected residents: On [DATE], the ARNP communicated to all direct care staff, licensed nurses State Registered Nurse Aides, that Resident #1 would be seated in the dining room at a table with other residents who received the same type of mechanically altered diet. On [DATE], the care plan was updated to reflect dining room seating arrangement for Resident #1. On [DATE], the care plan was updated to reflect a problem of At risk for Choking Possible Aspiration related to Dementia with Impulsive Behavior , Past Behavior of Grabbing food and/or liquids, with interventions to include, but not limited to: provide LCS pureed diet with honey thick liquids by small spoon per staff; encourage po intake and po fluids, fed per staff; encourage dining room attendance each meal and sit with resident with same texture diet; supervise all po intake and meal times. On [DATE], the care plan was updated, with a problem of no safety awareness as resident grabs out for people and items, with interventions to include, but not limited to: keep resident in supervised area when out of bed; notify nurse of any abnormal behavior; be attentive to resident when reaching; and encourage resident to attend activities. In addition, the Executive Director (ED), Director of Nursing Services (DNS), the District Director of Operations (DO), and the District Director of Clinical Operations, (DDCO), conducted further investigation for Resident #1 on [DATE]. This investigation consisted of staff interviews and medical record review, to include but not limited to: the comprehensive Minimum Data Set (MDS) Assessment, Resident Assessment Protocols (RAPs), Comprehensive Care Plan, Behavior and Mood Logs and Resident Progress Notes. The 24-hour report, the Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. The SRNA Assignment Sheet and the Dining Room Seating Arrangement Diagram were updated for Resident #1. The care plan for Resident #4 was revised on [DATE] with a problem of Inappropriate Behaviors of grabbing at items on dining room tables, including food, with interventions to include, but not limited to: place at table with residents with same diet; table cloth will be removed; center piece removed; staff will monitor during meals/activities; will not be seated within reach of other residents' food at meals; psych services as indicated for management of behaviors. On [DATE], the care plan was updated with an intervention to notify nurse of any new abnormal behaviors. The care plan for Resident #5 was revised on [DATE] with a problem of Inappropriate Behaviors of grabbing objects, food on dining table, and at persons, with interventions to include, but not limited to: sitting at table with others who have same diet; have snacks available when hungry, needs assistance; reassure resident; remove objects from table/tablecloth. On [DATE], the care plan was updated with an intervention to notify nurse of any new abnormal behaviors. The care plan for Resident #6 was revised on [DATE] with a problem of Repetitive Movements, Oral Fixation, does not currently, but in past, has taken food from others rooms or trays and over eating, with interventions to include, but not limited to: monitor all po intake; set up and episodic chewing during meals; feed assist if stops feeding self at meals; have resident slow down if eating fast; notify nurse of any new onset of abnormal behaviors and document. The care plan for Resident #7 was revised on [DATE] with a problem of Socially Inappropriate Behaviors, at time unable to tell the difference from edible and non-edible item, history of taking food off others' trays, with interventions to include, but not limited to: place at table without centerpieces; staff to monitor during meals; will not be seated within reach of other residents' food at meals. Homemade bread would continue to be served during meal service as appropriate and in accordance with MD order for diet consistency. For residents with mechanically altered diets, bread would be altered accordingly and served with the meal service. Effective [DATE], residents who have known behaviors of reaching for and obtaining items that are not on their meal tray or that are inedible, have been arranged to be seated at tables with same MD ordered mechanically altered diet. This is reflected on the Dining Room Seating Assignment Chart, effective [DATE]. Effective [DATE], each meal service will be monitored by a licensed nurse for the duration of the meal service. SRNAs are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse are responsible to conduct observations of all residents during the meal service to identify behaviors or concerns. The licensed nurse are responsible to document any behaviors or identified concerns on the Meal Supervision Log, the 24-hour report and will report the behaviors or identified concerns to the Director of Nursing Services and/or the Social Worker. The DNS and CM will also review the Meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns are identified and addressed on the care plan and that supervision is appropriate. In addition, the DNS and CM participate in the licensed staff dining room observation to validate appropriate supervision. Effective [DATE], each activity with meal service is monitored by the Activities Staff for the duration of the meal service. Activities Staff are responsible to report any identified behaviors or concerns to the licensed nurse. The licensed nurse is responsible to document any behaviors or identified concerns on the 24-hour Report and to report the behaviors or identified concerns to the DNS and/or Social Worker(SW). Effective [DATE], Administrative Licensed Nurses (DNS, Assistant Director of Nursing Services (ADNS), Unit Manager (UM), Minimum Data Set Coordinator (MDSC), Case Manager (CM), Weekend Supervisor (WS) and Staff Development Coordinator (SDC) participate in the licensed staff dining room observation. Administrative nurses through direct observation will validate that all behaviors and/or concerns have been identified, documented on the 24-Hour Report and report to the DNS and SW. Meal Supervision, behaviors and/or concerns will be documented at each meal on the Meal Supervision Log. The Meal Supervision Log will be reviewed daily in the Stand-Up meeting and on weekends by the WS to identify any concerns and to validate that appropriate corrective action has been taken. Any concerns identified will be documented on the Meal Supervision Log at the time of the review. All direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food, and to document on the 24-Hour Report and to address in care plan. Other Facility Residents with the Potential to be Affected: The DNS, UM, Registered Dietician (RD) and Assistant Dietary Services Manager (ADSM) reviewed the medical records of all other facility residents on mechanically altered diets on [DATE]. Record reviews included, but not limited to, the comprehensive MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs, and Resident Progress Notes. The 24-Hour Report, The Dining Room Communication Book and the Dining Room Seating Arrangement Diagram were also reviewed. Record review was conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The Comprehensive Care Plan, the State Registered Nurse Aide Assignment Sheet and the Dining Room Seating Arrangement Diagram were updated as indicated, based on record review and staff interviews. To ensure the safety of all mobile residents on mechanically altered diets with behaviors, all direct care staff, licensed nurses, and SRNAs have been in-serviced to report any and all behaviors, to include wandering or reaching for objects, to include food. Licensed nurses were educated to document on the 24-Hour Report, the Resident Progress Notes and on the Behavior Log and to address on the care plan. The SRNAs were educated to document on the Behavior Log and report to the licensed nurse. The DNS and CM will conduct 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plan. The DNS, UM, Minimum Data Set Coordinator (MDSC), Case Manager (CM), and Advanced Register Nurse Practitioner (ARNP) reviewed the medical records of all facility residents on [DATE]. Record reviews included but were not limited to: the MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs and Resident Progress Notes for the previous 30-day period. Record review was conducted to validate that all care plans were revised as appropriate and indicated based on documentation. In addition, staff interviews were conducted through the in-service offerings to identify residents with unreported behaviors. The comprehensive care plan, SRNA Assignment Sheet and Dining Room Seating Arrangement Diagram were updated, as indicated, based on record review and staff interviews. In addition, on [DATE], all SRNA Assignment Sheets were updated to reflect the intervention for staff to report any and all new behaviors to the licensed nurse. Systemic Changes to Prevent Reoccurrence of Deficient Practice: The DNS, UMS and Weekend Supervisor initiated in-servicing to all direct care staff, to include licensed nurses and SRNAs on [DATE]. In-service content included Care plans and Care plan Meeting and Assigned Seating Designations. In addition, all direct care staff, including Activities, were educated on the Dining Room Seating Assignment Chart and on how the chart was designed. All staff were educated that activity seating groups will be the same as the Dining Room Seating Assignment Chart. The DO and DDCO initiated Investigative Training in-servicing on [DATE] with the ED and DNS. The DDCO completed in-servicing to all Administrative Staff (ED, DNS, CM, MDSC, Social Worker, UM, RD, Activity Director, Housekeeping Supervisor, Rehab Manager, Program Director, Nutrition Services Manager, ARNP and Respiratory Therapist) on [DATE]. In-service content included Documentation of Resident Health Status, Needs and Services; Documenting in a Resident's Medical Record; 24-Hour Report and Investigative Protocol. The DNS and UM initiated additional in-servicing on [DATE] with all direct care staff to include licensed nurses, SRNAs, and Activities staff related to meal supervision. In-servicing was initiated on [DATE] and [DATE] and will continue until all appropriate staff have attended the appropriate in-service. Staff will not be allowed to work until having attended the appropriate in-service. The in-service will be included in New Employee Orientation for all new hires. The facility does not utilize Agency Staff. If the facility should employ Agency Staff, they will receive the in-service prior to working. The ED and DNS will be responsible to validate that staff do not work prior to receiving the in-service. A sign is posted at the time clock to notify staff they are not to work or provide care to any resident prior to reporting to a charge nurse to receive the in-service. If the staff in need of in-service is a charge nurse, they are to report to a charge nurse on a different unit. Facility Monitoring: An ad hoc Performance Improvement Committee was held on [DATE]. Members in attendance included the ED, DNS, UM and RD. The Medical Director was notified of the Facility Action Plan on [DATE]. The ED, DNS, RD and WS will audit residents on mechanically altered diets through staff interviews, direct observations of dining services and through record reviews of Behavior and Mood Logs and Resident Progress Notes. The review will also include the Meal Supervision Log and Dietary Communication Book. The ED, DNS, RD and WS will each conduct one audit per week for four weeks. The audit will validate that all behaviors have been appropriately identified and addressed. The DNS and CM will audit four random records (two per unit) per week for any new behaviors exhibited and to validate that all behaviors have been appropriately addressed on the comprehensive care plan. The audit will include but will not be limited to: the MDS Assessment, Comprehensive Care Plan, Behavior and Mood Logs and Resident Progress Notes for the previous 7-day period. The DNS and CM will also review the meal Supervision Logs for the previous 7-day period to validate that exhibited behaviors and/or concerns have been identified and addressed. In addition, the DNS and CM participate in the licensed staff dining room observation. In addition, the audit will include 4 random staff interviews of licensed nurses and SRNAs (two per unit) per week to identify any new behaviors exhibited and to validate that all behaviors have been appropriately reported and addressed on the comprehensive care plan. The DNS will be responsible to report all audit (residents on mechanically altered diets, behaviors, and the Meal Supervision Logs) findings at the weekly PIC meeting. The PIC will meet weekly (Tuesday) for four weeks to review audit findings to determine the need for additional action steps. If no concerns are identified during the weekly (Tuesday) PIC meetings, the audits on a monthly basis for two months, and on an as needed basis thereafter. The DNS will be responsible to report all audit findings at the monthly PIC meeting. All monthly findings will be reviewed at the monthly PIC to validate that any identified concerns were immediately corrected. Findings will be tracked and trended at the PIC for additional action steps, if indicated. The Interdisciplinary Team, to include but not limited to: ED, DNS, UM, RD, Social Worker, DM, Activities Director, will review all resident events during morning Stand-Ups by reviewing Event Reports, 24-Hour Reports, hospitalization s, Dietary Communications Book to ensure that all events are investigated to ensure the health, safety and overall well-being is met and maintained for the affected resident, other facility residents with the potential to be affected, to identify the need for systemic changes and to validate that the PI process is effective. The ED is responsible for overall compliance through attendance at the Stand -Up Meeting and by reviewing audits to ensure conducted. The ED will assume overall responsibility for the Performance Improvement Program at the Facility. The ED will utilize weekly (Wednesday) IDT recommendations to validate one medical record (from resident identified in the IDT Meeting) to ensure implementation of the Credible Allegation of Compliance. The ED/Administrator will then return to routine monitoring, of the facility systems each month as specified in the Facility Performance Improvement policy and procedure, when substantial compliance is achieved. In addition, the DDCO will conduct weekly calls with the facility to review events from the previous week to validate that all events are thoroughly investigated, to include care plan revision. Interviews conducted on [DATE], during the extended survey, with the DON and direct care staff (SW #2, RN #1, RN #3, LPN #2, LPN #6, LPN #7, LPN #8, CNA #3, CNA #5, CNA #6, CNA #11, CNA #13, CNA #14 and CNA #15 ), revealed there was now a seating chart for the dining room. Residents were seated with residents on the same diet consistency. Licensed staff were present in the dining room for all meals and Administrative staff participated in the dining room service. They revealed if any behaviors were noted, the staff reported the behavior to the licensed staff in the dining room. The licensed staff then documented it on the behavior log in the dining room and reported it to the Charge nurse and documented on the 24 hour report and in the resident's record. Observation of the noon meal on [DATE] revealed Resident #1 was seated at a table by him/herself. No food was placed on the table until Resident #1's tray was served. The CNA immediately sat down next to the resident when the tray was served. Residents #4, #5, #6 and #7 were seated with residents with like diets and were seated according to the dining room seating chart. A licensed staff was present during the entire meal. Staff were reporting observations of behaviors to the licensed staff during the meal. A review of the Dining Room behavior observation sheets for [DATE], revealed each resident's name was documented with the behaviors that were observed. Observations of Resident #,1 on [DATE] at 2:20 PM, revealed the resident was in a wheelchair seated in the area across from the nurse's station in view of staff. A review of Resident #1's comprehensive care plan revisions, dated [DATE], [DATE], [DATE] and [DATE], revealed the care plan had been revised to include interventions to seat the resident at a table with same texture diets, supervise all po intake and meal times, keep the resident in a supervised area when out of bed, notify the nurse of any abnormal behavior and be attentive to the resident when reaching. A review of Residents' #1, #4, #5, #6 and #7 comprehensive care plans, revealed the care plans were updated to include individual interventions to provide supervision for the residents related to their behaviors of grabbing for food/drinks. A review of the in-service trainings provided to all direct care staff, dated [DATE], [DATE], [DATE] and [DATE], revealed all staff received training on care plans and care plan meetings, assigned seating charts, dining/meal service supervision, activity seating groups, to report any and all behaviors (to include wandering or reaching for objects to include food/drink) and documentation. In addition, Administrative Staff were in-serviced on [DATE], on Documentation, Documenting Residents' Health Status, Needs and Services, and Documenting in a Resident's Medical Record and on the 24- Hour Report. The Executive Director and Director of Nursing received in-servicing on [DATE] related to conducting investigations. Although it was determined the Immediate Jeopardy was removed on [DATE], noncompliance continued with the scope and severity of a "D", based on the facility's need to monitor for the ongoing effectiveness of the corrective actions taken and to ensure evaluation through the facility's Quality Assurance process.