Every finding on record at Signature Healthcare of Hart County Rehab & Wellne

Based on interview, personnel record review, and facility policy review, it was determined the facility failed to ensure contracted employees had a Kentucky Adult Caregiver Misconduct Registry check prior to employment as required by KRS 209.032 for 5 of 7 contracted employee files sampled. The facility provided an acceptable plan for the removal of this deficiency on 11/01/2024. This plan alleged the deficiency was corrected on 10/28/2024, prior to the initiation of the survey. The plan provided by the facility alleged the following: 1. On 10/28/2024 the Administrator audited all dietary and housekeeping contracted employees. Each employee had a Kentucky Adult Caregiver Misconduct Registry (KACMR) check completed. 2. On 10/28/2024 the Housekeeping Supervisor and Dietary Manager were educated by the Administrator on the requirement for all new employees to have a completed KACMR check prior to beginning employment. Results must be sent to the contracted company's payroll department. The new employee will not be eligible for hire until all parameters of their background check were completed, including the KACMR check. 3. Beginning 10/29/2024 the Administrator, Director of Nursing (DON), or Business Office Manager will complete audits of new houskeeping and dietary employees to ensure the KACMR checks were completed before hire, 5 times a week for 2 weeks, 3 times a week for 2 weeks, weekly for 4 weeks, then monthly. Audits were completed on 10/29/2024, 10/30/2024, 10/31/2024 by the Administrator with no new contracted employees hired. 4. A Quality Assurance (QA) meeting held on 10/28/2024 formulated and implemented the plan. Audits will be reviewed in the monthly QAPI meeting until 100% compliance is achieved. Through record review and interview the State Survey Agency validated the facility implemented the plan of correction as alleged. The findings include: Review of the facility policy Abuse, Neglect and Misappropriation of Property, reviewed 09/13/2024, revealed the facility included screening to provide protection for the health, welfare, and rights of each resident residing in the facility. Continued review revealed the screening included conducting criminal background checks and a search of the State Aide Registry. Review further revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks were not included as part of the screening. Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation -- Administrative regulations -- Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel file for Housekeeper 1 revealed the facility employed her through a contracted company on 08/02/2024. Further review revealed the facility conducted the check of the Kentucky Adult Caregiver Misconduct Registry (KACMR) on 08/26/2024. 2. Review of the personnel file for Housekeeper 2 revealed the facility employed her through a contracted company on 08/21/2024. Further review revealed the facility conducted the check of the KACMR on 08/26/2024. 3. Review of Dietary Aide (DA) 3's personnel file revealed she was employed by the facility on 08/01/2024 through a contracted company. Further review revealed the facility conducted the check of the KACMR on 08/27/2024. 4. Review of the personnel file for DA 4 revealed he was employed by the facility through a contracted company on 07/23/2024. Further review revealed the facility conducted the check of the KACMR on 08/26/2024. 5. Review of the personnel file for DA 5 revealed she was employed by the facility on 09/03/2024 through a contracted company. Further review revealed the facility conducted the check of the KACMR on 09/09/2024. In interview on 11/01/2024 at 10:05 AM, the Director of Nursing (DON) stated she could not speak to the KACMR checks as she had only been with the facility a couple of weeks. She stated her expectation was for all staff checks be completed before staff entered the building. The DON stated the purpose of the checks was for the safety of the residents. She further stated if the checks were not completed timely there was a potential issue with safety of residents. In interview with the Signature Care Consultant (SCC) on 11/01/2024 at 10:33 AM, she stated the facility did not have a permanent DON for about 1 month and the current DON was there about 3 to 4 weeks. She stated the facility expected contracted staff have checks completed prior to working. The SCC further stated the purpose of the checks was to ensure the employee was not listed on the abuse registry. She also stated if the checks were not completed it was possible the facility could hire someone who could be listed on the abuse registry, and was against the regulation. The SCC stated on 10/28/2024, the facility identified the KACMR checks were not completed for contracted staff. She further stated on 10/28/2024, the facility held a QAPI meeting and conducted an audit of contracted staff who did not have the KACMR checks completed at the time they were hired. She also stated the Housekeeping and Dietary Managers were educated on completing the checks. In interview on 11/01/2024 at 10:57 AM the Housekeeping Manager stated the facility identified an issue with the completion of the KAGMR checks and had a QAPI meeting on 10/28/2024. She stated an audit of the (contracted) staff was completed on 10/28/2024. She also stated she was unaware of the requirement to complete the KAGMR checks and was informed by the Administrator. She stated the Administrator asked about new employees in housekeeping and dietary departments, with no new staff hired. In interview on 11/01/2024 at 11:05 AM the Dietary Manager stated she was made aware of the KACMR checks and a QAPI plan was immediately put in place by the facility on 10/28/2024. She stated all current employee files were audited and a plan put in place that no one would be on the payroll until the KACMR check was completed. She stated the audits were reviewed with the QAPI committee. She also stated her department did not have any new employees. In interview on 11/01/2024 at 10:47 AM, the Administrator stated the contracted company was required to complete the KACMR checks, per their contract, before the employee started working. He stated the purpose of the checks was to identify anyone that had issues in the past and to ensure the safety of residents. He further stated a Signature Healthcare employee would not be able to work without the check completed. The Administrator stated the facility self-identified and put a plan in place to ensure contracted staff had the KACMR checks completed. He further stated he completed an audit of contracted staff and educated the housekeeping and dietary managers. He also stated the two departments have not hired any new employees this week.

483.60 Based on observation, interview and record review, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of two nourishment refrigerators. Observation revealed the nourishment refrigerator on the Dogwood unit had two bowls of applesauce unlabeled or undated. The findings include: Review of the facility's policy, Food: Preparation, revised 2/2023, revealed all refrigerated, ready to eat foods held for more than twenty four (24) hours at a temperature of forty one (41) degrees Fahrenheit (F) or less, would be labelled and dated with a prepare date (day one) and a use by date (day seven). Review of the facility's policy, Food: Safe Handling for Foods from Visitors, dated 9/2017, revealed when food items were intended for later consumption, the responsible facility staff member labeled the food with the resident's name and the current date. Further review of the policy revealed there was daily monitoring of refrigerator storage duration and any food items stored more than seven days would be discarded. Observation of the nourishment refrigerator on the Dogwood unit, on 10/30/2024 at 8:33 AM, revealed two bowls of applesauce not labeled with a resident's name and not dated. During interview with the Dietary Manager and [NAME] 1 on 10/30/2024 at 9:46 AM, both stated all food from the kitchen except food placed on resident dining trays would be labeled with a name and date, including snacks. The only exception was the applesauce given to the nursing staff for medication administration. This applesauce would only have the date prepared and date to be discarded. During an interview with the Registered Dietician (RD) on 10/31/2024 at 8:44 AM she stated she expected food to be dated and labelled with a resident's name. During an interview with License Practical Nurse (LPN) 1 on 10/31/2024 at 12:11 PM LPN1 stated when residents had left over food from their meal tray and wanted it stored in the nourishment refrigerator, whomever placed it in the refrigerator was responsible for placing the resident's name and the preparation and use by date upon the food. This also included any foods brought by a resident's family. During an interview with the Director of Nursing (DON) on 11/01/2024 at 9:51 AM she stated her expectation was all food should be labeled with the date family brought it in, if it was brought from the outside along with the resident's name. Nursing staff should place this information on the food prior to placing it in the nourishment refrigerator. During an interview with the Administrator on 11/01/2024 at 9:57 AM he stated he expected the nursing staff would label and date the food prior to placing it in the refrigerator. He stated he was unsure if left over food from residents' trays were placed in the nourishment refrigerator. He stated that if left over food from a resident's tray was placed in the refrigerator that it was his expectation that it would be labeled with the resident's name and the date placed in the refrigerator.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of four (4) sampled residents was free from sexual abuse, Resident #1. On 01/29/2020, staff observed a resident with his/her hand inside the front of Resident #1's pants. The findings include: Review of the policy Abuse, Neglect and Misappropriation of Property, revised 05/08/19, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Abuse included physical abuse, mental abuse, verbal abuse, and sexual abuse. The policy revealed willful meant non-accidental, or not reasonably related to the appropriate provision of ordered care and services, depending on the context. Willful as used in the definition of 'abuse' meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further review of the policy revealed sexual abuse included sexual harassment, sexual coercion, or sexual assault. The policy revealed sexual abuse included, but was not limited to, any physical contact with a resident's body that was not reasonably related to appropriate provision of ordered care or services; sexually oriented comments or jokes; taking or sharing photographs of a resident that displayed nudity other than for appropriate therapeutic purposed; display of sexually oriented photographs or written materials to residents; and the like. Review of the policy Safety and Supervision of Resident, reviewed 05/31/18, revealed staff would make routine residents and environmental checks to ensure the safety and well-being of residents. The policy revealed routine resident checks by nursing staff involved entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs were met, identify any change in the resident's condition, identify whether the resident had any concerns and see if the resident was sleeping, needed toileting assistance, etc. The policy revealed staff would use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the Minimum Data Set (MDS). Further review revealed the interdisciplinary care team (IDT) would analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. Review of the policy Behavioral Management Program, revised 05/31/18, revealed it was the intent of the facility to identify and assess for disruptive behaviors in residents in order to develop interventions as appropriate. The policy revealed the Social Worker, or designee, would initiate a target behavior analysis and behavior management care plan when staff or the MDS process identified behaviors. The policy revealed a Behavior Management Care Plan (BMP) would be developed by the Social Worker/designee for any resident exhibiting a behavior that interfered with their Plan of Care or impacted negatively, another resident. The policy further revealed the Care Plan would identify appropriate interventions to manage the identified behavior(s) and the discipline responsible for implementing interventions. The policy revealed a copy of the BMP would be kept in a BMP Manual at each nursing station and in a BMP Manual in the Social Service Director (SSD) office. The policy revealed it was the responsibility of each discipline noted to read the BMP placed at each nurse's station. Review of the clinical record revealed the facility admitted Resident #2 on 12/01/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of seven (7). Further review of the MDS revealed the resident required limited assistance with wheelchair mobility. Review of the Social Services Progress Notes, dated 01/28/2020, revealed nursing staff witnessed Resident #2 raise his/her shirt in the dining room and ask a resident of the opposite sex to touch his/her breast. The note revealed Resident #2 was aware of his/her action and voiced that it was intentional. According to the note, the resident had a behavioral care plan that included inappropriate sexual comments behaviors, verbal/vocal symptoms like screaming/yelling, disruptive sounds, cursing, and false allegations. The Social Services Director (SSD) encouraged the resident that anything sexual in nature or involved exposure of private parts, such as breasts, should take place in a private setting not in a common area where others could see. The SSD also educated the resident must first obtain consent from the individual he/she addressed before such behaviors occurred. The note revealed Resident #2 voiced understanding of the education. The facility did not provide a policy for determination of capacity to consent to sexual contact. The facility did not provide evidence of increased supervision of Resident #2 following the incident on 01/28/2020. The facility did not provide an Event Report or Investigation of the incident on 01/28/2020. Review of the Psychiatric Evaluation, dated 01/28/2020, revealed staff reported Resident #2 often made sexually inappropriate comments and the incident was the first that involved physical contact with another resident. The note revealed Resident #2 reported the interaction was consensual. However, review of the mental status examination revealed the resident's thought process was confused at times, short- and long-term memory were poor, and insight/judgement was poor. Recommendations included monitoring for changes in mood/behavior. Review of the facility Investigation, dated 01/29/2020, revealed Certified Nursing Assistant (CNA) #5 observed Resident #2 in the Dogwood dining room with his/her hand under Resident #1's brief and pants. The CNA intervened and separated the residents. However, she did not report the incident immediately to the nurse. CNA #5 left Resident #1 and #2 unsupervised to assist another resident in the bathroom and reported the incident to LPN #5 after she finished. According to the investigation, LPN #5 and CNA #5 discovered Resident #2 on the Magnolia Unit talking to an 'alert mate', separated the residents, and increased his/her supervision. Observation, on 12/22/2020 at 11:25 AM, revealed Resident #2 seated in a wheelchair in his/her room. Interview during observation revealed the resident could not recall the incident with Resident #1 and denied placing a hand in another resident's pants. Interview with CNA #5, on 12/22/2020 at 12:08 PM, revealed she observed Resident #2 with his/her hand inside the front of Resident #1's pants. She stated she separated the residents; however, she did not report the incident immediately because she did not see a nurse. She revealed she left to assist a resident in the bathroom and reported the incident to LPN #2 when she returned. CNA #5 revealed she was supposed to stay with the residents and report the incident immediately to ensure their safety, but she was torn because she had a resident on the commode yelling. The Aide stated she thought there was enough space between the residents they would be okay for a minute. According to CNA #5, the aides were getting residents out of bed when the incident occurred. Interview with LPN #2, on 12/28/2020 at 1:55 PM, revealed she could not recall the incident involving Resident #1 and Resident #2. The LPN revealed staff tried to keep an eye on residents with identified behaviors. She stated she documented behaviors in the nursing progress notes and reported to the oncoming nurse at shift change. However, she had never heard of or used the Behavior Management binder. The LPN revealed staff were responsible for notifying the Administrator immediately of an allegation of abuse to prevent further incidents and protect residents. Interview with LPN #4, on 12/23/2020 at 12:11 PM, revealed a CNA observed Resident #2 with his/her hand in Resident #1's pants, separated the residents, and reported the incident to her. She stated she reported the incident to the Administrator because she thought it could be sexual abuse and the facility increased supervision of Resident #2. Further interview with LPN #4 revealed Resident #2 had a phase when he/she flirted and was observed rubbing the shoulder of a person of the opposite sex. She stated the facility increased monitoring of Resident #2's sexual behaviors for a week to ensure he/she did not touch anyone else. The LPN further revealed Resident #1 had pretty bad Alzheimer's and a lot of time would ask other residents or staff if they wanted to f***. She stated both Resident #1 and Resident #2 could propel in their wheelchair unassisted. Review of Resident #1's closed record revealed the facility admitted the resident on 10/04/16 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) of seven (3). Review of the Progress notes revealed a note on 01/29/2020 stated staff observed Resident #1 up in a wheelchair and another resident had his/her hand in Resident #1's pants. Interview with CNA #6, on 12/23/2020 at 2:14 PM, revealed Resident #2 would place a hand on the leg of residents of the opposite sex and every now and again would place a hand on their belly. She stated staff had to keep an eye on the resident, separate him/her from the other resident, redirect and educate that the behavior was inappropriate. Further review of Resident #2's Progress Notes, dated January 2020, revealed no documentation of the behavioral management review related to the exhibited behaviors. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed the practitioner reiterated behavior redirection. Review of the Psychiatric Evaluation, dated 02/06/2020, revealed Resident #2 continued sexually inappropriate verbalizations. Recommendations included monitoring for changes in mood/behavior. Review of the CNA Care Report, dated December 2020, for Resident #2 revealed aides should refer to the Behavior Management Binder for additional information. However, review of the binder revealed no behavior care plan for Resident #2. Interview with the SSD, on 12/22/2020 at 12:24 PM, revealed she was aware of the behaviors exhibited by Resident #2 but stated there was no history of physical contact with any other residents. The SSD stated she provided verbal education to Resident #2 after the 01/28/2020 incident but stated the resident's BIM fluctuated and there were no further incidents. Continued interview with the SSD revealed the IDT reviewed for behavioral changes during the morning clinical meeting and she noted the interventions implemented in the progress notes. She further revealed the facility conducted weekly behavioral meetings to include review of residents with new or worsening behaviors. She stated the facility reviewed Resident #2's behaviors in January related to the incident and discussed monitoring of medication changes. Interview with the SSD, on 12/28/2020 at 12:51 AM, revealed she could not locate Resident #2's behavior care plan. According to the SSD, she was in the process of updating the binders because of room changes related to COVID-19. Review of the Behavior Investigation, dated 01/29/2020, revealed the facility determined the root cause of the incident was Resident #2 attempted to put hands down a residents pants. The facility did not provide a phone number for the former Director of Nursing (DON) for interview. Interview with the current Director of Nursing (DON), on 12/30/2020 at 9:17 AM revealed she was not yet familiar with all aspects of the facility's residents. The DON stated the facility protects residents from abuse by re-directing behaviors and refer to a resident's BIMS score to determine a resident's capacity to consent. Interview with the Administrator, on 12/28/2020 at 11:04 AM, revealed knowledge of types of abuse to include sexual abuse. Continued interview with the Administrator, on 12/30/2020 at 10:48 AM, revealed the facility investigation unsubstantiated sexual abuse as Resident #2's had no intent to abuse the other resident on 01/29/2020. The Administrator stated the other resident involved in the 01/29/2020 incident was not capable of providing consent.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify a resident's physician regarding the significant weight loss for one (1) of twenty-two (22) sampled residents, Resident #77. Review of the medical record revealed no documentation regarding notification to the physician of Resident #77's weight loss of more than five (5) percent (%) in a one (1) month period. The findings include: Review of the facility policy, Change of Condition, revised 07/10/18, revealed the facility evaluated and documented a resident's health and mental or psychosocial status efficiently and effectively, to relay the evaluation information to a physician. Additionally, the facility documented actions including a significant change in resident's physical, mental or psychosocial status. Further review revealed the facility documented notifications in the resident's medical record. Review of the medical record revealed the facility admitted Resident #77 on 12/01/15 with [DIAGNOSES REDACTED]. Review of the comprehensive care plan for Resident #77, revealed the Problem, dated 04/15/19, the resident was a nutrition risk due to [DIAGNOSES REDACTED]. The interventions for this problem included monitoring meal intake, weights per order, diet as ordered, and the dietician to review quarterly and as needed. Review of the Vitals Report revealed the facility recorded the resident's weight on 06/05/19 at one hundred, forty-eight point two (148.2) pounds and on 07/15/19 at one hundred thirty-nine point six (139.6) pounds. A weight loss of eight point six (8.6) pounds, or five point eight (5.8) percent. Review of the resident progress notes for Resident #77, dated 07/17/19, revealed documentation recorded by the Assistant Director of Nursing (ADON), elder has had six point three percent (6.3%) weight loss in one month. Stable at this time at one hundred, thirty-nine point six (139.6). Elder receives pureed diet and SNP all meals. Will follow. Continued review of the medical record revealed no documentation of physician notification of the weight loss. Interview with the Dietician, on 08/01/19 at 11:36 AM, revealed she had no record of notification from the facility regarding Resident #77's weight loss. The Dietician stated the facility staff notified her of resident significant weight changes, admissions, or pressure ulcers. She stated staff notification to her of a resident's weight loss caused her to perform a nutritional assessment of a resident. The Dietician stated a resident could experience skin break down, continued weight loss, a decrease in activities of daily living, potential hospitalization , or dehydration if not assessed for nutrition concerns. Interview with Registered Nurse (RN) #1, on 08/02/19 at 10:20 AM, revealed the Dietary Manager (DM) monitored for resident weight loss, in conjunction with the ADON. RN #1 stated either the DM or the ADON contacted the resident's physician for notification and for orders. Additionally, RN #1 stated it was a nursing responsibility to ensure the facility notified providers of resident weight loss. She stated no notifications of a resident's weight loss could lead to additional weight loss, or skin breakdown. Interview with the Physician (MD), on 08/02/19 at 10:57 AM, revealed he could not verify if facility staff notified him Resident #77's weight loss. The MD stated if notified he could then follow the dietician recommendations for a resident with weight loss, in addition to weight monitoring and evaluation of a resident's needs. The MD stated a resident with weight loss and nutrition concerns could experience skin breakdown, wound healing, and generalized weakness. Interview with the DM, on 8/02/19 at 11:22 AM, revealed the ADON made the weight loss notifications to the physicians and stated she did not follow up with the ADON to insure she made the notification. The DM stated the facility was responsible to notify physicians of a resident's weight loss and their failure to do so could lead to additional weight loss. Interview with the Unit Manager (UM), on 08/02/19 at 12:13 PM, revealed she was aware of Resident #77's weight loss but did not notify the physician. The UM stated failing to make the notifications could potentially lead to additional weight loss, making the resident very ill. The UM stated the nurse who assessed a resident with significant weight loss was responsible to insure physician notification occurred. Interview with the ADON, on 08/02/19 at 12:47 PM, revealed nursing was responsible to notify a physician when staff assessed a resident with significant weight loss. The ADON stated failure to notify a physician of a resident's weight loss could lead to missed laboratory testing or potential medication changes. Interview with the Director of Nursing, on 08/02/19 at 1:09 PM, revealed either the UM or her designee called the physician with notification of a resident's significant weight loss. The DON stated a resident with long-term weight loss could develop skin problems.

Based on interview, record review, and facility policy review it was determined the facility failed to develop a comprehensive care plan for one (1) of twenty-two (22) sampled residents, Resident #77. The facility identified Resident #77 sustained significant weight loss (five (5) percent or more), however, the facility did not address the Problem in the resident's person-centered comprehensive care plan. The findings include: Review of facility policy Comprehensive Care Plans, dated 07/19/18, revealed the facility developed person-centered comprehensive care plans, which included measurable objectives and timetables that met residents' medical, nursing, mental and psychosocial needs. The facility's Comprehensive Care Plans policy was also designed to identify residents' problem areas, risk factors associated with identified problems, and assist with preventing and/or reducing declines in residents' functional capabilities. Continued review of the policy revealed when a resident's condition significantly changed the nurse/Interdisciplinary Team (IDT) would develop, reviewed, and/or revise their Comprehensive Care Plan. Review of Resident #77's medical record revealed the facility admitted the resident on 12/01/15, with [DIAGNOSES REDACTED]. Review of Resident #77's Vitals Report revealed the facility recorded the resident's weight at one hundred forty-eight point two (148.2) pounds on 06/05/19 and at one hundred thirty-nine point six (139.6) pounds on 07/15/19. The recorded weight calculation for Resident #77 revealed a significant weight loss of eight point six (8.6) pounds or five point eight percent (5.8%). Review of Resident #77's Progress Notes recorded by the Assistant Director of Nursing (ADON), dated 07/17/19, revealed she documented the resident had a six point three percent (6.3%) weight loss within one (1) month with a stable weight of one hundred thirty-nine point six pounds (139.6). The ADON also documented Resident #77 received a pureed diet and Supplemental Nutritional Program (SNP) with all meals. Continued review of Resident #77's Progress Notes revealed no documentation that staff notified the physician and/or Dietician of the resident's significant weight loss. Review of the Comprehensive Care Plan for Resident #77, dated 04/15/19, revealed the facility determined the resident was at risk for malnutrition due to [DIAGNOSES REDACTED]. The Comprehensive Care Plan's Interventions for Resident #77's risk of malnutrition included monitoring meal intake, monitoring weight, receiving meals according to ordered diet, and quarterly or as needed Dietician reviews. Continued review of Resident #77's Comprehensive Care Plan revealed no documentation addressing the resident's significant weight loss (of more than five (5) per cent within one (1) month). Interview with the Minimum Data Set (MDS) Coordinator, on 08/02/19 at 9:38 AM, revealed the Dietary Manager (DM) was responsible for completion of the portion of the assessment that triggered a comprehensive care plan related to resident nutrition. The MDS Coordinator stated the assigned staff member was then responsible to develop the care plan accordingly. Additionally, the MDS Coordinator stated care plans were developed during the morning meetings with the ADON, the Director of Nursing (DON), the Unit Manager (UM), and Dietary Manager (DM). The MDS Coordinator stated a fully developed, accurate care plan directly affected the care staff provided to residents. Interview with Certified Nursing Assistant (CNA) #1, on 08/02/19 at 10:16 AM, revealed she was unsure when the facility developed new areas for comprehensive care plans but she knew upper nursing staff completed this task. CNA #1 stated a resident could continue to lose weight, if staff failed to develop a resident's weight loss care plan. Interview with Registered Nurse (RN) #1, on 08/02/19 at 10:20 AM, revealed nursing staff developed a resident's weight loss care plan after assessment revealed the resident lost a significant amount of weight. RN #1 stated it could be detrimental to a resident, if staff failed to develop the resident's care plan related to weight loss because many of the residents do not have a lot of weight to lose. Additionally, developing a resident's care plan to include additional assessments and interventions prevented continued weight loss. Interview with the DM, on 08/02/19 at 11:22 AM, revealed she developed the nutrition section of a resident's comprehensive care plan. The DM admitted she failed to develop the nutritional care plan for Resident #77, after she became aware of the weight loss of greater than five (5) percent in a one (1) month period. The DM stated an incomplete care plan prevented staff from providing appropriate care to residents and a resident could lose additional weight. Interview with the UM, on 08/02/19 at 12:13 PM, revealed she did not develop the comprehensive care plan for Resident #77 when the weight loss occurred and was unable to verbalize her reasoning for not developing the care plan. She stated staff developed care plans for unplanned weight loss when staff assessed the resident for weight loss and the assessment revealed a significant change. The UM stated a resident would continue to lose weight and potentially become ill, if staff did not develop the resident's care plan for significant weight loss. Interview with the ADON, on 08/02/19 at 12:47 PM, revealed staff were supposed to develop a resident's care plan for unplanned weight loss to address the weight loss and implement interventions to re-gain that weight. The ADON stated no particular staff member was responsible for developing care plans; however, the facility trained and directed all nursing staff to develop care plans as needed. She stated when Resident #77 experienced significant weight loss, staff should have initiated a new Problem area on the resident's care plan to specifically address his/her weight loss. According to the ADON, failure to develop a resident's care plan prevented staff from identifying causes of the resident's weight loss. Interview with the DON, on 08/02/19 at 1:09 PM, revealed staff developed care plans with a new Problem in the morning meeting in order to reflect a resident accurately. She stated an inaccurate care plan regarding a resident's weight could lead to additional weight loss and development of skin issues over time. Interview with the Administrator, on 08/02/19 at 4:04 PM, revealed the facility had not identified concerns regarding staff not developing comprehensive care plans upon recognition of a resident's significant weight loss.

The facility failed to provide care and services for a resident with an identified weight loss of 5% and/or greater in one month to address and prevent further weight loss for one of twenty two residents, Resident #77. Resident #77 Nutrition [DATE] 11:30 AM MED PLUS [DATE] TID 240 CC FLUIDS WITH EACH MED PASS LIBERAL DIET NCI DOESN OT INITIALLY SEE WEEKLY ORDER FOR WT MONITORING W/ NOTED WT LOSS. NUTRITION AT RISK EVAL DATED [DATE] ON CHARGT LONG SPOUT FEEDING CUP IN (YEAR) ORG DATE ADMIT TO FACILIYT ,[DATE] CP: SHE HAS A CARE PLAN FOR AT RISK DUE TO OBESITY???? ,[DATE]: WT PER MDORDER (NONE CURRENLTY) SUPERVSION AS OF ,[DATE], FOOD IN G BOWLS, NO STRAW SMALL GLASSES. EAT IN DINING HALL. MEDS AS ORDERED ,[DATE] LAST CARE PLAN NOTE FUNCTIONAL QUAD [MEDICATION NAME][MEDICATION NAME][MEDICATION NAME] [DATE] 05:00 PM RR WEIGHT REIVEW ,[DATE] 141 ,[DATE] 139 6% LOSS ,[DATE] 148.2 ,[DATE] 147.4 ,[DATE] 148.2 [DATE] 148.1 RESIDENT REIVEW ,[DATE] TO ,[DATE] WEIGHT LOSS WAS A 6 PERCENT WEIGHT LOSS, HOWEVER SHE PICKED UP WEIGHT WITHIN 2 WEEKS WITH CHANGES TO CARE PLAN AND NEEDS: trouble swallowing: long spout cup no straws assist meals, mechanically soft. supplements tidi CoC note on ,[DATE]: by DON slight gain of weight, nectar thick liquids. with a renal diet eats 56 % of meals per dietician review and monitoring [DATE] note by adon of 6.3% weight loss, stable and reweight with 139 wt monitoring med plus three times a day from nursing meal tracking noted in physican orders and on MAR?TAR for 3 meal tracking on [DATE] and recorded cna is docuementing 4 x a day meal intake AS OF [DATE] [DATE] care planl for nutritional status update for swallowing difficulties, required mechanically altered diet. to eat 50 percent of emal renal puree encourage intake all liquids and food record intake liquid and foods monitor need to advance diet. HOWEVER NO CP FOR WT LOSS, NUTRITIONAL MONITORING. THE CARE PLAN ACTIVE IS STILL NUTRITIONAL RISK DUE TO OBESITY. [DATE]: ORAL ASSESSMENT DONE WITH REFERRAL TO BE APPROP WAS DENTIS AND DIETICIAN (HOWEVER I HAVE NOT SEEN AN EVAL BY THE DIETICIAN YET IN RR) [DATE] 11:36 AM LAUREL AKERS DIETCIAN PART TIME Q THURSDAY [DATE] 613 2495 CELL PHONE MILDRED PERKINS KEEP COPIES OF REC AND ASSESSMENTS I DONT ATTEND NAR BECAUSE THE DIETICIAN ATTENDS AND THEN SHE GIVES ME THE REQUREST FOR ASSESSMENTS THAT ARE DISCUSSED IN THE NAR MEETINGS. THE DIET WENT AND GOT HER BOOK FOR RECOMMENDATION FOR A REVIEW/EVLAUTION. NOTHING AFTER [DATE] SHE DOESN'T HAVE ANY RECORD OF A REFERRAL WHEN EXPECT A : NEW PRESSURE AREA OR DECLINE, NEW ADMIST, ANNUAL, SIGNIF CHANGE: COULD BE REL ADL, IMPROVE, WT SIG CHAGNE: FOLLOWING THE MDS GUILDINES OR INCIDOUS WTLOSS TREND, THE NUT AT RISK WILL PUT INTERVENTIONS IN PLACE: INCREASE. 25.5 BMI DOES NOTE CLASSIFY HER AS OBESE I WOULD WANT THEM TO REFER FOR REVIEW OF NUTRIIOTNAL STATUS DIETICIAN COMM WUTH DM COMMUNICATE RESIDENT REVIEW NEEDS SHE COMPLIES A LIST FOR ME FROM FINDINGS AND NAR MEETING RECOMMENDATIONS. WHO: RESPO TO NOTIFY OF WT LOSS: CDM LISA COMPLIES THE LIST BUT OTHER CAN ALSO AND I HAVEN'T HEARD OF ANY ISSUES OR REQUESTS TO LOOK WHY: INFORMED TO DO A NUTTIRONAL ASSESS TO EVALUATE ELDER EATING, IS THE THE DIET HAD BEEN LIBERIZED AND DO AN OVERALL REVIEW OF HER CARE AND SERVICES IS THE DYSPHAGIA GETTING WORSE. FAMILY DIDNT WANT THERAPY SERVICES, IS THAT SOMEHTIBG AT RISK LOOKED AT. BECASUE THE FAMILY DID W ANT DOESN'T MEAN IT DOESN'T MEAN TO BE REVISITED. WHAT CAN HAPPEN THE RESDIENT: SKIN BREAKDOWN CONTINUED WE LOSS , DECRASE ADL, POTENTIAL hospitalization . DEHYDRATION. THE D[NAME]TOR SHOULD OF BEEN NOTIFIED AND MAYBE LABS ORDERED. THE DIETICIAN REVIEWED THE RESIDENTS HARD CHART [DATE] PT REFUSED DENTIST: PER MD NOTE HOWEVER THE ORAL CAVITY ASSESSMENT REFERRAL TO DIETICIAN WAS TO [NAME]CUR. SUPPLEMENTS PRE VIUOS ORDRED SHE STATED HAVE NOT BEEN ALTERED OR CHANGED. SNP PROGRAM FOR HIGH PROTIEN CALORIES: PROVIDED ON TRAY PHILLIP BALE MD 270 5111 JANICE CURRY DTR 270 646 0856 ATTEMPTED TO CALL DAUGHTER JANICE LEFT MSG TO RETURN CALL (ATTEMPTED X 2 YESTERDAY )[DATE] 01:03 PM DR SWARAN CHANI 270 786 2373 270 535 6949 DEBBIE PRUITT MDS COORDINATIOR [DATE] 09:38 AM THREE YEARS FOR DIETARYN AND NUTRIUOTN CARE PLAN WOULD BE THE DIETARY MANAGER RESPONSIBILITY.I PR[NAME]ESS MDS : I HAVE A FORM THAT I GO BY AUDIT FORM THAT HAVE MADE A WORKSHEET FOR ME THAT REMINDS ME WHAT TO LOOK AT. I TAKE IT WITH ME TO INTERVIEW OR OBSERVATION. WORK THROUGH THE FORM. AFTER I COMPLETE WORK, WHEN IT IS ASSESSMENT TIME, I PULL REPORTS INCLUDE ADL REPORT, BATHING REPORT, RESTORATIVE, NO MEAL AND FLUID THAT GOES THORUGHT THE DIETARY MANAGER THROUGH SECTION K. RESP OF MDS AS A WHOLE I LOOK TO SEE EVERYTHING THAT IS GOING ON SOMETIMES I QUESTION HER ABOUT A WEIGHT, BUT SHE HAS HER NAR FORMS AND AUDITS. I TYR TO MAKE SURE THAT EVERYTHING IS CORRECT BUT EACH PERSON IS RESPONSIBLE WHEN THEY SIGN TO MAKE SURE THEIR SECTION IS CORRECT. RESP FOR THE CARE PLAN, I UPDATE THE CARE PLAN BUT SW, ACTI AND DM HAVE THEIR RESPONSIBLITES. THE RN: ERIC MINOR, RN MDS COORDINATOR-5 YEARS. I JUST MAKE SURE THE SECTIONS ARE COMPLETE. I DO MY SECTION OF THE CAREPLAN TO MAKE SURE THE CAREPLAN MATCHES MY ASSESSMENTS [DATE] 10:07 AM . WE DONT ATTEND MORNING MEETINGS PERIOD NEITHER. THE REVISIONS ARE SUPPOSED TO BE DONE ADON, SDC, DON, UM, DM, SS, ACTI, MR ARE SUPPOSED TO UPDATE THE CAREPLAN IN THE AM MEETINGS. I READ DEBBIE AND ERIC READ ALL PROGRESS NOTES, ORDERS OBSERVATION NOTES ON A DAILY BASIS TO SEE WHAT CHANGES HAVE [NAME]CURED AND REFER AS NECESSARY, WRITE IT DONW IN NTOEBOOK AND FOLLOW UP. I USALLY SEE A CHANGE I WILL ASK NUR SING IF IT IS SIGNIFICATN TO WHETHER I NEED TO DO AN ASSESSMENT OR NOT AND CLINICAL MEETING IS SUPPOSED TO UPDATE THE CAREPLAN. EX: REGULAR TO MECHANICAL SOFT IS STILL THE DM REPSONSIBLE TO UPDATE THE CARE PLAN. WHO: NUTRION PORTION AND MEALS ECT IS THE DM RESPONSIBILITY, (PDPM- IN [NAME]TOBER THAT WILL PROB CHANGE CAUSE ITS ONTHE RES CONDITION INSTEAD OF THERAPY). CHANGES TO CARE PLAN ARE TO BE DONE EVERY ASSESSMENT AND IF ANY CHANGES, WHATS THE RESON CORRECT, TO SHOW AN OVERALL ACCURATE PICTURE O F THE RESIDENT-DIRECTLY EFFECTS RESIDENT BECAUSE IT EFFECTS THEIR CARE. _________ MAGNOLIA UNIT 700 DOGWOOD 100 TORI EATON CAN 1 YEAR [DATE] 10:16 AM PR[NAME]ESS: CP I LOOK INTOR YOUR CARE PLAN BOOKS. UPDATED I THINK WEEKLY. OR CHANGES PERMANTELNY THEY WILL LET US KNOW. THE CARE PLAN GETS UPDATED BY THE NURSING UPPER PEOPLE WITH CARE PLAN MEETINGS. NUTRIOTION PORT OF CARE PLAN DIET, CONSISENTCY IF THEY HAVE ASSIST FULL FEED SNACKS IF THEY NEED TEETH. IF NOT CORRECT HOW IMPACT IT COULD BE BAD BECAUSE IF HAD WT LOSS THEY CAN CONTINUE TO LOSE WEIGHT IF WE ARE NOT MONITOIRNG OR ENCOURAGNING TO EAT. PRN: MAYBE ONCE A WEEK. LOOK IN THE CARE PLAN BOOK AND VERBAL REPORT. NOT CARRY SHEET. NEW RESIDETNS YOU HAVE TO REFER TO. SHANNON MATTHEWS RN[DATE] 10:20 AM HOW WHEN A RESIDENT FREQ WEITHS I GO ONTO THE MD ORDERS TO SEE IF THERE IS an order for [REDACTED].>IF THEY ARE NOT AN ADMISSION AND THEY NEED WEEKLY WEIGHTS THEY SHOULD HAVE AN ORDER. HOPEFULLY YOUR FAMILIAR WITH THE RESIDENT IF THER IS NO ORDER AND YOU CAN GO ONTO THE CARE PLAN AND LOOK AND SEE. IT COULD BE A PROBLEM AND IF YOU HAVE A QUESTION YOU CAN ASK ADON OR CALL THE DR. SO RESIDENT SIG WIEHT A MOTHN: WEIGHTS ARE LISTED INTHE VITALS, AND WE HAVE A WEIGHT LOSS BOOK AND IF THERE IS A PROBLEM ID SHOULD BE VERT RTRASFERRED IN REPORT. RESPON TO UPDATE WEEKLY WEIGHTS: , SOME RIGHT NOW IS ON HER DESK AND THE WKY WEIGHTS LOG IN THE BINDER CAN BE TOLD TO US TO ADD OR THE ADON CAN ADD. (THE MAGNOLIA UNIT LOG IS MARKED [DATE].) NOT EXACTLY SURE WHERE THE UPDATED SHEETS ARE AND WEEKLY WEIGHTS ARE DONE ON THE WEEKEND AND ADON PUTS THEM IN THE COMPUTER. RESIDENTS WITH WT LOSS MONITORING: THERE ARE FREQ MED PLUS MAR indicated [REDACTED]. DO CNA TRACK INTAKE: WE CAN MAKRE IN ON THEIR SHEETS, AND D[NAME]UEMTN INTO THE KIOSK. MEALS AND FLUIDS. THERE HAS BEEN [NAME]CASSIONS WHERE ITS BEEN PASSES ON IN REPORT THAT A RESIDENT HAS LOST WEIGHT AND WER ARE TO MONITOR THEM. THE DIETARY MANAGER HAS COME TO ME AND REPORTED THAT A RESIDENT HAS HAD RES WEIGHT LOSS. ORDERS TO INCLUDE MED PLUS TID, ORDERS FOR SNACKS, WILL ASK UPDATE ON CONDITION FOR ? WT CHANGES, WE CAN GET ORDER FOR ENSURE, EXTRA PROTIEN, MONITORS RESP FOR MONITORS: THE DM WILL SPEAK TO THE ADON ON WHAT NEEDS TO BE ORDRED/WORK OUT A PLAN AND WRITE AN ORDER. AND THE PHYSICAIN TO GET THE ORDERS AND UPDATE THE MD ON THE FINDINGS. N CAREPLAN: THE CP SHOULD BE UPDATED ON THE WT LOSS AS AN ACUTAL AND MEAUSRES TO HELP RESOLVE AND MONITORS. IF NOT UPDATED HOW IMPACT: IT COULD BE DERIMENTAL FOR THE RESIDENT:, IT NEEDS TO BE DONE THESE PEOPEL DONT HAVE EXTRA WT TO SPARE AND THEY NEED TO BE UIPDATED TO BE MONITORED AND MD CAN ORDER MEDS TO HELP APPETITE AND THEN REVIEW INTERVENTIONS AND CHANGE IF NEEDED. CARE PLAN REVISION IS VERY IMPORTATN. REVISOIN CP-AT THE AT RISK MEEITNG I THINK CALLED NAR. THE ADON/DON WOULD ENSURE THE CP WAS UPDATED. NOTIFICATION: THE ORDER WOIULD BE MD CONTACTED, THE ADON GETS THE ORDER AFTER NOTIFICATION. THE FAMILY CAN BE CONTACTED BY THE NRUSE OR THE ADON. ITS A NURSING RESPONSIBILTIY. IF NOT NOTIFIED IT WILL BE BAD BECAUSE CAN CONTINUE LOSE WT, SKIN BREAKDOWN, NOT FEEL WELL AND DECLINE. AND ITS PROT[NAME]OL TO CALL THE MD. WHN THE MD AS SOON AS WE FIND OUT TO FAM AND MD. Dr CHANI PHYISICAN TO RESIDENT [DATE] 10:57 AM WHEN YOU HAVE A RESIDENT WITH WEIGHT LOSS THEY DO OR THEY SEND ME A FAX OR VERBALLY. AND THEY WOULD AND SHOULD D[NAME]UMENT MY NOTIFICATION IN THEIR NOTES. NOTIFICAITON FOR MILDRED PERSKINS: DON'T REMEMBER BUT DM WOULD AUTOMATICALLY WRITE an order for [REDACTED]. USUALLY I FOLLOW DIETARY RECOMMENDATION. IF THEY HAVE LOST WEIGHT THEY WILL WRI HOW MATE AN ORDER TO THE WT LOSS AND START WEIGHT MONITORING AND REVIEW THE DIETARY/NUTRITION NEEDS. THE DIETCIAN WOULD BE APPROPRIATE TO REVIDEA AND ASSESS THE RESIDENT. USUALLY I HAVE TO ASK FOR A DIETARY CONSULT WHEN I SEE A NOTE FROM THE DM ON THE CHART FOR RECOMENDATIONS. IF THE DM/DIETICIAN HAD FOLLOW HO EFFECT RESIDENT IF WT LOSS AND THOSE HAVE VENN EVALUATED IT DEPENDS IF THEY HAVE [MEDICAL CONDITION], IT DEPENDS ON WHICH RESIDNET AND WOULD BE AT RISK IF NOT MANAGED FOR SKIN ISSUES, WOUND HEALING, EASIER SKIN INCREASING FALLS AND GENERALIZED WEAKNESS. SOMETIMES AT THE END OF LIFE OR NEW MEDICATIONS THEY MAY LOSE APPETITE AND CAN EFFECT. BUT I EXPECT SOMEONE, USUALLY THE DM TOMAKE A RECOMMENDATION NTHE ORDER SHEETS TO HAVE THE DIETCIAN ASSESS THE REMSIDENT FOR WEIGHT LOSS TO SEE IF IT CAN BE INTERVENED, AND REVIEW MEDS, CALORIES, HOW THE RESIDNET IS EATIN ALL OF THE ABOVE. IF ITS NOT IN THE WRITTEN CHART THEN I WOULDN'T OF COSIGNED AN ORDER BECUASE I HAVE SO MANY RESIDENTS AND I EXPECT THEM TO CHART TO THE NOTIFICATION. SHIRLEY BRADLEY CN1 [AGE] years HOW TO FIND ABOUT RES CARE: AT THE CARE PLAN BOOK AT THE NURSES STATION, I LOOK AT EVERYDAY WHEN WE COME ONTO SHIFT. PERKINS ,[DATE]: CARE NEEDS, TOTAL ASSIST MECH DIETY AND MECH LIFT. SHE CAN FEED HERSLEF MOST OF THE TIME AND SHE IS TO BE SUPERVISED. SHE COMES INTOT HE DINING ROOM FOR MEALS. HAS SHE HAD A RECENT WIEGHT LOSS: SHE HAS LOST A LITTLE TO WHAT THEY TOLD ME HER CARE PLAN WAS REVIEWED WITH THE CNA: SHE STATED IT SAID, KEEP TRAY, BOWLS, FOOD allergies [REDACTED]. NO STRAWS, DRINSOF 4 HOUZ, ENC FLUIDS. WEIGHT SON THE CAREPLAN:? NO WEIGHT MONITORING. EVERYOBDY GETS BLD INTAKE INTO THE KIOSK. ANYWHERE REPORT TO RN FOR <50% INTAKE: NO OFFER SOMETHING ELSE IF <50% INTAKE: NO IT WOULD BE ON THE WEIGHT SHEET: WEEKLY WEIGHTS ARE OBTAINED WE GET NAR WEIGHTS ON SUNDAY AND MONTHLY WEIGHTS ON THE FIRST OF THE MONTH, AND WEEKLY WEIGHTS MONTHLY. THE NURSES HAVE THE INFORMATION AND THEY TELL US AND WRITE IT DONW ON A PAPER, AFTER WE GET THE WIEGHT WE WRITE IT DONW AND TURN IT INOT THE NURSE. CAREGUIDE: IF NOT UP TO DATE THE RESIDENT MAY EFFECT THE RESIDENT WE WOULDN'T KNOW, THEY WILL DECLINE. WE ARE SUPPOSED TO REWEIGHT THE RESIDENT WITH THE NURSE WITH US TO ENSURE IF THEY WEIGHT WE GOT WAS CORRECT. WHO UPDATED THE CGUIDES THE UNIT COORDINATOR, WHEN ANYTHING CHANGES WITHTHE RESIDNET FOR CARE NEEDS. ----- TERESA ESTES DIETARY MANAGER 3 YEARS[DATE] 11:22 AM HOW PR[NAME]ESS IDEN RES W/ WEIGHT LOSS: WE DO WEEKY WIEGHS ON SUNDAY NIGHTS AND WE WILL GENERATE A WEEKLY REPORT AND IT WILL IDENTIFY A WEIGHTS AND WE DO IT FOR MONTHLY WEIGHTS. AN7D THE PULL 5, 7.5 AND 10 PERCNET FOR THE MONTH AND THEN WE WRITE THEM ON THE WHITE BOARD AND LET THE ADON'S/UM KNOW WHO HAS HAD WEIGHT LOSS WE SILL DISCUSS INTHE CLINICL MEETING AND WHAT OUR PLAN IS, SOMETIMES ITS A PLANNED WEIGHT LOSS, LOSTS OF [MEDICAL CONDITION] ECT AND IF ITS EXPLAINED WE DON'T ADD TO NAR. IF NOT WE GET A REWEIGHT AND IF IT IS WE WILL ADD THEM TO THE NAR. NAR: Q WEDNESDAY, START A SHEET, GET PO INTAKES, RECORD WEIGHTS AND HAVE A GENERAL DISCUSSION, IF PO < 50 WHY IS THE INTAKE POOR, IS IT DENTAL APPETITE, RECOMMEND TO THE D[NAME]TORS CAN [NAME]CUR, WE WILL REFER TO THE DIETICIAN SO SHE CAN DO AN ASSESSMENT. IF THEY LOSE 5 PERCENT AND DOING WELL WE IL ADD PCP SUPPLEMENT AND MONTIRO THE WEIGHT. ARE THE MD REQUIRED TO NOTIFY: ITS THE ADON TO NOTIFY DM DO YOU ENSURE THAT GETS DONE, NO I JUST LET THE ADON'S KNOW. WE DISCUSS IT AND WE WILL REVIEW WHAT WAS DONE LAST WEEK IN NAR. I HAVE THE MEETING WITH NAR AND THE NURSES D[NAME]UMENT IN THE COMPUTER WHAT WE SAY AND WHAT WAS PLANNED. RECOREDS ON PAPER AS WELL BY THE ACTIVIETY DIRECTOR SO HAVE 3 DIFFERENT AREA'S MDS :EVALATION: I AM RESP FOR SECTION K, IF RESIDENT WITH NEW WEIGHT LOSS, QUARTERLY I WOULD MAKE SURE CORRECT WIEGHT LOSS AND HAVE TO DO A CAA. CAA'S ADD MORE INFORMATION, INCLUDE DIAGNOSIES, WT LOSS. IF ITS THE NUTRITONAL CARE PLAN IT SI MY RESPONSIBILITY. I SHOULD OF UPDATED THE ORIGINAL CARE PLAN TO SHOW SHE HAD WIEGHT LOSS AT ?5% AND GENERALLY CAUGHT IN WHITE BOARD MEETING. WHO ELSE RESPO TO UPDATE CARE PLAN: I WOULD BE ULT RESP TO UPDATE A NUTRITIONAL CARE PLAN BUT IN WHTIE BOARD WHATEVER IS DISCUSSED SHOULD BE UPDATED. ORDERS/RECOMMENDATIONS/WT LOSS IS A TEAM EFFORT TO MAKE SURE ALL ORDERS GET PLACED THAT NEEDS TO GET DONE. GENREALLY IF ITS THE WEIGHT IS LOST 5 % THEN IT SHOULD BE FOLLOWED SHE CONT TO STATE IF THE WIGHT IS SIGNIFICATNT TO THE RESIDENT A LARGEER PERSON WHO LOSES 5% MAY NOT BE AS EFFECTED AS SOMEONE WHO DOESN'T HAVE WT TO LOSE. IF THEY HAVE A WT LOSS IT SHOUL BE PLACES O NTHE CARE PLAN IF NOT ON A CARE PLAN IT MIGHT NOT GET WHAT THEY NEED, ANY PERSON WHO MAY NOT KNOW SHE HAS HAD WT LOSS MAY NOT PICKJ UP THAT HER POOR FEEDING IS RECOGNIZNED AND BE REPORTED. WHEN THE CARE PLAN UPDATED: AFTER IT IS IDENTIFED AND WITH FIRST DICUSSION WITH IDT TEAM AND WHAT WE WILL BE DONE. WHO: THE TEAM AS A WHOLE, MDS NEW IDNTICATOR WHO IS RESPO TO UPDATE CP THAT WOULD BE ME WHAT: IF NOT CP WE MIGHT MISS AND LOSE MORE WIGHT. NOTIFIECATION RESP MD WERE TO BE NOTIFIED AND WAS TO BE NURSING WITH ANY SIG WEIGHT LOSS. STEVEN SANDERS MANT. DIRECTOR [DATE] 11:58 AM THE TELLS SYSTMES CUES US TO CHECK THE SCALES MONTHLY AND THIS INCLUDED THE LIFT SCALE. WE PUT A WIEGHT OF 25 BS IN THE SLING AND RAISE IT UP AND MAKES SURE IT MATCHES. WE HAVENT HAD ANY ISSUES WITH THE SCALES EXCEPT FOR NEEDING NEW BATTERY FO RTHE THE LIFT TO WORK. YES D[NAME]UEMTNED IN TELS SYSTEM; PROVIDE JUNE JULY RESULTS. REQUESTED. [DATE] 12:01 PM [DATE] 12:02 PM MELISSA HARMPER RN 15 MONTHS PR[NAME]ESS WTS: WT CHAIR HOYER LIFT AND SCALE FOR RESIDENTS. WE USE WC SCALE UNIFORMLY. DAILY WT EVERY AM BEFORE BREAKFAST. REPOTRED TO NURSE. WEEKLY WEIGHTS ARE DONE AND DIVIDED NIGH TO DAY AND DONE Q SUNDAY. AND WEIGHT NUMBER ARE PLACED INTHE BINDER FOR MONDAY AM, THE UM WILL ENTER INTO THE COMPUTER, WE LOOK AT WHAT THE WEIGHT WAS IF HIGH OR NLOW WE NOTIFY THE MD AFTER A REWEIGH. THE CNA IS NOT REQURIED TO REWEIGHT, THE NURSE HAS TO CATCH WHEN THE NTOICE AND THEAT AY NOT BE IMEEDIATELY. FIND OUT IF STARTED ON WEEKLY, 24 HOUR BOOK, LIST OF WEEKLY WEIGHTS IN BINDER AND EITHER TAR AND MAR FOR NEW ONES IT SHOULD BE PUT IN FOR A SUNDAY REWEIGHT. NURSES ARE REQURIED TO GET THAT ORDER AND THE MD WOULD BE NOTIFIED WITH THE ORDER, WHO: WT LOSS: THE NURSE WHO IS TKING CARE OF RESIDEN OR UM WHEN FOUND WHEN: IMMEDAILTY WHEN DISCOVERED AFTER REWEIGH. WHERE:NOTIFICATION IS TO BE WRITTEN INT HE PROGRESS NOTES, AND IF ITS NOT THEN IT DIDN'T HAPPEN. WHAT:[DATE] 12:07 PM THE MULT THINGS TO HAPPEN UNERLING INFECTOIN, DEPRESSION, ORAL ISSUES. [DATE] 12:07 PM [DATE] 12:07 PM [DATE] 12:07 PM AND TH RESIDENT MAY LOSE [MEDICATION NAME] CONT WEIGHT AND DELCINE IN ALL AREA'S STRENGTH, COGNTION ECT. CP: NEW WEIGHT LOSS SHOULD GENERATE A NEW CP: WHO THE NURSES SHOULD BE STARTING A NEW CP FOR WEIGHT LOSS, THEN WHITE BOARD CLINICAL MEETING, DM ADON/UM, DON. AND THE VERY NEXT DAY. ANY CHANGES OR NEW ORDERS ARE DISCUSSED. HOW EFFECT: NOT GONNA GET APPROPRIATE CARE THAT THEY NEEDS, MEDS, SUPPLEMENTS MONTIROING. UM: TRACY SANDERS ADON: KIM SIMMONS TRACY SANDERS UM DOGWOOD UNTI (100) 2YEARS [DATE] 12:13 PM PROT[NAME]OL WEIGHT/NAR RESIDENTS: IF PLACE D ON NAR FOR WTLOSS, NEW ADMIT WOUND [MEDICAL TREATMENT], NEW Q WEEK X4, THEN REMOVED IF STABLE IF OWUND LEAVE TILL 2 WEEKS AFTER HEALING WT LOSS: LEAVE ON TILL STABLIZED: AS IDT TEAM WE WOULD MAKE SURE WT LEVELED OFF, INTERVENTIONS STARTED WERE WORKING IT WOULD BE INDIVITDUALIZED. WEEKY WEIGHTS MD ORDER: AS A NURSING MEAUSRE YOU CAN WEIGHT WEEKLY. HOW DO ENSURE THE IS A WEEKY WEIGHT I ALWAYS TALKE TO THE NRUSES TO INFOMR THEM OF A WEIGHT LOSS: WE NEED TO BE MONITORING THEM TO ENSURE STAFF ARE DOING WEHAT THEY DO. WE HAVE THE WEIGHT BINDER WHICH INDICATES THE RESIDENT HAS HAD WEIGHT LOSS. WKY WTS: Q SUNDAYS DIVIdied ; WITH RESULTS THEY PUT A COPY IN MY DORR IN ADON DOOR AND LEAVE COPY NIN BINDER AND LEAVE COPY WITH REPORTS BOOK AND UM ME PUT INTO THE COMPUTER. I USED TO AUDIT THE WTS IN EMR AND IN NEW SYSTEM STARTED ,[DATE] YOU CAN AUDIT SO TERESA IS KEEPING UP WITH VARIANCE REPORT. NAR I ATTEND NAR: WHEN ID'D THEN WE TALK ABOUT THER ESIDNT HAS LOST WEIGHT, WE PUT IN INTERVENTIONS TO ADDRESS THE WEIGHT. CARE PLAN WILL TRIGGER IS WT LOSS IS > 5%. WHEN WE SEE THAT SOMETIMES WE WILL JUST PUT THEM ON WEEKLY WEIGHTS AND WATCH THEM EVEN WITH 5% WT LOSS. I IDENTIIFED THE WT LOSS WHEN I GOT THE MO WT AND BROUGHT TO THE IDT TEAM: AND WE PLACED HER ON NAR AND SHE SHOULD OF HAD A CARE PLAN BECAUSE IT WAS NEW AND SHE WAS PLACED ON NAR, IF IT WAS PUT ON THE MDS AS WT LOSS THEN THE DM SHOULD OF ALSO MADE SURE AN ACUTAL WT LOSS HAD [NAME]CURRED. I DID SPEAK TO TE DAUGHTER, HOWEVER I DID NOT SPEAK TO THE PHYSICIAN. J ITF ITS NOT BEEN D[NAME]UEMENTED I HAS NOT BEEN DONE. HOW EFFECT IF NOTIFICAITN SWER NOT COMPLETED AND CARE PLAN NOT UPDATED: TO INCLUDE WT LOSS: SHE CAN CONTINUE TO LOSE WEIGHT: LONG EFFECT HER IT CAN MAKE HER VERY ILL. WHO: NOTIF MD: THERE IS NOT REALLY ONE NURSE WITH WT LOSS, ITS THE NURSE WHO IS WORKING THAT SHIFT AND WHEN THEY WERE INFORMED BY ME OR THE ADON AND SHOULD BE D[NAME]UMENTED. CP: ALL OF THE IDT: INCLUDE SW, DM, DON, ADON, UM, AND MAKE HER VERY ILL. [DATE] 12:47 PM KIM SIMMONS 3 YEARS ADON NOT OVER THE DOGWOOD UNIT HOWEVER IDT TEAM AND NAR MEMEMBER ONCE ARESIDENT HAS BEEN IDENTIFIED W/ WT LOSS THEY ARE ADDED TO AT RISK NAR NAR MEETINSA THE RES ADDED, REVIEW INAKE, DIET, MED CHANGES ABILTIY TO FEED SELF AND TAK THE WHOLE PICTURE AND WHAT IS GOING ON. PUT INTERVENTIONS IN TO PLACE TO ADDRESS THE WT LOSS AND GET WT BACK. OLDER RESIDNETS WITH WT LOSS IS A BIG DEAL. CRITERA PUT IN PLACE EVERYONE: ADD SMP MEAL SUPP, SNACKS TO START, WEIGHTS ARE WEEKLY, WE EVIEW THEIR CARE PLAN AND WEEKLY INTAKE. ASSESSMENTS WITH NAR RESIDENTS: OR A REFFERALL : DO A ST REFERRAL, OT FOR ADAPTTIVE EQUIPEMENT. THE DIETICAIN IS NOTIFFIED: THEY ARE NOTIFIED FOR WT LOSS TO DO A REASSESSMENT A PROFESSIONAL ASSESSMENT TO ENSURE THE NUTITIORN SIDE IS REIVEWED. WHO NOTIFIES THE DIETICIAN: THE DM. NO ITS HER JOB. I FEEL ITS HER JOB. NURSING RESP IS T NOTIFEY THE D[NAME]OTR, FAMILY, FOLLOW UP THAT THE DIETICIAN DID SOMETHING WAS TOLD AND WAS ACTED UPON. IF THE MD WAS NOT NOTIFIED: NO ITS NOT ACCEPTABLE BECAUSE THE MD CAN ORDER LABS, CHECK THE MEDICAITON, MEIDCALLY GOING ON. THE DIETICIAN REASSESSMENT WOULD NED TO BE REORDERED FOR WEIGHT LOSS. WHO NOTIFIED MD: NAR: AFTER NAR I WOULD HAVE MY NURSES DO IT ON THE FLOOR WHO WAS RESPON. OR I CAN BUT MY NORMAL IS TO LET THE NURSES DO IT. THE NURSES ARE SUPPOSED TO D[NAME]UMENT THE NTOFICAITON: IF WASNT D[NAME]UEMENTED IT WASN'T DONE. WHEN NOTIFIED IMMED FRM THE MEETING. WHAT: AS ABL CP: NAR MEETING: WHO UPDATED NOT ANYONE IN PARTICULAR, WE UPDATE OUR OWN, BUT WE ALL CAN DO IT. CP SHOULD BE UPDATED IN NAR. REVIEW INTERV, REVIEW AND ADD NEW IF NEEDED. A NEW F[NAME]US SHOULD HAVE BEEN STARTED FOR THE ACUTAL WT LOSS: BECUASE SHE HAS HAD A SUDDEN WT LOSS FOR NO REASON AND IT WAS UNEXPECTED. BECAUSE OF THE 5% AND SHE WAS ADDED TO NAR: THE WHOLE TEAM IS RESPONSBLE TO START A NEW F[NAME]US. MDS REVIEW: Quarterly YES THE DM SHOULD OF SGTARTED A NEW F[NAME]US FOR WT LOSS. THEY ARE PUT ONT HE WEIGHT LOSS BOARD AND THE CP SHOUD BE NEW IMPLEMENTATION TO ID THAT THE WT LOSS HAS BEEN IDENTIIFED. EFFECT RESIDENT IF CARE PLAN NOT CORRECTEC CAN CUSE NEW WT LOSS AND PREVENT US TO IDENTIFY WHAT IS CAUSING THE WT LOSS AND EFFECTS HER BECAUSE THER EIS NOT GUIDE TO SEE IF THE INTERVENTIONS WERE INPLACE AND ACTUALLY WORKING. AUDITS: REIVEW THE CHARTS FOR ACCURACY NO ID ONT' I DONT HAVE TIME. NIGHT SHIFT DOES CHART CHECKS BUT ONLY FOR ORDERS NOT TO SEE IF THE CARE PLAN REFLECTS THE RESIDNETS AND I KNOW THE UM DOESNT BECAUSE WE DON'T HAVE TIME. [DATE] 01:09 PM DON BARBIE WOOD NAR: TEAM: ROLE AS DON I OVERSEE THE MEEGING IS FLOWING DISCUSS RESIDENTS INTERVENTIONS. THE DM RUNS THE MEETING. DM RUNS REPORTS TO IDENIFY THE WT LOSS AND TO BRING TO MEETING I LOOK AT MONTHLY WTS AND LOOK AT NAR RESIDENTS WEEKLY. PERKINS NAR ,[DATE] NAR: ACHART BROUGHT INTO ROOM: UPDATE INTERVENTIONS: NEW WT LOSS: ASK DM TO MAKE SURE DIETICINA TO SEE ON NEXT VISIT, CALL THE MD TO NOTIFY AND GET ORDRES IF INDICATED. CALL TO MD TO BE D[NAME]UMENTS THE, SOMEONE INT HE NURSIND DEPARTMENT, OR FLOOR NURSE, UM OR ADON USUALLY. CP: IN NAR: WHOEVER IS INTHE ROOM AND WHO GRABBED THE CHART: AUDIT: I HAVE NEVER AUDITED NAR CHARTS FOR CARE PLAN INTEVENTIONS AND TO ENSURE THEY REFLECT THE REFLECT. CP ARE TO UNPDATED NEW F[NAME]US SHOULD BE STARTED WHEN- IN THE MEETING AND IT SHOULD ACCURAGLEY REFLECT THE RESIDNET, MDS EVAL TO BE ACCURATE FREFLECT RESIDENT. IF NOT ACURRACT REFLECTIN: SHE COULD CONT TO HAVE WT LOSS. AND LONG TERM CAN DEV SKIN ISSUES. NOTIFICATIONS: NAR: EITH UM OR DESIGANTE TO CALL THE MD. UM SHOULD FU TO BE DONE, NOT DONE THEY SHOULD DO IT THEMSELVES AND IS TO BE CHARTED. DIETICIAN WAS NOT NOTIFIED: CONTINUE TO LOSE WT EFFECT SKIN AS DONE RESPON FOR RES IN FACILITY TO ENSURE THEY ARE TAKEN CARE OF SO NEW F[NAME]US SHOULD IF NAR AT LEAST WITH MDS: THE DM WOULD OF BEEN RESPONSIBLE TO DO A NEW F[NAME]US FOR WT LOSS. [DATE] 02:50 PM pc to dr bale medical director, vm left to call for interview needs BU

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to insure controlled medication records accounted for per facility procedures to prevent diversion. Review of a Narcotic Flow Sheet revealed no witness signature for the removal of a card. In addition, review of the narcotic sheet count revealed the count was incorrect for two (2) days. The findings include: Review of facility policy Medication Storage-Controlled Medication Storage, dated (MONTH) (YEAR), revealed medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and record keeping. Review of facility In-Service: (MONTH) (YEAR), revealed the facility requirement for staff to note medication removed, reason, and both nursing staff signatures and ending cart balance. Review of a Narcotic Flow Sheet, revealed the entry on [DATE] for the night shift indicated the removal of the medication card for [MEDICATION NAME] one hundred (100) milligrams. The entry contained the signature of only one (1) staff member, with the signature line for the second staff member blank. An audit of the narcotic cards in the lock box, on [DATE], revealed a discrepancy in the count of the narcotic card sheets. The audit revealed an incorrect count of the medication cards led to a discrepancy on the Narcotic Flow Sheet in which staff incorrectly documented the number of cards. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:01 PM, revealed two (2) nurses should sign-off when removing controlled substance cards from the available supply. LPN #1 stated a nurse removed the controlled substance and signed the record. That nurse then showed the card to a second nurse who then signed the record. LPN #1 stated the facility provided an in-service to staff regarding controlled substance card count. Continued interview with LPN #1 revealed the on-coming nurse and the off-going nurse failed to count the narcotic count sheets correctly for two (2) days. LPN #1 stated staff were incorrectly counting the boxes of [MEDICATION NAME], by counting the boxes of [MEDICATION NAME] as two (2) separate containers as opposed to one (1). LPN #1 stated the facility audited narcotics to insure there was no diversion of these medications from the facility. Interview with the Director of Nursing (DON), on [DATE] at 4:02 PM, revealed two (2) staff insured narcotic medication counts were correct and signed the sheet as a record. The DON stated the facility conducted an audit/count of controlled substances in (MONTH) 2014, and found no discrepancies. Interview with the Administrator, on [DATE] at 9:33 AM, revealed the facility secured controlled medications by requiring two (2) nursing staff to perform a manual count of controlled substances and sign-off on the counts. one of eight medication carts one of two nursing units Magnolia Unit and the Dogwood Unit The facility failed to follow the pharmacy process for narcotic reconciliation for one of two units. The narcotic card count was not accurate and staff failed to visualize/witness the empty narcotic card before signing off a correct count. (Magnolia unit) medication cart no citation for unlocked med cart due to orientation was ongoing with the cart and the cart was still in view of nurses FACILITY Medication Storage and Labeling [DATE] 11:01 AM Isabella(NAME)LPN- 400 cart-Nitro -09--0920, hemaocult-,[DATE] 7 ,[DATE], [MEDICATION NAME] -,[DATE], eye gtt ,[DATE], [MEDICATION NAME] ,[DATE], [MEDICATION NAME]-,[DATE] k exylate-,[DATE], [MEDICATION NAME] ,[DATE], [MEDICATION NAME] ,[DATE], narc- [MEDICATION NAME]es- 4 count,[MEDICATION NAME] count- no problems with expiration. Disscrepancy in narc count, 22 narc sheets correct 0, narc-4- Lea Kearney LPN- - 300 hall cart nitro-,[DATE], eye gtts ,[DATE] [MEDICATION NAME]-,[DATE], [MEDICATION NAME]-,[DATE] Nursing stationMagnoal<BR/(NAME)Cerry- LPNx ,[DATE] years. Medication cart unlocked- resident could get medication out adverse effect on resident =med error<BR/(NAME)Gettle LPN in training-she had eyes on medication cart at all times. insulin-,[DATE], Vit B ,[DATE], inhaler ,[DATE] Cart ,[DATE] nitro-,[DATE]eye gtts- ,[DATE], waste with 2 staff , put on sharps container and document on back of narc sheet Magnolia hall med room for all extra narcs- temp- 45 degrees TB serum -,[DATE], refib- ,[DATE], insulin-,[DATE], yello top tube ,[DATE], ER chart in stock room nothing expired, NS ,[DATE] Procedure to fdisposing narcs- 2 nurses take to DON takes 2 people to open narc box then disolve narcs , log of wasted narcs, and narcotic sheet; both sign sheet. Narcotic pkg cards count count cards when narc add to sheet then when go out take it off the sheet. No body signs off that they reordered it, put a sheet in Chart that , 2 nurses sign off and nurses should witnessed it . Is it procedure tto sign off without seeing it. No, it is ridelous to sign off something that you did not see it. They show cards to other nurse and sign off. and it should have been deducted from card sheet. Should hhave been looked at and signed off. syrgines ,[DATE], stock room ensure- ,[DATE], nephro-,[DATE], glucerna-,[DATE], 2 calHN-,[DATE], sterile ,[DATE]<BR/(NAME)didnt reove cart this morning, I was nervous, panic And the count hAS BEEN OFF FOR 2 DAYS THE CARD WAS REMOVED 2 DAYS AGO , the last signed out narc on the card was [DATE] and was . Process of narc shift change. We were counting them wrong D/T [MEDICATION NAME] boxes 2 and was counting. at what point do u count the cards and put on the card sheet, typically the cards match we look to see if something has been forgotten to add or delete cards. I realized that the card count was off when state ask about cards. On friday-trouble this weekend call MD for ER RX of narco.MD was called on Sat. call in partial script, 3 days worth of pills flow sheet the narc was not taken off of card sheet on tuesday. and card count was incorrect for 2 days. Education for all nurses inserviced to stop what they are doing if there is a narc count wrong. then everyone will count carts. 1 month ago audit count audit completed.Kelly(NAME)RN SDC, will inservice this evening . roaster to ensure that all employess have been inserviced. Anytime a decripency in count lock cart and get ADMIN to investigate hat happened and do an investigation . Barbie Wood get UM together bring narc to me log in book ensure that it was correct, the DON/ADON have to open box to narc together Cart locking always keep locked, if employee in eye view of cart is it ok to keep unlocked=NO Narc folder in DON office count that DON/ADON have to sign when narcs are destroyed. [DATE] 09:33 AM Fred(NAME)ADMIN- Narc are always double locked 2 key holders. Count for the nurses fo a manual count, theyb sign that the count is correct. How do you ensur that staff are doing we take it to QI, orientation, competency fairs throughout the year. Do you reviw audits review in QI, DON brings records to QI, never had any problems with count. Card count sysytem signature tool not a system is not a tool. (NAME)Stone SDC RN x2018.Completes all in-service in blg (MONTH) was all in-service, di all nurses attended, problem in (MONTH) whole in count in-service on how to count correctly, no issues with the narcotic cards.If there is an decrepency let the supervisor know statrt a inservice. should sign off if incorrect and you did not see card.<BR/(NAME)Carey- LPN [DATE] 09:48 AM process of card being removed take top off , write down meds empty then sign, can have a nurse sign if avaialbel. Policy stated that you have to havee 2 nurses to sign. Did not see that narc card and signed and I should not have sign that I did that . Did that d/t being nervous. If I did not see next time I would not do this. Yesterday I was inserviced on process and have been inserviced in the past. I saw that the sheet was accounted for and every med was accounted for.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for two (2) of twenty-two (22) sampled residents, Resident #18 and #54. Staff failed to provide care consistent with the care plan, which resulted in facial bruising to Resident #18 and Resident #54 was not monitored for side effects of [MEDICAL CONDITION] medication according to the care plan. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed the Comprehensive Care Plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The nurse/Interdisciplinary team developed and maintained a comprehensive care plan for each resident that would identify the highest level of functioning the resident might be expected to attain. Care plan interventions were to be implemented to reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. The policy stated care plans were ongoing and would be revised as information about the resident and the resident's condition changed. 1. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/01/12. The resident had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) and determined the resident not interviewable. Per the MDS, the resident had clear speech; usually had the ability to express ideas and wants; and had the ability to understand others. The facility assessed the resident displayed behaviors not directed toward others for one (1) to three (3) days. Observation of Resident #18, on 05/15/18 at 10:55 AM, revealed him/her in a reclined chair on the 200 Hall with a black/purple discoloration around the right periorbital (eye) area. Interview with Resident #18, on 05/15/18 at 10:55 AM, revealed two (2) Certified Nursing Assistants (CNA) had approached him/her during the night, and woke him/her out of a deep sleep to change his/her dirty brief. The resident stated when the CNAs turned him/her over to his/her side, it hurt because he/she had arthritis. The resident continued to state the CNAs would not listen to him/her when he/she tried to tell them how to turn him/her without hurting him/her. Resident #18 stated the CNAs hit him/her in the eye with something during the time they were changing his/her brief. Review of Resident #18's Progress Notes, dated 05/15/18 at 4:07 AM, revealed Registered Nurse (RN) #1 documented when the CNAs went into Resident #18's room to change a soiled brief, the resident began hollering for help. After explaining they were there to assist with peri-care, the resident cursed them and slapped one CNA on the mouth. Appropriate behaviors encouraged and the resident was left in a calm, quiet environment. Review of a Nursing Assessment, signed and dated by RN #1 on 05/15/18 at 6:15 AM, revealed while staff was changing Resident #18's soiled brief, the resident became combative and slapped staff on their face, with arms flailing. Later, bruising was noted under the resident's right eye. The CNA stated when she turned the resident she noticed his/her face was close to a bed remote hanging on a turning bar, but was unsure if the resident hit his/her head on the turning bar. Review of Resident #18's Comprehensive Care Plan, dated 09/02/17, revealed the resident was at risk for injury or harm related to potential misunderstandings that might arise secondary to his/her cognitive impairment related to the [DIAGNOSES REDACTED]. The goal was the resident would make routine daily decisions with cues/supervision regarding activities of daily living and participate with care. Interventions included if the resident was restless or agitated, re-approach later. Interview with CNA #2, on 05/16/18 at 11:35 AM, via telephone revealed she and CNA #3 approached Resident #18 during the early morning of 05/15/18 and informed the resident they came to change his/her brief. She stated they turned the resident to his/her right side and the resident proceeded to push his/her body away by pushing against the bed's grab bar and then the resident gave in and hit his/her head on the turn bar. She stated the resident was hollering to quit, but they continued to change the brief and wipe excrement off the resident's skin. The CNA stated she should have stopped changing the resident when he/she said too, and notified the resident's nurse. She stated she had been educated on the care of the Dementia residents and knew to leave agitated residents alone and try to re-attempt care after a brief time. Interview with CNA #3, on 05/16/18 at 1:58 PM, via telephone revealed she and CNA #2 went into Resident #18's room on 05/15/18 at around 3:40 AM to change the resident's brief and to turn him/her. She stated the resident used the grab bar to push himself/herself away from her as she was pulling him/her. It was then the resident rolled into the remote on his/her bed. She stated it was normal for the resident to have behaviors but it would have made more sense to stop trying to change the resident's brief and notify the resident's nurse. CNA #3 stated she noticed bruising on the resident's right eye at 5:40 AM, and immediately notified the resident's nurse. Review of Educational Training revealed CNA #2 and #3 received training and education on the care of residents with Dementia in (YEAR). Interview with CNA #4, on 05/16/18 at 2:33 PM, revealed she would go to the nurse if she encountered behaviors with any resident. She stated she had been educated to stop providing care to a resident when the resident was stating to stop or quit as long as the resident was safe, and it was never acceptable to force a resident to do anything. Interview with RN #1 via telephone, on 05/17/18 at 10:00 AM, revealed she was informed about Resident #18's bruised eye area around 6:00 AM the morning of 05/15/18 by a CNA. She stated staff told her the resident might have hit his/her eye area on a remote when he/she became disruptive during a brief change. The nurse stated the CNAs should have notified her when the resident became disruptive with the brief change, gave the resident a little time, and then went back and re-approached him/her later, which was an intervention often utilized with residents who had Dementia. The nurse stated the resident did have some confusion and sometimes refused medications, but with re-assurance and re-education, he/she generally became less agitated. She stated it was not very often the resident displayed behaviors while she provided care to him/her. She stated the resident was a high risk for bleeding due to his/her medications ([MEDICATION NAME] to reduce blood clot risk) which could have caused increased bleeding. She stated resident care plans helped staff better care for each individual resident. Interview with RN #2, on 05/16/18 at 3:00 PM, revealed she was familiar with Resident #18 and the resident's plan of care. She stated if the resident directed staff to stop or quit, staff should have re-assured the resident and/or re-approached the resident a while later as directed by the care plan. The RN stated Resident #18's behaviors would escalate when staff went against his/her requests, as the resident was not always confused. Interview with the Unit Manager, on 05/16/18 at 10:30 AM, revealed Resident #18's care plan indicated staff should re-approach the resident later when he/she displayed negative behaviors or specific requests, and the nurse should have been notified right away when the resident started having behaviors. Interview with the Director of Nursing (DON), on 05/16/18 at 10:30 AM, revealed the CNAs had received training related to how to effectively deal with and manage residents with behaviors and a Dementia diagnosis. She stated the CNAs should have stopped what they were doing with Resident #18, notified the nurse immediately, and re-approached the resident again after a short period of time. 2. Review of the facility's policy, [MEDICAL CONDITION] Medication, not dated, revealed the facility would make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks, and/or benefits. The policy revealed nursing staff was responsible for reviewing the use of the medication with the physician and the Interdisciplinary Team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. Review of the clinical record revealed the facility admitted Resident #54 on 12/01/15, with [DIAGNOSES REDACTED]. Review of Resident #54's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined he/she was interviewable. The facility assessed the resident had no potential indicators of [MEDICAL CONDITION] and had not displayed behavioral symptoms. Per the MDS, the resident received Antipsychotic medication for the last seven (7) days. Review of the Physician Orders, dated (MONTH) (YEAR), for Resident #54 revealed an order for [REDACTED]. Observation, on 05/15/18 at 12:52 PM, revealed Resident #54 in bed with his/her eyes closed and a lunch tray on the over the bed table. Interview with Resident #54, on 05/15/18 at 1:30 PM, revealed he/she had been sleepier the last few days. The resident was in bed with an uneaten lunch tray at the bedside. At 2:51 PM, the resident was in bed. Observation, on 05/16/18 at 9:43 AM, revealed Resident #54 in bed and the breakfast tray was on the over the bed table. At 3:09 PM, he/she remained in bed. Review of Resident #54's Care Plan, dated 03/23/16, revealed the resident was at risk for signs and symptoms of adverse effects of [MEDICAL CONDITION] medication with a goal to be free from signs and symptoms of adverse effects. The interventions included observe for signs and symptoms of drug related decline in appetite. Report to the Physician any negative outcomes associated with use of the drug. Review of the Progress Notes, dated 05/05/18 at 8:53 AM, revealed Resident #54 refused the evening dose of [MEDICATION NAME], had reportedly refused all week and stated he/she was not going to take the medication again because it made him/her sleepy. Review of the Medication Administration Record [REDACTED]. Further review of Physician order [REDACTED]. Review of Resident #54's Behavior Monitoring revealed the resident exhibited no behaviors 01/03/18 through 05/15/18. However, review of Progress Notes, dated 05/14/18, revealed the administration time for [MEDICATION NAME] was changed from 8:00 PM to 8:00 AM and further review of the MAR indicated [REDACTED]. Review of Resident #54's MAR, dated 02/01/18 through 05/15/18, for Antipsychotic Side Effect Monitoring revealed the resident exhibited no side effects related to the use of antipsychotics, including drowsiness and loss of appetite. Interview, on 05/17/18 at 10:01 AM, with CNA #5, revealed Resident #54 did not get out of bed much and slept a lot. The CNA stated the resident sometimes refused to take a shower, but she had not witnessed any behaviors. Interview with RN #4, on 05/17/18 at 10:25 AM, revealed resident behaviors should be documented in the behavior notes and medication side effects in the MAR. The RN stated Resident #54 slept a lot but she had not notified the physician because she thought it was part of his/her personality. Interview with RN #5, on 05/17/18 at 1:10 PM, revealed she requested a change of Resident #54's [MEDICATION NAME] administration time from bedtime to 8:00 AM because the resident reported the medication made him/her sleepy. The RN stated she had not noticed any recent changes in the resident's sleep patterns. Interview with the Assistant Director of Nursing (ADON), on 05/17/18 at 11:35 AM, revealed Resident #54 had decreased appetite and was in bed more since the last Gradual Dose Reduction (GDR), but she had not notified the physician. The ADON revealed the purpose of monitoring for side effects of psychoactive medication was to ensure the appropriateness of the medication. According to the ADON, there was no behavior or side effects documented in the clinical record to support the use or discontinuation of Resident #54's [MEDICATION NAME]. She further revealed the [MEDICAL CONDITION] medication care plan related to monitoring for side effects was not followed. Interview, on 05/17/18 at 3:30 PM, with the DON revealed she had not identified any concerns regarding monitoring for side effects of psychoactive medications.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide care following professional standards for three (3) of twenty-two (22) sampled residents, Resident #11, #24, and #84. Observation revealed staff did not verify Gastrostomy tube ([DEVICE]) placement prior to flushing the tube for Resident #24, and staff did not obtain accu-checks per the facility's guidelines for Resident #11 and #84. The findings include: Review of the facility's Gastrostomy Feeding Competency, dated 10/02/15, revealed guideline step #7 stated to verify tube placement. Review of the facility's Capillary Blood Glucose Level Competency, dated 06/01/15, revealed guideline step #8 stated to obtain a blood sample by using a sterile lancet (a spring-loaded or manual lancet). Discard the first drop of blood if alcohol was used to clean the fingertips because alcohol might alter the results. Observation of Resident #24, on 05/16/18 at 10:50 AM, revealed Licensed Practical Nurse (LPN) #2 flushed the resident's [DEVICE] with 60 cubic centimeters (cc) of water without checking for placement prior to flushing. Observation of Resident #84, on 05/16/18 at 10:35 AM, revealed LPN #2 performed an accu-check on the resident. The nurse cleaned the resident's finger with an alcohol prep, stuck the resident's finger, and did not discard the first sample of blood. Observation of Resident #11, on 05/17/18 at 11:00 AM, revealed LPN #1 performed an accu-check using an alcohol prep to clean the resident's finger and the proceeded to use the first sample of blood for the reading. Interview with LPN #2, on 05/17/18 at 2:00 PM, revealed she was not trained to discard the first drop of blood if alcohol was used to collect a sample for an accu-check. LPN #2 stated she knew when she stepped out of Resident #24 room; she forgot to check for [DEVICE] placement. She stated it was important to check for placement to make sure medications and flushes went to the right place, preventing possible infection. Interview with Registered Nurse (RN) #4, on 05/17/18 at 2:10 PM, revealed it was important to wipe away the first drop of blood when using an alcohol prep for accu-checks because alcohol interfered with the accuracy of the sample. RN #4 also stated it was important to check for placement of a [DEVICE] to make sure medications went into the right place. Interview with RN #3, on 05/17/18 at 2:20 PM, revealed it was important to check placement of a [DEVICE] to prevent medication or flushes from going into interstitial space, which could cause infection. RN #3 also stated the first drop of blood should be discarded due to alcohol tainting the accuracy of the accu-check reading, which could possibly cause harm to a resident because of an inaccurate result. Interview with RN #2, on 05/17/18 at 2:30 PM, revealed she discarded the first sample of blood after cleaning fingers with alcohol to ensure an accurate reading. RN #2 stated checking for [DEVICE] placement was important to prevent medication or flushes from going in between tissues and causing infection. Interview with the Director of Nursing (DON), on 05/17/18 at 2:40 PM, revealed it was important to check for [DEVICE] placement because it would be very detrimental to a resident if medications or flushes entered the wrong space, as it could possibly harm a resident. The DON also stated staff should always discard the first drop of blood when using an alcohol wipe to maintain accuracy of the sample.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain a hazard free environment for one (1) of twenty-two (22) sampled residents, Resident #18. Staff failed to implement care plan interventions while providing care, which resulted in facial bruising to the resident. The findings include: Review of the facility's policy, Dementia Care, revised 06/28/17, revealed the facility was to enhance the quality of life and care for residents with Dementia with a goal to provide an environment that was peaceful, calm, safe, and accepting thus enabling residents to reach their full potential. The policy continued to state the focus of care was directed toward what the resident could do so their optimal physical functioning, enjoyment of life, and self-esteem was maintained. Individualized approaches to care would be utilized to focus on the resident's needs in an attempt to reduce behavioral expressions of distress. The aims of care followed included promotion and maintenance of a safe environment, practice of minimal interaction with residents whom were highly agitated or who experienced an altered behavior in their responses, and respect of the personal space of each resident. Review of the facility's Management of Aggressive Behavior Tool, dated 06/01/15, revealed the purpose was to protect the residents from injuring themselves or others and to bring aggressive incidents and occurrences under control. The guideline steps included allowing the aggressive resident space, avoid standing too close, surrounding, or touching the aggressive resident, and to take a calm approach. Observation of Resident #18, on 05/15/18 at 10:55 AM, revealed the resident sitting in a reclined chair on the 200 Hall. The resident had a black/purple discoloration around the right eye. Interview, on 05/15/18 at 10:55 AM, with Resident #18 during the observation revealed two (2) Certified Nursing Assistants (CNA) came into his/her room during the night and woke him/her out of a deep sleep to change his/her brief. The resident stated when the CNAs turned him/her over to his/her side, it hurt as he/she had arthritis. Per the resident, the CNAs would not listen to him/her when he/she tried to tell them how to turn him/her without it hurting. Resident #18 revealed the CNAs hit him/her in the eye with something during the time they were changing his/her brief and he/she would hit anyone who tried to hurt him/her. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/01/12, and had multiple diagnoses, which included [MEDICAL CONDITIONS]/[MEDICAL CONDITION], and Dementia with Behaviors. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility determined the resident had clear speech; usually had the ability to express ideas and wants; and had the ability to understand others. The facility assessed the resident displayed behaviors not directed toward others for one (1) to three (3) days. Review of Progress Notes, dated 05/15/18 at 4:07 AM, revealed CNAs went into Resident #18's room to change a soiled brief; the resident began hollering for help. After explaining staff was there to assist with peri-care, the resident cursed them and slapped a CNA on the mouth. Appropriate behaviors were encouraged and the resident was left in a calm, quiet environment. Review of a Nursing Assessment, dated 05/15/18 at 6:15 AM, revealed Resident #18 became combative and slapped staff on the face, with arms flailing, while changing the resident's soiled brief. Bruising was noted under the resident's right eye later. The CNA said when she turned the resident, she noticed his/her face was close to a bed remote hanging on a turning bar, but she was unsure if the resident hit his/her head on the turning bar. Review of Resident #18's Care Plan, dated 09/02/17, revealed a risk for injury or harm related to potential misunderstandings that might arise secondary to the resident's cognitive impairment and interventions listed included if the resident was restless or agitated, re-approach later. Interview via telephone, on 05/16/18 at 11:35 AM, with CNA #2 revealed she and CNA #3 entered Resident #18's room early in the morning on 05/15/18 to change his/her brief. She stated while the resident was turned to his/her right side, he/she pushed away by pushing against the grab bar on the bed and when the resident gave in, he/she hit his/her head on the turn bar. She stated the resident yelled to stop but she and CNA #3 continued to change the brief. She revealed they should have stopped when the resident said too because she had been trained to leave agitated residents alone and re-attempt care after a brief period of time. Interview via telephone, on 05/16/18 at 1:58 PM, with CNA #3 revealed she went with CNA #2 to change Resident #18's brief and turn him/her on 05/15/18 at around 3:40 AM. She stated the resident pushed himself/herself away from her as she had was turning him/her and the resident rolled into the remote on the bed. She stated she and CNA #2 should have stopped trying to change the resident's brief and notified the nurse. CNA #3 stated she immediately notified the resident's nurse when she noticed bruising on the resident's right eye at 5:40 AM. Interview, on 05/16/18 at 2:33 PM, with CNA #4 revealed when providing care, it was never acceptable to force a resident to do anything if the resident said to stop, per the education she received. She stated she would notify the nurse if she encountered behaviors with a resident. Interview via telephone, on 05/17/18 at 10:00 AM, with Registered Nurse (RN) #1 revealed around 6:00 AM on 05/15/18, staff informed her about Resident #18's bruised eye area that happened when the resident became disruptive during a brief change and possibly hit his/her eye on a remote. RN #1 stated when the resident became disruptive with the brief change, staff should have notified her, and gave the resident a little time and then re-approached him/her later. She stated that was an intervention staff utilized with residents with Dementia. Per interview, the resident had some confusion and became less agitated with re-assurance and re-education. RN #1 stated the resident was a high risk for bleeding due to his/her medications ([MEDICATION NAME] to reduce blood clot risk) which could have caused increased bleeding. Interview, on 05/16/18 at 3:00 PM, with RN #2 revealed if Resident #18 told staff to stop, staff should have re-assured the resident, and/or re-approached the resident a while later. According to RN #2, Resident #18 was not always confused and his/her behaviors would escalate if staff went against his/her requests. Interview, on 05/16/18 at 10:30 AM, with the Director of Nursing revealed the nursing assistants should have stopped what they were doing and notified the nurse, and re-approached Resident #18 after a short period of time. She stated the CNAs were trained on how to manage residents with behaviors and diagnosed with [REDACTED]. Review of Educational Training revealed CNA #2 and #3 received training and education on the care of residents with Dementia in (YEAR), as well as Accident Prevention and Management.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide appropriate care and services to one (1) of twenty-two (22) sampled residents, Resident #18. The resident was diagnosed with [REDACTED]. The findings include: Review of the facility's Dementia Care Policy, revised 06/28/17, revealed it was the policy of the facility to enhance the quality of life and care for residents with Dementia and the goal for the residents with dementia was to provide an environment that was peaceful, calm, safe, and accepting, thus enabling them to reach their full potential. Individualized approaches to care would be utilized to focus on the resident's needs in an attempt to reduce behavioral expressions of distress. Review of the facility's Management of Aggressive Behavior Tool, dated 06/01/15, revealed the purpose was to protect the residents from injuring themselves or others, and to bring aggressive incidents and occurrences under control by allowing the aggressive resident space, avoid standing too close, surrounding, or touching the aggressive resident, and to take a calm approach. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/01/12 and had multiple [DIAGNOSES REDACTED]. Per the Quarterly Minimum Data Set, dated dated [DATE], the facility assessed the resident had clear speech, usually had the ability to express ideas and wants, and had the ability to understand others. The facility determined the resident displayed behaviors not directed toward others that occurred one (1) to three (3) days. Interview with Resident #18, on 05/15/18 at 10:55 AM, revealed two (2) Certified Nursing Assistants (CNA) woke him/her out of a deep sleep to change his/her brief. The resident stated he/she had arthritis and it hurt when they turned him/her over to his/her side. Resident #18 continued to state he/she tried to tell the CNAs how to turn him/her with it hurting, but they would not listen. According to the resident, the CNAs hit him in the eye with something during the brief change. Observation of the resident during the interview revealed he/she had a black/purple discoloration around the right eye. Review of Resident #18's Progress Notes, dated 05/15/18 at 4:07 AM, revealed when the CNAs went into Resident #18's room to change a soiled brief, the resident began hollering for help. After explaining they were there to assist with peri-care, the resident cursed them and slapped one CNA on the mouth. Appropriate behaviors encouraged and the resident was left in a calm, quiet environment. Review of a Nursing Assessment, dated 05/15/18 at 6:15 AM, revealed Registered Nurse (RN) #1 documented while staff was changing Resident #18's soiled brief, the resident became combative and slapped staff on the face, while arms flailing. Later, staff noticed bruising under the resident's right eye. The CNA stated when she turned the resident she noticed his/her face was close to a bed remote hanging on a turning bar, but was unsure if the resident hit his/her head on the turning bar. Review of Resident #18's Care Plan, dated 09/02/17, revealed a potential alteration in safety and well-being and the resident was at risk for injury or harm related to potential misunderstandings that might arise secondary to his/her [DIAGNOSES REDACTED]. The goal was for the resident to make routine daily decisions with cues/supervision regarding activities of daily living and participate with care. Interventions included to re-approach the resident later if the resident was restless or agitated. Interview with CNA #2 via telephone, on 05/16/18 at 11:35 AM, revealed on 05/15/18 in the early morning, she and CNA #3 approached Resident #18 and informed him/her they were going to change his/her brief. She stated the resident was turned to his/her right side and was pushing his/her body away by pushing against the bed grab bar. She stated the resident gave in and hit his/her head on the turn bar. According to CNA #2, the resident hollered to quit, but they continued to change the brief and clean the resident's skin; however, the CNA stated she should have stopped when the resident said too, and notified the nurse. She stated Dementia training instructed staff to leave agitated residents alone and try to re-attempt care after a brief period. Interview with CNA #3 via telephone, on 05/16/18 at 1:58 PM, revealed she and CNA #2 went into Resident #18's room on 05/15/18 at around 3:40 AM to change the resident's brief and to turn him/her. She stated the resident used the grab bar to push himself/herself away from her as she turned him/her and the resident rolled into the remote on his/her bed. The CNA stated the resident usually displayed behaviors, and they should have stop trying to change the resident's brief and notified the nurse. CNA #3 stated she noticed bruising on the resident's right eye at 5:40 AM and immediately notified the resident's nurse. Review of educational training revealed CNA #2 and CNA #3 received Dementia Training Behavior Management in (YEAR). Interview with CNA #4, on 05/16/18 at 2:33 PM, revealed she would always go to the nurse if she encountered behaviors with any resident. She stated she had been educated to immediately stop providing care to a resident when the resident was stating to stop or quit (as long as the resident was safe) and it was never acceptable to force a resident to do anything. Interview with Restorative Aide #1, on 05/17/18 at 10:10 AM, revealed she frequently cared for Resident #18 during the resident's restorative care sessions. She stated the resident could become agitated and combative and it was appropriate for staff to leave him/her alone and re-approach at another time. She stated the resident sometimes complained of pain with treatment and would state to stop. The Restorative Aide stated staff would halt therapy, resumed if the resident agreed, but if the resident became uncooperative, staff would then report his/her behaviors to the resident's nurse. She stated Resident #18 was mostly cognitively aware and appropriate when she worked with him/her. She stated by continuing to perform a task to a resident when the resident had stated stop was against resident rights, and stated staff had been trained multiple times on resident rights. Interview with RN #1 via telephone, on 05/17/18 at 10:00 AM, revealed the CNA reported to her about Resident #18's bruised eye around 6:00 AM the morning of 05/15/18, that occurred during a brief change when he/she became disruptive and might have hit his/her eye area on a remote. The nurse stated the CNAs should have notified her when the resident became disruptive, and gave him/her a little time and then went back and re-approached him/her later, which was an intervention often utilized with residents who had Dementia. RN #1 stated the resident had some confusion, but with re-assurance and re-education, he/she generally became less agitated. Interview with RN #2, on 05/16/18 at 3:00 PM, revealed she was familiar with Resident #18 and if the resident directed staff to stop, or quit, staff should have re-assured the resident and/or re-approached the resident a while later. The RN stated Resident #18's behaviors would escalate when staff went against his/her requests, as the resident was not always confused. Interview with the Unit Manager, on 05/16/18 at 10:30 AM, revealed the care plan for Resident #18 indicated the resident should have been re-approached later when he/she displayed behaviors. She stated the nurse should have been notified right away when the resident started having behaviors. Interview with the Director of Nursing, on 05/16/18 at 10:30 AM, revealed the CNAs were trained how to effectively deal and manage residents with behaviors and a Dementia diagnosis. She stated the CNAs should have stopped what they were doing with Resident #18, notified the nurse immediately, and re-approached the resident again after a short period of time.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents, Resident #54, was free from unnecessary medications. The facility failed to discontinue Resident #54's [MEDICATION NAME] (antipsychotic) as ordered by the physician and failed to monitor for side effects of the medication. The findings include: Review of the facility's policy, Behavior Management, reviewed (MONTH) (YEAR), revealed a Behavior Management Care Plan (BMP) would be developed by the Social Worker/designee for any resident exhibiting a behavior that interfered with the Plan of Care. The policy revealed the BMP would identify appropriate interventions to manage identified behavior(s) and include measurable goals related to the behavior. According to the policy, a copy of the BMP would be kept in a BMP Manual at each nurses' station and in a BMP Manual in the Social Services Director's office. Review of the facility's policy, Target Behavior Management, reviewed 11/23/15, revealed the Interdisciplinary team (IDT) would review residents with target behaviors at the weekly At Risk meeting and complete the [MEDICAL CONDITION] Review/Behavior Meeting form. The policy further revealed the IDT would review residents' [MEDICAL CONDITION] medications to determine if a Gradual Dose Reduction (GDR) was indicated and complete the [MEDICAL CONDITION] Review Committee Recommendation form. The form would then be reviewed and signed by Psychiatric Services and the Medical Director/Physician. Review of the facility's policy, [MEDICAL CONDITION] Medication, not dated, revealed the facility would make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications in the long-term care facility to include regular review for continue need, appropriate dosage, side effects, risks, and/or benefits. Efforts to reduce dosage or discontinue use of [MEDICAL CONDITION] mediations would be ongoing, as appropriate, for the clinical situation. The policy revealed nursing staff was responsible for reviewing the use of the medication with the physician and the IDT team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. Review of Resident #54's clinical record revealed the facility admitted the resident on 12/01/15, with multiple [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident had no potential indicators of [MEDICAL CONDITION], had not displayed behavioral symptoms, and had received Antipsychotic medication for the last seven (7) days. The facility assessed Resident #54 with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined he/she was interviewable. Observation, on 05/15/18 at 12:52 PM, revealed Resident #54 in bed with his/her eyes closed and a lunch tray on the over the bed table. Interview with Resident #54, on 05/15/18 at 1:30 PM, revealed he/she had been sleepier in the last few days. Observation revealed the resident in bed and an uneaten lunch tray at the bedside. At 2:51 PM, the resident was in bed. Observation, on 05/16/18 at 9:43 AM, revealed Resident #54 in bed. A breakfast tray was on the over the bed table. At 3:09 PM, the resident remained in bed. Review of Resident #54's Physician Orders, for (MONTH) (YEAR), revealed and ordered dated 12/14/17, for Quetiapine ER ([MEDICATION NAME]) 50 milligram (mg) at bedtime for [DIAGNOSES REDACTED]. Review of the Progress notes, dated 05/05/18 at 8:53 AM, revealed Resident #54 refused the evening dose of [MEDICATION NAME], had reportedly refused all week, and stated he/she was not going to take the medication again because it made him/her sleepy. Review of Resident #54's Medication Administration Record [REDACTED]. Further review of Physician order [REDACTED]. Review of the Treatment Notes for Resident #54's Behavior Monitoring revealed the resident exhibited no behaviors 01/03/18 through 05/15/18. However, review of Resident #54's Progress notes, dated 05/14/18, revealed the administration time for [MEDICATION NAME] was changed from 8:00 PM to 8:00 AM. Further review of the MAR indicated [REDACTED]. Review of the MAR, dated 02/01/18 through 05/15/18, for Antipsychotic Side Effect Monitoring revealed staff documented Resident #54 exhibited no side effects related to the use of antipsychotics, including drowsiness and loss of appetite. Interview with CNA #5, on 05/17/18 at 10:01 AM, revealed Resident #54 did not get out of bed much and slept a lot. The CNA revealed she had not witnessed any behaviors other than the resident sometimes refused to take a shower. Interview with Registered Nurse (RN) #4, on 05/17/18 at 10:25 AM, revealed Resident #54 had a history of [REDACTED]. She stated resident behaviors should be documented in the behavior notes and medication side effects in the MAR. RN #4 stated the resident slept a lot but she had not notified the physician because she thought it was part of his/her personality. Interview with RN #5, on 05/17/18 at 1:10 PM, revealed she requested a change of Resident #54's [MEDICATION NAME] administration time to 8:00 AM related to the his/her refusal of the 8:00 PM dose. The RN stated she requested the change because the resident reported the medication made him/her sleepy. She further stated she was not aware of the faxed physician's orders [REDACTED]. Interview with the Social Services Director (SSD), on 05/17/18 at 1:45 PM, revealed he was responsible for initiating and revising resident Behavior Monitoring Plans (BMP) and ensuring the BMP manuals were current. The SSD stated it was important to ensure the BMP was in the manuals so staff was aware of a resident's target behaviors, interventions for management of the behaviors, and any progress made towards the behavioral goal. He further stated the manuals should be current in order to track the behaviors and the need for [MEDICAL CONDITION] medications. The SSD revealed Resident #54 did not have a BMP in the SSD's manual. Review of the BMP manual located at the Magnolia nurses' station revealed there was no BMP for Resident #54. Interview with the Assistant Director of Nursing (ADON), on 05/17/18 at 11:35 AM, revealed Resident #54 had a decreased appetite and had been in bed more since the last GDR, but she had not notified the physician. She stated the resident used to get out of bed in the evenings, but now spent 75% of his/her time in bed. The ADON revealed the purpose of monitoring for side effects of psychoactive medication was to ensure the appropriateness of the medication and stated there was no documentation to support the use or discontinuation of Resident #54's [MEDICATION NAME]. The nurse revealed she did not audit the clinical record or the MARs for accuracy and stated the SSD was responsible for monitoring behaviors. She further stated she was not aware of the physician order [REDACTED].#54's [MEDICATION NAME]. Interview with the Director of Nursing (DON), on 05/17/18 at 3:30 PM, revealed she had identified concerns with the SSD's ability to handle the facility's behavior program. She stated it was important to ensure Resident #54 was in the BMP manual so that staff knew how to care for and address potential behaviors. The DON stated she was not aware of the physician order [REDACTED].

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure controlled substances, that required refrigeration, were stored within a locked, permanently affixed compartment within the refrigerator in one (1) of two (2) medication rooms. The findings include: Review of the facility's policy, Controlled Medication Storage, dated (MONTH) (YEAR), revealed controlled medications requiring refrigeration were stored within a locked, permanently affixed box within the refrigerator. Observation of the Dogwood Medication Room, on 05/17/18, at 1:40 PM, revealed the medication refrigerator contained a small emergency narcotic (controlled substance) container not secured within a locked permanently affixed box. There were six (6) tablets of [MEDICATION NAME] 0.5 milligram (mg), six (6) tablets of [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg, six (6) tablets of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg, six (6) tablets of [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg, two (2) vials of [MEDICATION NAME] 10 mg, and two (2) vials of [MEDICATION NAME] 2 mg in the container. There was a chain in the refrigerator, attached to the refrigerator, without any type of box attached to it. Interview with Licensed Practical Nurse #2, on 05/17/18 at 2:00 PM, revealed the chain had always been in the refrigerator but since she had been working there, nothing had ever been attached to it. She stated she thought a locked box should be attached to the chain for storage of narcotic medication, but it never had one attached. Interview with Registered Nurse #4, on 05/17/18 at 2:10 PM, revealed refrigerated narcotics were usually kept in a locked secured box in the refrigerator, but the unit did not have one. Interview with the Director of Nursing (DON), on 05/17/18 at 2:40 PM, revealed she was not aware the narcotic box was not secured in the refrigerator. The DON stated she had many concerns regarding the narcotic box not being secured. One concern was that the box was so small; any nurse could place it in a purse and walk out of the facility with it, unnoticed. She stated not having the narcotic box secured properly could cause a problem and the facility should be thinking of safety first.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure biohazard materials were not stored with medications in one (1) of two (2) medication rooms. The findings include: Review of the facility's Infection Control Policy, dated (MONTH) 2014, revealed the facility's infection control practices were intended to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public, and to help prevent and manage transmission of diseases and infections. Observation of the Dogwood Medication room, on 05/17/18, at 1:40 PM, revealed the bottom drawer in the medication refrigerator contained a red biohazard bag. The refrigerator contained several vials of Flu, Pneumonia, and [MEDICAL CONDITION] vaccines for resident use. There were resident insulin vials and an emergency use narcotic box that contained several medications for resident use. Interview with Licensed Practical Nurse #2, on 05/17/18 at 2:00 PM, revealed staff placed lab specimens that needed to be refrigerated, such as urine, in the biohazard bag until lab staff picked up the specimens. The nurse stated cross contamination could occur if labs specimens were housed with medications. Interview with Registered Nurse #3, on 05/17/18 at 2:20 PM, revealed the facility used the bottom of the refrigerator for urine specimens that needed to be refrigerator until lab staff came to collect, which could cause cross contamination making a resident sick. Interview with the Director of Nursing (DON), on 05/17/18 at 2:40 PM, revealed staff should not store labs in a medication refrigerator and she was not sure why biohazard bags were in the bottom of the refrigerator. The DON stated storing labs in the same refrigerator as medications was not best nursing practice.

Based on observation, interview and review of the facility policy and procedure, it was determined the facility failed to ensure dietary staff stored and distributed food in accordance with professional standards for food service safety. Observation of the kitchen dietary staff on 04/04/17 revealed the dishwasher coughed in his hand and proceeded to make coffee and put away utensils without washing his hands as well as left the kitchen area several times and returned to the food preparation area without washing his hands. Additionally, observation of the walk in refrigerator revealed food items opened and not dated and left uncovered. Review of the Census and Condition, dated 04/04/17, revealed eight-six (86) of eighty-eight (88) residents received their meals from the kitchen. The findings include: 1. Review of the facility's policy and procedure titled, Food Storage, last revised 01/12/16, revealed food items must be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. All products should be dated upon receipt and when they are prepared. Leftovers should be covered, labeled and dated. Observation of the refrigerators in the kitchen, on 04/04/17 at 10:30 AM, revealed a pan of jello not covered appropriately on the bottom rack of the shelf, not dated; a package of sausage opened to air; rotten cucumbers in the box with good ones; a gallon of milk and two (2) quarts of milk opened with no date; and a package of turkey with no date. Interview with Dietary Aide #1, on 04/04/17 at 11:00 AM, revealed the dietary cook was responsible for removing old and undated food from the refrigerator as well as dating items when they are opened. 2. Review of the facility's policy titled, Handwashing and Glove Use, last revised 02/01/14, revealed the guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the dietary department must be followed. Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances i.e., raw chicken to fresh fruit, and following with any unsanitary surface i.e. touching hair, sneezing, opening doors, etc. Observation of the kitchen, on 04/04/17 at 10:45 AM, revealed the dietary dishwasher left the kitchen area on four (4) occasions and returned to the food preparation area to put away clean dishes and utensils without washing his hands after he left the area. In addition, he failed to wash his hands after he coughed into his bare hand. Interview with the Dietary Manager, on 04/04/17 at 11:15 AM, revealed anyone who opens a food item was responsible to date the item when it was opened and she expected the dishwasher to wash his hands after leaving the kitchen area and after coughing in his hands. Interview with the Registered Dietitian, on 04/04/17 at 11:15 AM, revealed she expected all staff to follow dietary policies for all areas of the dietary department. Interview with the Administrator, on 04/06/17 at 5:40 PM, revealed he expected the dietary staff to follow policy and procedures. He stated the Dietary Manager would make immediate corrections and infection control type of issues would be prevented in the future.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation of four (4) of seven (7) medication carts for Hall 200, Hall 400, Hall 500 and Hall 700, on 04/15/17 revealed there were eight (8) Insulin pens and one (1) bottle of Lantus Insulin opened with no dates as to when they were opened. In addition, there were two (2) Novolog Insulin bottles and one (1) Lantus Insulin bottle expired in the drawer of the medication carts. Further observation revealed there was also a vial of Purified Protein Derivative (PPD) in the refrigerator in the medication room. The findings include: Review of the facility's policy and procedure titled, Medication Administration Injectable Vials and Ampules, dated May 2016, revealed vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations of the provider pharmacy's directions for storage, use and disposal. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose). 1. Observation of the medication cart for Hall 200, on 04/15/17 at 10:55 AM, revealed one (1) bottle of Lantus Insulin and two (2) Novolog Insulin pens opened with no date as to when they were opened for Unsampled Resident C. 2. Observation of the medication cart for Hall 400, on 04/15/17 at 11:00 AM, revealed two (2) Novolog Insulin pens with no date as to when they were opened for Unsampled Resident D. In addition, there were two (2) bottles of Novolog Insulin, one (1) dated as opened on 02/17/17 (expired) and one (1) dated as opened 02/18/17 (expired). There was also one (1) bottle of Lantus Insulin dated as opened 02/24/17 (expired). 3. Observation of the medication cart for Hall 500, on 04/15/17 at 11:10 AM, revealed two (2) Levemir Insulin pens and one (1) Novolog Insulin pen with no date as to when they were opened for Unsampled Resident A. 4. Observation of the medication cart for Hall 700, on 04/15/17 at 11:15 AM, revealed one (1) Novolog Insulin pen not dated as to when it was opened for Unsampled Resident B. Interview with Registered Nurse (RN) #1, on 04/15/17 at 10:55 AM, revealed the nurse who opens the insulins for the first time is responsible to label the vial or pen with their initials and put the date of opening on each one. She stated everyone who used the medication cart was responsible to remove outdated and expired medications. Interview with the Director of Nursing (DON), on 04/06/17 at 5:40 PM, revealed she expected insulins to be dated and initialed when opened. 5. Observation of the medication refrigerator on Magnolia Court on 04/05/17 at 2:40 PM, revealed a vial of Purified Protein Derivative (PPD) opened and not dated. Interview with the Assistant Director of Nursing (ADON), on 04/05/17 at 2:40 PM, revealed she expected opened vials of PPD to be dated by nursing staff when opened.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the Physician was notified when there was a need to alter treatment significantly (need to commence a new form of treatment); for one (1) of eighteen (18) sampled residents (Resident #1). The Registered Dietician (RD) identified Resident #1 had pressures sores and weight loss; and the resident's intake was not sufficient to promote wound healing and weight gain on 02/16/17, 02/23/17, 03/16/17, and 03/30/17. The Registered Dietician (RD) made recommendations each time for Med Pass, Juven, and Promod; however, the Unit Manager failed to notify the resident's physician to obtain the order for the recommended supplements until 04/05/17 (forty-eight {48} days after first recommended). The findings include: Review of the facility policy titled, Change of Condition, not dated, revealed the facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay findings to physician and to document actions related to a significant change in the resident's health status or a need to alter treatment. Record review revealed the facility admitted Resident #1 on 11/30/16 with [DIAGNOSES REDACTED]. Review of a Dietary Progress Notes Report, dated 02/16/17 at 12:01 PM, dated 02/23/17 at 2:06 PM, dated 03/16/17 at 10:47 AM, and 03/20/17 at 2:19 PM revealed Resident #1 had dropped from fifty-four percent (54%) to thirty-four percent (34%) and had pressure sores. The Dietician assessed the resident's estimated needs to promote wound healing and weight gain was sixty-six to eighty-two (66-82) grams protein and intake of 83-103 % by mouth (po) to meet estimated needs. Therefore, the Dietician recommended Med Pass 2.0, 120 millimeters (ml) three (3) times a day (TID); Promod thirty (30) ml two (2) times a day (BID), and one (1) packet of Juven BID at the time of each assessment. However, review of the Physician's Orders and Nursing Notes, dated 02/16/17 through 04/05/17, revealed there was no documented evidence the physician was made aware of the Dietician's recommendations until 04/05/17 when orders were received for the Med Pass, Juven, and Promod. Interview with Registered Nurse #4, Unit Manager, on 04/06/17 at 12:15 PM, revealed she was aware of the dietary recommendation and did place a call to the physician, but was never called back. She stated she failed to attempt to notify the physician again, and failed to follow through with the recommendation because she had to many other duties to perform. Interview with the Registered Dietician (RD), on 04/06/17 at 8:45 AM revealed she made dietary recommendations on 02/16/17 due to Resident #1 having a 7.5% weight loss in one (1) month, a 3.6% loss at three (3) months, and was continuing to lose weight. She stated the order was not written until 04/05/17. Interview with Resident #1's Physician, on 04/05/17 at 2:30 PM, revealed she was not aware of the dietary recommendation, and if she had of been, she would have given the order for use. The Physician stated she could not say the supplements would have made a difference but they should have at least been attempted, as a standard of care. She revealed she sees a lot of residents and counts on the staff to be her ears and eyes to keep her aware of changes with the residents.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure the accuracy of assessments to reflect the status for two (2) of eighteen (18) sampled residents. The facility failed to accurately code Resident #3's MDS assessment related to a catheter, and Resident #5 related to range of motion. The findings include: Review of facility policy titled, MDS Assessment Completion, not dated, revealed the facility will conduct and submit resident assessments in accordance with the Resident Assessment Instrument (RAI) Manual. 1. Review of the RAI User's Manual, dated July 2010, revealed section H as the intention of gathering information on the use of bowel and bladder appliance with (H0100A) representing coding to be selected if an indwelling catheter was used at any time in the past 7 days for the resident. Additionally, section H0100 is utilized as an assessment of the resident through bowel and bladder records and examination of the resident to note presence of any urinary or bowel appliance. Further review revealed if during the seven (7) day look back period the resident had an indwelling bladder catheter during the seven (7) days, Section H100A use of indwelling catheter and HO300 Urinary Incontinence should be coded a nine (9) which means the resident had an indwelling catheter during the (7) seven-day look back. Record review revealed the facility admitted Resident #3 on 08/16/16 with [DIAGNOSES REDACTED]. Review of April 2017 Physician Order, with order date of 11/16/16, revealed use full size urinary catheter bag and discontinue leg bag with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/11/17, revealed the facility coded H0100 a 9 indicating the resident had an indwelling catheter; however, coded Section H0300 as a three (3) (incontinent) instead of a 9 per RAI manual. 2. Review of the RAI User's Manual, dated July 2010, Section O0500 Restorative Nursing Programs (RNP) revealed the Restorative Nursing Program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible with the concept focusing on achieving and maintaining optimal physical, mental, and psychosocial functioning. Steps for Assessment are to review the restorative nursing program notes and/or flow sheets in the medical record for the seven (7) day look back period and enter the number of days on which the technique, training or skill practice was performed for a total of at least (15) fifteen minutes during the (24) twenty-four-hour period. Further review of RAI User's Manual revealed Section O0500A--should be coded if passive range of motion (PROM) was performed and Section O0500B if active range of motion (AROM) was performed. In addition, Section O0500D should be coded if activities provided to improve or maintain the resident's self-performance in moving to and from a lying position, turning side to side and positioning himself or herself in bed (bed mobility) and Section O0500E should be coded if activities provided to improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices (transfers). Section O0500D and section O0500E should be coded with the number of days the resident received training and skill practice during the seven-day look back period. Record review revealed the facility admitted Resident #5 on 12/01/15 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of January 2017 Restorative Service Delivery Record revealed Resident #5 was provided AROM to Bilateral Upper Extremities for fifteen (15) minutes on 01/09-14/17 and 01/16/17 (seven {7} days and PROM on 01/11/17 (one {1} day). However, review of Resident #5's Significant Change MDS assessment, dated 01/17/17, revealed in Section O0500 Restorative Nursing Programs that O0500A, was coded as a 0 indicating no PROM was performed and O0500B was coded as a 0 indicating no AROM was performed. Interview with MDS #1, on 04/06/17 at 1:15 PM and 3:00 PM, revealed Resident #3 should have been coded as a nine (9) if has a catheter, and they should have coded AROM and PROM for Resident #5. Interview on 04/06/17 at 5:40 PM with Director of Nursing (DON) and Administrator revealed the MDS coding should accurately reflect the resident's status.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, meets professional standards of quality and practice for one (1) of eighteen (18) sampled residents (Resident #9). Observation on 04/05/17 revealed the nurse failed to clean the visibly soiled over the bed table and place a barrier prior to placing wound care supplies on it. In addition, she failed to sanitize his/her scissors prior to cutting a new clean bandage. The findings include: Interview with the Assistant Director of Nursing (ADON), on 04/05/17 at 11:00 AM, revealed the facility follows the professional standards of practice as set forth in Lippincott's Nursing Procedures. Review of facility's Professional Standards of Practice Guidelines; Lippincott's Nursing Procedures, Sixth Edition, published in 2013, revealed to change the dressing frequently enough to keep the skin dry. Always follow standard precautions set by the Centers for Disease Control and Prevention. Implementation states to check the doctor's order for specific wound care and medication instructions. Caring for the wound revealed to establish a sterile field with all the equipment and supplies you'll need for care and the dressing change including a sterile dressing set. 1. Record review revealed the facility admitted Resident #9 on 11/22/16 with [DIAGNOSES REDACTED]. Review of Resident #9 Comprehensive Care Plan for Impaired skin integrity, dated 11/22/16, revealed an intervention for licensed staff to provide dressing changes to his left thigh surgical incisional wounds two (2) times daily. Observation of a dressing change to Resident #9's left thigh, on 04/05/17 at 10:30 AM, revealed Licensed Practical Nurse (LPN) #4 placed the dressing change supplies on the resident's over the bed table that was visibly dirty and had no barrier on the table. Further observation during the dressing change, revealed the LPN removed bandage scissors from her uniform pocket and cut the clean dressing without cleaning the scissors prior to using. Interview with LPN #4, on 05/04/17 at 11:05 AM, revealed she should have followed the care plan and the facility's Professional Standard of Practice for wound care by cleaning the over bed table, using a barrier for her dressings, and cleaning the bandage scissors prior to wound care. Further interview with the ADON, on 04/05/17 at 11:00 AM, revealed he expected Licensed Practical Nurse (LPN) #4 to have followed the care plan and the Professional Standards of Practice for wound care to include cleaning the over bed table, placing a barrier, and cleaning her bandage scissors prior to use. Interview with Director of Nursing (DON), on 04/06/17 at 5:40 PM, revealed LPN #4 should have followed the Comprehensive Care Plan and the Lippincott for Professional Standards of Practice for wound care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the services provided or arranged by the facility were in accordance with the residents written plan of care for two (2) of eighteen (18) sampled residents (Resident #1 and Resident #5). The facility failed to implement the care plan for Resident #1 related to floating heels while in bed and keeping him/her turned from side to side. In addition, the facility failed to place a bible under Resident #5's pillow and a mirror on his/her wall per his/her care plan. The findings include: Review of the facility policy titled, Care Plans-Comprehensive, last reviewed 06/01/15, revealed the Comprehensive Care Plan is designed to identify problem areas, incorporate risk factors associated with identified problems, reflect the resident's expressed wishes regarding care and treatment goals, and reflect treatment goals, timetables, and objectives in measurable outcomes. The nurse and Interdisciplinary Team (IDT) are responsible for the review and updating of care plans, and should reflect the current status of the resident and be updated with changes in the resident's status at least quarterly, when the resident has been readmitted , when there has been a significant change in the residents condition, and when the desired outcome is not met. 1. Record review revealed Resident #5 had been admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 01/17/17, revealed the facility assessed Resident #5's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. In addition, the resident required extensive assistance with Activities of Daily Living (ADL). Review of Comprehensive Care Plan for the resident has a perception that spirit called Haint in his/her room, dated 06/27/16 with a goal date of 06/09/17, revealed interventions to place a mirror in the room because the resident believed Haints do not like to see themselves because they are dead, and place a bible under the resident's pillow for protection. Review of Certified Nurse Aide (CNA) Care Card (means of communicating care plan interventions to CNAs), dated March 2017, revealed there was no mention of ensuring a mirror was in his/her room or a bible was placed underneath the resident's pillow. Observation on 04/04/17 at 9:22 AM and 2:20 PM revealed there was no mirror or bible seen in Resident #5's room. Observation and interview, on 04/06/17 at 10:20 AM and 2:20 PM with CNA #5, revealed there was no mirror on the wall and no bible beneath the pillow in Resident #5's room. She stated if the mirror and bible were on the resident's care plan then the items should be in the resident's room. Interviews on 04/06/17 at 5:10 PM, with CNA #1 and CNA #2, revealed the CNA Care Card should be the same as the Comprehensive Care Plan of the resident. CNA #2 stated she was not aware of the interventions of a mirror on the wall or of having a bible under his/her pillow per the resident's belief system. Interview with Licensed Practical Nurse (LPN) #2 , on 04/0617 at 10:33 AM, revealed the care plan should be followed because if not then correct care is not given to the resident. Interview with LPN #3, 04/06/17 at 11:05 AM, revealed the Comprehensive Care Plan and CNA Care Card should match, and if on the care plan then the mirror and bible should be in the room. LPN #3 stated not having the mirror and bible in the resident's room could be contributing to the resident's behaviors. Interview on 04/06/17 at 10:30 AM and 11:05 AM with LPN #2 and LPN #3 revealed nursing is responsible for ensuring the CNA Care Card and the Comprehensive Care Plan match. Interview on 04/05/17 at 1:44 PM with Unit Manager (UM) #1 revealed the UM makes sure the CNA Care Card matches from month to month with the Comprehensive Care Plan. Interview with the Director of Nursing (DON), on 04/06/17 at 10:40 AM, revealed she expected the Comprehensive Care Plan and CNA Care Card to match so the CNAs would know how to care for the resident according to the Comprehensive Care Plan. 2. Record review revealed the facility admitted Resident #1 on 11/30/16 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 01/16/17, revealed the facility assessed Resident #1's cognition to be severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. The MDS further revealed Resident #1 was dependent on staff, with the assistance of two (2) for transfer, dressing, bathing, toileting and bed mobility; was at risk for developing skin breakdown, and no pressure sores were identified. Review of Resident #1's Acute Care Plan for a Stage III pressure sore to the sacrum, dated 01/13/17, revealed an intervention to position the resident side to side while in bed; however, observation, on 04/06/17 at 9:50 AM, revealed Certified Nurse Aides (CNAs) #9 and #10 exiting Resident #1's room and Resident #1 was lying directly on his/her buttocks (not side per 01/13/17 care plan) with the head of the bed (HOB) elevated approximately forty (40) degrees. Review of the April 2017 Care Card revealed to turn Resident #1 side to side and the care card did not address the care plan intervention to float the residents heels until 04/04/17. However, observations on 04/04/17 at 3:30 PM and on 04/06/17 at 9:50 AM revealed Resident #1 was in bed with his/her heels directly on the bed. On 04/04/17, there was no pillow in the bed to float the resident's heels and on 04/06/17 two staff had just left the resident's room and the pillow was under the residents knees instead of the lower legs which would have kept the heels off the bed. Interview with Certified Nurse Aide (CNA) #9 and CNA #10, on 04/06/17 at 9:50 AM, revealed CNA #9 had not cared for Resident #1 in several months and CNA #10 had not cared for him/her in several weeks. CNA #10 stated she knew the resident's feet should have been floated because of skin breakdown, but they had failed to elevate them enough. The CNAs revealed they were not aware the resident was supposed to be positioned from side to side because they did not have time to look at the CNA care plan. Both CNA'S stated they should always look at the resident's care plan before giving care especially if it has been awhile since caring for that resident. Interview with the Unit Manager #8, on 04/06/17 at 3:30 PM, revealed she expected every CNA in the building to read the resident's care plan they are assigned to before caring for the resident. She stated the CNAs knew Resident #1 had wounds and they needed to know how he/she is to be turned and positioned. Interview with the Administrator and DON, on 04/06/17 at 5:40 PM, revealed the Unit Managers are responsible for updating CNA care cards and they expected all staff to follow the resident's care plan.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to implement the care plans for three (3) of twenty (20) sampled residents (Residents #3, #9 and #11). The facility care planned Resident #9 for a personal alarm to alert staff when the resident was attempting unassisted transfers; however, the facility failed to ensure the alarm was always functioning. Resident #9 sustained a right pelvic fracture during a fall in February 2014 and sustained a second fall with a right [MEDICAL CONDITION] in June 2014 with indications the alarm was malfunctioning with both falls. Resident #9 had a total of nine (9) unwitnessed falls the facility determined the alarms failed to sound during all nine (9) of the falls. In addition, the facility care planned Resident #3 for heel protectors to be worn at all times; however, the facility failed to consistently apply the heel protectors per the plan of care. The facility also care planned Resident #11 to have palm protectors when the splints were not in use; however, the palm protectors were not applied when splints were not in use per the plan of care. The facility did not check and change Resident #11 every two (2) hours as per the plan of care. The findings include: Review of the facility's policy regarding the Resident Assessment Instrument (RAI), dated October 2011, page 4-8, revealed the comprehensive care plan was an interdisciplinary communication tool and described the services being furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care planned services provided or arranged must be consistent with each resident's written plan of care. The care plan should reflect the care the resident was receiving. Review of the facility's policy regarding the RAI, dated April 2012, page 4-10 and page 4-11, revealed the overall care plan should be oriented towards preventing avoidable decline in functional levels. The care plan should manage risk factors to the extent possible or indicate the limits of such interventions. It should further address ways to preserve and build upon the resident's strength. Review of the facility's policy regarding the RAI, dated May 2013, page 4-9 and page 4-12 (page 4-10 and 4-11 was not provided by the facility) revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths and needs. Review of the facility's policy titled Falls Management, dated 01/10/10, revealed the facility was to screen residents, identify resident at risk for falls and implement interventions to reduce those risks. Review of the facility's in-service regarding Care Plans and Confidentiality, dated 01/05/15, revealed the staff was to follow care plans, and check care plans daily for any changes. 1. Review of Resident #9's clinical record revealed the facility readmitted the resident on 10/15/13 with [DIAGNOSES REDACTED]. Review of the POS [REDACTED]. Review of Resident #9's Quarterly Minimum Data Set (MDS) assessment, completed on 01/05/14, revealed the facility assessed the resident during a Brief Interview for Mental Status (BIMS) with a score of three (3) of fifteen (15), indicating the resident was severely impaired cognitively. In addition, the facility assessed the resident as requiring extensive assistance of two (2) persons with bed mobility, transfers and required a wheelchair for mobility. Review of the Physician Orders, dated 02/01/14 through 02/28/14, revealed the staff was to place hipsters on the resident at all times. Review of the Physician Orders, revealed a pad alarm to the bed and the chair with placement checks every shift and check function weekly was initially ordered on [DATE] and reordered on monthly reorders dated 02/01/14 through 02/28/14. Review of the Comprehensive Care Plan for Resident #9 revealed the facility developed a care plan, dated 01/28/14. Problems on the care plan included a History of Falls related to [MEDICAL CONDITION], poor balance, routine use of antidepressant, non compliant behavior and incontinence of bowel and bladder. Interventions included Hipsters on at all times and pad alarm to bed and chair. Review of the February 2014 Medication Administration Record [REDACTED]. The staff did not initial the checks as completed 02/07/14, 02/08/14, 02/16/14, 02/17/14, 02/25/14, and on 02/28/14 across all three shifts. The medication record did not specify when the pad alarm would be checked weekly for function. Hipsters were not noted on the MAR. Review of the POS [REDACTED]. The bed alarm was not sounding and no hipsters were noted. The resident was transferred to the hospital for evaluation. Review of the radiology report, dated 02/08/14, of the right hip revealed, on 10/10/13, Resident #9 underwent surgery for [REDACTED]. Review of the March and April 2014 MARs revealed the pad alarm to the bed and chair with placement checks was not listed for staff to monitor and hipsters were not noted on the MAR. Per the post fall investigation, Resident #9 experienced a fall on 03/04/14 and 04/10/14 and the alarms did not sound and hipsters were not applied. Review of the Falls Alert Progress Notes, dated 06/16/14, revealed the Director of Nurses (DON) documented Resident #9 was found in the doorway on the floor, on 06/14/14 at 11:40 PM, with skin tears in three (3) places on his/her right forearm and complaints of pain in both hips. In addition, the bed alarm was not sounding and there was no evidence the resident was wearing the hipsters as ordered. The resident was transferred to the hospital for evaluation and diagnosed with [REDACTED]. Review of the June 2014 MAR indicated [REDACTED]. This was initialed as completed on 06/14/14. Hipsters were not noted on the MAR. Review of the Physician Orders, dated 09/01/14 through 09/30/14, revealed the hipsters were to be worn at all times by the resident. Review of the September 2014 MAR indicated [REDACTED]. This was initialed as being completed on 09/06/14. Hipsters at all times were noted on the MAR indicated [REDACTED]. However, per the post fall investigation, Resident #9 experienced a fall on 09/06/14 and the alarms did not sound and hipsters were not applied. Review of the October 2014 MAR indicated [REDACTED]. This was initialed as being completed on 10/15/14 and 10/19/14. However, per the post fall investigations, Resident #9 experienced a fall on 10/15/14 and 10/19/14 and the alarms did not sound and hipsters were not applied. Interview with the CNA #6, on 02/26/15 at 2:20 PM, revealed she routinely cared for Resident #9 and knew the resident well. She stated Resident #9 had some falls when he/she tried to get up without assistance. CNA #6 stated as far as she could remember Resident #9's alarm worked most of the time. CNA #6 stated she had one alarm that did not sound a long time ago; however, she stated she had never been too busy to report alarms not working to the nurse. She reported staff must check to make sure Resident #9's alarms were working. In addition, she stated Resident #9 wore hipsters all the times. However, Review of the POS [REDACTED]. Interview with CNA #7, on 02/26/15 at 2:35 PM, revealed she provided care to Resident #9 and was frequently assigned to the resident. She stated Resident #9 had fallen several times. The resident had a seat belt alarm that he/she released and reconnected behind him/her. They all knew Resident #9 took the alarm off and reconnected the alarm behind him/her and they would have to check on the resident. She further stated the alarms had a light that blinked and a flashing light to show when the battery was low. She stated they changed the batteries on the alarm if the alarm did not work when they get the resident up. Per interview, if the alarms were not working, it must be reported to the nurses. Interview with CNA #8, on 02/26/15 at 2:50 PM, revealed she was familiar with the care for Resident #9. She stated Resident #9 had a self releasing seat belt that he/she took off and would try to get up. All the staff, including Licensed Practical Nurse (LPN) #2 and the Director of Nursing (DON), knew Resident #9 took the seat belt off and would try to get up. She stated she had never put hipsters on Resident #9 since she had been caring for him/her. However, per the resident's plan of care, hipsters should be applied at all times. Observation with CNA #8 of Resident #9 while lying in his/her bed, on 02/26/15 at 2:55 PM, revealed Resident #9 was not wearing any hipsters; however, there were two (2) pair of hipsters in his/her clothing drawer. Interview with LPN #2, on 02/26/15 at 2:00 PM, revealed Resident #9 had a long history of falls in the facility with fractures on a couple of occasions and the resident had an alarming seat belt. LPN #2 stated the resident could self release the alarming seat belt and reconnect it behind his/her back. She stated they were going to discontinue the self release seat belt, but the family insisted it not be removed since Resident #9 had so many falls. The family felt like it was one more way to alert the staff. The resident currently had two (2) types of alarms, a wheelchair alarm and a bed alarm. LPN #2 stated the resident had numerous falls and everyone knew the minute they heard the alarm, they had to respond because the resident would attempt to get out of the bed. She stated she checked the alarms at the beginning of her shift, and if there was a problem she would correct it at that time. Interview with the DON, on 02/26/15 at 4:40 PM, revealed she had daily morning meetings and falls were discussed at that time. The DON did not specify which interventions were working for Resident #9. She further stated the resident had behaviors, and he/she would take off the seat belt; however, she did not remember what happened. Interview with the Administrator, on 02/26/15 at 1:30 PM, revealed the DON and Unit Managers had daily morning meetings and the falls are discussed during that meeting. He stated the DON informed him during the department head meetings about any falls in the facility. However, it was only during the course of the survey, he had been made aware of Resident #9's falls and the problems with the personal alarms not working. He further stated upon review of the documents of the Post Fall Investigations, he realized he had not been kept abreast of Resident #9's multiple falls. 2. Review of Resident #3's clinical record revealed the facility admitted the resident on 10/16/08 with [DIAGNOSES REDACTED]. Review of the physician's admission note, not dated, revealed on admission, the resident was unable to care for himself/herself, and was in a state of general decline. Review of Resident #3's most recent Annual Minimum Data Set (MDS) Assessment, dated 08/06/14, revealed the facility assessed the resident with a score of five (5) out of fifteen (15) on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The facility also assessed the resident as needing extensive assistance with activities of daily living (hygiene, bathing, dressing, and eating); always incontinent of bladder and bowel; and, at risk for the development of pressure ulcers based on [MEDICATION NAME] risk factors which included incontinence, a history of poor nutrition, antidepressant use, [MEDICAL CONDITION], and severe [MEDICAL CONDITION] disease. Review of Resident #3's Quarterly MDS Assessment, dated 01/09/15, revealed the facility again scored the resident at a five (5) out of fifteen (15) on the BIMS and assessed the resident continued to be at risk for the development of pressure ulcers. Resident #3 continued to require extensive assistance with activities of daily living (personal hygiene, bathing, dressing, and eating). The facility also assessed the resident to be frequently incontinent of urine, and always incontinent of bowel. Review of an incident report, dated 02/03/15, revealed during a skin assessment, conducted on 02/03/15, a small dark area measuring 0.5 x 0.5 centimeters (cm) was identified on the back side of Resident #3's left heel. The nurse notified the physician, and the physician ordered the application of a soft heel boot to the resident's left heel, at all times while he/she was in bed. Daily monitoring of the area was to occur until it was healed. On 02/23/15, the facility assessed the area on Resident #3's left heel and it was measured by Registered Nurse (RN) #1 at 1.0 x 1.0 cm. The physician was notified and he gave an order for [REDACTED]. Review of Resident #3's Interdisciplinary Care Plan and Certified Nursing Assistant's (CNA's) Care Plan, revealed interventions for the prevention of pressure ulcers, which included the application of a heel boot while in bed, dated 02/04/15 on the initial care plan, and on 02/23/15 it was changed to be on the resident's left foot at all times. Review of the 400 Hallway CNA 24 Hour Report Sheet, revealed Resident #3 was to have a "blue boot" on at all times. Observation, on 02/24/15 at 11:25 AM, revealed Resident #3 was not in his/her room and a blue soft boot was lying on the resident's bed. Observation, on 02/24/15 at 11:50 AM, revealed Resident #3 was seated in his/her wheelchair in the restorative dining area of the facility's Magnolia Unit. The resident was wearing black shoes with Velcro closures. Resident #3 moved his/her feet back and forth with an almost constant shuffling movement. Observation, on 02/24/15 at 2:20 PM, revealed Resident #3 was seated in his/her wheelchair, in the day area of the facility's Magnolia Unit. The resident continued to wear black shoes with Velcro closures. Resident #3 was not wearing the soft blue boot on his/her left foot. Observation, on 02/25/15 at 7:20 AM, revealed Resident #3 was seated in his/her wheel chair with black shoes with Velcro closures. Resident #3 continued to move his/her feet and legs with an almost constant back and forth movement. Resident #3 did not have the soft blue boot on his/her left foot. Observation, on 02/25/15 at 8:07 AM, revealed Resident #3 continued to be seated in his/her wheelchair, with a clothing protector covering his/her upper torso, while waiting for his/her breakfast meal. Resident #3 was not wearing the soft blue boot on his/her left foot. Continued observation, on 02/25/15 at 8:45 AM, revealed direct care staff assisting Resident #3 with finishing his/her breakfast. The resident was not wearing the soft blue boot on his/her left foot. Interview, on 02/25/15 at 10:25 AM, with CNA #1, revealed she was typically assigned to work on the Magnolia Unit of the facility, and had helped dress Resident #3 earlier in the day, but had not placed the blue soft boot on Resident #3's left foot. CNA #1 stated that the licensed nurse assigned to the hallway where Resident #3 resided had just reminded her of the order to apply the blue soft boot to the resident's left foot. CNA #1 stated she was not exactly sure why Resident #3 needed the boot, but she thought it was because he/she had some skin breakdown. Interview, on 02/25/15 at 8:53 AM, with RN #1 revealed Resident #3 had a dark colored spot on his/her left heel and the physician ordered daily monitoring of the area until it was healed. In addition, she stated the resident was to wear the soft blue boot on his/her left foot at all times. Observation, on 02/25/15 at 9:55 AM, revealed Resident #3 was seated in his/her wheelchair with the soft blue boot on his/her left foot. This was immediately prior to a scheduled skin assessment that was performed by RN #1. Interview, on 02/25/15 at 11:10 AM, with RN #1 revealed she had applied the soft blue boot to Resident #3's heel just prior to the scheduled skin assessment, but RN #1 stated the boot had not been applied to the resident's left heel upon his/her rising. RN #1 stated that Resident #3's soft blue boot had been previously ordered for application while the resident was in bed, but on 02/23/15, the order was changed for continuous application of the boot with daily monitoring of the dark spot on the resident's left heel. RN #1 stated the boot was ordered to protect the resident's skin and to promote healing. She further stated the problem with not following the care planned intervention for the protective soft boot was the area could potentially worsen and the resident could experience additional skin breakdown. Further interview with RN #1, on 02/26/15 at 10:45 AM, revealed a new intervention would be reported to the oncoming nurse during the shift change. CNAs were to also report the new care area/intervention to oncoming CNAs during the shift change. RN #1 stated she was the nurse who received the order for Resident #3's blue soft boot on 02/23/15. She stated she updated the CNA care plan and informed the CNA, but she could not remember the CNA who was assigned to care for the resident on that day. RN #1 stated CNAs were to review the CNA care plans every shift. RN #1 stated she was not sure who was responsible for ensuring the CNA Care Plans and the CNA 24-Hour Report Sheets contained the same information about the residents' care needs. Interview, on 02/26/15 at 10:40 AM, with CNA #2 revealed upon reporting to work, she received a report on the residents from the CNA who worked the previous shift. This report included information about any new care interventions, ongoing care needs, and the type of monitoring needed. CNA #2 also stated the CNAs were supposed to review the CNA care plans daily to ensure they knew how to care for their assigned residents, but CNA #2 stated she did not review the CNA care plans daily, as this was just the way the work day flowed for most CNAs. CNA #2 stated she always carried a CNA 24 Hour Report Sheet with her that contained information passed on during the shift change. CNA #2 stated the requirement to apply Resident #3's blue soft boot to his/her left foot was added to the CNA 24 Hour Report Sheet on 02/25/15. CNA #2 stated that prior to 02/25/15, she was not aware Resident #3 was to wear the blue soft boot at all times. Interview, on 02/26/15 at 11:25 AM, with Director of Nurses (DON) revealed at the end of each shift, CNAs were to sign the back of the CNA Care Plans. Their signature verified they had reviewed the care plans and had followed them while providing care to their assigned residents. The DON stated the CNA 24 Hour Report Sheet was turned in to the Unit Managers (UMs) who reviewed them. The DON stated if CNAs were unable to review the care plans or did not understand how to provide resident care, they were to communicate that to the unit's licensed nurses or to her. 3. Review of the clinical record for Resident #11 revealed the facility admitted the resident on 09/28/11 with [DIAGNOSES REDACTED]. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment, completed on 02/15/15, revealed the resident was unable to walk and needed total assistance from staff to toilet, transfer, bed mobility, and for all activities of daily living (ADL) and hygiene needs. The facility completed a Brief Interview for Mental Status (BIMS) examination during the assessment and the resident scored a five (5) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #11's Care Plan, last updated 12/30/14, revealed the nursing staff would check and change the resident every two (2) hours and as needed. It also revealed that the resident needed total assist to conduct personal hygiene and bathing. The care plan identified the resident was at risk for developing pressure areas due to contractures of the hands, decreased mobility and incontinence. The care plan stated nursing staff should have turned and repositioned Resident #11 every two (2) hours with a two (2) staff assist. The care plan stated the resident would wear palm protectors when not wearing splints and would wear blue heel boots at all times. Review of the Nursing Assistant Care Plan for Resident #11, dated February 2015, revealed staff would ensure the resident's fingernails were not long enough to dig into the palm of the hand and that the resident was to wear palm protectors when the splints were not on. The care plan also stated the resident would wear blue heel boots. The Nursing Assistant Care Plan stated CNAs were to check and change as needed with two assist. Observation of Resident #11, on 02/25/15 at 7:30 AM, revealed CNA #1 and CNA #2, upon going into the resident's room with the CNAs, Resident #11 did not have the float boots on his/her heels. The resident had red, raw, open areas on the tops of his/her toes. The resident was not wearing palm guards. CNA #1 and #2 changed and dressed the resident. The resident's space boots were in his/her closet in the room and CNA #1 retrieved them from the closet. CNA #1 and #2 used a lift to place the resident into the Geri-chair. After the care was completed, the CNAs transported the resident out to a common area near the nurses station. Resident #11 did not have palm protectors on at that time. Continued observation, on 02/25/15 at 9:05 AM, revealed CNA #4 provided restorative care to Resident #11. The CNA took the resident to his/her room and provided restorative care and splinting. CNA #4 did not check and change or reposition the resident at that time. CNA #4 returned the resident to the common area after his/her restorative therapy. Interview at this time with CNA #4, revealed she did not check and change the resident during this care. Interview with CNA #2, on 02/26/15 at 9:30 AM, revealed CNA #2 was one of the CNAs responsible for the care of Resident #11 on 02/25/15 during first shift. She stated the resident wore heel boots, Geri-sleeves on his/her legs, palm protectors, and elbow protectors. The CNA stated the resident wore this equipment at all times, both in and out of the bed. CNA #2 also stated CNAs were responsible for repositioning Resident #11 every two hours. She stated Resident #11 was not wearing the heel boots at the time the CNA got the resident up and out of bed on the morning of 02/25/15. The boots were located in another part of the room. She indicated staff had not put the boots on the resident at the last round with the resident during the night shift. The CNA stated not using the heel boots could lead to skin breakdown or injury for Resident #11. The CNA further stated the resident was not wearing palm protectors when the CNA woke the resident. The CNA stated she did not put the palm protectors on the resident. The CNA stated the palm protectors kept the resident from injuring himself/herself due to contractures of the hands. The CNA stated check and change for Resident #11 involved taking the resident to his/her room, using the lift to place the resident onto the bed, and changing the resident's brief. CNA #2 stated she did not provide repositioning or check and change care for Resident #11 between when she provided AM care at 7:30 AM and after lunch at 12:15 PM, on 02/25/15. The CNA stated that by not checking and changing the resident, the resident was at higher risk for skin breakdown. Interview with LPN #1, on 02/26/15 at 9:15 AM, revealed Resident #11 was to wear heel boots at all times, including when in the bed. The LPN stated the heel boots were put in place because the resident had Restless Leg Syndrome that caused him/her to move his/her legs and caused abrasions. The LPN further stated the CNAs were to reposition, check, and change Resident #11 every two (2) hours. She stated this meant the CNAs would take the resident to his/her room, use the Hoyer lift to put the resident in the bed, and check and change the resident's brief. The LPN stated not following the care plan was a problem because not using the proper equipment could lead to skin issues such as abrasions or skin breakdown for the resident. Interview with the Director of Nursing (DON), on 02/26/15 at 10:25 AM, revealed the CNAs had access to the care plans located at the nurses' stations. The CNAs should have looked at the care plans in the mornings at the start of their shift and then must look at the care plan at the end of the shift when they signed off on the care plan. The DON stated she was surprised to hear the CNAs had not followed the care plan by not utilizing palm protectors and heel protectors and not providing incontinent care with Resident #11. The DON stated the resident was at increased risk for skin breakdown if the CNAs did not follow the care plan. The DON reviewed the resident's care plan and stated it was somewhat confusing because there was a lot of equipment listed and the Nurse Aide Care Plan had a lot of information hand written on it.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure adequate supervision to prevent accidents. The facility failed to assess their fall prevention interventions to determine if they were implemented and effective in promoting a safe environment for one (1) of twenty (20) sampled residents, (Residents #9). The facility had prior knowledge of Resident #9's falls. Resident #9 had a total of nine (9) unwitnessed falls and the facility determined the alarms failed to sound for all nine (9) of the falls. However, there was no documented evidence the alarm failure was addressed. The resident sustained [REDACTED]. (Refer to F282) The findings include: Review of the facility's policy regarding Falls Management, dated 01/10/10, revealed the facility was to screen all residents to identify possible risk factors that may place a resident at risk for falls, to evaluate those risks, implement interventions to reduce those risk, monitor the interventions and modify when necessary. The falls management policy was establish to identify residents with risk factors that may place them at risk for falls and to manage those residents who experienced a fall to minimize the risk of the fall reoccurring or minimize the risk of injury related to a fall. The staff was to review the current plan of care and if necessary revise interventions, or if no plan of care was in place, develop a plan of care to reduce the likelihood that the fall would reoccur and/or minimize the risk of injury related to a fall. Falls tracking was done individually as well as facility wide to analyze trends for Quality Assurance Reporting. The facility was to investigate any resident falls to determine appropriate interventions to put in place to reduce the likelihood that a fall would reoccur and to minimize the risk of injury related to a fall. Review of Resident #9's clinical record revealed the resident underwent [REDACTED]. The facility readmitted the resident on 10/15/13 with [DIAGNOSES REDACTED]. Review of Resident #9's Annual Minimum Data Set (MDS) assessment, completed on 03/05/14, revealed the facility assessed the resident during a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating the resident was severely impaired cognitively. The facility assessed the resident as requiring extensive assistance of two (2) persons with bed mobility, transfers and required a wheelchair for mobility. The facility identified Resident #9 in Section J1800 and J1900, with falls since admission including one (1) major injury since the prior assessment. Review of the Comprehensive Care Plan for Resident #9, dated 01/28/14, with updated goals and target dates for 04/28/14, revealed problems on the care plan included a History of Falls related to Hypotension, poor balance, non-compliant behavior and incontinence of bowel and bladder. Interventions listed included mat on floor next to bed; Hipsters on at all times; perimeter defining mattress; pad alarm to bed and chair; and, high backed wheelchair with rear tilt and elevating leg rest. Review of the Post Fall Investigation for Resident #9, dated 02/08/14 at 4:30 PM, revealed an unwitnessed fall when the resident was found on the floor. The bed alarm was not sounding and no hipsters were noted. Resident #9 was transferred to a local hospital on [DATE] for evaluation and diagnosed with [REDACTED]. Further review of Resident #9's Post Fall Investigations revealed an additional eight (8) unwitnessed falls when the resident was found on the floor by staff, the alarm was not sounding, and the physician ordered hipsters were not on the resident. These falls occurred on 03/04/14 at 4:15 PM, 04/10/14 at 7:15 PM, 04/12/14 at 4:45 PM, 06/14/14 at 11:40 PM, 09/06/14 at 3:00 PM, 10/15/14 at 10:00 PM, 10/19/14 at 11:15 AM, and on 01/17/15 at 12:05 AM. Review of the Falls Progress Note, dated 06/16/14, revealed the Director of Nursing (DON) documented on the Falls Progress Note that Resident #9 was found in the doorway on the floor, on 06/14/14 at 11:40 PM, with skin tears in three (3) places on his/her right forearm and complaints of pain in both hips. In addition, the falls progress note stated the bed alarm was not sounding and there was no evidence the resident was wearing the hipsters as ordered. The resident was transferred to the hospital for an evaluation and diagnosed with [REDACTED]. Interview with the DON, on 02/25/15 at 1:50 PM, revealed there was no post fall investigation for 06/14/14 found by the facility. Further review of the Post Fall Investigations revealed Resident #9 had tampered with the alarm preventing it from sounding when the resident fell , on 04/10/14 at 7:15 PM and 10/19/14 at 11:15 AM. Interview with the DON revealed, per review of the resident's plan of care, it could not be determined which changes on the care plan were initiated or discontinued related to these two (2) falls. Per the investigation report for 01/17/15, CNA #6 and #7 got Resident #9 out of bed that morning and the alarm did not go off in the morning and they were too busy getting people up to let the nurse know. Review of facility's In-service Training on Resident Alarms, revealed the Unit Manager and CNA #8 had attended training regarding the placement of the bed alarm under Resident #9, dated 10/19/14, and also had attended an inservice on 10/25/14. Further review of the facility In-service Training on Bed Alarms, dated 12/10/14, revealed CNA #6, #7 and #8 attended. The in-service agenda revealed staff was to ensure alarms sounded when the resident was gotten up. Also, if the alarm was not in proper working order, then immediately notify the nurse. In addition, the staff was to make sure all chair alarms and bed alarms were attached, plugged in and in working order. Interview with CNA #6, on 02/26/15 at 2:20 PM, revealed she routinely cared for Resident #9 and knew the resident well. Resident #9 had some falls, when he/she tried to get up without assistance. When they heard the alarm they had to go to the resident right then. CNA #6 stated as far as she could remember Resident #9's alarm worked most of the time. She stated she recalled having an in-service to report any alarms not working. CNA #6 stated she had one alarm that did not sound a long time ago; however, she stated she had never been to busy to report alarms not working to the nurse. She stated Resident #9's alarms usually worked. She stated staff must check to make sure Resident #9's alarms were working. The staff made rounds every one (1) to two (2) hours and checked on the alarms. In addition, she stated Resident #9 wore hipsters all the time. Interview with CNA #7, on 02/26/15 at 2:35 PM, revealed she provided care to Resident #9 and was frequently assigned to the resident. Resident #9 had fallen several times and the falls occurred when Resident #9 tried to find his/her children and other times it had been when he/she tried to get back in bed. Resident #9 had a seat belt alarm that he/she released and reconnected behind him/her. They all knew Resident #9 took the alarm off and reconnected the alarm behind him/her. She stated they would have to check on him/her right then. She stated the alarms had a light that blinked and a flashing light to show when the battery was low. She stated, she found the resident when he/she fell and broke his/her hip several months ago, back in June. The alarm was not sounding at that time. She stated they change the batteries or the alarm if the alarm did not work when they got the residents up. Alarms not working must be reported to the nurses. Interview with CNA #8, on 02/26/15 at 2:50 PM, revealed she had attended the in-service on checking the alarms and making sure they were working. She stated Resident #9 had a self releasing seat belt that he/she took off and would try to get up. All the staff knew the resident had several falls. The nurses, Licensed Practical Nurse (LPN) #2 and the DON, knew the resident repeatedly took the seat belt alarm off and tried to get up. The resident also had a bed alarm and fall mats at the bedside in the floor. She stated she had never put hipsters on Resident #9 since she had been caring for him/her. Interview with the LPN #2, on 02/26/15 at 2:00 PM, revealed Resident #9 had a long history of falls in the facility with fractures on a couple of occasions. The resident could roll around the facility while in the wheelchair and utilized an alarming seat belt. LPN #2 stated the resident could self release the alarming seat belt and reconnect it behind his/her back. She stated they were going to discontinue the self release seat belt, but the family resisted it being removed since Resident #9 had so many falls. The family felt like it was one more way to alert the staff. The resident currently had two (2) types of alarms, a wheelchair alarm and a bed alarm. LPN #2 stated the resident had numerous falls and everyone knew the minute they heard the alarm, they had to respond because the resident would attempt to get out of the bed. She stated she checked the alarms at the beginning of her shift, and if there was a problem she would correct the problem at that time. Interview with the DON, on 02/26/15 at 4:40 PM, revealed she held morning meetings with falls discussed. She stated during the meeting they looked at the care plans and if an inappropriate intervention was added, then they would add an appropriate intervention; however, the inappropriate intervention may not be discontinued. The DON stated twenty-six (26) of ninety-six (96) residents were assigned bed and/or chair alarms. The pad alarm batteries were changed every one (1) year. They documented when they started using them, when the alarm is opened, then they document that it needed to be changed in one (1) year. She stated they had disciplined two (2) CNAs for not reporting to the nurse that an alarm was not functioning and they provided an in-service for checking the alarms and any alarms not working must be reported to the nurse. She stated they would throw away any alarms that did not work. She stated the alarms were included on the Medication Administration and Treatment Administration Records with staff ensuring the function of the alarm and the placement of the alarms; however, she did not do any monitoring of the system to ensure the staff was compliant. Interview with the Administrator, on 02/26/15 at 1:30 PM, revealed the DON and Unit Managers had daily morning meetings and the falls are discussed during that meeting. The falls were tracked and trended by the DON. In addition, the falls were followed by the DON and she was supposed to look for patterns with the time of the falls. He stated the falls had not been monitored based on an injurious and non-injurious fall; therefore, the QA Committee had not identified any trends. He stated the DON informed him during the department head meetings about any falls in the facility. However, only during the course of the survey, he had been made aware of Resident #9's falls and the problems with the personal alarms not working. He further stated upon review of the documents of the Post Fall Investigations, he realized he had not been kept abreast of Resident #9's multiple falls.

Based on interview and record review, it was determined the facility failed to have an effective system in place to ensure the Quality Assurance (QA) Committee identified quality deficiencies, developed plans of action, and monitored for effectiveness. Resident #9 sustained multiple falls, two (2) that resulted in injuries and nine (9) that the alarm did not sound. The QA Committee failed to track and trend the falls to identify patterns and ensure appropriate plans of action were developed and monitored to prevent further falls. The findings include: Review of the clinical record for Resident #9 revealed the resident sustained [REDACTED]. Resident #9 had a total of nine (9) unwitnessed falls which the facility determined the alarms failed to sound. Interview with the Director of Nursing (DON), on 02/26/15 at 4:40 PM, revealed she tracked and trended the falls in the facility and reported the findings to the Quality Assurance (QA) Committee for analysis. She stated they talked about the falls in the QA committee; however, they had not identified any patterns with the falls. However, review of the falls tracking information provided by the facility revealed the following: January 2014, Dogwood Court residents (where Resident #9 resided) had two (2) falls on Sunday, two (2) falls on Monday, two (2) falls on Tuesday, one (1) fall on Wednesday, one (1) fall on Thursday, three (3) falls on Friday, four (4) falls on Saturday. The DON identified five (5) falls occurred on the 11:00 PM-7:00 AM shift, six (6) falls occurred on the 7:00 AM-3:00 PM Shift and four (4) falls occurred on the 3:00 PM-11:00 PM Shift for a total of fifteen (15) falls. January 2014, Magnolia Court residents had one (1) fall on Sunday, two (2) falls on Monday, two (2) falls on Tuesday, no fall on Wednesday, two (2) falls on Thursday, one (1) fall on Friday, two (2) falls on Saturday. The DON identified three (3) falls occurred on the 11:00 PM-7:00 AM shift, five (5) falls occurred on the 7:00 AM-3:00 PM Shift and two (2) falls occurred on the 3:00 PM-11:00 PM Shift for a total of ten (10) falls. The summarization revealed there were three (3) residents with repeated falls, two (2) residents with three (3) falls each and one (1) resident fell two times. Further review of the fall tracking information revealed the residents with repeated falls were all identified to reside on Dogwood Court. In addition, the DON documented she would continue to monitor fall patterns to identify any patterns of falls. The January 2014 report did not distinguish falls with or without injury, or falls involving equipment/assistive devices. No current information related to fall tracking and trending was provided. Interview with the Administrator, on 02/26/15 at 1:30 PM, revealed the DON and Unit Managers brought clinical issues to the Quality Assurance (QA) meeting, developed action plans to address the problems and then evaluated the effectiveness. He stated the DON and Unit Managers had daily morning meetings and the falls were discussed during that meeting. The DON informed the Administrator during the department head meeting about any falls in the facility. The falls were tracked and trended by the DON. The falls were followed by the DON and she was supposed to look for a pattern and the time of the falls. He stated the QA Committee had not identified any trends. He stated the falls tracking report had not distinguished between injurious and non-injurious falls. He stated the QA committee did not know of the multiple falls and the problems with the personal alarms, therefore, no action plan had been developed, implemented, or monitored.