Every finding on record at Signature Healthcare of McCreary County Rehab and

Based on observation, interview, record review and facility policy, the facility failed to ensure its staff implemented and provided care in accordance with the resident's written care plan interventions for 1 of 26 sampled residents (Resident (R47). R47 sustained a tibial (bone in the lower leg) fracture.The findings include:Review of the facility's policy titled, Comprehensive Care Plan last reviewed 01/31/2026, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident. Per review that care plan was to include measurable objective and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Continued policy review revealed the Licensed Nurses and/or Interdisciplinary Team (IDT) developed and maintained a comprehensive care plan for each resident that identified the highest level of functioning the resident might be expected to attain. Each resident's Comprehensive Care plan was designed to: incorporate identified problem areas and incorporate risk factors associated with identified problems. The care plan was to be revised as necessary with changes. Review of R47's Face Sheet revealed the facility admitted the resident on 07/30/2024, with diagnoses that included hemiparesis and hemiplegia following a right dominant side cerebral infarct (stroke). Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/05/2025, revealed the facility assessed R47 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15. This score indicated the resident was moderately cognitively impaired. Review of the facility's Comprehensive Care Plan (CCP) for R47 dated 07/30/2024, revealed a problem area was developed and initiated 08/05/2024, for self-care deficit related to impaired physical functioning and medical conditions. Per review, the goal was for R47 not to experience any adverse outcomes related to her need for assistance with activities of daily living (ADLs). Further review of the CCP revealed the facility noted R47 required assistance of two staff for all transfers. Additional review revealed the CCP was updated 10/25/2025 for use of a mechanical lift for R47's transfers (after R47's fall and subsequent tibial fracture). Review of the Nurse Progress Notes for R47 revealed on 10/17/2025 at 1:44 PM, R47 had bruising on the right leg which was painful when touched, and had slight redness to the right inner ankle, which was warm to the touch. Continued review of the Nurse Progress Notes revealed on 10/18/2025 at 3:36 PM, R47 refused to shower due to the pain in her right leg. Review of the Nurse Progress Notes dated 10/21/2025 at 6:31 PM, documented by Licensed Practical Nurse (LPN) 1, revealed R47 was observed to have bruising to her right lower leg and pain with any movement. The Nurse Practitioner (NP) was notified with a new order received to obtain x-rays of the resident's leg, ankle, and foot. Further review of the Nurse Progress Notes revealed on 10/22/2025 at 12:00 AM, the x-rays were performed at 9:30 AM, and the results dated 10/22/2025, noted the resident had an acute right distal tibia fracture. Review of the Interdisciplinary Team (IDT) Note dated 10/22/2025 at 12:21 PM revealed the Social Services Director (SSD), Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator held a meeting to discuss R47's x-ray results and reviewed the resident's care plan. Per review of the IDT Note, R47 was lowered to the floor by a CNA (Certified Nurse Assistant) after her legs gave way on 10/14/2025. R47 had no complaints at that time. Continued review of the Note revealed the NP was notified and ordered x-rays which were obtained and determined R47 had an acute appearing distal tibia fracture. Further review revealed the NP ordered an opioid pain medication, pain monitoring every shift and prn (as necessary), a boot for R47's RLE (right lower extremity), and to make a referral for the resident with an orthopedic physician. Additional review revealed R47's care plan was reviewed and an intervention added for the resident to be transferred with a mechanical lift. Review of CNA 8's employee file revealed the facility's documentation included a Violation of Conduct and Behavior Policy, which noted the CNA was educated to immediately notify the floor nurse of any falls, and even if the resident was assisted to the floor, was also considered a fall. CNA 8 was also educated to follow the residents' care profiles for ADL's before transferring any residents. In interview on 05/12/2026 at 2:03 PM, CNA 8 stated she was aware she was to look at the residents' care plans for their transfer information. She stated she had looked at R47's care plan previously; however, she did not recall specifically what the resident's care plan directed staff to do for transfers at the time of the incident on 10/14/2025. CNA 8 stated that on 10/14/2025, she had been transferring R47 from had wheelchair to her bed, and as she helped the resident into a standing position her legs (R47's) gave out. She explained she assisted R47 to the floor first, then picked the resident lifting her onto her bed. The CNA stated R47 had not complained of pain at the time. CNA 8 stated she had not reported the incident to anyone as she thought since she assisted R47 to the floor, it was not considered a fall. She stated she had transferred R47 numerous times by herself without any difficulty. CNA 8 further stated, after the incident, she had been off until the following week and upon returning to work became aware that R47 was having difficulty with her RLE. She stated (after learning that information) she informed LPN 1 of the incident on 10/14/2025 involving R47. During interview with CNA 10, she stated she had been called to R47's room by CNA 8 to assist her with getting the resident off the floor into the bed. She stated they used the Hoyer lift (brand of mechanical lift) to get R47 up off the floor and onto the bed. CNA 10 stated after she assisted CNA 8 with getting R47 on the bed, she reported the incident/fall to LPN 1. She stated she had cared for R47 prior and per R47's care plan the resident was a two person assist for transfers. CNA 10 further stated she would look at care plan for information on a resident's care needs prior to providing care. In interview on 05/13/2026 at 9:44 AM, LPN 1, who was on duty on 10/14/2025, stated she was not made aware of the incident involving R47 until the following week. She stated she was not sure of what type of transfer assistance R47 needed at the time of the incident, as she did not go into residents' rooms when CNAs were providing their care. LPN 1 stated she recalled initially when R47 had the redness, bruising and swelling of her right foot, the NP had been notified, and they thought the resident might have had a blood clot or cellulitis in her RLE. She stated when CNA 8 notified her of the incident involving R47 on 10/21/2025, she immediately informed the ADON and the DON. In interview on 05/13/2026 at 10:15 AM, the prior DON stated as soon as she was notified by LPN 1, of the incident involving R47, she informed the LPN to do vital signs and perform a skin assessment. She stated an investigation was also initiated. In interview on 05/13/2026 at 10:22 AM, the prior ADON, stated as soon as the DON made her aware of the incident involving R47, they immediately initiated an investigation. She stated the Administrator was also notified and the IDT met. The prior ADON stated R47's care plan at the time of the fall was for a two person assist with transfers. She further stated that when the IDT met after the fall R47's care plan was updated for usage of a mechanical lift with all transfers for R47. The prior ADON stated all staff were educated to follow the care plan interventions as required, as well as what was considered a fall, and reporting all falls. In interview on 05/14/2026 at 3:27 PM, the current DON stated she started on 03/24/2026. She stated she had been updated the past couple of days on the incident involving R47. The DON stated when a fall occurred, her expectation was for staff to assess for injuries, ensure resident safety, report to supervisors, and contact the physician. She stated staff were then to document the fall (to include care plan interventions, progress notes, and event note). The current DON explained a nurse would open the event in the resident's electronic medical record (EMR) and neuro checks would be triggered in the event which included pain, interventions, etc. She stated nursing staff should update the resident's care plan after a fall, then the IDT and she (DON) would check the event reports the next morning and go over each fall to review the fall as a team. The current DON stated they checked the resident's care plan and made sure the care plan had been updated. She stated falls were gone over in orientation, such as what was a fall, which included if a resident was assisted to the floor and how to report falls. The DON further stated she expected the resident's care plan to be updated immediately as soon as feasible after a change in condition (such as a fall) or decline. At the time of the incident R47 had been care planned for two person assist with transfers, however CNA8 transferred R47 from her wheelchair to the bed without assistance of another staff member.

Based on observation, interview, record review and facility policy review, the facility failed to ensure its staff provided adequate supervision and assistance to prevent injury for 1 of 26 sampled residents (Resident (R47), which resulted in the resident sustaining a fracture. The findings include: Review of the facility's policy titled, Accidents and Incidents last reviewed 01/31/2026, revealed the intent was to ensure the facility provided an environment that was as free from accidents and incidents that were avoidable, the facility investigates these occurrences with applicable documentation and appropriate reporting, as applicable. Review of the facility's policy titled, Notification of Change of Condition last reviewed 01/31/2026, revealed the policy was to ensure appropriate individuals were notified of changes in condition. Additional review revealed the medical provider would provide guidance related to the change in condition. Review of R47's Face Sheet revealed the facility admitted her on 07/30/2024, with diagnoses of hemiplegia and hemiparesis following a cerebral infarct (stroke) of the right dominant side. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/05/2025, revealed the facility assessed R47 as having a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Review of the Comprehensive Care Plan (CCP) for R47 revealed the facility identified a problem area initiated 08/05/2024, for the resident related to self-care deficit regarding impaired physical functioning and medical conditions. Per review, the CCP goal was for R47 to not experience any adverse outcomes related to requiring assistance with activities of daily living (ADLs). Further review of the CCP revealed the facility care planned R47 as requiring assistance of two staff for all transfers. Review of R47's Nurse Progress Note dated 10/21/2025 at 6:31 PM, documented by LPN 1, revealed R47 had bruising to her right lower leg and pain with movement. Per continued review of the 10/21/2025 Note, the nurse had made NP 1 aware, and a new order was received to obtain an x-ray of the foot, ankle, and leg. Review of R47's Nurse Progress Note dated 10/22/2025 at 12:00 AM, revealed the outside contracted radiology performed the ordered x-rays at 9:30 AM. Continued review of R47's medical record revealed the x-ray report results dated 10/22/2025, noted the resident had a right distal acute tibia fracture (lower leg fracture). Further review revealed the results had been relayed to the Physician and NP, a new order for Norco (an opioid pain medication) 7.5/325 milligrams (mg) every six hours was received. Review further revealed the NP was in the facility at the time, and ordered a walking boot/splint to R47's RLE (right lower extremity/leg) for six weeks; for the resident to be non-weight bearing for six weeks, and for a referral to be placed to orthopedics. Additional review revealed R47 was seen by an outside orthopedic physician on 10/23/2026. Review of the Interdisciplinary Team (IDT) Note dated 10/22/2025 at 12:21 PM, revealed the Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Social Services Director (SSD) had met to discuss R47's x-ray results. Per review, R47 had been previously noted to have been lowered to the floor by Certified Nursing Assistant (CNA) after the resident's legs gave way on 10/14/2025. Review of the IDT Note revealed R47 had no complaints at that time, and a few days later the resident presented with redness and right lower leg. Continued review of the Note revealed the NP ordered a doppler, Tylenol, and antibiotics for possible cellulitis, as R47 previously had a fever and was tested for covid, flu, respiratory syncytial virus (RSV) and a urinalysis (UA) was performed, which all resulted in being negative. Further review revealed after the doppler resulted as negative, R47 had been noted with some bruising where it once had been red, and the NP ordered x-rays at that time. Review of the Note revealed the NP also ordered for R47 to remain non-weightbearing during that time. The x-rays results noted an acute appearing distal tibia fracture. According to the Note, R47 had been receiving Tylenol 650 mg every four prn (as necessary) with good results noted. Review revealed R47 was to continue having pain monitoring every shift and prn, a new order for a boot to her right lower extremity (RLE) and Hydrocodone/Aspirin (an opioid pain medication) 7.5/325 mg every six hours as needed for pain. Further review revealed R47 had been seen on 10/23/2025, by the orthopedic physician, with the orders continued for the boot, to remain non-weight bearing for six weeks, and to repeat the x-ray in one month. Review further revealed R47 continued wearing a boot to her RLE as of 05/14/2026. Additional review revealed no documentation of a root cause identified for R47's fall. During interview on 05/12/2026 at 2:03 PM, Certified Nurse Assistant (CNA) 8 stated on 10/14/2025, she had been transferring R47 from the wheelchair to the bed, and when she assisted the resident to a standing position her (R47's) legs gave out. CNA 8 stated she used her knee behind R47 and assisted the resident to the floor. She stated she then picked R47 up by the back of her pants and under her legs and lifted her up on to the bed. CNA 8 explained R47 had not complained of pain at that time. She stated she did not report the fall to anyone as she thought since she assisted the to the floor it was not considered a fall. CNA 8 stated she had transferred R47 numerous times by herself without difficulty. She stated she was aware of needing to look at residents' care plans for their transfer information. The CNA stated she had looked at R47's care plan and did not recall specifically what the care plan directed for the resident's transfers at that time (October 2025). She stated she was off until the following week and became aware of R47 having difficulty with her right lower extremity upon return to work. CNA 8 further stated she then informed LPN 1 of the incident on 10/14/2025, of her transfer of R47. However, review of R47s care plan revealed at the time of the fall she had been care planned for two person assist with all transfers. In interview on 05/13/2026 at 10:51 AM, CNA 10 stated she was called to R47's room (on 10/14/2025) by CNA 8 to assist with getting the resident back to bed. She stated when she arrived at R47's room, the resident was on the floor, with her back against the bed. CNA 10 stated they used the Hoyer lift (brand of mechanical lift) to get R47 back to bed and then reported the incident/fall to LPN 1. However, LPN 1 was adamant that it was not reported to her. During interview on 05/13/2026 at 9:44 AM, Licensed Practical Nurse (LPN) 1, who had been on duty on 10/14/2025, stated she had not been made aware of the incident with R47 until the following week. She stated she was unsure of the type of transfer assist R47 required at the time of the incident. LPN1 stated she recalled initially when the redness, bruising and swelling of R47's foot was noted. She stated NP 1 was made aware, and they thought R47 might have had a blood clot or cellulitis in the right lower extremity. The LPN stated when she made her aware of the incident on 10/21/2025, she immediately informed the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). During interview on 05/13/2026 at 10:15 AM, the prior DON stated as soon as she was made aware of the incident involving R47 by LPN 1, she informed the LPN to do a skin assessment. She additionally stated she told LPN 1 to obtain R47's vital signs and an investigation was initiated. During interview on 05/13/2026 at 10:22 AM. the former ADON stated as soon as she was made aware of the incident involving R47 by the DON, they immediately initiated an investigation. She further stated the IDT met, and the Administrator was made aware. During interview with NP 1 on 05/13/2026 at 3:38 PM, she stated R47 had not been able to stand for a long time due to weakness. NP 1 stated R47 had osteoporosis, but she was not aware of how long the resident had that diagnosis. In interview on 05/14/2026 at 3:27 PM, the current DON stated she started working as DON on 03/24/2026. She stated in the past couple of days she had been updated on the incident involving R47. The current DON explained when a fall occurred, her expectation was for staff to assess the resident for injuries, ensure the resident's safety, report to supervisors, and contact the physician. She stated her expectations included for staff to then document the fall (to include care plan interventions, progress notes, and event note). The current DON stated the nurse would open the event note in the resident's electronic medical record (EMR). which included pain, interventions, etc. She stated nursing should update the resident's care plan, then the IDT and she would check the event reports the next morning. The current DON stated that she and the IDT would go over each resident, reviewing the fall as a team, and checking the care plan to ensure it had been updated. She stated if a fall happened on the weekend, the on-call manager was to be contacted, and the ADON and DON checked on the weekend. The current DON stated if a fall occurred on a weekend a supervisor came in and verified the implementation of care plan updates were in place, on weekdays the IDT checked for the interventions. She stated in the facility's monthly Quality Assurance Performance Improvement (QAPI) meetings they went over topics such as falls, wounds, infections, etc. tracking systems-looking for patterns and things specific to a resident, such as the certain time of day. The current DON further stated falls were discussed in the employees' orientation, such as, what a fall was, which included assisting a resident to the floor, how to report a fall, and implementation of interventions. She additionally stated she expected the resident's care plan to be updated immediately as soon as feasible after a change in condition (including a fall) or decline in condition.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to disclose and provide to a resident or potential resident prior to the time of admission, a notice of special characteristics or service limitations of the facility as determined by the facility's Admissions Policy. Resident #11 was listed on the Sex Offender Registry and was transferred to the facility from the referring facility (the hospital). However, it was the practice and not a written policy, of the facility to refuse admission of persons that were on the sex offender registry. Therefore, the facility transferred Resident #11 back to the referring facility, based on his/her background check. The facility failed to have a policy that addressed its practice to refuse admissions of sex offenders and failed to ensure systems were in place to complete background checks on the residents prior to admission. The findings include: Review of the facility's policy titled, Admissions, dated 07/30/2018, revealed the facility would receive appropriate medical and financial records prior to or upon the resident's admission. Interview with the Director of Admissions Navigator Central Intake Coordinator #1, on 11/07/2022 at 10:01 AM, revealed there was no policy concerning not accepting a resident listed on the sex offender registry. Review of the facility's report titled, Admit/Discharge Report, dated 10/05/2022 to 10/31/2022, revealed six (6) resident admissions with sex offender background checks. Four (4) of the six (6) residents had their sex offender background checks run two (2) days prior to admission. One (1) resident's background check was run four (4) days after the resident's return from the hospital and was for a long-term resident. One (1) resident's background check was run seven (7) days prior to admission. Review of the facility's email, dated 10/05/2022 at 12:28 PM, revealed the Market Liaison #1 for the facility had notified the Assistant Business Office/Assistant Director of Nursing (ADON) and left a voice mail with the Social Worker/Case Manager of the referring facility to admit Resident #11 under his/her primary insurance and not Medicaid Insurance. Review of the facility's email, dated 10/07/2022 at 3:29 PM, revealed Market Liaison #2 revealed to Central Intake Market Liaison #1 that he/she would see Resident #11 on Monday morning (10/10/2022). Review of the facility's email, dated 10/12/2022 at 9:53 AM, revealed Market Liaison #1 sent Resident #11's clinical information to the Director of Nursing (DON), Business Office #1, and the Administrator to see if they had any other questions. Review of the facility's email, dated 10/12/2022 at 10:32 AM, revealed the DON sent to Market Liaison #1, Business Office #1, and the Administrator, a message of yes, the facility can accept pending authorization. Review of the facility's email, dated 10/12/2022 at 11:35 AM and 1:49 PM, revealed the Director of Admissions Navigator Central Intake Coordinator #1 notified the DON, Business Office #1, and the Administrator that Resident #11's information had been sent to the pre-certification team and was approved. Review of the facility's email, dated 10/13/2022 at 11:51 AM, revealed Market Liaison #1 notified the DON, Business Office #1, and the Administrator, per the case manager from the referring facility, that Resident #11, when discharged , was assigned to this facility. The email stated the estimated time of arrival (ETA) was on 10/13/2022, between 2:00 PM and 3:00 PM. Per the email, Resident #11's sister would follow the resident to the facility and help him/her get settled. Review of the facility's email, dated 10/13/2022 at 11:53 AM, revealed Business Office/ADON #2 notified Market Liaison #1, the DON, and the Administrator she had received the discharge summary and was taking it to the nurses and informing them of the resident's expected time of arrival (ETA). Review of the facility's email from the Medical Collection Group, LLC (the company hired by the facility to do pre-admission background checks), dated 10/14/2022 at 9:47 AM, revealed a re-cap of the conversation with the Administrator and the Assistant Director of Nursing (ADON) regarding the alert of Sexual Predator History for Resident #11. The email stated that a prior email link had been sent to the facility that provided, in the Summary Report, more detailed information on the resident/patient's offense history. Per the email, the background check company stated they had uploaded a detailed sexual offense report, from national and state resources, and attached it to the online order for reference. Review of the acute care discharge medical record from the referring facility revealed the referring facility admitted Resident #11, on 03/14/2022, and discharged him/her on 10/13/2022. The resident/patient's admitting diagnoses included Chronic Respiratory Failure, Hypokalemia, and Positive Blood Cultures for Staphylococcal Bacteremia (MRSA) with a Large Pleural Effusion, Hemothorax, and Hepatitis B and C. Continued review revealed of the discharge summary revealed Social Services/Case Manager #1 documented, on 10/13/2022 at 11:30 AM, that discharge plans were completed for a transfer to the facility, and the resident/patient and sister both took part in the admission process to the facility. Per the medical record, the admission liaison from the other facility had them complete the paperwork, and the resident/patient's sister packed his/her belongings to take to the new facility. Continued review of the acute care medical record from the referring facility revealed Registered Nurse (RN) #6, on 10/13/2022 at 12:55 PM, 10/13/2022 at 1:00 PM, and 10/13/2022 at 1:25 PM documented the sister was at the resident/patient's bedside helping the resident/patient get ready for discharge to the other facility. The record stated a full head-to-toe assessment was performed prior to discharge from the acute care facility. Interview with Market Liaison #1, on 11/08/2022 at 9:05 AM, revealed she provided the referring facility the fax number, the nurse's name taking the report, and the phone number to the facility. She stated the facility accepted the referral because there was no report sent by the acute care facility that Resident #1 was on the sex offender registry. Interview with the sister of Resident #11, on 11/06/2022 at 2:37 PM, revealed the resident arrived at the facility at approximately 3:00 PM to 3:30 PM on 10/13/2022. The sister stated she had filled out paperwork on the computer for admission to the facility during the Market Liaison #1's visit. She stated Market Liaison #1 told her the facility would receive the paperwork. She stated Resident #11 was transferred to the facility and in a room when she arrived. She stated she started to bring in belongings and unpack the resident's boxes. The sister stated staff assisted her with putting clothes into the closet. She stated staff came to the door and asked to speak with her privately. The sister stated she was told by staff that Resident #11 was on the sex offender registry, and Resident #11 would have to leave and could not be admitted to the facility because the facility could not admit sex offenders. Continued interview with Resident #11's sister, on 11/06/2022 at 2:37 PM, revealed she contacted the Social Services/Case Manager #1 from the referring facility and Ombudsman #2. She stated the Administrator explained to her it was against the facility's policy to accept a sex offender as a resident. The sister stated she asked for the policy, and the Administrator explained she did not know where to find the policy. The sister stated she continued to voice concern over not knowing where Resident #11 would be sent. She stated nursing staff in the resident's room said when the ambulance arrived, Resident #11 had to leave the facility, and they would call the police if they did not leave. The sister stated she felt threatened by the staff. She stated she then packed up the resident's belongings and returned to the referring facility (acute care hospital). Interview with Licensed Practical Nurse (LPN) #5, on 11/07/2022 at 3:49 PM, revealed she did not receive a call or a report from the referring facility. She stated Resident #11 just appeared at the facility by ambulance. She stated she looked at Resident #11's discharge paperwork from the acute care facility and found the documentation of the history of sex offender. She stated she notified the front office immediately. Interview with Business Office #1 and Assistant Business Office/ADON #2, on 11/07/2022 at 9:41 AM, revealed they assisted with the resident's admission paperwork and forms. Per the interview, they identified the resident's Power of Attorney (POA) and worked with the Central Intake team for admissions concerning financial information and medical records. They stated Resident #11 arrived in front of the facility and was assisted to his/her room. Continued interviews revealed they assisted the resident and his/her sister with one (1) box of his/her belongings. They further stated they were not aware Resident #11 was on the sex offender registry, and they were told by LPN #5 that the discharge paperwork had documentation the resident was a sex offender. Further, they stated they notified administration. Interview with the Director of Admissions Navigator Central Intake Coordinator #1, on 11/07/2022 at 10:01 AM and 11/08/2022 at 8:00 PM, revealed her process was to review the financial information, background checks, and medical record. She stated she had received the sex offender registry list with the first section of the medical record; however, she forgot to save the registry and did not review it because the record had not been saved. She stated she requested the updated medical record from the referring facility (hospital) and verified the insurance. She stated the information was sent for approval for admission, and she forgot to review the background check which was part of the admission process. Interview with the [NAME] President of Operations (VP), on 11/08/2022 at 5:45 PM, revealed the background check for Resident #11 for the sex offender registry had been run. Interview with Clinical Director of Nursing (DON) Acute Care Hospital (referring facility), on 11/06/2022 at 2:06 PM, revealed Resident #11 was admitted to the skilled nursing facility on 10/13/2022 after discharge from the referring facility. She stated the facility called back stating they could not accept the resident due to his/her registration on the sex offender registry. She stated staff reviewed the medical record and found a note documented by psychiatric services that Resident #11 was a sex offender. The DON stated they accepted the return of Resident #11 as an admission from the other facility. Interview with Social Services/Case Manager Acute Care Hospital #1, on 11/07/2022 at 4:00 PM, revealed the facility Resident #11 was referred to, had a policy not to admit sex offenders; however, she was not aware that Resident #11 was listed on the sex offender registry. She stated the acute care hospital sent to the skilled nursing facility all of Resident #11's medical records. She revealed the sister called her stating the facility would not admit the resident. Interview with Ombudsman #2 on 11/07/2022 at 8:53 AM, revealed Resident #11's sister called her very distraught. She stated the sister asked what to do about the discharge because the resident was a sex offender, and the facility was going to discharge him/her. She stated the sister told her she had filled out admission paperwork for the skilled facility at the acute care hospital and had not been given a hard copy. Ombudsman #2 stated she directed the sister not to allow Resident #11 to be discharged and to ask for a copy of the policy concerning the background check. Interview with Licensed Practical Nurse (LPN) #1/Unit Manager, on 11/07/2022 at 10:59 AM, revealed she stayed with Resident #11 and the sister in his/her room until arrangements could be made to transfer Resident #11 back to the referring facility (the hospital). She stated the sister was not happy, and it was made very clear that Resident #11 was not admitted due to the resident being listed as a sex offender. She stated both Resident #11 and his/her sister received supper trays. She stated the resident only had one (1) box of belongings, and it was not fully unpacked. LPN #1 stated the admission process was stopped immediately as soon as the reference to Resident #11 being a sex offender was found in the clinical record documented by the acute care psychiatric staff member. Interview with the Director of Nursing (DON), on 11/07/2022 at 10:45 AM, 11/07/2022 at 3:23 PM, and 11/08/2022 at 4:22 PM, revealed the nurse reviewed the discharge paperwork sent by the referring facility. She stated she was informed Resident #11 had been documented from the clinical record as being listed on the sex offender registry. The DON stated she and the Administrator explained to the sister why Resident #11 could not be admitted to the facility and would have to return to the other facility. She stated the Unit Manager stayed with the sister and the resident, and guest meal trays were provided during the wait. The DON stated the Medical Director reviewed and approved or denied all new admissions. The DON stated the background checks for the sex offender registry were always run-on potential residents for admission to the facility. Interview with the Administrator, on 11/07/2022 at 11:12 AM, 11/07/2022 at 3:23 PM, and 11/08/2022 at 4:44 PM, revealed the resident just appeared at the door of the facility, and staff had not received a report from the referring facility. She stated the nurse contacted her concerning the hospital paperwork which identified Resident #11 as a sex offender. She further stated she explained to the sister and the resident why he/she could not be admitted to the facility. She revealed the Unit Manager stayed with the sister and the resident until he/she was transferred back to the referring facility. She stated the facility provided them with guest meal trays. The Administrator stated, prior to admission, the background check was run for the sex offender registry for all residents. She stated the facility was within a few miles of schools, children visited the facility, and the safety of all the residents in the facility was the reason for not admitting persons who were listed on the sex offender registry. Interview with the Medical Director (MD), on 11/07/2022 at 9:08 AM, revealed he approved Resident #11's admission and was not aware the resident was listed on the sex offender registry. The MD stated he would not have approved the admission if he had known about the listing on the sex offender registry. He stated it was not his practice to admit any resident with this history.

Based on observation, interview, record review, review of the facility investigation documentation, and facility policy, it was determined the facility failed to ensure an allegation of abuse was immediately reported for two (2) of ten (10) sampled residents (Resident #2 and Resident #3). Resident #2 sustained a proximal tibia-fibula (area just below knee) fracture of the right leg on 12/01/2020, during a transfer from his/her bed to a wheelchair. The facility was unaware how the inury of unknown origin occurred and failed to report the injuries to state agencies. Resident #3 sustained a fractured index finger on 06/14/2022, when he/she was having a Covid test performed. The facility's investigation revealed several different occurances of the injury of unknown, thus failed to report the allegations to the reporting agencies. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property effective date 05/27/2016, last revised 07/06/2022, revealed the Reporting Guidelines, revealed any abuse allegation was to be reported to the State within two (2) hours from the time the allegation was received. Per policy review, in the case of neglect, exploitation or misappropriation resulting in serious bodily injury report was to be made to the State Regulatory Agency within two (2) hours. Further review revealed allegations were to be investigated and the Administrator was to provide the appropriate agencies with a written report of the investigation findings within five (5) working days from when the incident occurred. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 09/29/2020, with diagnoses that included Systolic Congestive Heart Failure, Depressive Disorder, Chronic Obstructive Pulmonary Disease, and Osteoarthritis. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as cognitively intact and interviewable based on the Brief Interview for Mental Status (BIMS) score of thirteen (13). Review of the progress notes for Resident #2 revealed on 12/02/2020 at 12:51 PM, Licensed Practical Nurse (LPN) #4 documented the facility's prior Assistant Director of Nursing (ADON) informed LPN #4 that Resident #2 complained of right knee pain. Continued review of the 12/02/2020 progress note revealed the ADON also told LPN #4 that Resident #2 reported he/she bumped his/her leg on the wheelchair when the SRNA's were weighing her/him. Per review, Licensed Practical Nurse (LPN) #4 at that time contacted the Physician for a mobile x-ray. Review revealed the x-ray results confirmed Resident #2 had a tibia/fibula (the two [2] long bones in the lower leg) fracture to his/her right leg, just below knee. Further review revealed RN#1 documented the Physician, DON, and Administrator were made aware of Resident #2's injuries. In addition, review revealed the Physician gave orders for Ibuprofen, a foot boot stabilizer, an orthopedic appointment to be made, and if his/her pain was uncontrolled to send him/her to the emergency room (ER). Review further revealed Resident #2 initially refused transfer to the ER for assessment, although pain continued to be an issue. The progress notes further revealed on 12/02/2020, Resident #2 agreed to be transported to the ER for treatment. Interview with Resident #2, on 07/25/2022 at 3:05 PM, revealed that when the incident happened a State Registered Nursing Assistant (SRNA) came in to assist him/her, put the resident's socks and shoes on and then proceeded to try to lift Resident #2 from the bed over to the wheelchair. Resident #2 reported when the SRNA dropped him/her into the wheelchair the resident felt his/her leg pop and he/she immediately had terrible pain. According to Resident #2, he/she cried out in pain and told the SRNA she had hurt his/her leg. The resident stated the SRNA flew me down the hallway in the wheelchair to the scales to be weighed. Further interview revealed when staff tried to have Resident #2 stand to be weighed, he/she had been unable to stand. In addition, Resident #2 was able to give the State Survey Agency (SSA) Surveyor the first name of the SRNA, who was SRNA #12. Interview further revealed Resident #2 stated some of the SRNA's did not know how to care for her/him. Interview with Licensed Practical Nurse (LPN) #4 on 08/01/2022 at 4:00 PM, revealed she remembered assessing Resident #2 regarding his/her complaints of pain in the right knee area and remembered the resident reporting his/her leg was injured during a transfer. She stated she felt that the ADON had reported the allegation of the physical injury of Resident #2 during a transfer to the appropriate persons. Interview with Registered Nurse (RN) #1 on 08/02/2022 at 1:35 PM, revealed she recalled getting the results of Resident #2's x-ray regarding the fracture. RN #1 revealed she remembered contacting the Director of Nursing (DON) and being told the incident was being followed up on and SRNA was not to be in Resident #2's room. Further interview revealed RN #1 reported the information to the Administrator, including the x-ray results. Interview with State Registered Nurse Aide (SRNA) #6 on 08/08/2022 at 3:16 PM, revealed the SRNA overheard Resident #2 telling SRNA #11 and SRNA #12 you broke my leg and heard SRNA #11 tell the resident, no we didn't. Per SRNA #6, she had not reported that information to anyone as she got busy and forgot. Further interview revealed everyone was talking about Resident's x-ray showing the fractures, and by then everyone was aware. The State Survey Agency (SSA) surveyor attempted an interview with SRNA #12 by phone; however, it was unsuccessful. The attempted calls were made on 08/02/2022 at 2:00 PM; 08/04/2022 at 9:22 AM; and 08/07/2022 at 1:53 PM. Interview with State Registered Nurse Aide (SRNA) #11 on 08/07/2022 at 1:56 PM, revealed she remembered assisting SRNA #12 with Resident #2's transfer on 12/01/2020, as the resident was a two (2) person assist. Per SRNA #11, no hoyer lift had been used for Resident #2's transfer at that time. SRNA #11 further revealed she recalled assisting Resident #2 back to bed and did not recall the resident having any complaints of pain to his/her leg. Interview with the facility's prior Assisted Director of Nursing (ADON), on 07/30/2022 at 8:20 PM, revealed she did not specifically remember the incident involving Resident #2. The prior ADON reported she only worked at the facility for approximately three (3) weeks when the incident occurred; however, if during her rounds a resident complained of pain or had other complaints, she would have informed the resident's nurse to follow-up. Further interview revealed the prior ADON stated she would have reported any residents' complaints to the Administrator and/or the DON if the complaints had been any type of abuse allegation. Interview with the Administrator, on 07/26/2022 at 4:27 PM, who was also the facility's Abuse Coordinator, revealed she had not been made aware of the allegation that Resident #2's fracture was obtained during a transfer. The Administrator revealed; however, she had been told the fracture happened when Resident #2 stood up to obtain his/her weight, and was aware the resident had Osteoporosis (a disease that thins and weakens the bones). 2. Review of Resident #3's medical record revealed the facility admitted the resident on 05/13/2019, with diagnoses that included Dementia, Hypertension, Bipolar Disorder, Epilepsy, and Diabetes. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15) which indicated moderate cognitive impairment. Review of the facility's event report dated 06/14/2022 at 5:10 PM, documented by the DON revealed Resident #3 had black/blue bruise to left index finger. Continued review revealed Resident #3 stated that earlier that day he/she threw a 1/2 full pop bottle at the nurse who performed a Covid test and had hurt his/her finger. Further review revealed the Physician was made aware. Review of the progress note dated 06/14/2022 at 10:16 PM, documented by Registered Nurse (RN) #1 revealed Resident #3 had complained of pain in his/her left index finger which had bruising and swelling. Continued review revealed the Physician was contacted and orders received for an x-ray to be obtained. Further review revealed the x-ray results showed a fracture of the middle joint of the resident's left index finger. In addition, review of the progress note revealed the Administrator and DON were notified. Continued review of the progress notes revealed on 06/15/2022, Adult Protective Services (APS) was in Resident #'3's room with the resident, and he/she told the APS worker that the girl with the red bandana threatened me. Review of the facility's investigation of the verbal abuse allegation reported to the APS worker on 06/15/2022, revealed a written statement documented by the facility's prior ADON which noted Resident #3 had told prior Staff Development Coordinator (SDC) that the girl that broke his/her finger was in his/her room and threatened the resident. Further review revealed Resident #3 had reported she (the girl) had been wearing a red bandana or headband. Review of the facility's investigation final report revealed based on available information obtained during the investigation, the allegation of verbal abuse could not be substantiated. Interview with the Director of Nursing (DON) on 08/10/2022 at 1:13 PM, revealed she had been notified of Resident with a bruised finger on 06/14/2022 at 5:10 PM and contacted Physician for orders. DON was notified of Resident #3's x-ray results on 06/15/2022 at 1:16 PM. The DON revealed that because the facility knew how the injury happened to Resident #3 per documentation in progress notes dated 06/14/2022 at 5:10 PM that Resident stated she threw a half full pop bottle after her Covid test and hurt her finger. The DON stated she had not thought that incident had been reportable to the State Survey Agency (SSA). Further interview revealed on 06/15/2022, when Resident #3 made the allegation he/she was being verbally threatened, the facility initiated an investigation regarding the alleged verbal abuse. Interview with the facility's prior ADON on 08/02/2022 at 10:15 AM, revealed she was only employed for five (5) or six (6) weeks at the facility. She stated to her recollection, she remembered placing a splint on Resident #3's finger after the Physician's order was received. Per the ADON, Resident #3 did tell her his/her finger was broken during a Covid swab by a nurse the day before. Interview revealed that information was passed on to the DON and LPN #1, the Unit Manager (UM). Interview with State Registered Nurse Aide (SRNA) #3 on 08/03/2022 at 4:21 PM, revealed Resident #3 had stated to her, the lady in the bandana bent his/her finger and broke it during the Covid test. SRNA #3 stated she did not report that information to anyone though, because all the staff were talking about the incident and she thought the incident was already being investigated. Interview with the Social Worker (SW) on 08/02/2022 at 11:01 AM, revealed he was with the DON when Resident #3 was interviewed about how he/she injured his/her finger. Further interview revealed Resident #3 indicated during the interview, he/she threw a half full bottle of pop at the nurse during a Covid test and stated he/she could have broken it (the finger) when throwing the pop bottle. Interview with LPN#1, the Unit Manager (UM) on 07/26/2022 at 4:28 PM, revealed the LPN along with SRNA #5 had been performing Covid testing for all residents on 06/14/2022. LPN #1/UM stated Resident #3 had been in the dining room in his/her wheelchair waiting for Bingo to start, and initially told the LPN he/she did not want the Covid test done. Continued interview reveled after coaxing and talking with Resident #3, the resident agreed to have the Covid test performed, and leaned his/her head back for the LPN to do the test. LPN #1/UM revealed after swabbing Resident #3 for the Covid test the resident was upset and threw an empty plastic pop bottle at her and stated, this will not happen again. Further interview revealed Resident #3 was flailing his/her hands while he/she was upset after the testing. LPN #1/UM further stated Resident #3 was fine with no complaints of pain when she left the resident. In addition, she revealed she was not made aware of Resident #3's complaints until the next day when the facility suspended her for an allegation of threatening the resident. Interview with State Registered Nurse Aide (SRNA) #5 on 07/30/2022 at 8:53 PM, revealed Resident #3 had been sitting in the dining room in his/her wheelchair at a table when Licensed Practical Nurse (LPN) #1 went to perform the Covid test. According to SRNA #5, when LPN #1 informed Resident #3 of the need for a Covid test to be done, the resident started throwing and slinging his/her arms and fussing at the nurse. Continued interview revealed Resident #3 had an empty bottle of pop, and she and LPN #1 told the resident they would buy him/her another pop if he/she would let them do the Covid test. Further interview revealed Resident #3 finally agreed and allowed LPN #1 to swab him/her, but then through the empty pop bottle at LPN #1 after the Covid test was completed. Interview further revealed SRNA #5 had not been aware of any complaints of pain to Resident #3's finger until the next day. Interview with the Administrator on 08/08/2022 at 5:06 PM, revealed she was the facility's Abuse Coordinator and had been notified of the incident involving Resident #3. The Administrator stated she completed the five (5) day investigation, and had not felt Resident #3's fractured finger had been a reportable incident to the SSA as the facility knew how the fracture happened. Per the Administrator, the allegation of the LPN #1 verbally threatening Resident #3 was investigated; however, had been unable to be substantiated due to the lack of information. Further interview revealed the Administrator stated she would have reported the incident of Resident #3's injury allegation if she had not known how the fracture happened. The Administrator further revealed per her investigation Resident #3 had been flailing his/her hands and hitting the table when the fracture occurred. Interview with the facility's Registered Nurse Consultant on 08/11/2022 at 4:36 PM revealed she had been notified by DON on 06/14/2022, of the injury to the finger of Resident #3; however, felt the injury had not been reportable due to the resident stating he/she hurt the finger after his/her Covid test.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop a Comprehensive Person-Centered Care Plan for each resident to assist in attaining or maintaining the residents' highest practicable quality of life for one (1) of ten (10) sampled residents, (Residents #4). Resident #4 had an indwelling Foley catheter. The resident had Physician's Orders for the Foley catheters to be changed monthly and as needed (PRN). However, the facility failed to care plan Resident #4 for his/her ordered Foley catheter changes. The findings include: Review of the facility's, Care Plans-Comprehensive Policy, revised 07/19/2018, revealed a Baseline Care Plan was to ensure newly admitted residents or readmitted residents had their care needs met, utilizing a person-centered focus. Continued review revealed high risk areas for residents must be care planned within twenty-four (24) hours. Per review of the facility's Comprehensive Care Plan policy, a person-centered Comprehensive Care Plan was to be developed for each resident to include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. Further review revealed the Comprehensive Care Plan was to include how the facility would assist the resident to meet their needs, goals, and preferences. Review of Resident #4's medical record revealed the facility admitted the resident on 03/04/2022, with diagnoses to include Acute Kidney Failure, Pressure Ulcer (sacral) unstageable, Hypertension, Heart Failure, and Paroxysmal Atrial Fibrillation. Continued record review revealed on 04/08/2022, the diagnosis, Urinary Tract Infection was added and on 06/16/2022, a diagnosis of Dysuria was added. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 06/11/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Continued review of the Quarterly MDS Assessment revealed under Section H the facility documented Resident #4's continence status was Not Rated, resident with a catheter. Review of Resident #4's laboratory (lab) results revealed a urine sample was obtained on 07/08/2022, and the final results were reported on 07/10/2022. Continued review revealed Resident #4's urine culture results revealed Citrobacter freundii complex and Proteus Mirabilis (types of bacteria) were identified. Continued review of Resident #4's lab results revealed on 07/18/2022, a Urinalysis with culture revealed Proteus, and on 07/28/2022 the Urinalysis final noted Proteus Mirabilis present. Review of Resident #4's Comprehensive Care Plan dated 03/05/2022 revealed the facility had noted a Problem for Potential for Infection related to an indwelling catheter with interventions to include: monitoring for retention and abdominal pain; monitoring the characteristics of the resident's urine; irrigating the catheter as ordered; and providing catheter care as ordered. Review of Resident #4's Physician's Order, dated 03/04/2022, revealed orders for his/her Foley catheter to be changed every month with a 16 French (size of catheter) with a 10-20 cubic centimeters (cc) balloon (to hold the catheter in place) related to a diagnosis of a coccyx wound. Further review of the Physician's Order revealed nursing staff were to change Resident #4's Foley catheter as needed (PRN) for blockage, dislodgement, or leakage, and contact the Physician if a Foley catheter or balloon size change was required. Review of Resident #4 Treatment Administration Record (TAR) dated 07/04/2022 through 08/03/2022, revealed the orders included Foley catheter change PRN (as needed) for leakage, blockage or dislodgement. Continued review revealed the orders additionally included change Foley catheter once a month on the fourth (4th) of the month; and Foley catheter care every shift. However, further review of Resident #4's Comprehensive Care Plan revealed no documentation noting the resident's Foley catheter was to be changed monthly as ordered and PRN for blockage, dislodgement, or leakage. Interview with Resident #4 on 08/03/2022 at 10:55 AM, revealed that his/her Foley catheter was changed frequently due to hurting him/her often. Continued interview with the resident revealed he/she felt better after the catheter changes. Interview with Licensed Practical Nurse (LPN) #5 on 08/08/2022 at 2:18 PM, revealed the LPN was not certain of the use of or reason for Resident #4 to have a Foley catheter; however, thought it was probably due to the wound. Per interview, the nurse was aware that there had to be a medical reason for a Foley catheter to be inserted, and that interventions/approaches and goals should all be on a resident's care plan. In addition, LPN #5 stated it was the nurses' responsibility to get orders for Foley catheters and update residents' care plans. Interview on 08/04/2022 at 3:22 PM, with the Minimum Date Set (MDS) Coordinator revealed the Coordinator had been in that role since 04/11/2022. Per interview, residents' care planning was done as a collaborative task during the facility's Interdisciplinary Team (IDT) meetings. Continued interview revealed the nurse performing a resident's initial assessment added nursing care plans from the Physician's Orders, and the Unit Manager also had a large input. The MDS Coordinator stated the IDT meetings held every morning were to discuss new admissions, changes in residents, and other pertinent resident information. Further review revealed if a Care Area Assessment (CAA-the process providing guidance on how to focus on key issues identified during a comprehensive MDS assessment) was triggered on the MDS, the MDS Coordinator checked to ensure the identified issues were care planned. Interview on 08/18/2022 at 4:31 PM, with the MDS Coordinator and Clinical Reimbursement Specialist revealed the IDT discussed at risk residents, and catheters consistently. Continued interview revealed the goal of the IDT was to get rid of a resident's Foley catheter as soon as feasible. Further interview revealed residents' plans of care were updated as part of the whiteboard (the facility's morning meeting with key staff present which included the Administrator, Director of Nursing [DON], Unit Managers, MDS Coordinator and Social Worker) meeting held to discuss care plan goals and issue plans, and/or in the IDT meetings Interview with the Administrator on 08/14/2022 at 4:55 PM, revealed the facility's oversight of care planning was by randomly pulling residents' care plans to ensure the accuracy of them. Per the Administrator, the Nurse Managers compared resident's care plans with their assessments to ensure that each resident's needs were met. The Administrator stated residents' baseline care plans were discussed in the facility's morning whiteboard meetings and updated as needed. Further interview revealed otherwise, residents' Comprehensive Care Plans were updated with the MDS Assessments performed. In addition, the Administrator revealed if a resident had new orders, changes in their condition, or other concerns their Comprehensive Care Plans were updated in the morning meetings.

Based on observation, interview, record review, review of the facility's investigation documentation, and facility policy, it was determined the facility failed to provide adequate supervision and assistance to prevent accidents for one (1) of ten (10) sampled residents, (Resident #2). The facility assessed Resident #2 as cognitively intact, and to be dependent on two (2) or more staff with transferring. However, Resident #2 sustained a proximal tibia-fibula (long bones of the leg below the knee) on 12/01/2020, during a transfer performed by only one (1) staff person, from his/her bed to the wheelchair. The findings include: Review of the facility's, Care Plans-Comprehensive Policy, revised 07/19/2018, revealed a person-centered Comprehensive Care Plan was to be developed for each resident to include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. Further review revealed the Comprehensive Care Plan was to include how the facility would assist the resident to meet their needs, goals, and preferences. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 09/29/2020, with diagnoses that included: Osteoarthritis, Systolic Congestive Heart Failure, Depressive Disorder, and Chronic Obstructive Pulmonary Disease. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as cognitively intact and interviewable based on the Brief Interview for Mental Status (BIMS) score of thirteen (13). Review of the facility's initial MDS Assessment for Resident #2 dated 10/02/2020, (the MDS Assessment current at the time of the incident involving Resident #2) revealed the resident was dependent (required assistance of two [2] or more staff ) for transfers from the chair to the bed, or from the bed to the chair. Review of Resident #2's Comprehensive Care Plan dated 10/08/2020, revealed the facility care planned the resident for Activities of Daily Living (ADL) functional deficits. Continued review revealed interventions included Resident #2 required assist of two (2) for transfers. However, review of the facility's computerized point of care history dated 12/01/2020 at 12:08 AM, revealed documentation which noted staff support provided for transferring of one (1) person assist and lifted manually. Review of the progress notes for Resident #2 revealed on 12/02/2020 at 12:51 PM, Licensed Practical Nurse (LPN) #4 documented the facility's prior Assistant Director of Nursing (ADON) informed the LPN that Resident #2 complained of right knee pain. Continued review of the 12/02/2020 progress note revealed the Assisted Director of Nursing (ADON) also told Licensed Practical Nurse (LPN) #4 that Resident #2 reported he/she bumped his/her leg on the wheelchair when the SRNAs were weighing her/him. Per review, LPN #4 contacted the Physician for a mobile x-ray after the ADON's report. The x-ray results review revealed Resident #2 had a tibia/fibula (the two [2] long bones in the lower leg) fracture to his/her right leg, just below knee. Review revealed RN#1 made the Physician, Director of Nursing (DON), and Administrator aware of Resident #2's injuries. Further review revealed the Physician ordered Ibuprofen (a non-steroidal pain reliever), a foot boot stabilizer, a orthopedic appointment to be scheduled, and if the resident's pain was uncontrolled to send him/her to the emergency room (ER). Review further revealed Resident #2 initially refused transfer to the ER for assessment, although his/her pain continued to be an issue. In addition, review revealed the progress notes revealed on 12/02/2020, Resident #2 agreed to be transported to the ER for evaluation and treatment. Interview with Resident #2 on 07/25/2022 at 3:05 PM, revealed he/she needed staff's assistance to get up to his/her chair. Per interview, on the day the incident happened a State Registered Nursing Assistant (SRNA) came to his/her room to assist the resident to get up from the bed to the chair. Interview revealed the SRNA put Resident #2's socks and shoes on and proceeded to try to lift the resident from his/her bed to the wheelchair. The resident revealed the SRNA did not ask for staff assistance with his/her transfer. Resident #2 stated the SRNA dropped him/her into the wheelchair and the resident stated he/she felt his/her leg pop and immediately had terrible pain in the leg. Continued interview revealed Resident #2 stated he/she cried out in pain and told the SRNA she had hurt the resident's leg. Resident #2 stated the SRNA then flew me in the wheelchair down the hallway to be weighed on the scales. Per the interview, Resident #2 stated staff tried to get him/her to stand to be weighed on the scales; however, he/she had been unable to stand up due to the pain in his/her leg. Further interview revealed Resident #2 was able to recall the SRNA's first name, who was identified as SRNA #12. Resident #2 further stated some of the SRNA's did not know how to care for her/him. Interview with SRNA #6 on 08/08/2022 at 3:16 PM, revealed the SRNA had heard Resident #2 telling SRNA #11 and SRNA #12 you broke his/her leg, and heard SRNA #11 state to the resident, no we did not. SRNA #6 revealed she got busy and forgot to report that information to anyone. Interview further revealed everyone was discussing Resident #2's x-ray results which had shown the fractures, and the SRNA knew by then that everyone was aware. Interview with SRNA #11 on 08/07/2022 at 1:56 PM, revealed she recalled assisting SRNA #12 with the transfer of Resident #2 on 12/01/2020, because the resident required assistance of two (2) people for transfers. SRNA #11 stated they had not used a hoyer lift for Resident #2's transfer. Further interview revealed SRNA #11 recalled helping Resident #2 back to bed; however, did not recall the resident having complaints of leg pain. Review of the Point of Care (POC), a check off sheet for the SRNA's to document resident care, signed by SRNA #12, on 12/01/2020 at 12:08 PM, revealed the SRNA provided a transfer of one (1) person assist and lifted manually. However, the resident was care planned to have two (2) staff assist with transfers. The State Survey Agency (SSA) surveyor attempted a telephone interview with SRNA #12, who was no longer employed by the facility, on 08/02/2022 at 2:00 PM; 08/04/2022 at 9:22 AM; and 08/07/2022 at 1:53 PM. The SRNA did not answer or return the state surveyor's call. Interview with Licensed Practical Nurse (LPN) #4 on 08/01/2022 at 4:00 PM, revealed she recalled assessing Resident #2 when he/she had complaints of pain in his/her right knee area. Per interview, she remembered Resident #2 saying his/her leg was injured during a transfer. She stated she thought the ADON had reported the allegation of Resident #2's physical injury which occurred during a transfer to the appropriate persons. Further interview revealed she assessed Resident #2 and he/she was able to move his/her right knee slightly, with some pain with movement. The LPN stated the resident's right knew was slightly swollen and she contacted the APRN to obtain an order for an X-ray to the right leg. Record review of the resident's progress note, dated on 12/01/2021 at 9:30 PM, documented by Registered Nurse (RN) #1 revealed the X-ray results were received and reviewed with the Physician. Further review revealed a new order was obtained for Ibuprofen 800 milligram (mg) three (3) times daily for three (3) days. Continued review revealed the resident was ordered a foot stabilizer and an appointment was scheduled with orthopedics. Additional review revealed staff were to send the resident to the emergency room if his/her pain was not controlled. The progress note further revealed the resident was administered his/her Ibuprofen and refused to go to the emergency room . Review of the progress note, dated 12/01/2022 at 10:00 PM, documented by RN #1, revealed Resident #4 expressed complaints of pain to his/her right leg. The RN documented the resident's leg was tender to the touch, moved his/her toes, but was unable to move his/her foot or leg. Continued review of the progress note revealed the resident declined to go to the ER and wanted to wait until morning. RN #1 further documented the resident stated his/her leg was hurt when resident was assisted out of bed to obtain his/her weight. She further documented the resident stated, she put my socks and shoes on and stood me up and I had not stood up in months. Further, RN #1 documented the resident told the SRNA #12 to stop, adding, you are breaking my knee. Interview with Registered Nurse (RN) #1 on 08/02/2022 at 1:35 PM, revealed she recalled getting the results of Resident #2's X-ray regarding the fracture. Per the interview, RN #1 stated she remembered contacting the DON and being told the incident was being followed up on, and the SRNA involved was not to be in Resident #2's room. Interview further revealed RN #1 reported the information to the Administrator, including the X-ray results. Interview with the facility's prior ADON on 07/30/2022 at 8:20 PM, revealed she did not specifically remember the incident involving Resident #2. The prior ADON reported she had only worked at the facility for approximately three (3) weeks when the incident occurred. She revealed however, if during her rounds a resident complained of pain or had other complaints, she would have informed the resident's nurse to follow-up. Interview further revealed the prior ADON would have reported any residents' complaints to the Administrator and/or the DON if the complaints had been related to any type of abuse allegation. Interview with the Administrator on 07/26/2022 at 4:27 PM,also the facility's Abuse Coordinator, revealed she had not been notified of information regarding the allegation that Resident #2's fracture was obtained during a transfer. The Administrator stated however, she had been told the fracture happened when Resident #2 was stood up to obtain his/her weight, and she was also aware the resident had Osteoporosis (a disease that thins and weakens the bones).

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure that residents who entered the facility with an indwelling catheter or received one (1) after admission was assessed for removal of the catheter as soon as possible and received the appropriate treatment and services to prevent urinary tract infections for one (1) of three (3) sampled residents observed for indwelling urinary catheter care out of ten (10) total sampled residents (Resident #4). Observation and interview with Resident #4 revealed the resident had an indwelling urinary catheter-related to wound management for a coccyx pressure ulcer. However, medical record review revealed no documented evidence of timely and appropriate assessments regarding the indication for the use of an indwelling catheter. Medical record review also revealed no documented evidence of criteria for the discontinuation of the catheter when the need for the use was no longer present. In addition, record review revealed no documented evidence for ongoing care and catheter removal protocols. Further, there was no documented evidence of Resident #4's response regarding the use of the catheter. The findings include: Review of the facility's policy titled, Catheter Care Procedure, last reviewed 05/23/2018, revealed routine checks were to be performed to ensure catheter tubing was secured; tubing was not kinked or clamped; drainage bag was not overfull; and the drainage bag was to be emptied when half full or every three (3) to six (6) hours. Continued review revealed no evidence of an assessment tool available for staff use to assess for removal of catheters as soon as possible. Interview with the facility's Registered Nurse (RN) Consultant, on 08/10/2022 at 12:20 PM, revealed the facility had no indwelling urinary catheter policy which addressed catheter changes based on professional standards of practice. The RN Consultant stated however, the Lippincott Nursing Manual was followed regarding catheters, and the Consultant provided pages from the Lippincott Manual which were used for catheter changes. Further interview revealed the facility's Electronic Medical Record (EMR) computer system did not currently add the information for residents' Foley catheter changes, the catheter size, nor the frequency of changes. Review of Resident #4's medical record revealed the facility admitted the resident on 03/04/2022, with diagnoses that included Pressure Ulcer of the sacral region, unstageable; Urinary Tract Infection; and Heart Failure. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated he/she was cognitively intact. Continued review revealed the facility assessed Resident #4 to require extensive assistance of two (2) staff with personal hygiene and transfers. Further review of the MDS revealed Resident #4 was totally dependent of two (2) staff assist with toilet use and bed mobility. Review of Resident #4''s Comprehensive Care Plan (CCP), dated 03/08/2022, revealed the facility had developed a care plan for at risk for infection related to Foley Catheter for the resident. Continued review revealed the goals included for Resident #4 to remain free of infection, with interventions which included monitoring the characteristics of the resident's urine and for abdominal pain and/or retention. Review further revealed additional interventions included secure the catheter in place at all times, encourage fluid intake as recommended, and provide catheter care as ordered. However, further review revealed no documented evidence of an approach/intervention for changing the resident's Foley catheter. Review of Resident #4's Physician's Orders, dated 03/04/2022, revealed orders for his/her Foley catheter to be changed every month with a 16 French (size of catheter) with a 10-20 cubic centimeters (cc) balloon (to hold the catheter in place) related to a diagnosis of a coccyx wound. Further review of the Physician's Order revealed nursing staff were to change Resident #4's Foley catheter as needed (PRN) for blockage, dislodgement, or leakage, and contact the Physician if a Foley catheter or balloon size change was required. Review of Resident #4's progress notes revealed a noted dated 07/16/2022 at 4:40 PM, documented by Licensed Practical Nurse (LPN) #5 which documented the resident's Foley catheter was changed due to not properly draining and Resident #4 screaming, I can't pee, and the Physician was notified. Continued review of the 07/16/2022 progress note revealed LPN #5 noted a 16 French (F) catheter was inserted per sterile technique with Resident #4 stating, it feels better already. Review of the progress note dated 07/20/2022 at 12:46 PM documented by LPN #6 revealed Resident #4's Foley catheter had been changed related to it being clogged, and a 20 (F) catheter was inserted with a thirty (30) cubic centimeter (cc) balloon placed. Continued review of the Progress Note revealed no documentation to support the reason for the catheter or balloon size change and no documented evidence the physician was contacted, as per the physician's orders. Interview with Resident #4 on 08/03/2022 at 10:55 AM, revealed the resident's Foley catheter had been removed and the resident stated he/she felt so much better. Resident #4 stated, I don't want it back in, it hurts me so bad. Continued interview revealed Resident #4 did not mean to aggravate anyone, but his/her catheter had been hurting so bad. According to Resident #4, I tried to keep quiet, but I was hurting so bad I couldn't. I waited and begged a long time for them to help me. My roommate had family in here and they heard the aide tell me to be quiet. Per interview, staff told Resident #4 he/she was upsetting his/her roommate and family who were in the room. Further interview revealed on the day Resident #4's catheter had been hurting him/her, the resident had asked for pain medication; however, was told by the aide that medication was not due to be given until 6:00 PM. Resident #4 revealed the nurse came in and changed the Foley catheter and the resident felt relief immediately. Interview further revealed most of the staff were familiar with his/her care and did a good job. The resident stated he/she usually did not complain because he/she has no other place to go and was fearful of being kicked out of the facility if he/she complained too much. Interview with Licensed Practical Nurse (LPN) #5, on 08/11/2022 at 9:49 AM, revealed on 07/16/2022 when she came in from her break, SRNA #6 made her aware that Resident #4 was upset and yelling out. Per interview LPN #5 was not aware of the resident having pain prior to going out to break. LPN #5 revealed she went to Resident #4's room to assess the resident and when arrived at the room he/she was yelling, I can't pee. Continued interview revealed while accessing Resident #4's Foley catheter she gently tugged on it and the catheter came out, but she did not remember if the catheter balloon had still been inflated or not. Per LPN #5, when she inserted the new catheter there had been urine return; however, she did not measure the amount of the urine. LPN #5 stated Resident #4 expressed immediate relief of his/her pain with the insertion of the new Foley catheter. Further interview revealed LPN #5 was aware there was a limit on the amount of urine that was contraindicated to drain upon initial insertion of a Foley catheter but was unsure of the amount. Interview with Resident #4's roommate's family member (Family Member #9) on 08/03/2022 at 9:09 PM, revealed on 07/16/2022 the family member had been visiting Resident #5, Resident #4's roommate. Interview revealed while initially in the room during her visit, Resident #4 had been crying out in pain, and had already rung his/her call light with not staff response. Per Family Member #9, she went to the Nurse's Station and told the staff present there that Resident #4 needed assistance because he/she was hurting. Continued interview revealed Family Member #9 thought a nurse came in and spoke with Resident #4 and told her (Family Member #9), the nurse had Resident #4 calmed down now. Interview revealed the nurse told her they could take their family member (Resident #5) to go to the lobby to visit or a room change could be made; however, Family Member #9 reported telling the nurse she just wanted the staff to help Resident #4's pain. Continued interview with Family Member #9, on 08/03/2022 at 9:09 PM, revealed after the nurse left Resident #4 the resident started crying out in pain again saying, someone just kill me, I can't stand this any longer. Further interview revealed Resident #4 had been holding onto his/her bed stating, I can't pee, so she went to the nurse's station again to get Resident #4 assistance. Family Member #9 stated a State Registered Nursing Assistant (SRNA #7) came into the room, pulled the bedside curtain around Resident #4's bed and tried to calm the resident down. Interview further revealed Family Member #9 overheard the SRNA telling Resident #4 he/she needed to shut up and that his/her pain meds were not due to be given until 6:00 PM. In addition, Family Member #9 revealed the nurse and another SRNA came in the room to change Resident #4's Foley catheter, and as soon as that was completed Resident #4 went right to sleep and had no further complaints of pain. Interview with SRNA #3 on 08/03/2022 at 3:54 PM, revealed Resident #4 frequently complained of his/her Foley catheter hurting, and the resident had also been complaining of abdominal and genitalia pain. Continued interview revealed SRNA #3 always reported Resident #4's complaints of pain to the nurse responsible for the resident that shift. Per SRNA #3, it was important for catheter care to be given each shift to decrease the risk for infection and/or trauma to a resident. Further interview revealed it was also important for residents' catheters to be observed each shift and their output documented. SRNA #3 stated it was always important to let the nurses know of any changes observed with Foley catheters to ensure the resident received the care required for his/her catheter. In addition, SRNA #3 revealed residents' catheter drainage bags were emptied every shift and the amount of urine was documented. The SRNA further revealed she had been provided skills training on catheter care, intake and output, and abnormal urine. Interview with SRNA #7 on 08/08/2022 at 3:16 PM, revealed on 07/12/2022 Family Member #9 came into hallway and screamed at the SRNA that she needed to help Resident #4. Per SRNA #7, she went into Resident #4's room and the resident complained of hurting and burning at the Foley catheter insertion site. Continued interview revealed SRNA #7 attempted to calm Resident #4 down; however, had never told the resident to shut up. SRNA #7 stated the nurse had been gone on a smoking break at the time and she tried to keep Resident #4 calm until the nurse returned from break. According to SRNA #7, she walked back to the nurse's station and the nurse had returned from break and so they both walked to Resident #4's room. The SRNA was unsure of the timeframe from Resident #4's initial complaints of pain to the time the nurse changed the resident's Foley catheter; however, after the Foley catheter was changed, Resident #4 was calm and resting. Interview with the Director of Nursing (DON) on 08/17/2022 at 9:15 AM, revealed she had been employed at the facility as the DON since 09/2021. Per interview, it was the DON's expectation nursing staff-maintained standards of practice regarding residents' indwelling urinary catheters to ensure the catheter was needed, and the facility provided the necessary care to decrease the risk for infections. Continued interview revealed the facility's current electronic medical record (EMR) had built in features/templates that automatically applied interventions/approaches for residents' care plans related to the applicable problems entered by staff. The DON stated after the information was entered by the staff member unchecked any intervention/approach that was not applicable or appropriate for that resident. According to the DON, the facility's Electronic Medical Record (EMR) computer system did not have interventions/approaches that included Foley catheter changes, frequency of changes, and/or assessment for catheter discontinuation. Further interview revealed Foley catheters were discussed as part of the Interdisciplinary Team (IDT) meetings on a regular basis. The DON further revealed she did not remember discussion in the IDT meetings recently of issues with Foley catheters, such as frequent pain or changes required up until discontinuation of the Foley catheter. In addition, the DON revealed she provided oversight through walking rounds, speaking with residents, and spot checks of residents' medical records and documentation. Interview with the Physician, who was also the facility's Medical Director, on 08/18/2022 at 11:26 AM revealed he had not been made aware of the multiple catheter changes and other issues Resident #4 had experienced. He stated had he been aware, when staff called him with the urinalysis (UA) laboratory (lab) results, he would have addressed things differently. Per interview, if a Foley catheter was placed for wound management, there should have been an assessment completed within fourteen (14) days after placement to assess if the benefits of continuation of the Foley catheter outweighed the risks. Continued interview revealed the facility should have policies in place regarding all aspects of Foley catheter care. The Physician/Medical Director revealed his expectation was that he would be notified of any complications or concerns regarding residents' Foley catheters. Further interview revealed continuing a Foley catheter without ensuring close monitoring and discussion regarding management was not something that was recommended. In addition, he revealed he needed to be notified of any pain issues related to a resident's Foley catheter so the pain could be addressed and managed appropriately. Interview with the Administrator, on 08/18/2022 at 4:55 PM, revealed she expected Physician orders to be obtained related to any changes in a resident's status since admission including Foley catheters. Continued interview revealed she expected there to be documentation regarding the reason and indicated use for a resident with an indwelling catheter. Per the Administrator, her expectations also included staff ensuring documentation of ongoing catheter care, and the criteria for discontinuation of the catheter for all residents who had catheters. Further interview revealed it was important to maintain standards of practice related to urinary catheters to ensure the necessary quality care was provided to meet the needs of each resident and ensure their safety. In addition, the Administrator revealed the results of not notifying the Physician in a timely manner could cause harm.

Based on observation, interview, and record review, the facility failed to ensure two (2) of ten (10) residents were free from sexual abuse. (Resident #1 and Resident #6). On 06/27/2022, Resident #1 was found in the room of Resident #6. Resident #1 had his pants undone standing next to the bed of Resident #6. Resident #6 had his/her hand on Resident #6's genitalia. Incident was witnessed by State Registered Nursing Assistant (SRNA) #10. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, dated 05/27/2016 and last revised 07/06/2022, revealed it was the facility's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property. Continued review revealed the facility intended to assure all alleged violations of federal and state laws which involved abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property were investigated. Review revealed all alleged violations were to be reported immediately to the facility Administrator, State Survey Agency, and other state and local agencies in accordance with federal and state law. The policy review revealed abuse included physical, mental, verbal, and sexual abuse, and included deprivation by a caretaker of goods and services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Further review revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. In addition, review revealed the policy presumed all abuse, as defined in the policy caused physical harm, pain or mental anguish to any resident, irrespective of any mental, or physical condition. Review of the facility's investigation documentation dated 06/27/2022, revealed Resident #1 had been found in Resident #6's room by facility staff. Continued review revealed Resident #1 was standing by Resident #6's bed with his/her genitalia exposed and Resident #6 touching his/her exposed genitalia. Per review of the investigation documentation, Resident #1 and Resident #6 were immediately separated and their safety was ensured. Further review revealed the facility interviewed all residents with a Brief Interview for Mental Status (BIMS) scores of eight (8) and above regarding concerns of sexual or other abuse, with no issues identified. Additional review further revealed for all residents with BIMS of seven (7) and below the facility provided a skin assessment for signs/symptoms of abuse, completed by nursing staff with no issues identified. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 06/11/2021, with diagnoses that included: Dementia without behavioral disturbance; Psychosis; Osteoarthritis; Chronic Kidney Disease; and history of wandering/elopement. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1 to have a BIMS score of three (3) out of fifteen (15) which indicated severe cognitive impairment. Continued record review revealed on 04/14/2022 Resident was placed on every fifteen (15) minute checks, with no documentation noting as to why, other than an entry in his/her progress notes stating the checks were due to exit seeking. Record review further revealed on 06/09/2022, the every fifteen (15) minutes checks were stopped. Review of the 06/09/2022 Social Service (SS) Progress Note at 2:30 PM, documented in writing on paper, revealed Resident returned to facility from a Physician's appointment with his/her daughter. Continued review revealed Resident #1's daughter reported resident to be very calm during outing. Per review of the SS Progress Note, revealed the daughter reported Resident #1 made no comments of leaving the facility. Further review revealed the Interdisciplinary Team (IDT) met to discuss Resident #1 being removed from every fifteen (15) minute checks, and the decision was made to discontinue the checks for the resident. Review additionally revealed the SS Progress Note had been signed by the SSD. Review of the Psychiatric Consult Note for Resident #1 dated 06/28/2022, revealed a telehealth visit was conducted with the resident which concluded with Resident #1 being evaluated with increased anxiousness and wandering, and determined to be an elopement risk. Further review of the Note revealed medication adjustments were made for the visit due to a recent decrease of Resident #1's Seroquel (second generation antipsychotic medication) dose on 06/07/2022, with a gradual dose reduction (GDR) noted. Observation of Resident #1 on 07/20/2022 at 3:00 PM, revealed the resident lying on his/her bed with State Registered Nursing Assistant (SRNA) #2 at his/her bedside. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 08/30/2021, with diagnoses that included Calculus of gallbladder with Acute Cholecystitis, Bowel Ischemia, Pressure Ulcer, sacral Stage 2, and Chronic Obstructive Pulmornary Disease (COPD). Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #6 to have a BIMS of five (5) out of fifteen (15) which indicated severe cognitive impairment. Observation of Resident #6 at 3:15 PM revealed the resident lying on his/her bed holding a stuffed animal in his/her hands. Interview with Resident #6 was attempted with the resident stating he/she did not remember the incident involving Resident #1. Interview with the facility's Plant Operations Manager on 07/26/2022 at 2:55 PM, revealed on 06/27/2022, he had been doing air temperature checks and noticed Resident #1 standing next to the bed of Resident #6. Per the interview, as he walked around the end of Resident #6's bed towards the other side of the room he observed Resident #1 with his/her pants partially unbuttoned and unzipped; however, did not completely see if Resident #1's genitalia was exposed. He stated he did see Resident #6 reaching his/her hand towards Resident #6's genitalia area. Continued interview revealed he yelled for assistance and touched Resident #1's shoulder as SRNA #10 entered the room from just outside the door. He revealed the residents were immediately separated, and the incident was reported to the Administrator who was the facility's Abuse Coordinator. Further interview revealed neither resident appeared to be in any distress after the incident, and he revealed his statement regarding the incident was given during the facility's investigation. Interview with SRNA #10, on 08/01/2022 at 8:03 PM, revealed he had been in the hallway when the Plant Operations Manager yelled for assistance in a resident's room. The SRNA revealed when he walked into Resident #6's room in response to the Plant Operations Manager yelling, he observed Resident #1 standing beside the bed of Resident #6. Per interview, Resident #1 had his/her pants pulled partially down in the front with his/her genitalia out and Resident #6 had his/her hand on Resident #1's genitalia. SRNA #10 stated he placed his hand on Resident #1's shoulder and told him/her to come out of the room with him. Further interview revealed Resident #1 pulled his/her pants up and zipped them, and walked out of the room with the SRNA. In addition, SRNA #10 revealed he walked Resident #6 to his/her room and reported the incident to the MDS Coordinator and the Administrator. Interview with the Social Services Director (SSD) on 08/02/2022 at 11:01 AM, revealed the SSD had been in that role since May 2022. Continued interview revealed the SSD was made aware of the incident involving Resident #1 and Resident #6 immediately after the incident. Per the SSD, the facility's Interdisciplinary Team (IDT) met after the incident and made the decision to place Resident #1 on one to one (1:1) supervision. Continued interview revealed Resident #1 had been on every fifteen (15 minute) checks prior to the SSD starting to work. The SSD stated after Resident #1 had been out of the facility with a family member for a Physician's appointment, the family member requested to stop the every fifteen (15) minute checks due to the resident no longer having exit seeking behaviors. Further interview revealed the IDT had met and made the decision on 06/09/2022 to stop Resident #1's every fifteen (15) minute checks. In addition, the SSD revealed no assessment tool had been used to make the determination to stop the checks; however, the IDT reviewed documentation and discussed the resident with staff during their decision making. Interview with SRNA #8, on 07/21/2022 at 4:11 PM, revealed the SRNA had been employed for four (4) years and had frequently cared for Resident #1. Continued interview revealed Resident #1 roamed frequently throughout the facility, and often went into other residents' rooms. SRNA #8 stated Resident #1 wandered into other residents' rooms mainly because he/she was seeking a bathroom or could not find his/her own room. Further interview revealed SRNA #8 was not aware of and had never witnessed Resident #1 expressing inappropriate behaviors towards other residents. The SRNA further revealed Resident #1 was easily redirected by staff. Interview with SRNA #1, on 07/23/2022, at 1:58 PM, revealed the SRNA had been employed for eight (8) years, and had often worked caring for Resident #1. SRNA #1 stated Resident #1 would lose his/her room often and needed redirection from staff. Interview with the facility's Nurse Consultant, on 07/21/2022 at 2:40 PM, revealed no Physician's order was needed for increased monitoring of residents, such as every fifteen (15) minute checks as that was considered a nursing judgement. Continued interview revealed the process was that when nursing staff determined increased supervision was needed they made either the Administrator, DON, Nurse Consultant, or Regional [NAME] President aware, then the IDT met and made the decision. Per the Nurse Consultant, from that point the information was passed on to nursing staff in report. Further interview revealed the same process was followed when the decision was made to stop the increased monitoring. The Nurse Consultant additionally stated no updated elopement assessment was completed upon discontinuing the increased monitoring, and updating residents' care plans was the responsibility of the facility's IDT. Interview with the Administrator on 08/11/2022 at 12:58 PM, revealed Resident #1 had been out with family and after discussion with the resident's family member and meeting with the IDT, the decision had been made to stop the every fifteen (15) minute checks of the resident. Continued interview revealed when the facility initiated increased monitoring for a resident, staff made the DON, Administrator, and Nurse Consultant aware, and at that point the issue would be discussed in the IDT meetings. Per the Administrator, the IDT's decision(s) were relayed to staff, and the resident's care plan updated by the IDT. Further interview revealed if a nursing approach was needed then nursing staff could also update residents' care plans as needed. The Administrator further revealed there had been no other incidents noted with any type of sexual behaviors for Resident #1 or Resident #6 in the past.

Based on observation, interview, review of the facility policy and Centers for Disease Control (CDC) guidelines, it was determined the facility failed to prevent the possible spread of COVID-19 on two (2) of the three (3) resident halls and also in the kitchen. Observation on Hall A and C revealed, State Registered Nurse Aide (SRNA) #1 and #3, were not utilizing eye protection as required by current COVID infection control policy. SRNA #1 was observed to exit a resident room while wearing an isolation gown and then removed the gown in the hall. Further observation revealed Dietary Aide #1, prepping desserts, with her face mask pulled under her chin. In addition, observation revealed three (3) of twelve (12) resident's rooms on Hall A, that were on droplet precautions, without signage to alert staff. The findings include: Review of the facility policy, Novel Coronavirus (COVID-19), revised 08/31/2020, revealed under General Prevention Measures a facility should require all direct care stakeholders (employees) to wear a surgical facemask and face shield or goggles while in the facility. Review of the facility policy, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed when a resident was placed on transmission-based precautions, appropriate notification was placed on the room entrance. The signage would inform the staff of the type of precaution, instructions for use of PPE, and/or instructions to see a nurse prior to entering the room. Review of the CDC (Center for Disease Control) guideline, Healthcare Workers Using Personal Protective Equipment (PPE), dated 08/19/2020, revealed the healthcare worker was to remove gloves then gown prior to exiting a patient's room. 1. Observation of the kitchen, from outside the entry door, on 10/28/2020 at 9:15 AM, revealed Dietary Aide #1, with facial mask pulled below her chin while prepping desserts and then placing the desserts on the cart. The surveyor observed the aide for nearly a minute. Interview with Dietary Aide #1 and #2, on 10/28/2020 at 9:17 AM, revealed while in the kitchen, only face masks were required. The Dietary Aides stated once they took carts to the floor or in a patient care area, they had to also have on goggles. Continued interview with Dietary Aide #1 revealed she did have her face mask pulled down and she stated she was getting ready to blow her nose. She further stated the mask falls down a lot when she was talking. Interview with the Dietary Manager, on 10/28/2020 at 11:10 AM, revealed dietary staff were to wear a face mask at all times while in the kitchen. She stated once they were in a patient care area, they had to wear goggles or a face shield. She then stated the staff should have a mask on when preparing foods. Further interview with the Dietary Manager revealed she did monitor the staff's infection control practices daily and had not noted any issues with improper wearing of face masks. 2. Observation during tour of Hall A, on 10/28/2020, between 8:55 AM and 9:15 AM, revealed rooms #3, #7 and #11 with PPE available on the doors; however, the doors were without any signage to detail the type of precautions or any directions to notify the nurse. Observation on Hall A, of SRNA #1, on 10/28/2020 at 9:30 AM, revealed the aide exited a resident room while wearing an isolation gown and then proceeded to remove the gown while in the hall. Further observation revealed the SRNA was not wearing goggles or a face shield. Observation on Hall C, of SRNA #3, on 10/28/2020 at 10:30 AM, revealed the aide entering a resident room and was not wearing goggles or a face shield. Interview with SRNA #1, on 10/28/2020 at 9:30 AM, revealed that PPE should be put on prior to entering a resident room and removed/discarded prior to exiting the room. The SRNA stated she had gone into the resident room just to retrieve some lotion and admitted she had removed the gown in the hall. Per the SRNA, the goggles would not fit over her eyeglasses and that she could not be heard when wearing the face shield. She then stated that she guessed she should wear a face shield. Interview with SRNA #3, on 10/28/2020 at 10:47 AM, revealed she had received education as recent as two (2) weeks ago related to PPE and infection control. She stated that all staff were required to wear face masks and goggles or a face shield. Surveyor inquired as to why she was not wearing either goggles or face shield and she stated she lost her goggles. She then added they (facility) told her they did not have any more goggles and she was told to use a face shield. She further stated she had not had a face shield on today. Interview with SRNA #2 and #4, on 10/28/2020 at 10:17 AM and 11:45 AM, respectively, both revealed face masks and eye protection were required at all times while in patient care areas. Interview with Licensed Practical Nurse (LPN) #2, on 10/28/2020 at 10:22 AM, revealed staff know when residents were on precautions because an isolation sign on the door alerted staff. She stated all staff were to wear masks and eye protection when in a patient area. She further added nursing and management monitored to ensure infection control practices were maintained and she had not noted any problems. Interview with the Director of Nursing, on 10/28/2020 at 11:25 AM, revealed the residents who had been placed into transmission based precautions should have signage on the door to alert the staff. She revealed at least one of the residents in each of the three rooms, A3, A7 and A11, were in droplet precautions. She stated there was a resident who had a behavior of removing signs from the resident's doors. The DON then revealed the required PPE for all staff/employees was a face mask for all areas of the facility and eye protection was added when in any patient area or with patient contact. She further stated the eye protection was either goggles or a face shield. The DON stated personal eye wear (eye glasses) would not be considered eye protection. The DON added that SRNA #1 and #3 should have worn eye protection while in the resident halls and when entering the resident rooms. Further interview revealed the residents who were on droplet precautions required the additional PPE of a gown and gloves, as well as mask and eye protection. She stated this PPE should be put on prior to entering the room and upon exiting the room, staff were to remove gloves and gown, as close to the door as possible and disposed of the items. She revealed staff should not enter the hallway from a resident's room with gown and/or gloves still on. She added she liked to round the resident care areas every two (2) hours to observe for appropriate infection control practices and if any issue were noted it would be remediated at that time. Interview with Administrator/Infection Preventionist, on 10/28/2020 at 11:50 AM, revealed staff were educated on infection control and updated on COVID on a frequent basis by way of huddle staff meetings, some one to one training, and random spot audits. The administrator stated staff were currently having competencies rechecked. She stated staff must wear a face mask and eye protection when in patient areas. She further stated when a resident was placed on transmission based precautions, a sign was placed on the door as well as the PPE required for the precautions. Further interview revealed if a resident was on droplet precautions the PPE required would be mask, eye protection, gown and gloves. She stated prior to exiting the room, of a resident on precautions, the staff would remove gloves and gown and dispose of them in a biohazard bag prior to leaving the room. The Administrator stated eye protection should always be worn as required and signage on doors should be present when a resident was on transmission based precautions.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately notify the physician when there was a change in resident condition and/or a need to alter treatment for [REDACTED].#250, Resident #7, Resident #19, Resident #12, and Resident #42). The facility utilized a protocol for [DIAGNOSES REDACTED] (low blood glucose) that required staff to notify the resident's physician for blood glucose levels (blood sugar) less than 70. On 08/06/2020, Resident #250's fingerstick blood glucose level was 66 (ADA recommendation range for someone with diabetes: 80-130 mg/dl) at 5:09 PM and was 59 at 8:15 PM. However, the resident's physician was not notified of the resident's low blood glucose level. On 08/07/2020 at 12:26 PM, the resident's blood glucose level was 56. On 08/07/2020 at 5:09 PM, the resident had a blood glucose level of 46. Again the facility failed to notify Resident #250's physician of the low blood glucose level. Approximately, four (4) hours hours later at 9:19 PM, the resident's blood glucose level was 37. The physician was notified and Glucagel (used to treat low blood glucose levels) was ordered orally. Resident #250 requested to be sent to the hospital on [DATE] at 9:30 PM. The facility rechecked Resident #250's blood glucose level and documented the level as being 85 prior to the resident leaving the facility; however, the time was not documented. Review of the ambulance documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The resident was transported to the acute care hospital where he/she required intravenous fluids and medication to maintain his/her blood sugar. Resident #250 was diagnosed with [REDACTED]. In addition, the facility failed to notify the resident's physician when Resident #7, Resident #19, Resident #12, and Resident #42 had blood glucose levels less than 70. The facility's failure to notify the resident's physician has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/17/2020 and determined to exist on 08/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on 09/17/2020. An acceptable Allegation of Compliance was received on 09/23/2020, which alleged removal of Immediate Jeopardy on 09/22/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 09/22/2020 as alleged, prior to exit on 10/01/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy titled, Change of Condition, with a revision date of 11/06/19, revealed the facility would evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to the physician and to document actions. A review of a protocol titled,[DIAGNOSES REDACTED] Management Algorithm, with a revision date of 09/01/15, utilized by the facility and developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than seventy (70). The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be administered. Per the protocol, the blood glucose level would be rechecked after fifteen (15) minutes. The protocol revealed if the blood glucose level was not greater than or equal to seventy (70) the physician would be notified again for further direction. The protocol stated if the blood glucose level was greater than or equal to seventy (70) then a protein or nutrious snack such as yogurt would be administered. 1. A review of Resident #250's closed medical record revealed the facility admitted the resident on 08/05/2020, with [DIAGNOSES REDACTED]. A review of the Baseline Admission Care Plan for Resident #250, undated, revealed the facility identified the resident had a [DIAGNOSES REDACTED]. The interventions included to continue medications and blood sugars as ordered. A review of the physician's orders [REDACTED]. A review of Resident #250's Medication Administration Records (MARS), revealed documentation of blood glucose monitoring for Resident #250. On 08/06/2020 at 5:09 PM, the resident had a blood glucose level of 66 and with no evidence the physician was notified; on 08/06/2020 at 8:15 PM, the resident had a documented blood glucose level of 59 with no evidence the physician was notified. On 08/07/2020 at 6:00 AM, there was no evidence blood glucose monitoring was completed. Further review revealed on 08/07/2020 at 5:09 PM, the resident's blood glucose level was 46, with no evidence the physician was notified; on 08/07/2020 at 9:19 PM, the resident had a thirty seven (37) documented blood glucose level. A review of Resident #250's Nurses Notes, revealed no documentation of the resident's physician being notified of low blood glucose levels for the resident, until 08/07/2020 at 2:27 PM, when the resident's physician visited the resident and wrote a physician's orders [REDACTED]. The next mention of physician notification related to the resident's blood glucose levels was on 08/07/2020 at 9:30 PM. The nurses notes further revealed on 08/07/2020 at 9:30 PM, Resident #1's physician was notified due to the resident having a blood glucose level of thirty seven (37), and a new order was received to administer Glucose Gel (to raise blood glucose level) orally now and to discontinue both [MEDICATION NAME] one thousand (1000) mg twice daily orally (to lower blood glucose level) and [MEDICATION NAME] one hundred (100) mg daily orally (to lower blood glucose level). The nurse documented when she entered the resident's room to administer the Glucose Gel (to raise blood glucose level), the resident stated he/she wanted to be transferred to the hospital. The nurse documented she had notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after he/she was administered Glucose Gel (to raise blood glucose level). However no time was documented when the blood glucose level was obtained. The results were documented as being 85 and the resident was documented as being lethargic and very difficult to arouse. The nurses notes revealed the ambulance service arrived at the facility on 08/07/2020 at 10:27 PM, and departed from the facility to the hospital on [DATE] at 10:34 PM. A review of the ambulance service documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The ambulance record revealed an intravenous line was obtained and 50% [MEDICATION NAME] 25 mg intravenously (used to increase blood glucose level) was administered. The ambulance record revealed the resident opened his/her eyes and was able to nod answers to questions. The ambulance record revealed a second 50% [MEDICATION NAME] 25 mg intravenously was administered and then the resident was able to speak in sentences and move his/her extremities independently. The ambulance documentation revealed the resident was then transferred to the acute care hospital. A review of the acute care hospital record for Resident #250, revealed the resident arrived at the hospital on [DATE] at 11:35 PM. The hospital medical record revealed the resident received a D5W intravenous drip. On 08/07/2020 at 11:45 PM, a blood glucose level of sixty nine (69) was documented and 50% [MEDICATION NAME] 25 mg was administered intravenously. The acute care hospital record further revealed on 08/08/2020 at 1:45 AM, the resident's blood glucose level was documented as being less than 60 and an additional 50% [MEDICATION NAME] 25 mg was administered. The acute care hospital record revealed the resident was admitted by the acute care hospital on [DATE] at 4:19 AM with a [DIAGNOSES REDACTED]. An interview with Licensed Practical Nurse (LPN) #2, on 09/14/2020 at 6:51 PM, revealed she had helped LPN #3 on 08/07/2020 at 9:19 PM when Resident #250's blood glucose level was 37. The LPN stated she had told LPN #3 to notify Resident #250's physician. LPN #2 stated LPN #3 had administered Glucagel (to raise blood glucose level) and had rechecked the blood glucose level and it was 85. The LPN stated she had assisted LPN #3 with the resident until the resident was sent out of the facility to the acute care hospital. The LPN stated the resident was lethargic. The LPN stated she had not been aware of the [DIAGNOSES REDACTED] Management Algorithm. The LPN stated she had only worked at the facility approximately three (3) weeks when the incident occurred. An interview conducted with LPN #3, on 09/15/2020 at 5:45 PM, revealed she was responsible for conducting the blood glucose monitoring, on 08/06/2020 at 8:15 PM, for Resident #250. The LPN stated she was not aware of the [DIAGNOSES REDACTED] Management Algorithm on 08/06/2020 and 08/07/2020, when she was responsible for obtaining Resident #250's blood glucose levels. The LPN stated she guessed she should have notified the physician, on 08/06/2020 at 8:15 PM, when Resident #1's blood glucose level was 59. An interview conducted with LPN #7, on 09/16/2020 at 8:46 AM, revealed she had completed the blood glucose monitoring for Resident #250, on the 7:00 AM to 7:00 PM shift on 08/06/2020. The LPN stated on 08/06/2020 at 5:00 PM, the resident's blood glucose level was 66. The LPN stated she had done nothing because she knew resident would be receiving a supper meal tray and the resident had ate well. LPN #7 stated she did not repeat the blood glucose monitoring nor did she notify the physician but should have. The LPN stated she had not been aware of the [DIAGNOSES REDACTED] Management Algorithm until after the inservice on 08/11/2020. An interview conducted with Resident #250's Physician, on 09/16/2020 at 10:00 AM, revealed he had been notified and had been aware of Resident #1's blood glucose level on 08/07/2020 at 12:26 PM and on 08/07/2020 at 9:19 PM. The physician stated the facility did not notify him of the resident's blood glucose levels on 08/06/2020 at 5:00 PM of sixty six (66); or the level on 08/06/2020 at 8:15 PM of fifty nine (59); nor of the 08/07/2020 at 5:09 PM, level of forty six (46). The physician stated he should have been notified and would probably have changed the resident's orders. 2. A review of Resident #7's medical record, revealed the facility admitted the resident on 04/10/19, with [DIAGNOSES REDACTED]. A review of Resident #7's physician's orders [REDACTED]. The physicians orders also revealed orders dated 07/08/2020, for the resident to receive [MEDICATION NAME] six (6) unit subcutaneous daily (insulin to lower blood glucose level); and [MEDICATION NAME] R five (5) units subcutaneous before meals (to lower blood glucose level). A review of Resident #7's current quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #7's comprehensive care plan with a review date of 07/14/2020, revealed interventions were developed to perform blood glucose monitoring as ordered; and to observe for and report signs and symptoms of [DIAGNOSES REDACTED]. A review of Resident #7's MARS revealed blood glucose monitoring on 08/31/2020 at 4:40 PM at a level of 64; 09/03/2020 at 5:08 PM at a level of 63; on 09/08/2020 at 8:08 PM at a level of 65. Review of the nurse's notes revealed no evidence the resident's physician was notified of the resident's low (less than 70) blood glucose levels on 08/31/2020, 09/03/2020 or 09/08/2020. An interview conducted with Registered Nurse (RN) #2 on 09/16/2020 at 8:20 AM, revealed she had been responsible for performing blood glucose monitoring for Resident #7 on 09/08/2020 at 8:08 PM. The RN stated she had been aware of the [DIAGNOSES REDACTED] Management Algorithm, but stated since she felt she could take care of the low level herself, she had not notified the physician and probably should have. An interview conducted with LPN #7 on 09/17/2020 at 10:50 AM, revealed she had been responsible for completing the blood glucose monitoring for Resident #7 on 09/03/2020 at 5:08 PM. The LPN stated she had not notified the physician nor had she repeated the blood glucose monitoring and guessed she probably should have. An interview conducted with LPN #6 on 09/17/2020 at 1:30 PM, revealed she was responsible for completing the blood glucose monitoring on 08/31/2020 at 4:40 PM for Resident #7. The LPN stated she had not repeated the resident's blood glucose monitoring, nor had she notified the resident's physician and should have. 3. A review of the medical record for Resident #19, revealed the resident had been admitted by the facility on 12/17/19, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Further review revealed an order dated 09/02/2020 for the resident to receive [MEDICATION NAME] R Regular U-100 Insulin (to lower blood glucose levels) twelve (12) units subcutaneous after breakfast and after lunch. If the resident does not eat a lot only administer one half the dose; [MEDICATION NAME] R Regular U-100 Insulin (to lower blood glucose level) eight (8) units subcutaneous after the evening meal, if the resident does not eat a lot only administer one half the dose. A review of the most current quarterly MDS assessment for Resident #19 dated 08/27/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #19's comprehensive care plan with a revision date of 09/02/2020, revealed interventions had been developed for the resident to receive a [MEDICATION NAME] (to increase blood glucose levels) injection if the resident's blood glucose level was less than 60 and the resident has difficulty responding; provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of [DIAGNOSES REDACTED]. A review of the MAR for Resident #19, revealed on 09/06/2020 at 5:03 PM, the blood glucose level was documented as being 64 and no insulin (to lower blood glucose level) was administered. There was no evidence the physician was notified or the blood glucose monitoring was repeated. An interview with LPN #9 on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the [DIAGNOSES REDACTED] Management Algorithm, and was aware she was required to notify the physician for Resident #19 blood glucose level on 09/06/2020 at 5:03 PM. The LPN stated she did not know why she had not but should have notified the physician. 4. A review of Resident #12's medical record, revealed the facility admitted the resident on 05/13/2020, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the most current quarterly MDS assessment for Resident #12 dated 08/12/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #12's comprehensive care plan with a revision date of 08/14/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of [DIAGNOSES REDACTED]. A review of the MAR for Resident #12, revealed on 09/03/2020 at 5:13 AM, the blood glucose was documented as being 61; and on 09/09/2020 at 5:22 AM, the blood glucose was documented as being sixty four 64. There was no evidence the physician was notified or the blood glucose monitoring were repeated. An interview conducted with LPN #2 on 09/17/2020 at 10:00 AM, revealed she should have notified Resident #12's physician on 09/03/3030 at 5:13 AM and 09/09/2020 at 5:22 AM when Resident #12 had low blood glucose levels. The LPN stated she was unsure why she had not. The LPN stated she had not been aware of the facility protocol ([DIAGNOSES REDACTED] Management Algorithm). 5. A review of Resident #42's medical record, revealed the facility admitted the resident on 09/25/19, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the most current annual MDS assessment for Resident #42 dated 09/08/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #42's comprehensive care plan with a revision date of 09/11/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of [DIAGNOSES REDACTED]. A review of the MAR for Resident #42, for 08/20/2020 at 4:40 PM, revealed the blood glucose was documented as being 64; on 08/22/2020 at 4:44 PM, the blood glucose was documented as being 64; on 09/03/2020 at 11:54 AM, the blood glucose was documented as being 57. There was no evidence the physician was notified or the blood glucose monitoring were repeated. An interview conducted with LPN #9 on 09/17/2020 at 10:40 AM, revealed the LPN was aware she was required to notify the physician for Resident #42's low blood glucose levels on 08/20/2020 at 4:40 PM; on 08/22/2020 at 4:44 PM; and on 09/03/2020 at 11:54 AM. The LPN stated she was unsure why she had not. The LPN stated she had not been aware of the [DIAGNOSES REDACTED] Management Algorithm. An interview with the Director of Nursing (DON), on 09/17/2020 at 2:30 PM, revealed nurses were required to utilize the [DIAGNOSES REDACTED] Management Algorithm anytime a resident had a blood glucose level of 70 or lower. The DON stated if a resident had a blood glucose level of 70 or lower, the resident's physician was required to be notified. The DON stated not notifying the physician for Resident #250's low blood glucose level could have caused the resident harm. Per the DON, she had recently moved to the DON position and was also doing the duties of the Staff Development Nurse and the Infection Control Nurse. The DON stated she had been very busy, due to the additional duties, and had not identified any concerns recently with the physician not being notified of low glucose levels. Interview conducted with the Administrator, on 09/17/2020 at 3:00 PM, revealed staff were required to use the [DIAGNOSES REDACTED] Management Algorithm for any resident who had a blood glucose level of 70 or less. The Administrator stated the resident's physician was required to be notified if a resident's blood glucose level was 70 or lower. The facility alleged the following was implemented to remove Immediate Jeopardy on 09/22/2020: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on 08/11/2020, and completed on 08/14/2020 for all licensed nursing staff. 2. Residents at the facility with [DIAGNOSES REDACTED]. No concerns were identified. 3. Residents at the facility with [DIAGNOSES REDACTED]. The SCC looked for signs and symptoms of hypo/[MEDICAL CONDITION] for the last 30 days and the treatment plan for hypo/[MEDICAL CONDITION] was followed per physician order. Any issues from chart audits had physician and family notification on 09/21/2020, by the DON or Administrator. No injury or harm was noted. 4. On 09/18/2020, residents with BIMS score of eight (8) or above were asked the following questions by the Social Services Director (SSD) 1): Do the staff address your needs? 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? No concerns were voiced. 5. On 09/18/2020, residents (with BIMS score of less than eight) families were called and asked the following questions by the SW: 1.) Do you feel the staff address your family members needs appropriately? 2.) If your family member has a change in condition, are you and the physician notified? 3.) Do you have any concerns with your family members care? Any issues were addressed by the Administrator by 09/21/2020. 6. Residents with BIMS of less than eight (8) received an assessment for any signs or symptoms of a change in condition that had not been addressed on 09/18/2020 by the DON and Restorative Nurse. No new concern were noted. 7. The SCC educated the Administrator, DON, MDS Coordinator and the Restorative Nurse on 09/17/2020, regarding the signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights and Abuse/Neglect. 8. All licensed nurses were educated on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights, Abuse/Neglect, and the [DIAGNOSES REDACTED] Management Algorithm. The training included appropriate steps to follow such as results received/steps such as management to include simple carbohydrate administration, rechecking of glucose levels and when to notify MD with action to take when new orders were received. This training was initiated by the DON, Restorative Nurse, MDS Coordinator and Administrator, on 09/17/2020. Education would continue prior to staff working their next scheduled shift by 09/21/2020. Licensed Nurse staff who were as needed, on FMLA or on leave would be issued a certified letter by Administrator with return receipt on 09/21/2020, alerting them that they must receive an education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, completing SBAR and Accucheck competency completed prior to their first shift back to work. A pre-post test would be given in which a passing score of 100% must be obtained on the post test. If 100% not obtained the staff member would be re-educated and a post test would be reissued. 9. All State Registered Nurse Aides (SRNA) and all other facility staff would be provided education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect was initiated by the DON, MDS Coordinator, Restorative Nurse and Administrator on 09/17/2020. Education would continue prior to staff working their next scheduled shift by 09/21/2020. SRNAs and all other facility staff who are PRN, on FLMA or on leave would be issued a certified letter by Administrator with return receipt on 09/21/2020 alerting them that they must receive education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect completed prior to their first shift back to work. A pre-post test would be given in which a passing score of 100% must be obtained on the post test. If 100% not obtained the staff member would be re-educated and a post test would be reissued. 10. Accucheck competency would include training on how to perform a glucose check-disinfection process for glucometer, interpretation of glucose results, documentation of glucose results, process for refusal of glucose by resident to include MD notification, and to promptly report abnormal results to the MD and promptly act on any new orders given by physician. This education was performed for Licensed Nurses by the SCC, DON, Restorative Nurse or Administrator beginning on 09/17/2020. Any Licensed Nurses not on duty on 9/17/2020 would receive an accucheck competency, as described above prior to the start of their shift by the DON, Restorative Nurse or Administrator until 100% of Licensed Nurses receive the Accucheck competency. Staff who were PRN, on FLMA or on leave would be issued a certified letter by Administrator with return receipt, on 09/21/2020, alerting them they must receive an education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, completing SBAR and accucheck competency before being allowed to work their next shift. 11. A QA meeting was held on 09/18/2020 and attended by the Medical Director, Regional Vice President (RVP) Administrator, SCC and DON in regards to root cause of event, education, interventions and plans to prevent reoccurrence. 12. Administrator, DON, Restorative Nurse and/or SCC reviewed all grievances for the last 30 days on 09/19/2020 for any other concerns of treatment of [REDACTED]. 13. Administrator, DON and SCC reviewed all SBARs and nurse progress notes for the last 30 days starting on 09/18/2020 and completed on 09/21/2020 for any other concerns of treatment of [REDACTED]. 14. Beginning 09/19/2020, daily, and until removal of jeopardy, the Administrator (who is a registered nurse) and DON would audit five (5) diabetic residents each shift that reside in the facility to ensure appropriate interventions and appropriate MD notifications has occurred regarding abnormal glucose levels. The Administrator, DON, or Restorative Nurse would give one (1) nurse each shift the posttest for how to care for a resident with Diabetes Mellitus. A score of 100% would be required, if less than 100%, employee would be re-educated and then given the posttest again until 100% compliance was obtained by the Admin/ DON or Restorative Nurse. Beginning 09/22/2020, these audits would be completed three times a week through 10/19/2020. Results of the audits and posttest would be reported to the QA committee (to include but not limited to the Medical Director/ Admin, DON, Restorative Nurse, Dietary Manager, Plant Ops Director, Activities Director, and Medical Records) weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee would determine at what frequency, the audits and administration of the posttest need to continue. The DON would report findings of the audits in QA and any concerns identified would be corrected immediately and reported to Administrator to ensure appropriate follow up is completed. 15. Beginning 09/19/2020 and going through abatement, daily 5 residents with a BIMS of 8 and above would be asked the following questions by the Admin, DON, SSD and/or the MDS Coordinator- 1) Do the staff address your needs?, 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? Any concerns will be reported to the Administrator or DON immediately and follow up will be completed. Results of the resident interviews, audits and licensed nurse test will be reported to the QA committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA committee would determine at what frequency the resident interviews, audits and Licensed Nurse test would need to continue. Concerns identified would be corrected immediately and reported to Administrator to ensure appropriate follow up was completed. 16. Beginning 09/19/2020 and going through abatement, daily 5 residents with BIMS of less than 8 would have an assessment for any signs or symptoms of a change in condition that had not been addressed in the 24 hour lookback period by the Administrator, DON, MDS Coordinator and Restorative Nurse. No new concern were noted. 17. Daily starting 09/19/2020, the Administrator or DON would review the Post Tests given for any noted concerns. Any concerns would be addressed immediately. 18. SCC or other member of the Regional Team, would provide oversight to the audits, three times a week, beginning 09/17/2020 and continuing through abatement. 19. Education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, an accucheck competency to include training on how to perform a glucose check-disinfection process for glucometer, interpretation of glucose results, documentation of glucose results, process for refusal of glucose by resident to include MD notification, and to promptly report abnormal results to the MD and promptly act on any new orders given by physician, also physician and family notification, completing and SBAR. Abuse/Neglect and Resident Rights would be included in orientation prior to providing resident care. This education would be provided by provided by the DON/ Admin and or designee. The posttest would be given by the Admin/ Don or designee for all new-hire licensed nurses in which a pre-posttest would be given and a score of 100% must be obtained on the post test. 20. Education would be provided by the Administrator/ DON and or designee on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus and licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect would be included in orientation for all new hire SRNAs and other facili (TRUNCATED)

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to implement the care plan for six (6) of eighteen sampled residents (Resident #7, #12, #19, #42, #29 and #250) and failed to develop a person-centered care plan for one (1) residents (Resident #31) out of eighteen (18) sampled residents related to activity preferences. Resident #7, #12, #19, #42, and #250 had care plans related to their [DIAGNOSES REDACTED]. However, the facility failed to implement the care plans for these residents related to obtaining blood glucose monitoring and monitoring/notifying the physician of low blood glucose levels. On 08/06/2020, Resident #250's fingerstick blood glucose level was 66 (ADA recommendation range for someone with diabetes: 80-130 mg/dl) at 5:09 PM and was 59 at 8:15 PM. However, the resident's physician was not notified of the resident's low blood glucose level. On 08/07/2020 at 12:26 PM, the resident's blood glucose level was 56. On 08/07/2020 at 5:09 PM, the resident had a blood glucose level of 46. Again the facility failed to notify Resident #250's physician of the low blood glucose level. Approximately, four (4) hours hours later at 9:19 PM, the resident's blood glucose level was 37. The physician was notified and Glucagel (used to treat low blood glucose levels) was ordered orally. Resident #250 requested to be sent to the hospital on [DATE] at 9:30 PM. The facility rechecked Resident #250's blood glucose level and documented the level as being 85 prior to the resident leaving the facility; however, the time was not documented. Review of the ambulance documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The resident was transported to the acute care hospital where he/she required intravenous fluids and medication to maintain his/her blood sugar. Resident #250 was diagnosed with [REDACTED]. In addition, review of the record for Resident #29 revealed the facility assessed Resident #29 to be at risk for dehydration and developed care plan interventions that included monitoring fluid intake for the resident. However, the facility failed to document and/or monitor the resident's intake on 09/25/2020, 09/26/2020, and 09/27/2020. The facility failed to develop person-centered care plan interventions related to Resident #31's activity preference of spending time outdoors. The facility's failure to implement the resident's plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/17/2020 and determined to exist on 08/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on 09/17/2020. An acceptable Allegation of Compliance was received on 09/23/2020, which alleged removal of Immediate Jeopardy on 09/22/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 09/22/2020 as alleged, prior to exit on 10/01/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Comprehensive Care Plans, last reviewed and revised on 07/19/2018 revealed it is the goal of the facility to develop a person-centered comprehensive care plan that includes measurable objective, and timetables to meet the resident's medical, nursing, mental and psychological needs for each resident. The policy further stated that care plan interventions would be implemented after consideration of the resident's problem areas and their causes. A review of a protocol titled, [DIAGNOSES REDACTED] Management Algorithm, with a revision date of 09/01/15, utilized by the facility and developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than seventy (70). The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be administered. Per the protocol, the blood glucose level would be rechecked after fifteen (15) minutes. The protocol revealed if the blood glucose level was not greater than or equal to seventy (70) the physician would be notified again for further direction. The protocol stated if the blood glucose level was greater than or equal to seventy (70) then a protein or nutrious snack such as yogurt would be administered. 1. A review of Resident #250's closed medical record revealed the facility admitted the resident on 08/05/2020, with [DIAGNOSES REDACTED]. A review of the Baseline Admission Care Plan for Resident #250, undated, revealed the facility identified the resident had a [DIAGNOSES REDACTED]. The interventions included to continue medications and blood sugars as ordered. A review of the physician's orders for Resident #250, dated 08/05/2020, revealed the resident had an order for [REDACTED]. A review of Resident #250's Medication Administration Records (MARS), revealed documentation of blood glucose monitoring for Resident #250. On 08/06/2020 at 5:09 PM, the resident had a blood glucose level of 66. On 08/06/2020 at 8:15 PM, the resident had a documented blood glucose level of 59. On 08/07/2020 at 6:00 AM, there was no evidence blood glucose monitoring was completed. Further review revealed on 08/07/2020 at 5:09 PM, the resident's blood glucose level was 46, and on 08/07/2020 at 9:19 PM, the resident had a thirty seven (37) documented blood glucose level. A review of Resident #250's Nurses Notes, revealed no documentation of the resident's physician being notified of low blood glucose levels for the resident, until 08/07/2020 at 2:27 PM, when the resident's physician visited the resident and wrote a physician's order to discontinue administration of [MEDICATION NAME] four (4) mg daily orally (to lower blood glucose level). The next mention of physician notification related to the resident's blood glucose levels was on 08/07/2020 at 9:30 PM. The nurses notes further revealed on 08/07/2020 at 9:30 PM, Resident #1's physician was notified due to the resident having a blood glucose level of thirty seven (37), and a new order was received to administer Glucose Gel (to raise blood glucose level) orally now and to discontinue both [MEDICATION NAME] one thousand (1000) mg twice daily orally (to lower blood glucose level) and [MEDICATION NAME] one hundred (100) mg daily orally (to lower blood glucose level). The nurse documented when she entered the resident's room to administer the Glucose Gel (to raise blood glucose level), the resident stated he/she wanted to be transferred to the hospital. The nurse documented she had notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after he/she was administered Glucose Gel (to raise blood glucose level). However no time was documented when the blood glucose level was obtained. The results were documented as being 85 and the resident was documented as being lethargic and very difficult to arouse. The nurses notes revealed the ambulance service arrived at the facility on 08/07/2020 at 10:27 PM, and departed from the facility to the hospital on [DATE] at 10:34 PM. A review of the ambulance service documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level as being 34. The ambulance record revealed an intravenous line was obtained and 50% [MEDICATION NAME] 25 mg intravenously (used to increase blood glucose level) was administered. The ambulance record revealed the resident opened his/her eyes and was able to nod answers to questions. The ambulance record revealed a second 50% [MEDICATION NAME] 25 mg intravenously was administered and then the resident was able to speak in sentences and move his/her extremities independently. The ambulance documentation revealed the resident was then transferred to the acute care hospital. A review of the acute care hospital record for Resident #250, revealed the resident arrived at the hospital on [DATE] at 11:35 PM. The hospital medical record revealed the resident received a D5W intravenous drip. On 08/07/2020 at 11:45 PM, a blood glucose level of sixty nine (69) was documented and 50% [MEDICATION NAME] 25 mg was administered intravenously. The acute care hospital record further revealed on 08/08/2020 at 1:45 AM, the resident's blood glucose level was documented as being less than 60 and an additional 50% [MEDICATION NAME] 25 mg was administered. The acute care hospital record revealed the resident was admitted by the acute care hospital on [DATE] at 4:19 AM with a [DIAGNOSES REDACTED]. An interview with Licensed Practical Nurse (LPN) #2, on 09/14/2020 at 6:51 PM, revealed she had helped LPN #3 on 08/07/2020 at 9:19 PM when Resident #250's blood glucose level was 37. The LPN stated she had told LPN #3 to notify Resident #250's physician. LPN #2 stated LPN #3 had administered Glucagel (to raise blood glucose level) and had rechecked the blood glucose level and it was 85. The LPN stated she had assisted LPN #3 with the resident until the resident was sent out of the facility to the acute care hospital. The LPN stated the resident was lethargic. The LPN stated she had not been aware of the [DIAGNOSES REDACTED] Management Algorithm. The LPN stated she had only worked at the facility approximately three (3) weeks when the incident occurred. An interview conducted with LPN #3, on 09/15/2020 at 5:45 PM, revealed she was responsible for conducting the blood glucose monitoring, on 08/06/2020 at 8:15 PM, for Resident #250. The LPN stated she was not aware of the [DIAGNOSES REDACTED] Management Algorithm on 08/06/2020 and 08/07/2020, when she was responsible for obtaining Resident #250's blood glucose levels. The LPN stated she was unsure why there was no documented evidence the resident's blood sugar was obtained, on 08/07/2020 at 6:00 AM. She stated she probably obtained the resident's blood sugar, but was unable to recall the result. The LPN stated she guessed she should have notified the physician, on 08/06/2020 at 8:15 PM, when Resident #1's blood glucose level was 59. An interview conducted with LPN #7, on 09/16/2020 at 8:46 AM, revealed she had completed the blood glucose monitoring for Resident #250, on the 7:00 AM to 7:00 PM shift on 08/06/2020. The LPN stated on 08/06/2020 at 5:00 PM, the resident's blood glucose level was 66. The LPN stated she had done nothing because she knew resident would be receiving a supper meal tray and the resident had ate well. LPN #7 stated she did not repeat the blood glucose monitoring nor did she notify the physician but should have. The LPN stated she had not been aware of the [DIAGNOSES REDACTED] Management Algorithm until after the inservice on 08/11/2020. An interview conducted with Resident #250's Physician, on 09/16/2020 at 10:00 AM, revealed he had been notified and had been aware of Resident #1's blood glucose level on 08/07/2020 at 12:26 PM and on 08/07/2020 at 9:19 PM. The physician stated the facility did not notify him of the resident's blood glucose levels on 08/06/2020 at 5:00 PM of sixty six (66); or the level on 08/06/2020 at 8:15 PM of fifty nine (59); nor of the 08/07/2020 at 5:09 PM, level of forty six (46). The physician stated he should have been notified and would probably have changed the resident's orders. 2. Review of Resident #7's medical record revealed the facility admitted the resident on 04/10/2019, with [DIAGNOSES REDACTED]. Review of Physician Orders for Resident #7, dated 05/30/2020, revealed staff were to obtain the resident's blood glucose level before meals and at bedtime. In addition, physician orders dated 07/08/2020, revealed staff were to administer Resident #7, six (6) units of [MEDICATION NAME] subcutaneously every morning, and five (5) units of [MEDICATION NAME] R insulin before meals. Review of Resident #7's Minimum Data Set (MDS) assessment, dated 07/08/2020, revealed the resident had a BIMS score of four (4) which revealed the facility assessed the resident to be severely impaired cognition. Review of Resident #7's Comprehensive Care Plan, reviewed on 07/14/2020, revealed interventions directed staff to manage the resident's Diabetes Mellitus by performing blood glucose monitoring as ordered, observe the resident for signs/symptoms of [DIAGNOSES REDACTED] and report any concerns to the physician. Review of Resident #7's Medication Administration Record [REDACTED]. However, there was no evidence found to indicate the staff notified the resident's physician or the resident's blood glucose levels were monitored or rechecked by staff. Resident # 7 was observed, on 09/29/20 at 9:21 AM, to be resting with his/her eyes closed. No signs or symptoms of [DIAGNOSES REDACTED] was observed. Interview with LPN #6, on 09/17/2020 at 1:30 PM, revealed she obtained Resident #7's blood glucose level on 08/31/2020 at 4:40 PM, however, she had not rechecked the resident's blood glucose level after obtaining a reading of below 70 mg/dl, or notified the resident's physician of the resident's low glucose level. LPN #6 stated she was unaware of the facility's [DIAGNOSES REDACTED] Management Algorithm policy that staff was to utilize when a resident experienced a hypoglycemic episode. Although the LPN stated she had attended the facility's annual in-service on how to perform blood glucose monitoring, the in-service did not address what action to take if a resident's blood glucose level was low. LPN #6 stated she took no further action related to Resident #6's blood glucose level on 08/31/2020, because the resident's blood glucose level was not below 60 mg/dl. Interview with LPN #7, on 09/17/2020 at 10:50 AM, revealed she obtained Resident #7's blood glucose level on 09/03/2020 at 5:08 PM, when the resident's glucose level was 63 mg/dl. The LPN stated she did not notified the resident's physician or recheck the resident's glucose level in fifteen (15) minutes as required by the facility's policy. LPN #7 stated she had not been aware of the facility's [DIAGNOSES REDACTED] Management Algorithm protocol. Further interview with LPN #7, revealed she attended the facility's in-service on performing blood glucose, however, the in-service did not address what to do if a resident experienced [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #2, on 09/16/2020 at 8:20 AM, revealed she obtained Resident #7's blood glucose level, on 09/08/2020 at 8:08 PM, when the resident's blood glucose level was 65 mg/dl. However, RN #2 stated she had not notified the resident's physician of the low blood glucose level or rechecked the resident's blood glucose level in fifteen (15) minutes as required. Continued interview with the RN revealed she had been aware of the facility's [DIAGNOSES REDACTED] Management Algorithm, but felt she could manage the resident's [DIAGNOSES REDACTED] on her own, and did not need to notify the physician. RN #2 stated she had given the resident a peanut butter sandwich and a cup of orange juice, which the resident had eaten, and therefore she did not feel like she needed to recheck the resident's blood glucose level. RN #2 stated she attended the facility's in-services on how to perform blood glucose monitoring, but could not recall if managing a resident who was hypoglycemic was discussed. 3. Review of Resident #19's medical record revealed the facility admitted the resident on 12/17/2019, with [DIAGNOSES REDACTED]. Review of Resident #19's MDS assessment dated [DATE], revealed the resident had a BIMS score of nine (9) which indicated the resident had been assessed to have moderately impaired cognition. Review of Resident #19's Comprehensive Care Plan, revised on 09/02/2020, revealed interventions to manage the resident's Diabetes Mellitus included observing the resident's for signs and symptoms of [DIAGNOSES REDACTED], administering the resident a [MEDICATION NAME] injection if the resident's blood glucose level was less than 60 mg/dl and the resident had difficulty responding, providing blood glucose monitoring as ordered, and notifying the resident's physician with significant changes. Review of Physician Orders for Resident #19, dated 08/24/2020, revealed staff were to obtain the resident's blood glucose levels before meals. Further review of the orders revealed an order, dated 09/02/2020, for the resident to receive [MEDICATION NAME] R insulin 12 units subcutaneously after breakfast and lunch, and 8 units after the evening meal, unless the resident does not eat a lot only administer one half the dose. Review of Resident #19's MARS for September 2020, revealed on 09/06/2020 at 5:03 PM, staff documented the resident's blood glucose level was 64 and no insulin was administered. However, there was no evidence the staff notified the resident's physician or that the resident's blood glucose level was rechecked or monitored per the facility protocol and care plan. Resident #19 was observed on 09/30/2020 9:31 AM, ambulating in hall. No signs of [DIAGNOSES REDACTED] were observed. Interview conducted with Resident #19, on 09/30/2020 at 9:15 AM, revealed the resident had no concerns with blood glucose monitoring done by the facility. Interview on 09/17/2020 with LPN #9 at 10:40 AM, revealed the LPN was aware of the facility's [DIAGNOSES REDACTED] Management Algorithm, and nursing was to notify the physician and recheck Resident #19's glucose level, on 09/06/2020 at 5:03 PM, and stated she did not know why she had not done it as required. 4. Review of Resident #12's medical record revealed the facility admitted the resident on 05/13/2020, with [DIAGNOSES REDACTED]. Review of Resident #12's MDS assessment, dated 08/12/2020, revealed the resident had a BIMS score of fifteen (15) which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #12's Comprehensive Care Plan revised on 08/14/2020, revealed interventions implemented to address the resident's Diabetes Mellitus included providing blood glucose monitoring as ordered, notifying the physician with significant changes, and observing for signs and symptoms of [DIAGNOSES REDACTED]. Review of the Physician's Orders for Resident #12, dated 05/25/2020, revealed an order for [REDACTED]. Review of Resident #12's MARS for September 2020, revealed on 09/03/2020 at 5:13 AM, the resident's blood glucose level was 61 mg/dl, and on 09/09/2020 at 5:22 AM, the resident's blood glucose level was 64 mg/dl. However, there was no evidence the staff notified the physician of the resident's low blood glucose levels or that the glucose level was rechecked or monitored as required. Observation of Resident #12 on 09/29/2020 at 11:30 AM, revealed the resident was observed to be sitting in his/her wheelchair in the resident's room. No signs or symptoms of [DIAGNOSES REDACTED] were observed. Interview conducted with Resident #12, on 09/29/2020 at 11:35 AM, revealed the resident stated he/she had no concerns with the blood glucose monitoring provided to him/her by the facility. Interview with LPN #2, on 09/17/2020 at 10:00 AM, revealed she was not aware of the facility's [DIAGNOSES REDACTED] Management Algorithm protocol. The LPN stated she should have rechecked and monitored the resident's blood glucose level and provided the resident a snack. 5. Review of Resident #42's medical record revealed the facility admitted the resident on 09/25/2019, with [DIAGNOSES REDACTED]. Review of Resident #42's MDS assessment, dated 09/08/2020, revealed the facility assessed the resident to have a BIMS score of fifteen (15), which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #42's Comprehensive Care Plan, revised on 09/11/2020, revealed interventions implemented to manage the resident's Diabetes Mellitus included monitoring the resident's glucose levels, notifying the resident's physician of any significant changes in signs and symptoms, and observing for signs and symptoms of [DIAGNOSES REDACTED]. Review of Physician Orders for Resident #42, revealed an order dated 11/04/2019, for staff to obtain the resident's blood glucose level before meals and at bedtime, and an order dated 04/24/2020, for the resident to receive Tresiba insulin subcutaneously every morning. Review of Resident #42's MARS for September 2020, revealed on 08/20/2020 at 4:40 PM, revealed the resident's blood glucose level was 64 mg/dl, 08/22/2020 at 4:44 PM, the resident's blood glucose level was 64 mg/dl, and on 09/03/2020 at 11:54 AM, the resident's blood glucose level was 57 mg/dl. However, there was no evidence the physician was notified or the resident's blood glucose level was rechecked or monitored as required. Observation of Resident #42 on 09/30/2020 at 10:45 AM, revealed the resident was observed to be up in a wheelchair in his/her room. No signs or symptoms [DIAGNOSES REDACTED] observed. Interview with Resident #42, on 09/30/2020 at 10:50 AM, revealed the resident stated he/she had no concerns regarding the care he/she received by the facility. Interview with LPN #9, on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the facility's [DIAGNOSES REDACTED] Management Algorithm and was aware that any time a resident was hypoglycemic she was required to notify the physician and recheck the blood glucose level. However, LPN #9 stated she failed to follow the facility's policy hypoglycemic management for Resident #42, on 08/20/2020 at 4:40 PM, 08/22/2020 at 4:44 PM, and on 09/03/2020 at 11:54 AM, when the resident was hypoglycemic. The LPN stated she should have rechecked the blood glucose level after providing the resident a snack and notified the resident's physician. A post-survey interview with the Director of Nursing (DON) on 10/14/2020 at 8:14 AM, revealed she made rounds daily and attended the Interdisciplinary Team Meeting (IDT) daily Monday through Friday. The resident's care plans were reviewed every morning in the IDT meeting to make sure things were in place for all residents. The DON stated the facility also reviewed all new physician's orders to ensure they have been added to the care plan if needed. She stated Resident #250, Resident #7, Resident #12, Resident #19, and Resident #42's physicians should have been notified when their blood glucose levels dropped to seventy (70) or below. A post-survey interview, on 10/14/2020 at 8:20 AM, with the MDS Coordinator, revealed she was responsible for developing the comprehensive care plans for all residents. The MDS Coordinator stated the admitting nurse was responsible for completing the interim (baseline) care plan, which was then reviewed in the daily IDT meeting Monday through Friday. The MDS Coordinator stated the care plans were reviewed and any needed changes would be made to the care plans. The MDS Coordinator further stated all new physician orders were reviewed daily and to ensure they had been added to the care plan if needed. The MDS Coordinator stated Resident #250, Resident #7, Resident #12, Resident #19, and Resident #42's physician should have been notified when their blood glucose levels dropped to seventy (70) or below. The MDS Coordinator stated she utilized a care plan template for diabetics, and all diabetics had interventions to monitor for [DIAGNOSES REDACTED] or [MEDICAL CONDITION], and to notify the physician for any signs or symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. A post-survey interview on 10/14/2020 at 8:30 AM with the Administrator revealed the baseline care plan was completed by the admitting nurse when a resident was admitted . The Administrator stated the care plan would then be reviewed in the IDT meeting every morning Monday through Friday to ensure everything was in place for the resident. The Administrator stated Resident #250, Resident #7, Resident #12, Resident #19, and Resident #42's physician should have been notified when their blood glucose levels dropped to seventy (70) or below per each resident's care plan. 6. Review of the record for Resident #29 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2020, revealed the facility assessed the resident's mental status with a Brief Interview for Mental Status (BIMS) and the resident scored a four (4) indicating severe cognitive impairment. The assessment further noted the resident was able to make himself/herself understood and the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the comprehensive care plan revealed the problem of Nutritional Status with a problem start date of 08/08/2019. The care plan stated that the resident was at nutritional and hydration risk and interventions included Monitor intake of food and liquids. Further review of the record for Resident #29 revealed, on 09/25/2020 and 09/26/2020, there was no fluid intake documented for the resident and only 480 ml was documented as intake for 09/27/2020. Observation of Resident #29 on 09/29/2020 at 3:18 PM revealed the resident was awake and alert and had a pitcher of ice water available at the bedside. Observation on 09/30/2020 at 10:50 AM revealed the resident was in the room in bed and asked for a drink of water. The resident had water at the bedside on the bedside table that appeared to be within the resident's reach, but the resident stated I can't get it. A staff member passed by the room, entered the room and assisted the resident to drink water from the water pitcher/container at the bedside. Interview with Certified Nursing Assistant (CNA) #7 on 10/01/2020 at 10:06 AM revealed that they are required to document fluid intake on residents. CNA #7 stated that Resident #29 asks for a drink often and he/she is given drinks of water several times throughout the day. CNA #7 stated that sometimes the intake may not be documented because staff just forget to document it. Interview on 10/01/2020 at 10:11 AM with Licensed Practical Nurse (LPN) #10 revealed that the nurses monitor each resident's hydration status daily. LPN #10 stated that the fluid intake is documented in the computer and the Director of Nursing (DON) monitors the intakes to ensure that residents are meeting their needs. Interview with the DON and the Facility Administrator on 10/01/2020 at 1:37 PM revealed that the Dietary Manager reviews the residents fluid needs daily and if there are concerns with a resident not meeting their recommended fluid needs, the Dietary Manager brings the concern to the morning clinical meeting for discussion with the Interdisciplinary team (IDT). The Administrator stated that the Dietary Manager is currently on sick leave and the Dietitian has been reviewing the intakes while the Dietary Manager was off and the Dietitian had not reported any concerns with fluid intake or gaps in the documentation for any residents. 7. Review of Resident #31's Clinical Record revealed the facility admitted the resident on 12/04/2019 with [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 score of fourteen (14) out of fifteen (15), which indicates the resident is cognitively intact. Review of Resident #31's Admission MDS dated [DATE] revealed it was very important to the resident to go outside for fresh air when the weather was nice. Review of the most recent quarterly MDS completed on 09/03/2020 revealed resident #31 was assessed to be independent with transfers, and be independent with locomotion on and off the unit. Review of Resident #31 Comprehensive Care Plan for the category of Activities dated 04/24/2020 revealed that the resident enjoyed going outside when the weather was good. The Care Plan had no interventions that addressed how to ensure the resident participates in the activity of going outside. Interview with Resident #31, on 09/29/2020 09:46 AM, revealed that he/she was never allowed to go outside. The resident stated he/she was not allowed to go outside unless he/she was going to a doctor's appointment. The resident stated she enjoyed being outside when the weather was nice. Observation on 09/29/2020 at 9:46 AM, 09/30/2020 at 10:24 AM, and 10/01/2020 at 1:19 PM, revealed Resident #31 was in his/her room, despite the sunny, mild weather. Interview with Licensed Practical Nurse (LPN #10), on 10/01/2020 9:39 AM, revealed she thought Resident #31 could go to the courtyard if he/she wanted to. She further stated that any staff could take the resident outside when asked. Interview with Activities Director, on 10/01/2020 at 10:24 AM, revealed that residents were permitted to go outside; however, it had been a while since Resident #31 had asked to go outside. The Activity Director further stated that she gauges allowing residents to go outside on the amount of staff that was available to watch them. Interview with the MDS Coordinator, on 10/01/2020 at 2:26 PM, revealed the activities department develops the care plan for activities. MDS Coordinator further indicated that care plans are reviewed during clinical morning meetings to ensure accuracy. Interview with Activity Director, on 10/01/2020 at 2:26 PM, revealed she developed the care plan for activities for residents of the facility. She further stated care plans were reviewed by the interdisciplinary team during the quarterly care plan meetings, and the Activity Director stated she was unaware the care plan did not include resident specific interventions related to Resident #31 preference to go outside. The facility alleged the following was implemented to remove Immediate Jeopardy on 09/22/2020: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on 08/11/2020, and completed on 08/14/2020 for all licensed nursing staff. <b (TRUNCATED)

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care and treatment in accordance with accepted standards of practice to treat and prevent adverse events related to [DIAGNOSES REDACTED] (low blood sugar) for five (5) of eighteen (18) sampled residents (Resident #250, Resident #7, Resident #19, Resident #12, and Resident #42). Review of the facility's [DIAGNOSES REDACTED] Management Algorithm, developed by the American Diabetes Association, revealed if a resident's blood sugar was less than or equal to 70 milligrams per deciliter (mg/dl), staff were required to notify the resident's physician, recheck the resident's blood sugar in 15 minutes, then take other necessary actions based on the resident's blood sugar result. ([DIAGNOSES REDACTED] is a condition in which your blood sugar (glucose) level is lower than normal and needs immediate treatment). However, on [DATE] at 5:00 PM and 8:15 PM, Resident #1's blood sugar was less than 70 mg/dl (66 and 59) and there was no evidence the [DIAGNOSES REDACTED] Algorithm was initiated; subsequently, there was no evidence the facility assessed the resident, nor reassessed the resident's blood sugar. In addition, staff continued to administer medication to lower the resident's blood sugar. On [DATE], the facility failed to check the resident's blood sugar as ordered by the resident's physician at 6:00 AM. Record review revealed staff administered three (3) oral medications to lower the resident's blood sugar without knowledge of the resident's blood sugar level. At 12:26 PM, on [DATE], the resident's blood sugar was 56 mg/dl. Staff notified the resident's physician, but failed to implement the [DIAGNOSES REDACTED] protocol and reassess the resident per the algorithm. At 5:09 PM on [DATE], the resident's blood sugar had dropped to 46 mg/dl. Again, staff failed to implement the [DIAGNOSES REDACTED] Algorithm and took no action to address the resident's low blood sugar. In addition, staff documented that medication was administered to lower the resident's blood sugar, despite the low blood sugar level. By 9:19 PM, on [DATE], the resident's blood sugar was 37 mg/dl. The facility notified the resident's physician, administered glucose gel (increases blood sugar), and the resident's blood sugar increased to 85 mg/dl, at which time the resident requested to be transferred to the hospital. However, by 10:21 PM on [DATE], staff documented the resident was lethargic and difficult to arouse (signs that [DIAGNOSES REDACTED] had worsened) and there was no evidence staff took any action to assess/treat the resident. When Emergency Medical Services (EMS) arrived, the resident's blood sugar was 33 mg/dl and the resident was unresponsive (late signs of [DIAGNOSES REDACTED]). The resident was transferred and admitted to an acute care hospital where he/she required intravenous therapy (IV) to treat his/her low blood sugar. In addition, review of the medical records for Resident #7, Resident #19, Resident #12, and Resident #42, revealed when the residents had blood glucose levels less than 70 mg/dl, there was no evidence the facility implemented the [DIAGNOSES REDACTED] Management Algorithm; subsequently, there was no evidence the physicians were notified, nor was repeat blood glucose monitoring completed. The facility's failure to ensure residents received appropriate care and treatment in accordance with accepted standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled,Blood Glucose Monitoring, reviewed [DATE], revealed upon a [DIAGNOSES REDACTED]. Review of a facility protocol titled, [DIAGNOSES REDACTED] Management Algorithm, revised [DATE], developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than 70 mg/dl. The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be provided. According to the protocol, the facility was required to recheck the resident's blood glucose level after 15 minutes. The protocol stated if the blood glucose level was greater than or equal to 70, a protein or nutritious snack such as yogurt should be provided and the family member and physician would be notified. However, if the blood glucose level was still not greater than or equal to 70, the physician should be notified for further direction. Interview conducted with the Director of Nursing (DON) on [DATE] at 2:30 PM, revealed the facility did not have a policy regarding nursing assessment and utilized the facility's Change of Condition policy related to resident assessment. Review of the facility's policy titled, Change of Condition, with a revision date of [DATE], revealed the facility would evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay evaluation information to the physician and to document actions. 1. Review of Resident #250's closed medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #250's Baseline Admission Care Plan, undated, revealed the facility identified the resident had a [DIAGNOSES REDACTED]. Review of Resident #250's Physician Orders, dated [DATE], revealed the resident had an order for [REDACTED]. Review of Resident #250's Medication Administration Record [REDACTED]. Continued review revealed on [DATE], the day after admission to the facility, at 5:09 PM, the resident's blood sugar level was 66 mg/dl. There was no evidence the facility assessed the resident's condition to relay findings to the physician as required by the facility's change in condition protocol or implemented the [DIAGNOSES REDACTED] management algorithm that required staff to take action and re-evaluate the resident in 15 minutes. Interview conducted with Licensed Practical Nurse (LPN) #7, on [DATE] at 8:46 AM, revealed she obtained Resident #250's blood sugar, on [DATE] at 5:09 PM. The LPN stated she took no action because the resident had not eaten the evening meal and believed meal intake would increase the resident's blood sugar. The LPN stated she did not reassess Resident #250's blood sugar as required by the [DIAGNOSES REDACTED] algorithm because, at the time, she was not aware that the protocol existed. Further review of Resident #250's MAR indicated [REDACTED]. Again, there was no evidence the facility assessed the resident, nor implemented the [DIAGNOSES REDACTED] algorithm to address the resident's low blood sugar. In addition, according to the resident's MAR, staff administered [MEDICATION NAME] to the resident, on [DATE] between 4:00 PM and 11:00 PM (exact time not documented), with no evidence the resident's blood sugar was monitored any further, until [DATE] at 12:26 PM, when the resident's blood sugar was 56. Even though there was no documented evidence staff obtained Resident #250's blood sugar, on [DATE] at 6:00 AM, as ordered by the resident's physician, staff documented that medications were administered to lower the resident's blood sugar. According to Resident #250's MAR, the resident received [MEDICATION NAME] on [DATE] between at 6:00 AM and 11:00 AM (exact time not documented), and [MEDICATION NAME] and [MEDICATION NAME], on [DATE] between 7:15 AM and 11:00 AM (exact time not documented). Interview conducted with LPN #3, on [DATE] at 5:45 PM, revealed she was responsible for Resident #250's care on ,[DATE]-,[DATE], during the night shift (7:00 PM-7:00 AM). LPN #3 stated she obtained the resident's blood sugar, on [DATE] at 8:15 PM, but did not implement the [DIAGNOSES REDACTED] algorithm or reassess the resident, because she was not aware of the protocol. According to LPN #3, she was unsure why there was no documented evidence that the resident's blood sugar was obtained, on [DATE] at 6:00 AM. She stated she probably obtained the resident's blood sugar, but was unable to recall the result. Review of the Nurses Notes for Resident #250, revealed on [DATE] at 2:27 PM, the resident's physician visited the resident as a result of the low blood sugar at 12:26 PM, and wrote a physician's orders [REDACTED]. In addition, staff documented that [MEDICATION NAME] medication was administered to the resident on [DATE] between 4:00 PM and 11:00 PM (exact time not documented). Continued review of Resident #250's MAR, revealed on [DATE] at 5:09 PM, the resident's blood sugar continued to decrease at 46 mg/dl. However, there was no evidence the [DIAGNOSES REDACTED] protocol was implemented, nor was there documentation that the resident was assessed/reassessed to determine whether further action was needed. Interview conducted with LPN #1, on [DATE] at 6:25 PM, revealed on [DATE] at 12:26 PM, she notified the resident's physician of the resident's blood sugar result and gave the resident orange juice. The LPN stated the physician was at the facility and saw the resident. The LPN stated she had observed the resident eat his/her lunch meal; however, she did not recheck the resident's blood glucose level and was not aware she should have. Further interview with the LPN revealed when the resident's blood glucose level was 46 mg/dl, on [DATE] at 5:09 PM, she gave the resident a cup of orange juice and asked if he/she would like a peanut butter sandwich. The resident declined the peanut butter sandwich and stated his/her family was bringing a piece of cheesecake. The LPN stated she did not recheck the resident's blood glucose level, nor did she notified the resident's physician. According to the LPN, she was not aware of the facility's [DIAGNOSES REDACTED] Management Algorithm. Further review of Resident #250's MAR, revealed no evidence staff checked the resident's blood sugar again until 9:19 PM, on [DATE] when it was 37 mg/dl. Review of Resident #250's Nurses' Notes revealed, on [DATE] at 9:30 PM, Resident #1's physician was notified the resident's blood sugar was 37 mg/dl and a new order was received to administer Glucose Gel (to raise blood glucose level) orally and to discontinue both [MEDICATION NAME] and [MEDICATION NAME]. However, according to the MAR, the medications had already been administered, on [DATE]. Further review of the nurse's note revealed when the nurse entered the resident's room to administer Glucose Gel, the resident asked to be transferred to the hospital. The nurse documented she had notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after Glucose Gel was administered (time not documented) and was 85 mg/dl. Continued review of Resident #250's nurses notes revealed, on [DATE] at 10:27 PM, staff documented that the resident was lethargic and very difficult to arouse. However, there was no evidence the facility assessed the resident's blood sugar or took any other action to address the resident's condition. Continued interview with LPN #3, on [DATE] at 5:45 PM, revealed she was responsible for Resident #250's care, on [DATE] at 9:19 PM, when the resident's blood sugar was 37 mg/dl. The LPN stated she notified the resident's physician, administered Glucogel, and made arrangements to transfer the resident to the hospital per the resident's request. According to LPN #3 she rechecked the resident's blood sugar after administering Glucogel and it was 85 mg/dl (not sure of the time). The LPN stated she should have reassessed the resident again when he/she was lethargic prior to the EMS arrival at the facility and stated she did not know why a reassessment was not completed. Interview conducted with Resident #250's Physician, on [DATE] at 10:00 AM, revealed staff should have assessed the resident and followed the facility's. [DIAGNOSES REDACTED] Management Algorithm. The physician stated Resident #250 could have expired from a low blood glucose level. Review of EMS documentation for Resident #250 revealed, on [DATE] at 10:51 PM, the resident was unresponsive with snoring respirations. The ambulance personnel documented the resident's blood glucose level was 34 mg/dl. According to the report, EMS obtained an intravenous (IV) line and administered 50% [MEDICATION NAME] intravenously (used to rapidly increase blood sugar levels). After the [MEDICATION NAME], the resident was able to open his/her eyes and was able to nod answers to questions. The EMS report revealed a second 50% [MEDICATION NAME] dose was administered and the resident was able to speak in sentences and move his/her extremities independently. Interview conducted with Advanced Emergency Medical Technician (EMT), on [DATE] at 9:50 AM, confirmed Resident #250 was unresponsive when she arrived at the facility to transport the resident to the acute care hospital. The EMT stated when she and her partner transported the resident into the ambulance, the resident's blood sugar was 34 mg/dl and took two (2) doses of [MEDICATION NAME] for the resident to be able to speak in sentences and move his/her extremities. Review of the Acute Care Hospital record for Resident #250, revealed the resident arrived at the hospital, on [DATE] at 11:35 PM. The resident's blood sugar on arrival was 69 mg/dl at 11:45 PM, and a D5W ([MEDICATION NAME]) IV continuous drip was initiated and 50% [MEDICATION NAME] twenty five (25) mg administered intravenously. Resident #250 was admitted to the acute care hospital with a [DIAGNOSES REDACTED]. Resident #250 was discharged from the facility on [DATE]. Attempted to interview the resident via phone, on [DATE] at 11:15 AM, [DATE] at 4:30 PM , [DATE] at 12:15 PM and [DATE] at 10:30 AM were unsuccessful. Interview conducted with the Director of Nursing (DON), on [DATE] at 2:30 PM, and with the Administrator, on [DATE] at 3:00 PM, revealed nurses were required to implement the [DIAGNOSES REDACTED] Management Algorithm anytime a resident had a blood glucose level of 70 or lower. The DON stated she was not aware the algorithm was not being implemented until after the incidents with Resident #250. 2. Review of Resident #7's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. In addition, physician orders [REDACTED].#7, six (6) units of [MEDICATION NAME] subcutaneously every morning, and five (5) units of [MEDICATION NAME] R insulin before meals. Review of Resident #7's Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a BIMS score of four (4) which revealed the facility assessed the resident to be severely impaired cognition. Review of Resident #7's Comprehensive Care Plan, reviewed on [DATE], revealed interventions directed staff to manage the resident's Diabetes Mellitus by performing blood glucose monitoring as ordered, observe the resident for signs/symptoms of [DIAGNOSES REDACTED] and report any concerns to the physician. Review of Resident #7's Medication Administration Record [REDACTED]. However, there was no evidence found to indicate that the staff notified the resident's physician or the resident's blood glucose levels were monitored or rechecked by staff. Resident # 7 was observed on [DATE] at 9:21 AM, to be resting with his/her eyes closed. No signs or symptoms of [DIAGNOSES REDACTED] was observed. Interview with LPN #6 on [DATE] at 1:30 PM, revealed she obtained Resident #7's blood glucose level on [DATE] at 4:40 PM, however, she had not recheck the resident's blood glucose level after obtaining a reading of below 70 mg/dl or notified the resident's physician of the resident's low glucose level. LPN #6 stated she was unaware of the facility's [DIAGNOSES REDACTED] Management Algorithm policy that staff was to utilize when a resident experienced a hypoglycemic episode. Although the LPN stated she had attended the facility's annual in-service on how to perform blood glucose monitoring, the in-service did not address what action to take if a resident's blood glucose level was low. LPN #6 stated she took no further action related to Resident #6's blood glucose level on [DATE] because the resident's blood glucose level was not below 60 mg/dl. Interview with LPN #7 on [DATE] at 10:50 AM, revealed she obtained Resident #7's blood glucose level on [DATE] at 5:08 PM, when the resident's glucose level was 63 mg/dl. The LPN stated she did not notified the resident's physician or recheck the resident's glucose level in fifteen (15) minutes as required by the facility's policy. LPN #7 stated she had not been aware of the facility's [DIAGNOSES REDACTED] Management Algorithm. Further interview with LPN #7 revealed she attended the facility's in-service on performing blood glucose, however, the in-service did not address what to do if a resident experienced [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #2, on [DATE] at 8:20 AM, revealed she obtained Resident #7's blood glucose level, on [DATE] at 8:08 PM, when the resident's blood glucose level was 65 mg/dl. However, RN #2 stated she had not notified the resident's physician of the low blood glucose level or rechecked the resident's blood glucose level in fifteen (15) minutes as required. Continued interview with the RN revealed she had been aware of the facility's [DIAGNOSES REDACTED] Management Algorithm, but felt she could manage the resident's [DIAGNOSES REDACTED] on her own, and did not need to notify the physician. RN #2 stated she had given the resident a peanut butter sandwich and a cup of orange juice, which the resident had eaten, and therefore she did not feel like she needed to recheck the resident's blood glucose level. RN #2 stated she attended the facility's in-services on how to perform blood glucose monitoring, but could not recall if managing a resident who was hypoglycemic was discussed. 3. Review of Resident #19's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #19's MDS assessment dated [DATE] revealed the resident had a BIMS score of nine (9) which indicated the resident had been assessed to have moderately impaired cognition. Review of Resident #19's Comprehensive Care Plan, revised on [DATE], revealed interventions to manage the resident's Diabetes Mellitus included observing the resident's for signs and symptoms of [DIAGNOSES REDACTED], administering the resident a [MEDICATION NAME] injection if the resident's blood glucose level was less than 60 mg/dl and the resident had difficulty responding, providing blood glucose monitoring as ordered, and notifying the resident's physician with significant changes. Review of Physician order [REDACTED]. Further review of the orders revealed an order, dated [DATE], for the resident to receive [MEDICATION NAME] R insulin 12 units subcutaneously after breakfast and lunch, and 8 units after the evening meal, unless the resident does not eat a lot only administer one half the dose. Review of Resident #19's MARS for [DATE], revealed on [DATE] at 5:03 PM, staff documented the resident's blood glucose level was 64 and no insulin was administered. However, there was no evidence the staff notified the resident's physician or that the resident's blood glucose level was rechecked or monitored. Resident #19 was observed on [DATE] 9:31 AM, ambulating in hall. No signs of [DIAGNOSES REDACTED] were observed. Interview conducted with Resident #19 on [DATE] at 9:15 AM, revealed the resident had no concerns with blood glucose monitoring done by the facility. Interview on [DATE] with LPN #9 at 10:40 AM, revealed the LPN was aware of the facility's [DIAGNOSES REDACTED] Management Algorithm, and that nursing was to notify the physician and recheck Resident #19's glucose level on [DATE] at 5:03 PM, and stated she did not know why she had not done it as required. 4. Review of Resident #12's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #12's MDS assessment, dated [DATE], revealed the resident had a BIMS score of fifteen (15) which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #12's Comprehensive Care Plan revised on [DATE], revealed interventions implemented to address the resident's Diabetes Mellitus included providing blood glucose monitoring as ordered, notifying the physician with significant changes, and observing for signs and symptoms of [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of Resident #12's MARS for [DATE], revealed on [DATE] at 5:13 AM, the resident's blood glucose level was 61 mg/dl, and on [DATE] at 5:22 AM, the resident's blood glucose level was 64 mg/dl. However, there was no evidence the staff notified the physician of the resident's low blood glucose levels or that the glucose level was rechecked or monitored as required. Observation of Resident #12, on [DATE] at 11:30 AM, revealed the resident was observed to be sitting in his/her wheelchair in the resident's room. No signs or symptoms of [DIAGNOSES REDACTED] were observed. Interview conducted with Resident #12, on [DATE] at 11:35 AM, revealed the resident stated he/she had no concerns with the blood glucose monitoring provided to him/her by the facility. Interview with LPN #2, on [DATE] at 10:00 AM, revealed she was not aware of the facility's [DIAGNOSES REDACTED] Management Algorithm, however, should have rechecked and monitored the resident's blood glucose level and provided the resident a snack. 5. Review of Resident #42's medical record, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #42's MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15), which indicated the resident had been assessed to have no concerns with cognition. Review of Resident #42's Comprehensive Care Plan, revised on [DATE], revealed interventions implemented to manage the resident's Diabetes Mellitus included monitoring the resident's glucose levels, notifying the resident's physician of any significant changes in signs and symptoms, and observing for signs and symptoms of [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident #42's MARS for [DATE], revealed on [DATE] at 4:40 PM, revealed the resident's blood glucose level was 64 mg/dl, [DATE] at 4:44 PM, the resident's blood glucose level was 64 mg/dl, and on [DATE] at 11:54 AM, the resident's blood glucose level was 57 mg/dl. However, there was no evidence the physician was notified or the resident's blood glucose level was rechecked or monitored as required. Observation of Resident #42, on [DATE] at 10:45 AM, revealed the resident was observed to be up in a wheelchair in his/her room. No signs or symptoms [DIAGNOSES REDACTED] observed. Interview conducted with Resident #42, on [DATE] at 10:50 AM, revealed the resident stated he/she had no concerns regarding the care he/she received by the facility. Interview with LPN #9 on [DATE] at 10:40 AM, revealed the LPN was aware of the facility's [DIAGNOSES REDACTED] Management Algorithm and was aware that any time a resident was hypoglycemic she was required to notify the physician and recheck the blood glucose level. However, LPN #9 stated she failed to follow the facility's policy hypoglycemic management for Resident #42 on [DATE] at 4:40 PM, [DATE] at 4:44 PM, and on [DATE] at 11:54 AM, when the resident was hypoglycemic. The LPN stated she should have rechecked the blood glucose level after providing the resident a snack and notified the resident's physician. Interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, revealed the facility identified staff had not followed the [DIAGNOSES REDACTED] Management Algorithm after Resident #250 was transferred to the hospital. However, according to the DON, she had not identified that staff did not follow the algorithm for Resident #7, Resident #19, Resident #12, nor Resident #42. The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on [DATE], and completed on [DATE] for all licensed nursing staff. 2. Residents at the facility with [DIAGNOSES REDACTED]. No concerns were identified. 3. Residents at the facility with [DIAGNOSES REDACTED]. The SCC looked for signs and symptoms of hypo/[MEDICAL CONDITION] for the last 30 days and the treatment plan for hypo/[MEDICAL CONDITION] was followed per physician order. Any issues from chart audits had physician and family notification on [DATE], by the DON or Administrator. No injury or harm was noted. 4. On [DATE], residents with BIMS score of eight (8) or above were asked the following questions by the Social Services Director (SSD) 1): Do the staff address your needs? 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? No concerns were voiced. 5. On [DATE], residents (with BIMS score of less than eight) families were called and asked the following questions by the SW: 1.) Do you feel the staff address your family members needs appropriately? 2.) If your family member has a change in condition, are you and the physician notified? 3.) Do you have any concerns with your family members care? Any issues were addressed by the Administrator by [DATE]. 6. Residents with BIMS of less than eight (8) received an assessment for any signs or symptoms of a change in condition that had not been addressed on [DATE] by the DON and Restorative Nurse. No new concern were noted. 7. The SCC educated the Administrator, DON, MDS Coordinator and the Restorative Nurse on [DATE], regarding the signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights and Abuse/Neglect. 8. All licensed nurses were educated on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, physician and family notification, completing SBAR, Accuchecks, Resident Rights, Abuse/Neglect, and the [DIAGNOSES REDACTED] Management Algorithm. The training included appropriate steps to follow such as results received/steps such as management to include simple carbohydrate administration, rechecking of glucose levels and when to notify MD with action to take when new orders were received. This training was initiated by the DON, Restorative Nurse, MDS Coordinator and Administrator, on [DATE]. Education would continue prior to staff working their next scheduled shift by [DATE]. Licensed Nurse staff who were as needed, on FMLA or on leave would be issued a certified letter by Administrator with return receipt on [DATE], alerting them that they must receive an education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, completing SBAR and Accucheck competency completed prior to their first shift back to work. A pre-post test would be given in which a passing score of 100% must be obtained on the post test. If 100% not obtained the staff member would be re-educated and a post test would be reissued. 9. All State Registered Nurse Aides (SRNA) and all other facility staff would be provided education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect was initiated by the DON, MDS Coordinator, Restorative Nurse and Administrator on [DATE]. Education would continue prior to staff working their next scheduled shift by [DATE]. SRNAs and all other facility staff who are PRN, on FLMA or on leave would be issued a certified letter by Administrator with return receipt on [DATE] alerting them that they must receive education on signs and symptoms of hypo/[MEDICAL CONDITION], how to care for a resident with Diabetes Mellitus, licensed nurse notification of a change in the resident's condition, completing a Stop and Watch Form, Resident Rights and Abuse/Neglect completed prior to their first shift back to work. A pre-post test would be given

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure licensed nursing staff had the knowledge and competency to provide care for residents that require blood glucose monitoring and the implementation of the facility's [DIAGNOSES REDACTED] Management Algorithm, for five (5) of eighteen (18) sampled residents (Resident #250, Resident #7, Resident #19, Resident #12, and Resident #42). Record review and interviews revealed, on 08/06/2020, Resident #250's fingerstick blood glucose level was 66 (ADA recommendation range for someone with diabetes: 80-130 mg/dl) at 5:09 PM and was 59 at 8:15 PM. On 08/07/2020 at 5:09 PM, the resident had a blood glucose level of 46. Approximately, four (4) hours hours later at 9:19 PM, the resident's blood glucose level was 37. Resident #250 requested to be sent to the hospital, on 08/07/2020 at 9:30 PM. Review of the ambulance documentation for Resident #250, dated 08/07/2020 at 10:51 PM, when they arrived at the facility, the resident was unresponsive with snoring respirations and had a blood glucose level of 34. The resident was transported to the acute care hospital where he/she required intravenous fluids and medication to maintain his/her blood sugar. Further record review and interviews, revealed the facility utilized a [DIAGNOSES REDACTED] Management Algorithm, which required staff to notify the resident's physician for blood glucose levels (blood sugar) less than 70, and continue to monitor blood glucose levels, after fifteen minutes and offer simple carbohydrates. Licensed Practical Nurse (LPN) #1, #2, #3, and #7 provided care for Resident #250, on 08/06/2020 and 08/07/2020, and checked the resident's blood glucose. The LPN's documented during their shift that the resident's blood glucose was less that 70. However, there was no evidence the LPN's took appropriate action to address the resident's [DIAGNOSES REDACTED], as required by the facility's algorithm. Interviews with Licensed Practical Nurse (LPN) #1 and LPN #3, revealed both nurses had been employed by the facility approximately three (3) weeks (around the first week of August 2020). However, neither had been educated on the facility's [DIAGNOSES REDACTED] Algorithm, nor had their competency evaluated related to the implementation of [DIAGNOSES REDACTED] Management Algorithm. Further interviews revealed, LPN #2, who had been employed by the facility for five (5) years, and LPN #7, who had been employed two (2) years, stated they were also not aware of the facility [DIAGNOSES REDACTED] Algorithm; nor had been evaluated by the facility for competency related to the implementation of the algorithm. In addition, licensed nursing staff failed to notify the resident's physician per the facility's protocol when Resident #7, Resident #19, Resident #12, and Resident #42 had blood glucose levels less than 70. The facility's failure to ensure licensed nurses were knowledgeable and competent has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/17/2020 and determined to exist on 08/06/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726). The facility was notified of the Immediate Jeopardy on 09/17/2020. An acceptable Allegation of Compliance was received on 09/23/2020, which alleged removal of Immediate Jeopardy on 09/22/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 09/22/2020 as alleged, prior to exit on 10/01/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F684), and 42 CFR 483.35 Nursing Services (F726), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of a policy titled,Blood Glucose Monitoring, with a review date of 05/24/18, revealed upon a [DIAGNOSES REDACTED]. A review of a protocol titled,[DIAGNOSES REDACTED] Management Algorithm, with a revision date of 09/01/2015, utilized by the facility and developed by the American Diabetes Association, revealed staff were required to notify a resident's physician for blood glucose levels (blood sugar) less than seventy (70). The protocol also revealed if the resident was awake and able to swallow a simple carbohydrate such as juice, regular soda, milk, hard piece of candy, glucose gel, or glucose tablets would be administered. Per the protocol, the blood glucose level would be rechecked after fifteen (15) minutes. The protocol revealed if the blood glucose level was not greater than or equal to seventy (70) the physician would be notified again for further direction. The protocol stated if the blood glucose level was greater than or equal to seventy (70) then a protein or nutrious snack such as yogurt would be administered. Interview with the Director of Nursing (DON), on 09/17/2020 at 2:30 PM, revealed the facility did not have a policy related to staff competency or orientation training. The DON stated all new nurses were required to attend orientation and would work with another nurse for approximately two (2) weeks or longer if needed. The DON stated all nurses received an annual competency checklist completed as well. 1. Review of Resident #250's closed medical record, revealed the facility admitted the resident on 08/05/2020, with [DIAGNOSES REDACTED]. Review of Resident #250's Baseline Admission Care Plan, undated, revealed the facility identified that the resident had a [DIAGNOSES REDACTED]. Review of Resident #250's Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview conducted with LPN #7, on 09/16/2020 at 8:46 AM, revealed she had been employed by the facility for two (2) years. The LPN revealed she had completed the blood glucose monitoring for Resident #250, on 08/06/2020 at 5:00 PM, when the level was documented as being 66. The LPN stated she had done nothing because she knew the resident would be receiving a supper meal tray. The LPN stated she did not repeat the blood glucose monitoring nor did she notify the physician and should have. The LPN stated she had not been aware of the facility protocol ([DIAGNOSES REDACTED] Management Algorithm) for [DIAGNOSES REDACTED] until after the inservice on 08/11/2020. The LPN stated she should have repeated the blood glucose monitoring and should have notified the physician. In addition, the MAR indicated [REDACTED]. Continued review of the MAR, revealed on 08/07/2020 at 6:00 AM, there was no evidence blood glucose monitoring was completed per the facility policy/protocol or Physician Order. Interview conducted with LPN #3, on 09/15/2020 at 5:45 PM, revealed she had been employed for three (3) weeks when she was responsible for conducting the blood glucose monitoring for Resident #250, on 08/06/2020 at 8:15 PM, and 08/07/2020 at 6:00 AM, which had been missed, and on 08/07/2020 at 9:19 PM. The LPN stated she was unsure but probably had completed Resident #1's blood glucose monitoring, on 08/07/2020 at 6:00 AM, but could not recall the level. Interview with Licensed Practical Nurse (LPN) #1, on 09/14/2020 at 6:25 PM, revealed she had only been employed by the facility for three (3) weeks when, on 08/07/2020 at 12:26 PM, she checked Resident #250's blood glucose level and it was 56. LPN #1 stated she notified the resident's physician and gave the resident orange juice. The LPN stated she had observed the resident to eat his/her lunch meal tray. However, she did not recheck the resident's blood glucose level and was not aware she should have. The LPN stated the physician had come to the facility and had saw the resident on 08/07/2020. The LPN stated Resident #250's blood glucose level on 08/07/2020 at 5:09 PM, was 46. The LPN stated she had given the resident a cup of orange juice and asked him/her if he/she would like a peanut butter sandwich; however, the resident declined the peanut butter sandwich. The LPN stated she did not recheck the resident's blood glucose level nor did she notify the resident's physician. The LPN stated no one at the facility had observed her performing blood glucose monitoring nor had she completed a competency evaluation. The LPN stated she had been in orientation for two (2) weeks and was only working two (2) days per week. The LPN stated she was not aware of the [DIAGNOSES REDACTED] Management Algorithm protocol nor had she been instructed by the facility on what to do if a resident had a low blood glucose level. Further review of the MAR indicated [REDACTED]. A review of Resident #250's Nurses Notes, revealed no evidence the resident's physician was notified of low blood glucose levels for the resident, until 08/07/2020 at 2:27 PM, when the resident's physician physically visited the resident and wrote a physician's orders [REDACTED]. The next mention of physician notification related to the resident's blood glucose levels was on 08/07/2020 at 9:30 PM. The nurses notes further revealed, on 08/07/2020 at 9:30 PM, Resident #1's physician was notified due to the resident having a blood glucose level of thirty seven (37), and a new order was received to administer Glucose Gel (to raise blood glucose level) orally now and to discontinue both [MEDICATION NAME] one thousand (1000) mg twice daily orally (to lower blood glucose level) and [MEDICATION NAME] one hundred (100) mg daily orally (to lower blood glucose level). Continued review of the Nurses Notes, revealed at 9:30 PM on 08/07/2020, Licensed Practical Nurse (LPN) #3, administered Glucose Gel (to raise blood glucose level), and the resident requested to be transferred to the hospital. The nurse documented she notified the resident's physician and arrangements were made to transfer the resident to the hospital. The nurses's notes revealed the resident's blood glucose level was rechecked after he/she was administered Glucose Gel (to raise blood glucose level). However, no time was documented when the blood glucose level was obtained. The results were documented as being 85 and the resident was documented as being lethargic and very difficult to arouse. Further, review revealed no evidence of continued resident monitoring. The nurses notes revealed the ambulance service arrived at the facility, on 08/07/2020 at 10:27 PM, and departed from the facility to the hospital, on 08/07/2020 at 10:34 PM. A review of the Ambulance Service documentation for Resident #250, dated 08/07/2020 at 10:51 PM, revealed they assessed the resident to be unresponsive with snoring respirations and the resident's blood glucose level as being 34. The ambulance record revealed an intravenous line was obtained and 50% [MEDICATION NAME] 25 mg intravenously (used to increase blood glucose level) was administered. The ambulance record revealed the resident opened his/her eyes and was able to nod answers to questions. The ambulance record revealed a second 50% [MEDICATION NAME] 25 mg intravenously was administered and then the resident was able to speak in sentences and move his/her extremities independently. The ambulance documentation revealed the resident was then transferred to the acute care hospital. A review of the Acute Care Hospital record for Resident #250, revealed the resident arrived at the hospital, on 08/07/2020 at 11:35 PM. The hospital medical record revealed the resident received a D5W intravenous drip. On 08/07/2020 at 11:45 PM, a blood glucose level of sixty nine (69) was documented and 50% [MEDICATION NAME] 25 mg was administered intravenously. The acute care hospital record further revealed on 08/08/2020 at 1:45 AM, the resident's blood glucose level was documented as being less than 60 and an additional 50% [MEDICATION NAME] 25 mg was administered. The acute care hospital record revealed the resident was admitted by the acute care hospital, on 08/08/2020 at 4:19 AM, with a [DIAGNOSES REDACTED]. Interview with LPN #2, on 09/14/2020 at 6:51 PM, revealed she had helped LPN #3 on 08/07/2020 at 9:19 PM, when Resident #250's blood glucose level was 37. The LPN stated she had told LPN #3, to notify Resident #250's physician. LPN #2 stated LPN #3 had administered Glucagel (to raise blood glucose level) and had rechecked the blood glucose level and it was 85. The LPN stated she had assisted LPN #3 with the resident until the resident was sent out of the facility to the acute care hospital. The LPN stated she had been employed by the facility for five (5) years, and had not been aware of the facility protocol ([DIAGNOSES REDACTED] Management Algorithm). Continued interview on 09/15/2020 at 5:45 PM, with LPN #3, revealed she was not aware of the facility protocol ([DIAGNOSES REDACTED] Management Algorithm) on 08/06/2020 and 08/07/2020. The LPN stated no one had ever watched her do blood glucose monitoring. The LPN stated she had notified the physician when Resident #1 had a blood glucose level of 37, had administered Glucogel (to raise blood glucose level), and had made arrangements and transferred the resident to the acute care hospital. The LPN stated she had rechecked the resident's blood glucose level after administering the Glucogel (to raise blood glucose level) and it was 85 at that time but could not recall the exact time. The LPN stated she was unsure but probably had completed Resident #1's blood glucose monitoring, on 08/07/2020 at 6:00 AM, but could not recall the level. The LPN stated she had been in orientation with another nurse for two (2) weeks. Review of facility staff education records revealed the facility conducted annual inservices on 11/01/2019. Further review revealed staff completed a Medication Administration Skills Checklist and a Nurse Competency Skills Checklist upon hire and annually that included blood glucose monitoring which had been attended by LPN #2 and LPN #7. The competency checklists had been completed and signed by the Administrator dated 11/01/19. Review of the facility staff education records for LPN #1 and LPN #3, revealed the nurses had a Medication Administration Skills Checklist and a Nurse Competency Skills Checklist that included blood glucose monitoring, which had been completed for them by the DON, on 07/15/2020. Further review of the checklist/competency, revealed the nurse was checked off related to calling the physician if the resident's blood glucose level was high or low. However, review of the checklists, revealed the the blood glucose monitoring did not evaluate the nurse's knowledge/competency as to treating and assessing a resident with signs/symptoms of [DIAGNOSES REDACTED]. 2. A review of Resident #7's medical record, revealed the facility admitted the resident on 04/10/19, with [DIAGNOSES REDACTED]. A review of Resident #7's physician's orders [REDACTED]. The physicians orders also revealed orders, dated 07/08/2020, for the resident to receive [MEDICATION NAME] six (6) unit subcutaneous daily (insulin to lower blood glucose level); and [MEDICATION NAME] R five (5) units subcutaneous before meals (to lower blood glucose level). A review of Resident #7's Quarterly Minimum Data Set (MDS) assessment, dated 07/08/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #7's Comprehensive Care Plan with a review date of 07/14/2020, revealed interventions were developed to perform blood glucose monitoring as ordered; and to observe for and report signs and symptoms of [DIAGNOSES REDACTED]. A review of Resident #7's MARS, revealed blood glucose monitoring on 08/31/2020 at 4:40 PM at a level of 64; 09/03/2020 at 5:08 PM at a level of 63; on 09/08/2020 at 8:08 PM at a level of 65. Review of the Nurse's Notes, revealed no evidence the resident's physician was notified of the resident's low (less than 70) blood glucose levels on 08/31/2020, 09/03/2020 or 09/08/2020. Interview with Registered Nurse (RN) #2, on 09/16/2020 at 8:20 AM, revealed she was responsible for performing blood glucose monitoring for Resident #7, on 09/08/2020 at 8:08 PM. The RN stated she was aware of the facility's [DIAGNOSES REDACTED] Management Algorithm, but had not notified the physician, since she felt she could take care of the low level herself. The RN further stated she had not rechecked the blood glucose level for the resident. The RN stated she had given the resident a peanut butter sandwich and a cup of orange juice. The RN stated she attended annual inservices on blood glucose monitoring. The RN stated she had to provide a return demonstration on how to perform the testing but could not recall if [DIAGNOSES REDACTED] was discussed. Per the RN, an outcome of staff not reassessing resident after a low blood glucose level, was the resident could go into a diabetic coma. Interview conducted with LPN #7, on 09/17/2020 at 10:50 AM, revealed she was responsible for completing the blood glucose monitoring for Resident #7, on 09/03/2020 at 5:08 PM. The LPN stated she had not notified the physician nor had she repeated the blood glucose monitoring and guessed she probably should have. The LPN stated she was not aware of the facility protocol for treating [DIAGNOSES REDACTED]. The LPN stated nurses including herself were in orientation approximately two (2) weeks. The LPN stated she was required to attend an annual orientation on blood glucose monitoring and had to provide a return demonstration of how to perform the testing. However, the LPN stated she had not been educated on what to do if blood glucose levels were too low. The LPN stated she had been a mentor for LPN #1. Interview with LPN #6, on 09/17/2020 at 1:30 PM, revealed she was responsible for completing the blood glucose monitoring for Resident #7, on 08/31/2020 at 4:40 PM. The LPN stated she had not repeated the resident's blood glucose monitoring, nor had she notified the resident's physician, but should have. The LPN stated she was unaware of the facility protocol for treating [DIAGNOSES REDACTED]. The LPN stated she was required to attend an annual inservice and had to provide a return demonstration on how to perform blood glucose monitoring. The LPN stated the inservice did not address what to do if a blood glucose level was too low. The LPN further stated if a resident had a blood glucose level of less than sixty, she would notify the physician and recheck the level after providing a snack. The LPN stated she thought the resident was alright because his/her blood glucose level was not below sixty (60). 3. A review of the medical record for Resident #19, revealed the facility admitted the resident on 12/17/19, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Further review revealed an order dated 09/02/2020, for the resident to receive [MEDICATION NAME] R Regular U-100 Insulin (to lower blood glucose levels) twelve (12) units subcutaneous after breakfast and lunch. If the resident does not eat a lot only administer one half the dose; [MEDICATION NAME] R Regular U-100 Insulin (to lower blood glucose level) eight (8) units subcutaneous after the evening meal, if the resident does not eat a lot only administer one half the dose. A review of the Quarterly MDS assessment for Resident #19, dated 08/27/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #19's Comprehensive Care Plan, with a revision date of 09/02/2020, revealed interventions had been developed for the resident to receive a [MEDICATION NAME] (to increase blood glucose levels) injection if the resident's blood glucose level was less than 60, and had difficulty responding; provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of [DIAGNOSES REDACTED]. A review of the MAR for Resident #19, revealed on 09/06/2020 at 5:03 PM, the blood glucose level was documented as being 64, and no insulin (to lower blood glucose level) was administered. There was no evidence the physician was notified or the blood glucose monitoring was repeated. Interview with LPN #9, on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the facility protocol ([DIAGNOSES REDACTED] Management Algorithm). The LPN stated she was aware she was required to notify the physician and repeat the blood glucose monitoring for Resident #19 on 09/06/2020 at 5:03 PM. The LPN stated she did not know why she had not but should have. The LPN stated she had been trained on the [DIAGNOSES REDACTED] Management Algorithmand also received an annual inservice on blood glucose monitoring in which a return demonstration was required. 4. A review of Resident #12's medical record, revealed the facility admitted the resident on 05/13/2020, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Quarterly MDS assessment for Resident #12, dated 08/12/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #12's Comprehensive Care Plan with a revision date of 08/14/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of [DIAGNOSES REDACTED]. A review of the MAR for Resident #12 revealed, on 09/03/2020 at 5:13 AM, the blood glucose was documented as being 61; and on 09/09/2020 at 5:22 AM, the blood glucose was documented as being 64. There was no evidence the physician was notified or the blood glucose monitoring were repeated. Interview with LPN #2, on 09/17/2020 at 10:00 AM, revealed she had not been aware of the facility protocol for [DIAGNOSES REDACTED]. The LPN stated she should have repeated the blood glucose monitoring, provided a snack and should have notified the resident's physician. The LPN stated she was unsure why she had not. 5. A review of Resident #42's medical record, revealed the facility admitted the resident on 09/25/19, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review Resident #42's Annual MDS Assessment, dated 09/08/2020, revealed the resident had a [DIAGNOSES REDACTED]. A review of Resident #42's Comprehensive Care Plan, with a revision date of 09/11/2020, revealed interventions developed to provide blood glucose monitoring as ordered; notify the physician with significant changes in signs and symptoms; and observe for signs and symptoms of [DIAGNOSES REDACTED]. A review of the MAR for Resident #42, for 08/20/2020 at 4:40 PM, revealed the blood glucose was documented as being 64; on 08/22/2020 at 4:44 PM, the blood glucose was documented as being 64; on 09/03/2020 at 11:54 AM, the blood glucose was documented as being 57. There was no evidence the physician was notified or the blood glucose monitoring was repeated. Interview conducted with LPN #9, on 09/17/2020 at 10:40 AM, revealed the LPN was aware of the facility [DIAGNOSES REDACTED] Management Algorithm. The LPN stated she was aware that she was required to notify the physician and repeat the blood glucose monitoring for Resident #42, on 08/20/2020 at 4:40 PM; on 08/22/2020 at 4:44 PM; and on 09/03/2020 at 11:54 AM. The LPN stated she should have rechecked the blood glucose monitoring after providing a snack and notification of the physician. Review of an inservice roster titled, Diabetic Care, dated 08/11/2020, revealed nurses had attended an inservice on diabetic care and had received policies related to diabetic care. However, there was no evidence the facility had evaluated the effectiveness of the training or checked the competency of the nurses after the training. Interview with LPN #6, on 09/17/2020 at 1:30 PM, LPN #7 on 09/17/2020 at 10:50 AM, LPN #1 on 09/14/2020 at 6:25 PM, and LPN #2 on 09/17/2020 at 10:00 AM, revealed they were not aware of the facility protocol for the management of [DIAGNOSES REDACTED]. In addition, interview with LPN #9, on 09/17/2020 at 10:40 AM, and Registered Nurse (RN) #2, on 09/16/2020 at 8:20 AM, revealed both had been aware of the facility protocol for managing [DIAGNOSES REDACTED] but had failed to follow the protocol. As noted above, LPN #9 failed to follow the protocol related to physician notification, on 08/20/2020, 08/22/2020, 09/03/2020 and 09/06/2020 and RN #2 failed to follow the protocol on 09/08/2020. Interview with the Director of Nursing (DON), on 09/17/2020 at 2:30 PM, revealed upon hire all nurses were placed in orientation for two (2) weeks with another nurse. The DON stated nurses were required to attend orientation on the computer for the first three (3) days of employment, from 9:00 AM to 1:00 PM. The DON stated the new nurse would then be placed with another more experienced nurse who would be responsible for completing the nurses competency checklist of which blood glucose monitoring was included. The DON stated she had provided an inservice on 08/11/2020, for the facility nurses on diabetic care which included blood glucose monitoring and the use of the [DIAGNOSES REDACTED] Management Algorithm. The DON stated she had required the nurses to provide a return demonstration which included the nurse performing a fingerstick blood glucose. The DON stated she ensured nurses knew they were to call the physician for a blood glucose level of 70 or below. However, the DON stated she had no documentation on the return demonstration or of any evaluation of the nurse's understanding of the training. Further interview with the DON, revealed nurses were required to utilize the [DIAGNOSES REDACTED] Management Algorithm anytime a resident had a blood glucose level of seventy (70) or lower. The DON stated she had been monitoring residents who received blood glucose monitoring daily, during rounds and during the interdisciplinary Team (IDT) Meetings, which were held daily Monday through Friday. The DON stated she monitored to ensure staff provided residents with appropriate blood glucose monitoring (per the facility protocol) and she had not identified any further care issues, after the incident with Resident #250. The DON stated she had not identified the blood glucose levels that were less than 70 (as noted above) for Resident #7, #12, #19 and #42, nor had she identified that nursing staff had not implemented the [DIAGNOSES REDACTED] protocol/algorithm. In addition, the DON stated she was responsible for providing inservice training for all staff, as the facility currently did not have a Staff Development Coordinator (SDC). The DON revealed she had only been in her new position, for two (2) weeks, and was responsible for ensuring orientation and the competency checklists were completed. The DON stated she had completed the Medication Administration Skills Checklist and a Nurse Competency Skills Checklist which included competency related to glucose monitoring for LPN #1 and LPN #3. However, the skills checklists did not include all requirements of the algorithm, and only assessed the nurses knowledge to call the physician for high or low blood glucose levels. Interview with the Administrator, on 09/17/2020 at 3:00 PM PM, revealed staff were required to use the [DIAGNOSES REDACTED] Management Algorithm for any resident who had a blood glucose level of seventy (70) or less. The Administrator stated all nurses were in orientation at least two (2) weeks and were required to have competency checklist completed of which blood glucose monitoring was included. The Administrator stated the nurses were also required to have an annual inservice with competency checklists completed. The Administrator stated she had completed the Medication Administration Skills Checklist and a Nurse Competency Skills Checklist, for LPN #2 and LPN #7, on 11/01/19 (Administrator is a nurse). The Administrator stated the checklist included competency with glucose monitoring but did not include the specifics in the algorithm and only assessed that the nurse knew to call the physician for high or low blood glucose levels . The facility alleged the following was implemented to remove Immediate Jeopardy on 09/22/2020: 1. Education related to documentation of blood glucose checks, physician notification, and documentation of physician notification related to change in resident's condition was initiated on 08/11/2020, and completed on 08/14/2020 for all licensed nursing staff. 2. Residents at the facility with [DIAGNOSES REDACTED]. No concerns were identified. 3. Residents at the facility with [DIAGNOSES REDACTED]. The SCC looked for signs and symptoms of hypo/[MEDICAL CONDITION] for the last 30 days and the treatment plan for hypo/[MEDICAL CONDITION] was followed per physician order. Any issues from chart audits had physician and family notification on 09/21/2020, by the DON or Administrator. No injury or harm was noted. 4. On 09/18/2020, residents with BIMS score of eight (8) or above were asked the following questions by the Social Services Director (SSD) 1): Do the staff address your needs? 2.) If you have a concern or a medical problem, for example a low blood sugar, do the staff respond, notify your doctor and provide treatment if needed? 3.) Do you have any concerns related to your care at this time? No concerns were voiced. 5. On 09/18/2020, residents (with BIMS score of less than eight) families were called and asked the following questions by the SW: 1.) Do you feel the staff address your family members needs appropriately? 2.) If your family member has a change in condition, are you and the physician notified? 3.) Do you have any concerns with your family members care? Any issues were addressed by the Admini (TRUNCATED)

Based on observation, interview, record review, and a review of the facility freezer policy, it was determined the facility failed to store food under sanitary conditions. Observations of the facility walk-in freezer revealed water had leaked from the condenser unit causing ice buildup on containers of frozen strawberries and ice cream cups stored directly under the condenser unit in the freezer. The findings include: A review of the facility freezer policy titled Freezer with a revision date of 08/31/2018, revealed ice buildup should be removed from the freezer at least monthly and the freezer should be frost-free. A review of the weekly cleaning schedule for the freezer revealed that freezer was cleaned weekly and according to the schedule was last cleaned on 09/23/2020. Observations of the Walk in Freezer, on 09/29/2020 at 9:10 AM, (during initial tour of the kitchen) and on 10/01/2020 at 10:50 AM, (during the sanitization tour), revealed condensate water had leaked from the freezer condenser unit and had frozen on containers of strawberries and ice cream. The containers of strawberries and ice cream were stored directly beneath the condenser unit in the freezer causing a buildup of ice on the food containers. An interview on 10/01/2020 at 10:55 AM, with the Interim Dietary Manager, revealed the freezer was cleaned weekly and ice buildup removed according to the freezer-cleaning schedule. The Interim Dietary Manager stated the she checked the freezer daily for concerns and had not noticed the ice buildup or the water leaking on the food containers.

Based on observation, interview, record review, and facility policy review, the facility failed to revise the care plan for one (2) of eighteen (18) sampled residents (Resident #37 and Resident #38). Resident #37 was assessed to be at risk for pressure ulcers and had a physician's orders [REDACTED].#37, revealed the care plan did not include interventions to address the use of the heal protectors. Interviews with staff revealed Resident #38 threw cups/pitchers of fluids on the floor and staff did not leave cups/pitchers at the resident's bedside. However, review of the resident's care plan revealed the facility did not revise the care plan to address the behavior, nor did it address how staff were required to ensure the resident met hydration needs. The findings include: Review of the facility's policy, Comprehensive Care Plans, last revised on 07/19/2018 revealed it was the goal of the facility to develop a person-centered comprehensive care plan that included measurable objectives, and timetables to meet the resident's medical, nursing, mental and psychological needs for each resident. Further review revealed the care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. 1. Review of the record for Resident #37 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimal Data Set (MDS) Assessment on 09/08/2020, revealed a Brief Interview for Mental Status (BIMS) score of (99) ninety-nine indicating the resident was unable to complete the interview. Further review of the record revealed the facility completed a Braden Scale Assessment on 09/03/2020, to determine the residents risk for developing pressure ulcers and the resident scored twelve (12), indicating that Resident #37 was at high risk for developing pressure ulcers. Further review of the record revealed a physician's orders [REDACTED]. Review of the Comprehensive Care Plan for Resident #37, dated 07/26/2020, revealed a care plan was in place for the resident's risk for developing pressure ulcers and included interventions directing staff to ensure the resident avoided prolonged skin to skin contact, staff inspected the skin during bathing, and daily care. Further review of the care plan revealed the order for the heel protectors was not addressed on the comprehensive care plan. Observation of Resident #37, on 09/30/2020 at 10:24 AM, revealed the resident was sitting in a wheelchair in his/her room with non-skid socks on and no heel protectors. On 10/01/2020 at 1:19 PM, Resident #37 was observed to be in a wheelchair and did not have heel protectors in use at that time. The Licensed Practical Nurse (LPN) #10 removed Resident #37's socks and the skin on the resident's heels was noted to be intact with no pressure injury noted. Interview with the MDS Coordinator, on 10/01/2020 at 2:26 PM, revealed she reviewed the assessment and the record and compares that information to the care plan to ensure that the care plan was accurate. She further stated that when a new order was received, the nurse who received the order should update the plan of care. Per the MDS Coordinator, physician orders [REDACTED]. The MDS Coordinator stated she was unaware Resident #37's care plan did not address the use of the heel protectors. Interview with the facility Administrator, on 10/01/2020 at 2:35 PM, revealed she was usually involved in the clinical meeting each morning and the team reviewed physician orders, during those meetings to ensure care plans were accurate. She was unaware Resident #37's care plan, did not reflect the use of heel protectors. 2. Record review revealed the facility admitted Resident #38 on 06/27/2019, with [DIAGNOSES REDACTED]. Review of Resident #38's Quarterly Minimum Data Set (MDS) assessment, dated 09/08/2020, revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) score of 99, and staff assessed the resident had severely impaired cognition for daily decision making skills. Further review of the resident's MDS revealed the resident required supervision with eating/drinking and exhibited no behaviors of rejecting care, nor behavior directed toward others, such as throwing food. Observation of Resident #38, on 09/29/2020 at 10:50 AM, and on 09/30/2020 at 3:49 PM, revealed the resident had no fluids available to drink. Further observations on 09/29/2020 at 12:29 PM, revealed there was a small glass half-filled with fluids in the resident's room and, on 10/01/2020 at 9:13 AM, a plastic tumbler with a lid that contained a small amount of clear liquid was available. Interview on 09/30/2020 at 3:50 PM, with State Registered Nursing Assistant (SRNA) #6, and on 10/01/2020 at 9:27 AM, with SRNA #9, revealed they did not usually leave fluids at Resident #38's bedside because the resident threw liquids. SNRA #9 stated staff usually took in cups of fluids for the resident, encouraged the resident to drink, then removed the cup from the room. Interview on 10/01/2020 at 9:18 AM, with SRNA #8, revealed the SRNA had only been at the facility for a few days and was unaware why Resident #38 did not have a water pitcher at bedside. She stated she would review the resident's care plan for information about the resident's fluids. Continued interview with SRNA #9, on 10/01/2020 also revealed she would review the resident's care plan to determine the care the resident required. However, review of Resident #38's Care Plan and Resident Profile (the care guide for State Registered Nurse Aides), revealed the facility had not addressed the resident throwing cups/pitchers of liquids nor interventions to ensure the resident's fluid needs were met. Interview on 10/01/2020 at 1:35 PM, with the Director of Nursing and Administrator, revealed MDS nurses updated care plans when they completed MDS assessments; however, nursing staff was required to revise care plans when changes occurred.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure activities were provided based on residents choices and preferences for one (1) of eighteen (18) sampled residents (Resident #31). Resident #31's admission assessment noted that it was very important to the resident to go outside for fresh air when the weather was nice; however, observations and interviews revealed that the resident was not given the opportunity to spend time outside. The findings include: Review of the facility's policy titled Activity Program dated last reviewed, and last revised on 07/25/2017, revealed it was the goal of the facility to provide an on-going activities program designed to support residents in their choice of activities, and to meet the interests of and support the physical, mental, psychosocial well-being of each resident. Review of the record for Resident #31 revealed the facility admitted the resident on 12/04/2019, with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 09/03/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating the resident is cognitively intact. Further review of the record revealed the admission MDS for Resident #31 that was completed on 12/11/2019, revealed that it was very important for Resident #31 to go outside for fresh air when the weather was good. Review of resident #31 most recent MDS assessment, which was a quarterly assessment completed, on 09/03/2020, revealed Resident #31 was independent with transfers, and mobility/locomotion on and off the unit. Interview with Resident #31, on 09/29/2020 at 9:46 AM, revealed he/she was never allowed to go outside. The resident stated he/she asked to go outside at times, but was not allowed to go. The resident stated the only time he/she went outside was to go to an appointment. Observation on 09/29/2020 at 9:46 AM, 09/30/2020 at 10:24 AM, and 10/01/2020 at 1:19 PM revealed the weather outside was mild and sunny; however, Resident #31 was observed to be in his/her room. Interview with Certified Nursing Assistant (CNA) #7, on 10/01/2020 at 10:46 AM, revealed when residents go outside, staff like to maintain eyesight of the resident. CNA #1 stated she had seen Resident #31 go outside a couple of times, but had not taken the resident outside. Interview with the Activities Director (AD), on 10/01/2020 at 10:24 AM, revealed it had been a while since Resident #31 had the opportunity to go outside. The AD further stated that Resident #31 used to ask to go outside more often, but does not ask as often lately. She stated that Resident #31 was assessed to enjoy going outside, but sometimes there was not enough staff to stay with the residents once they go outside and therefore they were not given the opportunity to go outside.

Based on observation, interview, record review, and facility policy review, the facility failed to implement ordered devices to assist in maintaining skin integrity, and to assist in preventing the development of pressure ulcers for one (1) of eighteen (18) sampled residents (Resident #37). Resident #37 had a physician's orders [REDACTED]. Observations of Resident #37, on 09/30/2020 and 10/01/2020, revealed the heel protectors were not being used as ordered. The findings include: Review of facility's policy, Pressure Ulcer/Injury Risk Evaluation, revised 01/08/2020, revealed it was the goal of the facility to provide guidelines for evaluation, and identification of residents at risk of developing a pressure ulcer/injury. Further review revealed Once skin inspection is complete, if a new skin alteration is noted, initiate a wound management or non pressure observation in the electronic medical record, and proceed to care planning and interventions individualized for the resident and their particular risk factors Observation of Resident #37, on 09/30/2020 at 10:24 AM, revealed Resident #37 was sitting in a wheelchair in his/her room. Heel protectors were not observed on the resident, but noted to be in the recliner in the room. On 10/01/2020 at 1:19 PM, Resident #37 was observed again to be in the wheelchair without the heel protectors on. Further observation and interview with Licensed Practical Nurse (LPN) #10 at 1:19 PM, revealed the skin on Resident #37's heels was intact and the resident did not have pressure sores. Review of Resident #37 Clinical Record revealed the resident was admitted on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimal Data Set (MDS) Assessment, dated 09/08/2020, revealed Resident #37 was assessed to have a Brief Interview for Mental Status (BIMS) score of (99) ninety-nine indicating the resident was non-interviewable. Review record of a Braden Scale assessment completed, on 09/03/2020, revealed the resident to be at high risk for developing pressure ulcers. Review of the Comprehensive Care Plan for Resident #37, with a start date of 01/14/2020, revealed the resident was at risk for developing pressure sores with interventions for the avoidance of prolonged skin to skin contact and for staff to inspect the skin during bathing/daily care. The comprehensive care plan did not include information regarding the heel protectors. Interview with Certified Nursing Assistant (CNA) (#7), on 09/30/2020 at 10:24 AM, revealed she was unaware of whether the resident required the heel protectors at all times. Interview with the MDS Coordinator, on 10/01/2020 at 2:26 PM, revealed she reviewed resident assessments and compared the information to the care plan, to ensure the care plan was accurate. She further stated when a new order was received then the nurse who obtained the order should update the care plan if necessary. The MDS coordinator further stated a clinical meeting was conducted every morning and orders were supposed to be reviewed during these meetings to ensure the care plans accurately reflected the needs of the residents. The MDS coordinator stated she was unaware the heel protectors were not being implemented for the resident as ordered. Interview with the facility Administrator and Director of Nursing (DON), on 10/01/2020 at 2:35 PM, revealed they were usually involved in the clinical meeting each morning and the team reviewed orders during those meetings to ensure interventions were implemented as ordered. The Administrator stated she was unaware the heel protectors were not being implemented as ordered for Resident #37.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure fluid intake was monitored related to sufficient fluid intake to maintain hydration and health for two (2) of eighteen (18) sampled residents (Resident #29 and Resident #38). Resident #29 and Resident #38 were assessed to be at risk for hydration concerns; however, the facility failed to monitor to ensure residents were meeting their fluid needs. The Findings Include: Review of the facility policy titled, Hydration, last reviewed 06/27/2018 revealed Residents will receive sufficient amounts of fluid to maintain proper hydration. Further review of the policy revealed, Water is made available at mealtime, at bedside, on hydration cart (unless contraindicated). The policy did not indicate how the facility would ensure fluid intake was monitored. 1. Review of the record for Resident #29 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2020, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) and the resident scored a four (4) indicating severe cognitive impairment. The assessment further noted the resident was able to make himself/herself understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of Resident #29's Comprehensive Care Plan, revealed the problem of Nutritional Status with a start date of 08/08/2019. The care plan stated the resident was at nutritional and hydration risk and interventions included Monitor intake of food and liquids. Further review of the record for Resident #29 revealed, on 09/25/2020 and 09/26/2020, there was no fluid intake documented for the resident and only 480 ml was documented as intake for 09/27/2020. Observation of Resident #29, on 09/29/2020 at 3:18 PM, revealed the resident was awake and alert and had a pitcher of ice water available at the bedside. The resident's lips and skin appeared moist and there were no visible signs of dehydration. Observation on 09/30/2020 at 10:50 AM, revealed the resident was in the room in bed and asked for a drink of water. The resident had water at the bedside on the bedside table that appeared to be within the resident's reach, but the resident stated, I can't get it. The facility's Social Services Director (SSD) passed by the room and heard the resident say give me a drink. The SSD entered the room and assisted the resident to drink water from the water pitcher/container at the bedside. Interview with the SSD, on 09/30/2020 at 10:53 AM, revealed Resident #29 often requested a drink of water during the day and staff who were passing gave the resident a drink. Interview with State Registered Nurse Aide (SRNA) #7, on 10/01/2020 at 10:06 AM, revealed that they were required to document fluid intake on residents. SRNA #7 stated Resident #29 asked for a drink often and he/she was given drinks of water several times throughout the day. SRNA #7 stated that sometimes the intake might not be documented because staff just forget to document it. 2. Record review revealed the facility admitted Resident #38, on 06/27/2019, with [DIAGNOSES REDACTED]. Review of Resident #38's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the assessment because the resident refused or had short term and long term memory problems. Further review of the resident's MDS revealed the resident required supervision with eating/drinking. Review of Resident #38's Care plan, dated 09/23/2020, revealed the facility identified that the resident was at nutritional and/or hydration risk due to a low body mass index (BMI). The facility developed an intervention to Observe for signs or symptoms of dehydration and Monitor intake of food and liquids. Review of Resident #38's Resident Profile (a care guide for State Registered Nurse Aides) revealed staff were required to provide regular, thin liquids for the resident. Observation and an attempted interview with Resident #38, on 09/29/2020 at 10:50 AM, revealed the resident was unable to answer questions. The resident was sitting in a wheelchair and no fluids were available. Further observations, on 09/30/2020 at 3:49 PM, revealed a small, empty tumbler with a clear lid at the bedside. Review of Resident #38's Medical Nutrition Review, dated 11/17/2019, revealed the resident required 1560 milliliters (ml) of fluids daily to meet his/her hydration needs. Review of Resident #38's fluid intake for September 2020, revealed the resident never met his/her estimated fluid intake on any day. On 09/29/2020, staff documented the resident's intake was 600 ml and on 09/30/2020, the resident's intake was 340 ml of fluids. Review of Resident #38's laboratory data, revealed on 03/27/2020, the resident's Blood Urea Nitrogen (BUN)/Creatinine Ratio was 33 (normal is 12-22). Further review revealed on 06/26/2020 the ratio was 31 and on 08/26/2020 the ratio was 28. The BUN/Creatinine Ration indicated dehydration. Interview on 09/30/2020 at 3:50 PM, with State Registered Nursing Assistant (SRNA) #6 and with SRNA #8, on 10/01/2020 at 9:18 AM, revealed they had provided fluids to Resident #38; however, they did not leave fluids at the resident's bedside, because the resident threw liquids on the floor. Interview on 10/01/2020 at 9:18 AM with SRNA #8 revealed the SRNA had only been at the facility for a few days and was unaware of why Resident #38 would not have a water pitcher at bedside. She further revealed she would look at the care plan to see why the resident did not have fluids. Interview on 10/01/2020 at 9:27 AM, with SRNA #9, revealed they looked at the care plan on the computer to see what kind of care the residents needed. Further review with the SRNA revealed they charted intake at breakfast, lunch, and dinner and any fluids taken in between meals. The SRNA stated they provided Resident #38 fluids in cups and try to encourage them to drink but then take the cups out due to the resident throws things in the room. Interview on 10/01/2020 at 10:11 AM, with Licensed Practical Nurse (LPN) #10, revealed nurses monitored each resident's hydration status daily through assessment. LPN #10 stated the fluid intake was documented in the computer and the Director of Nursing (DON) monitored the intakes to ensure residents were meeting their fluid needs. Interview with the MDS Coordinator, on 10/01/2020 at 2:25 PM, revealed the facility Interdisciplinary Team (IDT) met every morning and discussed any resident who was not meeting their fluid needs or if there were nutrition/hydration concerns for residents. The MDS Coordinator stated she was not aware of any residents not meeting their fluid needs. The MDS Coordinator was asked about the fluid intake for Resident #29, on 09/25/2020, 09/26/2020, and 09/27/2020. The MDS coordinator returned approximately 10 minutes later and stated she called staff who worked during those times and the resident had fluid intake on those days; however, it was not documented. Interview with the DON and the Facility Administrator, on 10/01/2020 at 1:37 PM, revealed the Dietary Manager reviewed the residents fluid needs daily and if there were concerns with a resident not meeting their recommended fluid needs, the Dietary Manager brought the concerns to the morning clinical meeting for discussion with the Interdisciplinary team (IDT). The Administrator stated the Dietary Manager was currently on sick leave and the Dietitian and reviewed the intakes while the Dietary Manager was off, and the Dietitian had not reported any concerns with fluid intake or gaps in the documentation for any residents.

Based on observation, interview, record review, review of facility policy and CDC guidelines, it was determined the facility failed to prevent the possible spread of COVID-19. Staff were observed in two (2) resident rooms (Resident #20 and #29) without donning appropriate Personal Protective Equipment (PPE). The findings include: Review of the facility policy titled, Novel Coronavirus (COVID-19), last revised date 08/31/2020, revealed For residents admitted to a facility and whose COVID status is unknown/they have not been tested : Resident/patient placed in droplet precautions for 14 days. Review of the CDC Preparing for COVID-19 in Nursing Homes updated 06/25/2020, revealed as demonstrated by the COVID-19 pandemic, a strong infection prevention and control (ICP) program was critical to protect residents and healthcare personnel (HCP). Continued review of CDC guidance revealed the facility should create a plan for managing new admissions and readmissions whose COVID-19 status was unknown to include: placing the resident in a single person room or in a separate observation area so the resident can be monitored for evidence of COVID-19; and HCP should wear an N95 or higher level respirator, eye protection (goggles or a face shield that covered the front and sides of the face), gloves, and gown when caring for these residents. Further review revealed residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Record review revealed the facility admitted Resident #20 to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's record revealed the resident left the facility, on 09/26/2020 at 9:05 AM, for a procedure and returned to the facility on [DATE] at 3:37 PM. Review of Resident #20 Minimum Data Set (MDS) assessment dated , 07/26/2020 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #20 Care Plan, dated 09/15/20, revealed the resident was care planned with a problem of At risk for active infection related to (r/t) potential exposure to COVID-19. The resident had intervention to, Maintain appropriate PPE use according to state requirements and availability. Observation on 09/29/2020 at 9:14 AM of Resident #20, revealed the resident lying in his/her bed. The Administrator was squatted down beside the resident's bed talking to the resident. The Administrator had on a mask and face shield but no gown. There was a droplet precaution sign on the resident's room door. Observation on 09/29/2020 at 12:35 PM, of Resident #20, revealed staff taking lunch tray into resident's room without donning a gown. Interview on 09/29/2020 at 3:15 PM, with Resident #20, revealed the resident had been out of the facility on Saturday for surgery. Interview on 09/30/2020 at 2:36 PM, with the Administrator who was also the Infection Preventionist, revealed all residents coming back from the hospital were placed in droplet precautions and were viewed as suspected of COVID-19. The Administrator admitted to going into the room without donning a gown and stated, I am just so use to going into the room when a resident ask me to. She further stated that staff should have donned gowns before providing care. 2. Review of the record for Resident #29 revealed the facility admitted the resident on 11/04/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/05/2020, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) and he/she scored a four (4) indicating severe cognitive impairment. Review of the progress notes revealed the resident went to the emergency department of the hospital on [DATE] and returned the same day. Review of Resident #29's plan of care revealed the plan of care did not include the resident's isolation precautions. Observation on 09/29/2020 at 10:30 AM, revealed Resident #29 was in his/her room in bed and called out to the Regional Vice President (RVP) that was passing by the room and the RVP entered the room. Continued observation revealed no PPE (Personal Protective Equipment) and no signage noted on the door that indicated the resident was in contact precautions or required the use of PPE when entering the room. The RVP went into the room without donning PPE, touched the residents bedside table and water pitcher and told the resident he would find a straw for the resident. Observation on 09/29/2020 at 12:43 PM, revealed the facility Administrator was entered Resident #29's room, and was noted to be putting on a gown and gloves before entering the room. The administrator also placed a mesh bag on the outside of the door that had PPE in the bag for staff to use. Interview with the Administrator at the time of observation, revealed the resident was in contact precautions because he/she had been to the emergency room a few days ago and was required to be under contact precautions due to being outside of the facility. Observation on 09/29/2020 at 3:21 PM, revealed the Regional Vice President was again (same staff from the observation at 10:30 AM) observed entering Resident #29's room without donning PPE. He went into the room, touched the resident's doll that was on the bed and was talking to the resident. When the staff member returned to the door, he then noticed the gowns and gloves and put on the PPE (gown and gloves) and went to the roommate of Resident #29 and spoke to the roommate. The staff member was interviewed upon exiting the room at 3:27 PM. Interview with the RVP after he exited Resident #29's room, revealed he was not aware the resident was in contact precautions, and when he noticed the sign and the PPE on the door, he corrected himself and put on the PPE. He stated that he also had been in the room earlier in the day and the PPE was not available at that time and he had not utilized the PPE. Interview with the Administrator, on 09/30/2020 at 11:11 AM, revealed she was restocking the PPE for Resident #29 on 09/29/2020 at 12:43 PM. The administrator stated the PPE had been on the outside of Resident #29's door previously; however, another resident had removed it so they put the PPE on the inside of the door. She stated when she was restocking the PPE on the previous day, they put the PPE back on the outside of the door so that staff would see it and be able to put it on before entering the room. When the surveyor informed the administrator that staff were observed entering the room without PPE, she stated staff should have known the PPE was on the inside of the door.

Based on observation, interview, and policy review, it was determined that the facility failed to store medications in accordance with accepted professional principles. Observation revealed staff left a medication cart unlocked and unattended. In addition, expired medication was stored in a medication cart and available for resident usage. The findings include: 1. Review of the facility's Medication Administration, General Guidelines, Section 7.1, policy, dated (MONTH) (YEAR), revealed the medication cart was kept closed and locked when out of sight of the medication nurse and no medications were kept on top of the cart. Observation of medication administration on 05/02/19 at 11:55 AM revealed Registered Nurse (RN) #2 was administering medication for Resident #7. RN #2 entered Resident #7's room and administered the medication, leaving the residents' medication cart unlocked outside the resident's room, not within view. Interview with RN #2 on 05/02/19 at 12:20 PM, revealed she should have locked the medication cart. RN #2 stated she had been trained during orientation upon employment with the facility in (MONTH) 2019 and was aware that the medication cart should be locked, but forgot to lock the cart. Interview with the Director of Nursing (DON) on 05/02/19 at 7:00 PM, revealed the medication carts should always be locked when staff step away from the cart. The DON stated she had not identified any concerns with unlocked medication carts. 2. Continued review of the facility's Medication Administration General Guidelines policy, dated (MONTH) (YEAR), revealed staff should check expiration dates on medication packages/containers, and no expired medication should be administered to a resident. Observation on 05/02/19 at 3:14 PM of a medication cart called Cart A Even stored in the medication room revealed Resident #38 had a package of 46 tablets of [MEDICATION NAME] HCL 5 MG (a medication used to prevent nausea and vomiting) with an expiration date of 11/10/18 available for use. Interview on 05/02/19 at 3:14 PM with the Assistant Director of Nursing (ADON) revealed she was responsible for checking medication carts for expired medication. In addition, she stated a Pharmacist spot checked the carts monthly. The ADON stated she checked the medication carts on Monday of that week, three days earlier, and did not identify Resident #38's expired [MEDICATION NAME]. Interview on 05/02/19 at 7:51 PM with the Director of Nursing (DON) revealed nurses who worked night shift were also responsible for cleaning medication carts and checking for expired medications. The DON stated the expired [MEDICATION NAME] should not have been in the cart.

Based on interview, record review, review of the facility's investigation, and review of the facility's policies it was determined the facility failed to notify the physician of the need to alter treatment and the presence of acute pain for one (1) of three (3) sampled residents (Resident #1). Interviews with Certified Nurse Aides (CNAs) that were caring for Resident #1 revealed that on 03/20/16 at approximately 6:00 PM, the resident was noted to be in pain when the staff attempted to provide care for him/her. The CNAs stated they reported the pain to the night shift nurse. Review of an SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated 03/20/16 and not timed, revealed Resident #1 was assessed to have tenderness to the left hip/leg. However, the resident's physician was not notified of the tenderness to the resident's hip/leg until 03/21/16 at 5:45 PM (approximately 24 hours after the CNAs reported that the resident had hip pain), at which time an x-ray of the hip was ordered. Resident #1's hip x-ray was obtained on 03/21/16 at 10:25 PM and was read by the radiologist and the results were faxed to the facility at 11:15 PM. Review of a SBAR Communication Form, dated 03/22/16, revealed the resident had a [MEDICAL CONDITION] hip. The resident's physician was notified of the fracture and an order was received to transfer the resident to the hospital for evaluation and treatment of [REDACTED]. The facility's failure to have an effective system in place to ensure each resident's physician was immediately notified of changes in resident condition and a need to alter treatment was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/20/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514). The facility was notified of the Immediate Jeopardy on 03/30/16. An acceptable Allegation of Compliance was received on 04/07/16 which alleged removal of the Immediate Jeopardy on 04/07/16. A partial extended survey was conducted on 04/11-12/16. The State Survey Agency determined the Immediate Jeopardy was removed on 04/07/16 as alleged, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Change in Condition policy, not dated, revealed the facility staff should assess any change in condition through direct observation and physical examination. Further review of the policy revealed if the resident's condition did not appear to be life threatening to utilize the SBAR Communication Form and notify the physician. Review of the facility's Pain Management policy, not dated, revealed if the resident had pain the resident's pain should be assessed, an SBAR communication form should be utilized, and the resident's physician should be notified. Review of Resident #1's medical record revealed the facility admitted the resident on 03/12/12 with [DIAGNOSES REDACTED]. Review of the resident's most recent Quarterly Minimum Data Set (MDS) assessment, dated 02/12/16, revealed the resident was cognitively impaired and required extensive assistance from staff for all activities of daily living. Review of Resident #1's SBAR Communication Form, dated 03/20/16 and not timed, revealed the facility assessed the resident to have tenderness to the left hip/leg. However, further review of the Form revealed the resident's physician was not notified and an order for [REDACTED]. Review of Resident #1's Nurse's Notes, dated 03/22/16 at 12:30 PM, revealed the resident was noted to have bruising and [MEDICAL CONDITION] to the left knee and would grimace when moved. Further review of the Nurse's Notes revealed the physician was notified at 12:30 PM about the issue with the resident's knee. An order was obtained for a knee x-ray. Review of Resident #1's SBAR Communication Form, dated 03/22/16 at 6:00 PM, revealed Resident #1's physician was notified of the results of the hip x-ray which showed a [MEDICAL CONDITION] hip and the knee x-ray which showed arthritis. Continued review of the SBAR Form revealed the physician gave an order for [REDACTED]. Interviews on 03/28/16 with CNA #1 at 10:57 AM and CNA #4 at 3:57 PM revealed Resident #1 was in pain and moaned when the staff sat him/her up for the evening meal on 03/20/16. The CNAs stated they notified Licensed Practical Nurse (LPN) #3 of the resident's pain. Interviews on 03/28/16 with CNA #6 at 4:08 PM and CNA #7 at 10:44 PM, revealed Resident #1 appeared to be in pain (attempted to push staff's hands away when staff touched his/her left hip, and moaned when moved) when the staff turned, repositioned, and provided incontinence care on the evening of 03/20/16. The CNAs reported to LPN #3 that the resident was in pain. Further interview with CNA #6 and CNA #7 revealed Resident #1 continued to be in pain throughout the night when he/she was turned, repositioned, and changed. Interviews on 03/28/16 with CNA #3 at 3:43 PM and CNA #5 at 4:04 PM, and on 03/29/16 with CNA #8 at 9:42 PM, CNA #9 at 9:45 AM, and CNA #10 at 10:03 AM revealed the CNAs had provided care for Resident #1 from the evening of 03/20/16 through 03/22/16. The CNAs stated Resident #1 continued to be in pain with turning, repositioning, and incontinence care and would moan and attempt to swat at and push staff away when they attempted to provide care for him/her. The staff stated they reported the resident's pain to the licensed nursing staff. Interview on 03/29/16 at 10:10 AM with LPN #3 revealed the CNAs caring for Resident #1 on 03/20/16 did report the resident was in pain with turning, repositioning, and when he/she was changed. The LPN stated she assessed the resident at approximately 4:00 AM and the resident had tenderness to the left hip/leg area. LPN #3 stated she completed an SBAR Communication Form related to the resident's pain and passed the Form on to the day shift nurse to follow up. She stated she should have immediately contacted the resident's physician about the resident's pain. However, LPN #3 stated the resident was not in severe pain and it was almost time for her to start her medication pass. Interview with LPN #1 on 03/28/16 at 1:19 PM, and on 03/30/16 at 11:10 AM revealed she provided care for Resident #1 on 03/21/16 but was not aware the resident was having hip pain. The LPN stated she asked the resident if he/she had pain, but she did not assess the resident for pain or contact the resident's physician. Further interview with LPN #1 revealed she was the nurse assigned to care for Resident #1 on 03/22/16. LPN #1 stated she had observed the resident's hip x-ray results lying at the nurses' station around mid-morning. She stated the report revealed the resident's left hip was fractured; however, she stated the seriousness of the injury did not click until later in the day. LPN #1 stated at around lunchtime the CNAs reported to her that Resident #1's left knee was swollen and bruised. She stated that she and LPN #4 went to assess the resident and found the resident had [MEDICAL CONDITION] and bruising to the left knee. LPN #1 stated that LPN #4 contacted the physician about Resident #1's knee and she assumed LPN #4 would notify the physician of the [MEDICAL CONDITION] also. However, according to LPN #1, she (LPN #1) was responsible for Resident #1's care on 03/22/16. Interview with LPN #2 on 03/29/16 at 2:39 PM revealed LPN #3 had passed on to her Resident #1's SBAR Form with the complaints of left hip/leg tenderness. LPN #2 stated she assessed the resident and did not find the resident to appear to be in pain. Continued interview with LPN #2 revealed the LPN denied she had attempted to turn and reposition the resident to assess for the resident's pain. She stated the resident frequently had back pain and she felt like the pain was typical for the resident. LPN #2 stated she did not feel like the issue with Resident #1 was an emergency and she did not feel it was necessary to contact the doctor immediately because staff often waited until the end of the shift to contact the physician for all non-emergent issues. Further interview revealed LPN #2 contacted Resident #1's physician on 03/21/16 at approximately 6:00 PM and the resident's physician ordered a hip x-ray. Interview on 03/30/16 at 8:15 AM with the mobile x-ray company Dispatch Coordinator revealed Resident #1's hip x-ray was obtained on 03/21/16 at 10:25 PM. The results were read by the radiologist and faxed to the facility at 11:15 PM that night. Interview on 03/29/16 at 11:29 PM with LPN #5 revealed he provided care for Resident #1 on the evening/night of 03/21/16. LPN #5 stated he asked the resident if he/she was in any pain and the resident denied being in pain (shook head no). The interview further revealed he was aware the resident had an order for [REDACTED].#5 stated that he did not check the facsimile (fax) machine for the results of Resident #1's x-ray, nor did he contact the mobile x-ray company to obtain the results of the x-ray. Interview on 03/30/16 at 10:42 AM with LPN #4 revealed she provided care to Resident #1 on the afternoon of 03/22/16. LPN #4 stated she and LPN #1 assessed Resident #1 for the bruising and [MEDICAL CONDITION] to the left knee that was reported by the CNAs around lunchtime. The interview further revealed the LPN notified the resident's physician of the bruising and [MEDICAL CONDITION] to the resident's knee and obtained an order for [REDACTED].#4 revealed the LPN notified the physician on 03/22/16 at around 6:00 PM of the results of the hip and knee x-rays and received an order to transfer the resident to the emergency room for treatment and evaluation of the [MEDICAL CONDITION]. Interview on 04/12/16 at 11:53 AM with Resident #1's physician revealed the physician would have expected to be notified immediately of an abnormal x-ray result. Interviews on 03/30/16 with the Director of Nursing at 1:16 PM and the Administrator at 1:36 PM revealed Resident #1's pain should have been thoroughly assessed by licensed nursing staff and the resident's physician should have been notified immediately of the resident's pain and the [MEDICAL CONDITION]. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/07/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The facility Director of Nursing (DON) reported the allegation of the Injury of unknown origin on Resident #1 to the Office of Inspector General on 03/22/16. The facility DON initiated the initial investigation on 03/22/16 to include: a) Staff assessed Resident #1 for injury on 03/20/16 after complaints of pain were reported to the Charge Nurse by the Certified Nurse Aide (CNA) caring for the resident. The Charge Nurse assessed the resident and found the resident had tenderness to palpation of the left hip with no outward signs of such as swelling, bruising, or deformity. The staff notified Resident #1's Physician on 03/21/16, and orders were received to obtain an x- ray of the left hip. Resident #1's left hip x-ray results were noted to be positive for an acute complete slightly displaced left intertrochanteric fracture and the resident was sent to the emergency roiagnom on [DATE]. Resident #1's family was notified by the Charge Nurse on 03/21/16 and again on 03/22/16. Facility staff notified the DON and the Administrator on 03/22/16. Resident #1 was assessed by the Charge Nurse on 03/22/16 for any signs and symptoms of abuse and none were noted. 2) Resident #1's Attending Physician was notified on 03/22/16 by the Charge Nurse and orders were given for an in-house x-ray for the left knee. The x-ray results were obtained on 03/22/16 showing Resident #1's bones were osteogenic with mild [MEDICAL CONDITION] changes. 3) All residents were assessed for any signs and symptoms of abuse/neglect on 03/22/16 by the DON, Staff Development Coordinator (SDC), and the Unit Manager to ensure the current residents felt safe, that they were being treated well and felt that staff was caring for them appropriately, by questions that included: 1.) Has anyone been rough with you when providing care? 2.) Has anyone yelled at you? 3.) Do you have any concerns? No concerns were noted. 4) On 03/23/16, the Signature Care Consultant (SCC) conducted an education with the Nursing Administration Team to include but not limited to the DON, Unit Manager, SDC, and MDS Coordinator; and the Restorative Nurse Manager on the abuse policy. Six Nursing Administration staff was educated. The SCC performed the training face to face in order to facilitate discussion and questions and to include examples of abuse. A post-test on abuse was administered and 100% score obtained, if managers did not score 100% on post-test, the manager was immediately re-educated and the post-test was re-administered. The SCC continued the process until all managers obtained 100% score on the post-tests. All post-tests were reviewed for compliance by the SCC. The facility does not use agency staffing. The Administrator and DON were responsible for ensuring staff members were educated prior to returning to work. 5) Once the Nursing Administration Team received their education and completed post-test on abuse, they were reassigned to educate the staff on abuse on 03/22/16. The Nursing Administrative Team performed the training with facility staff face to face in order to facilitate discussion and questions and to include examples. The facility will continue the training until all nursing staff and therapy staff is educated. The staff that had not worked as of 03/26/16 will receive education prior to returning to work on abuse. 95 % of the staff had received the training as of 04/01/16. Facility nursing staff on Family Medical Leave of Absence (FMLA), Medical Leave or vacation will be educated prior to returning to work. Staff members will not return to work until education has been provided, post-test completed with a score of 100%. If the staff member did not achieve a score of a 100% on the post-test, the staff member will be re-educated on the policy and given the post-¿test again. The process will continue until the staff member achieves 100% score on the post-test. 6) Residents with a Brief Interview for Mental Status (BIMS) score of greater than 8 were interviewed by the DON, Unit Manager or Social Services Director, for any abuse/neglect concerns to ensure that current residents felt safe; that they were being treated well; and felt the staff was caring for them appropriately, which started on 03/22/16 and was completed on 03/23/16. There were no concerns voiced. 7) Residents with a BIMS score less than 8 were physically assessed by the DON, Unit Managers, or MDS Nurses for any signs and symptoms of abuse/neglect on 03/22/16 and 03/23/16. Staff completed skin assessments for these residents and no concerns were identified. 8) The Administrator and/or Signature Care Consultant (SCC) reviewed the resident assessments for abuse that included the questionnaires for residents with BIMS scores of 8 or greater and skin assessments for residents with a BIMS score less than 8 on 03/23/16. No concerns were identified. 9) On 03/23/16, the Director of Nursing (DON) reviewed x-rays for the month. The physician was notified of abnormal x-rays of other residents for the month of March. A total of 7 x-rays (including two for Resident #1) were performed in March 2016. Six (6) x-rays were abnormal and 1 x-ray was normal. With review of the audit, concern was identified that physician notification of abnormal x-rays was not always done timely. One abnormal chest x-ray notification to physician varied from two (2) minutes to five (5) hours. The facility initiated education with the licensed nurses regarding physician notification and change of condition. See #13, #15, and #16. 10) Nursing staff completed pain assessments on current residents every shift from 03/23/16 through 03/26/16 and any issues were addressed. The staff identified no concerns with residents not receiving pain medication as requested. The SCC and Director of Clinical Programs reviewed these assessments and validated that the assessments were complete and no concerns identified as it related to assessment, pain management or physician notification. 11) Beginning on 03/23/16 the Interdisciplinary Team (IDT) reviewed in the morning clinical meeting telephone orders, SBARs, 24 Hour Report and medical records of residents to ensure timely notification to physician occurred and any changes in resident pain was addressed timely and x-rays were completed, results obtained timely, reported to physician timely and care plans were updated. The SCC or Director of Clinical Programs has been attending this meeting since 04/01/16 and assisting with medical record review, care plan review, providing oversight and consultation. 12) Daily, beginning 04/01/16, until immediacy is lifted, a stand down meeting will occur in the afternoon around 3:00 PM where the DON, Unit Manager, Restorative Nurse Manager and or MDS Coordinator will report on the status of residents for the day and follow up for MD notification, documentation in the medical record, SBARs, Stop and Watch, pain and or x ray reports and updating of care plans was occurring. The SCC or Director of Clinical Programs will attend this meeting to provide oversight and consultation of physician notification, updating care plans, pain assessments and documentation. 13) Beginning on 03/23/16, licensed nurses were educated regarding physician notification and changes in residents' condition by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work by the facility. The facility will not allow staff members to return to work until education has been provided. The education included notifying the physician of all changes in residents' condition as it occurs throughout the shift. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 14) Beginning on 03/23/16, licensed nurses were educated on pain management and assessing residents for pain by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16, will receive education prior to returning to work by the facility. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included performing pain assessments. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 15) Beginning on 03/23/16, licensed nurses were educated on documentation by the DON, SDC, Unit Manager, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included documenting notification to the physician and change in conditions. The initial education was initiated on 03/23/16 and the post-test was not administered until re-education was initiated on 03/30/16. 16) Beginning on 03/30/16 licensed nurses were educated by the DON, SDC, Unit Manager, MDS Coordinator and/or the Restorative Nurse Manager on assessing for pain, the facility's pain policy, 24 hour report, pain management, lab policy and lab tracking log, and documentation in the medical record and updating care plans. The education the facility staff was provided included pain assessments, pain policy, assessing for pain, assessing for new, worsening and different pain, assessing for pain includes range of motion (ROM) if that is where the pain is originating from, use of the Wong Baker pain form, 24 hour report policy, updating care plans, notification to the physician for any change in condition, completing SBAR for change in resident condition and nurse assessing after Stop and Watch, is received, follow up documentation for change in condition, and lab tracking form to be completed and checked daily. The Stop and Watch is an extra tool (along with verbally reporting) to remind staff to tell the charge nurse if there is a change in a resident. The staff was trained that a life threatening event/change of condition, will be immediately reported verbally to a licensed nurse and other change of conditions will be reported by Stop and Watch and verbally. The staff was trained when a staff member recognizes a change of condition in a resident that is not a life threatening event, they obtain a Stop and Watch form (located throughout the facility) fill out the Stop and Watch form by either checking one of the boxes or writing in the change of condition. Then the staff member gives the form to a licensed nurse along with verbally telling them of the Stop and Watch. The licensed nurse then assesses/evaluates the resident, completes an SBAR/Nurse's Note if there is a change of condition, and notifies the physician immediately. 17) Beginning on 03/30/16 current staff (all departments) was educated by the DON, SDC, Unit Manager, MDS Coordinator, and/or the Restorative Nurse Manager, completing a Stop and Watch form for a change in the resident's condition. When a staff member fills out a Stop and Watch form and feels that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. The current staff (all departments) has been trained by the DON and or SDC on the Stop and Watch process. The DON and Administrator are accessible 24 hours a day, their phone numbers are posted throughout the facility in each department. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note if there is a change of condition and notify the physician immediately. Beginning 04/01/16, a member of the Nursing Administration Team to include but not limited have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting, Stop and Watch forms are addressed with the nurse and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. Beginning the evening of 04/06/16, Department Heads including but not limited to Dietary Director, Housekeeping/Laundry Supervisor, Quality of Life Director (QOL); and the Nursing Administration Team to include but not limited to the DON, Unit Manager, Staff Development Coordinator (SDC), MDS Coordinator and the Restorative Nurse Manager will round at the end of each shift and ensure with staff that if a Stop and Watch has been completed or if any verbal reports of change of condition have been reported to the licensed nurse that the change in condition has been addressed, until immediacy has been lifted. Once the Department Managers have talked with their staff, if a Stop and Watch or verbal communication was given to a licensed nurse, the Department Managers will then go to a member of the Nursing Administration Team (to include but not limited to the DON, Unit Managers, Staff Development Coordinator (SDC), and MDS Coordinators and the Restorative Nurse Manager) and communicate verbally that there was a Stop and Watch completed or a verbal report of a change of condition on a resident, until immediacy is lifted. A carbon copy of the Stop and Watch will be given to the DON when completed. The DON or member of the Nursing Administration Team will review the carbon copies of the Stop and Watch and verify with the charge nurses they have been addressed every shift until immediacy has been lifted. The Nursing Administration team member will then go to the charge nurse assigned to the resident that had a Stop and Watch completed or verbal report given regarding a change of condition and verify that the change of condition has been addressed by the charge nurse by an assessment/evaluation, having a SBAR or nurse's note completed, physician notification, orders followed and care plans updated. The Department Managers that included the Dietary Director, Quality of Life Director, Housekeeping/ Laundry Supervisor, DON and the Administrator were educated on this process on 04/06/16 by the Director of Clinical Programs. The results will be discussed in the Quality Assurance and Performance Improvement (QAPI) meeting. At that time based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 18) Facility education included physician notification immediately for change of condition of a resident. When facility staff was provided re-education, a post-test was administered to the licensed nursing staff on pain, change of condition, physician notification, charting and documentation and lab tracking. 99% of full and part time staff have completed the education. One employee was on vacation and was mailed a certified letter regarding education needing to be completed before returning to work. 63% of prn staff members have received the training and the remaining have been mailed a certified letter regarding education needing to be completed before returning to work. 19) Beginning on 03/29/16 education was initiated for current staff (all departments) on the Stop and Watch process which includes completing a Stop and Watch form with a change in condition and giving the form to the charge nurse. Any staff member can complete a Stop and Watch and give to the charge nurse. If a staff member fills out a Stop and Watch and finds that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note, if there is a change in condition and notify the physician within an hour. Beginning 04/01/16, a member of the Nursing Administration Team have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. 20) The facility will continue education until current staff is educated on the process. Staff not educated by 04/01/16 will be educated before they return to work. Staff on FMLA, Medical Leave or vacation will be educated prior to returning to work and staff members will not return to work until education has been provided. 21) A nurse from the regional team or corporate office has been available since 03/22/16 and onsite since 03/30/16. The nurse(s) from the regional team or home office are assisting with pain assessments, performing chart audits, and providing oversight and consultation. 22) On 03/31/16, current residents' charts were audited by the Nursing Administration Team, for the past thirty (30) days reviewing pain, change in condition and physician notification. The chart audits looked for the following; incomplete documentation, physician notification not being done and care plans updated. No concerns were identified with physician notification. Twelve (12) care plans were updated. One care plan was updated for an ADL improvement. Two (2) care plans were updated for impaired skin integrity, redness under breast and a rash. One care plan was updated for abnormal labs, positive [MEDICAL CONDITION]. One care plan was updated for [MEDICAL CONDITION] in leg and transfer to hospital. Two (2) care plans were updated for initiating of antibiotics. One care plan was updated for anticoagulant therapy changes. One care plan was updated for insulin changes. One care plan was updated for blood pressure medication changes. One care plan was updated for skin integrity, self-inflicted scratches. One care plan was updated for cataract surgery. 23) On 03/23/16 the SCC; and again on 04/01/16 the SCC and Director of Clinical Programs audited care plans of current residents with fractures to ensure they were updated and current. On 03/23/16, the care plan of Resident # 1 was not updated, the resident was in the hospital and the facility was awaiting his/her return to update the care plan. On 04/01/16, the SCC and/or Director of Clinical Programs reviewed current residents with fractures, care plans for pain, and change in condition. No issues were identified. 24) Beginning daily on 03/31/16, a member of the Nursing Administration will conduct visits on five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. Any issues identified will be addressed with an SBAR being completed and physician notification. Results of audits will be discussed in the QAPI meeting. 25) Beginning daily on 04/01/16, ten (10) residents' charts will be audited by the Nursing Administration Team for physician notification being completed, change in condition (including updating care plans) being addressed by completion of SBAR, care plans being updated and documentation being present, until immediacy is lifted. Then five (5) charts per day five (5) days a week will be checked for two (2) weeks; and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery; results of audits will be discussed in the QAPI meeting. 26) On 04/01/16, current residents' care plans were audited by SCC, Director of Clinical Programs, Clinical Reimbursement Coordinator, and the MDS Coordinator to ensure current residents' care plans with pain were updated and accurate, and residents with fractures care plans were updated and accurate. There were three (3) residents in the facility with fractures; Resident #1's care plan has been updated for his/her fracture and pain on 03/28/16 upon his/her return from the hospital. The other two (2) care plans were current. 27) Administrative oversight of the facility will be completed by the VP of Operations, Signature Care Consultant (SCC), and the Director of Clinical Programs daily until removal of immediacy beginning 03/23/16, then weekly for four (4) weeks, then monthly to ensure the above audits were completed and any concerns were

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure the plan of care was revised after a change in condition was identified for one (1) of three (3) sampled residents (Resident #1). On 03/20/16, Certified Nurse Aides (CNAs) reported to licensed nursing staff that Resident #1 was in pain when staff turned, repositioned, and provided incontinence care for him/her. The resident's physician was not notified of the resident's pain until 03/21/16 at 5:45 PM, approximately twenty-four (24) hours after the initial report of pain. an order for [REDACTED]. Even though licensed nursing staff was aware the hip x-ray showed the resident had a [MEDICAL CONDITION] hip, Resident #1's physician was not notified of the [MEDICAL CONDITION] until 03/22/16 at 6:00 PM (approximately nineteen hours after the x-ray results were faxed to the facility). However, review of the plan of care revealed Resident #1's plan of care was not updated to include interventions to address the pain. As a result, the resident continued to have pain that was untreated. The facility's failure to ensure each resident's plan of care was updated was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/20/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514). The facility was notified of the Immediate Jeopardy on 03/30/16. An acceptable Allegation of Compliance was received on 04/07/16 which alleged removal of the Immediate Jeopardy on 04/07/16. A partial extended survey was conducted on 04/11-12/16. The State Survey Agency determined the Immediate Jeopardy was removed on 04/07/16 as alleged, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Care Plans - Comprehensive, review date of 06/01/15, revealed the resident's care plan was revised as information about the resident and the resident's condition changed. The policy stated the nurse and the Interdisciplinary Team (IDT) were responsible for the review and updating of care plans. Review of Resident #1's medical record revealed the facility admitted the resident on 03/12/12 with [DIAGNOSES REDACTED]. Review of the resident's most recent Quarterly Minimum Data Set (MDS) assessment, dated 02/12/16, revealed the resident was cognitively impaired and required extensive assistance from staff for all activities of daily living. Review of Resident #1's plan of care dated 07/10/15 revealed the following interventions to address the resident's pain: administer Tylenol (a non-narcotic pain medication), position for comfort, and administer [MEDICATION NAME] (a narcotic pain medication) as ordered. Review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form, dated 03/20/16 and not timed, revealed the resident was assessed to have tenderness to the left hip/leg. However, further review of the Form revealed the resident's physician was not notified until 03/21/16 at 5:45 PM. At that time, an order for [REDACTED]. Review of Resident #1's SBAR Communication Form, dated 03/22/16 at 6:00 PM (approximately 19 hours after the x-ray results were faxed to the facility and 2 days after the resident started experiencing pain), revealed the physician was notified of the results of the hip x-ray which showed a [MEDICAL CONDITION] hip and the results of the knee x-ray showed arthritis. Continued review of the SBAR Form revealed the physician gave an order for [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Interviews on 03/28/16 with CNA #1 at 10:57 AM and CNA #4 at 3:57 PM revealed Resident #1 was in pain and moaned when staff positioned the resident up for the evening meal on 03/20/16. The interview further revealed the CNAs stated they reported that the resident was in pain to Licensed Practical Nurse (LPN) #3. Interviews on 03/28/16 with CNA #6 at 4:08 PM and CNA #7 at 10:44 PM revealed Resident #1 was in pain as the resident moaned when moved and placed his/her hand on the left hip and pushed the CNAs away when staff turned, repositioned, and changed him/her on the evening and throughout the night on 03/20/16. The interviews further revealed the CNAs stated they reported that the resident was in pain to LPN #3 because the resident did not typically show signs or symptoms that he/she was in pain. Interview on 03/29/16 at 10:10 AM, with LPN #3 revealed the CNAs reported to her on 03/20/16 that Resident #1 was in pain when the staff positioned the resident up for the evening meal and with turning, repositioning, and incontinence care. LPN #3 stated that she assessed Resident #1 and found the resident had left hip/leg tenderness. However, LPN #3 did not administer an as needed pain medication to the resident, notify the resident's physician, or update the resident's care plan to include the hip pain/tenderness. LPN #3 stated Resident #1's plan of care should have been updated with the hip/leg tenderness (a new pain for the resident) and the physician should have been notified of the pain and possibly a new intervention would have been provided. Interview on 03/28/16 at 2:39 PM with LPN #2 revealed she received the SBAR Communication Form related to Resident #1's hip/leg tenderness on the morning of 03/21/16 from the night shift nurse. She stated Resident #1 had a history of [REDACTED]. Interview on 03/30/16 at 11:10 AM with LPN #1 revealed she was assigned to provide care to Resident #1 on 03/22/16 and should have updated Resident #1's plan of care when she became aware of the resident's hip pain and the resident's [MEDICAL CONDITION] on 03/22/16. The interview revealed LPN #1 denied Resident #1 had hip pain previously. LPN #1 stated the nursing staff was responsible for updating the resident's plan of care with new orders and all changes in the resident's condition. Interviews on 03/30/16 with the Director of Nursing (DON) at 1:16 PM and the Administrator at 1:36 PM revealed Resident #1's plan of care should have been updated with the hip pain/tenderness and with the [MEDICAL CONDITION] and new interventions implemented. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/07/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The facility Director of Nursing (DON) reported the allegation of the Injury of unknown origin on Resident #1 to the Office of Inspector General on 03/22/16. The facility DON initiated the initial investigation on 03/22/16 to include: a) Staff assessed Resident #1 for injury on 03/20/16 after complaints of pain were reported to the Charge Nurse by the Certified Nurse Aide (CNA) caring for the resident. The Charge Nurse assessed the resident and found the resident had tenderness to palpation of the left hip with no outward signs of such as swelling, bruising, or deformity. The staff notified Resident #1's Physician on 03/21/16, and orders were received to obtain an x- ray of the left hip. Resident #1's left hip x-ray results were noted to be positive for an acute complete slightly displaced left intertrochanteric fracture and the resident was sent to the emergency roiagnom on [DATE]. Resident #1's family was notified by the Charge Nurse on 03/21/16 and again on 03/22/16. Facility staff notified the DON and the Administrator on 03/22/16. Resident #1 was assessed by the Charge Nurse on 03/22/16 for any signs and symptoms of abuse and none were noted. 2) Resident #1's Attending Physician was notified on 03/22/16 by the Charge Nurse and orders were given for an in-house x-ray for the left knee. The x-ray results were obtained on 03/22/16 showing Resident #1's bones were osteogenic with mild [MEDICAL CONDITION] changes. 3) All residents were assessed for any signs and symptoms of abuse/neglect on 03/22/16 by the DON, Staff Development Coordinator (SDC), and the Unit Manager to ensure the current residents felt safe, that they were being treated well and felt that staff was caring for them appropriately, by questions that included: 1.) Has anyone been rough with you when providing care? 2.) Has anyone yelled at you? 3.) Do you have any concerns? No concerns were noted. 4) On 03/23/16, the Signature Care Consultant (SCC) conducted an education with the Nursing Administration Team to include but not limited to the DON, Unit Manager, SDC, and MDS Coordinator; and the Restorative Nurse Manager on the abuse policy. Six Nursing Administration staff was educated. The SCC performed the training face to face in order to facilitate discussion and questions and to include examples of abuse. A post-test on abuse was administered and 100% score obtained, if managers did not score 100% on post-test, the manager was immediately re-educated and the post-test was re-administered. The SCC continued the process until all managers obtained 100% score on the post-tests. All post-tests were reviewed for compliance by the SCC. The facility does not use agency staffing. The Administrator and DON were responsible for ensuring staff members were educated prior to returning to work. 5) Once the Nursing Administration Team received their education and completed post-test on abuse, they were reassigned to educate the staff on abuse on 03/22/16. The Nursing Administrative Team performed the training with facility staff face to face in order to facilitate discussion and questions and to include examples. The facility will continue the training until all nursing staff and therapy staff is educated. The staff that had not worked as of 03/26/16 will receive education prior to returning to work on abuse. 95 % of the staff had received the training as of 04/01/16. Facility nursing staff on Family Medical Leave of Absence (FMLA), Medical Leave or vacation will be educated prior to returning to work. Staff members will not return to work until education has been provided, post-test completed with a score of 100%. If the staff member did not achieve a score of a 100% on the post-test, the staff member will be re-educated on the policy and given the post-¿test again. The process will continue until the staff member achieves 100% score on the post-test. 6) Residents with a Brief Interview for Mental Status (BIMS) score of greater than 8 were interviewed by the DON, Unit Manager or Social Services Director, for any abuse/neglect concerns to ensure that current residents felt safe; that they were being treated well; and felt the staff was caring for them appropriately, which started on 03/22/16 and was completed on 03/23/16. There were no concerns voiced. 7) Residents with a BIMS score less than 8 were physically assessed by the DON, Unit Managers, or MDS Nurses for any signs and symptoms of abuse/neglect on 03/22/16 and 03/23/16. Staff completed skin assessments for these residents and no concerns were identified. 8) The Administrator and/or Signature Care Consultant (SCC) reviewed the resident assessments for abuse that included the questionnaires for residents with BIMS scores of 8 or greater and skin assessments for residents with a BIMS score less than 8 on 03/23/16. No concerns were identified. 9) On 03/23/16, the Director of Nursing (DON) reviewed x-rays for the month. The physician was notified of abnormal x-rays of other residents for the month of March. A total of 7 x-rays (including two for Resident #1) were performed in March 2016. Six (6) x-rays were abnormal and 1 x-ray was normal. With review of the audit, concern was identified that physician notification of abnormal x-rays was not always done timely. One abnormal chest x-ray notification to physician varied from two (2) minutes to five (5) hours. The facility initiated education with the licensed nurses regarding physician notification and change of condition. See #13, #15, and #16. 10) Nursing staff completed pain assessments on current residents every shift from 03/23/16 through 03/26/16 and any issues were addressed. The staff identified no concerns with residents not receiving pain medication as requested. The SCC and Director of Clinical Programs reviewed these assessments and validated that the assessments were complete and no concerns identified as it related to assessment, pain management or physician notification. 11) Beginning on 03/23/16 the Interdisciplinary Team (IDT) reviewed in the morning clinical meeting telephone orders, SBARs, 24 Hour Report and medical records of residents to ensure timely notification to physician occurred and any changes in resident pain was addressed timely and x-rays were completed, results obtained timely, reported to physician timely and care plans were updated. The SCC or Director of Clinical Programs has been attending this meeting since 04/01/16 and assisting with medical record review, care plan review, providing oversight and consultation. 12) Daily, beginning 04/01/16, until immediacy is lifted, a stand down meeting will occur in the afternoon around 3:00 PM where the DON, Unit Manager, Restorative Nurse Manager and or MDS Coordinator will report on the status of residents for the day and follow up for MD notification, documentation in the medical record, SBARs, Stop and Watch, pain and or x ray reports and updating of care plans was occurring. The SCC or Director of Clinical Programs will attend this meeting to provide oversight and consultation of physician notification, updating care plans, pain assessments and documentation. 13) Beginning on 03/23/16, licensed nurses were educated regarding physician notification and changes in residents' condition by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work by the facility. The facility will not allow staff members to return to work until education has been provided. The education included notifying the physician of all changes in residents' condition as it occurs throughout the shift. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 14) Beginning on 03/23/16, licensed nurses were educated on pain management and assessing residents for pain by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16, will receive education prior to returning to work by the facility. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included performing pain assessments. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 15) Beginning on 03/23/16, licensed nurses were educated on documentation by the DON, SDC, Unit Manager, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included documenting notification to the physician and change in conditions. The initial education was initiated on 03/23/16 and the post-test was not administered until re-education was initiated on 03/30/16. 16) Beginning on 03/30/16 licensed nurses were educated by the DON, SDC, Unit Manager, MDS Coordinator and/or the Restorative Nurse Manager on assessing for pain, the facility's pain policy, 24 hour report, pain management, lab policy and lab tracking log, and documentation in the medical record and updating care plans. The education the facility staff was provided included pain assessments, pain policy, assessing for pain, assessing for new, worsening and different pain, assessing for pain includes range of motion (ROM) if that is where the pain is originating from, use of the Wong Baker pain form, 24 hour report policy, updating care plans, notification to the physician for any change in condition, completing SBAR for change in resident condition and nurse assessing after Stop and Watch, is received, follow up documentation for change in condition, and lab tracking form to be completed and checked daily. The Stop and Watch is an extra tool (along with verbally reporting) to remind staff to tell the charge nurse if there is a change in a resident. The staff was trained that a life threatening event/change of condition, will be immediately reported verbally to a licensed nurse and other change of conditions will be reported by Stop and Watch and verbally. The staff was trained when a staff member recognizes a change of condition in a resident that is not a life threatening event, they obtain a Stop and Watch form (located throughout the facility) fill out the Stop and Watch form by either checking one of the boxes or writing in the change of condition. Then the staff member gives the form to a licensed nurse along with verbally telling them of the Stop and Watch. The licensed nurse then assesses/evaluates the resident, completes an SBAR/Nurse's Note if there is a change of condition, and notifies the physician immediately. 17) Beginning on 03/30/16 current staff (all departments) was educated by the DON, SDC, Unit Manager, MDS Coordinator, and/or the Restorative Nurse Manager, completing a Stop and Watch form for a change in the resident's condition. When a staff member fills out a Stop and Watch form and feels that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. The current staff (all departments) has been trained by the DON and or SDC on the Stop and Watch process. The DON and Administrator are accessible 24 hours a day, their phone numbers are posted throughout the facility in each department. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note if there is a change of condition and notify the physician immediately. Beginning 04/01/16, a member of the Nursing Administration Team to include but not limited have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting, Stop and Watch forms are addressed with the nurse and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. Beginning the evening of 04/06/16, Department Heads including but not limited to Dietary Director, Housekeeping/Laundry Supervisor, Quality of Life Director (QOL); and the Nursing Administration Team to include but not limited to the DON, Unit Manager, Staff Development Coordinator (SDC), MDS Coordinator and the Restorative Nurse Manager will round at the end of each shift and ensure with staff that if a Stop and Watch has been completed or if any verbal reports of change of condition have been reported to the licensed nurse that the change in condition has been addressed, until immediacy has been lifted. Once the Department Managers have talked with their staff, if a Stop and Watch or verbal communication was given to a licensed nurse, the Department Managers will then go to a member of the Nursing Administration Team (to include but not limited to the DON, Unit Managers, Staff Development Coordinator (SDC), and MDS Coordinators and the Restorative Nurse Manager) and communicate verbally that there was a Stop and Watch completed or a verbal report of a change of condition on a resident, until immediacy is lifted. A carbon copy of the Stop and Watch will be given to the DON when completed. The DON or member of the Nursing Administration Team will review the carbon copies of the Stop and Watch and verify with the charge nurses they have been addressed every shift until immediacy has been lifted. The Nursing Administration team member will then go to the charge nurse assigned to the resident that had a Stop and Watch completed or verbal report given regarding a change of condition and verify that the change of condition has been addressed by the charge nurse by an assessment/evaluation, having a SBAR or nurse's note completed, physician notification, orders followed and care plans updated. The Department Managers that included the Dietary Director, Quality of Life Director, Housekeeping/ Laundry Supervisor, DON and the Administrator were educated on this process on 04/06/16 by the Director of Clinical Programs. The results will be discussed in the Quality Assurance and Performance Improvement (QAPI) meeting. At that time based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 18) Facility education included physician notification immediately for change of condition of a resident. When facility staff was provided re-education, a post-test was administered to the licensed nursing staff on pain, change of condition, physician notification, charting and documentation and lab tracking. 99% of full and part time staff have completed the education. One employee was on vacation and was mailed a certified letter regarding education needing to be completed before returning to work. 63% of prn staff members have received the training and the remaining have been mailed a certified letter regarding education needing to be completed before returning to work. 19) Beginning on 03/29/16 education was initiated for current staff (all departments) on the Stop and Watch process which includes completing a Stop and Watch form with a change in condition and giving the form to the charge nurse. Any staff member can complete a Stop and Watch and give to the charge nurse. If a staff member fills out a Stop and Watch and finds that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note, if there is a change in condition and notify the physician within an hour. Beginning 04/01/16, a member of the Nursing Administration Team have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. 20) The facility will continue education until current staff is educated on the process. Staff not educated by 04/01/16 will be educated before they return to work. Staff on FMLA, Medical Leave or vacation will be educated prior to returning to work and staff members will not return to work until education has been provided. 21) A nurse from the regional team or corporate office has been available since 03/22/16 and onsite since 03/30/16. The nurse(s) from the regional team or home office are assisting with pain assessments, performing chart audits, and providing oversight and consultation. 22) On 03/31/16, current residents' charts were audited by the Nursing Administration Team, for the past thirty (30) days reviewing pain, change in condition and physician notification. The chart audits looked for the following; incomplete documentation, physician notification not being done and care plans updated. No concerns were identified with physician notification. Twelve (12) care plans were updated. One care plan was updated for an ADL improvement. Two (2) care plans were updated for impaired skin integrity, redness under breast and a rash. One care plan was updated for abnormal labs, positive [MEDICAL CONDITION]. One care plan was updated for [MEDICAL CONDITION] in leg and transfer to hospital. Two (2) care plans were updated for initiating of antibiotics. One care plan was updated for anticoagulant therapy changes. One care plan was updated for insulin changes. One care plan was updated for blood pressure medication changes. One care plan was updated for skin integrity, self-inflicted scratches. One care plan was updated for cataract surgery. 23) On 03/23/16 the SCC; and again on 04/01/16 the SCC and Director of Clinical Programs audited care plans of current residents with fractures to ensure they were updated and current. On 03/23/16, the care plan of Resident # 1 was not updated, the resident was in the hospital and the facility was awaiting his/her return to update the care plan. On 04/01/16, the SCC and/or Director of Clinical Programs reviewed current residents with fractures, care plans for pain, and change in condition. No issues were identified. 24) Beginning daily on 03/31/16, a member of the Nursing Administration will conduct visits on five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. Any issues identified will be addressed with an SBAR being completed and physician notification. Results of audits will be discussed in the QAPI meeting. 25) Beginning daily on 04/01/16, ten (10) residents' charts will be audited by the Nursing Administration Team for physician notification being completed, change in condition (including updating care plans) being addressed by completion of SBAR, care plans being updated and documentation being present, until immediacy is lifted. Then five (5) charts per day five (5) days a week will be checked for two (2) weeks; and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery; results of audits will be discussed in the QAPI meeting. 26) On 04/01/16, current residents' care plans were audited by SCC, Director of Clinical Programs, Clinical Reimbursement Coordinator, and the MDS Coordinator to ensure current residents' care plans with pain were updated and accurate, and residents with fractures care plans were updated and accurate. There were three (3) residents in the facility with fractures; Resident #1's care plan has been updated for his/her fracture and pain on 03/28/16 upon his/her return from the hospital. The other two (2) care plans were current. 27) Administrative oversight of the facility will be completed by the VP of Operations, Signature Care Consultant (SCC), and the Director of Clinical Programs daily until removal of immediacy beginning 03/23/16, then weekly for four (4) weeks, then monthly to ensure the above audits were completed and any concerns were addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the Stop and Watch, SBARs/Nurse's Notes for change in condition and care plans occurs daily by the SCC or Director of Clinical Programs along with attending the morning clinical meeting and daily stand down meeting where the Stop and Watch, SBARs and pain assessments are reviewed. 28) Ongoing pain assessments every shift will be completed by the charge nurses and reviewed daily in the morning clinical meeting until immediacy is lifted, looking for new, worsening or different pain. Any issues will be addressed at time of discovery. Beginning 04/01/16 a member of the Nursing Administration Team have been in the facility 24 hours a day, checking every at minimum every 45 minutes to one hour with the nurses and other staff in the facility on changes in residents conditions, pain monitoring including assessing pain, physician notification, documentation and charting and that care plans are updated. No concerns have been identified. 29) A QA meeting was held on 03/30/16 with the Medical Director (by phone), Administrator, DON, Unit Manager, Restorative Nurse Manager, SCC, MDS Coordinator and Social Services Director reviewing the occurrence of Resident # 1's fracture and the steps that have been put in place. 30) A QAPI meeting will be held weekly until immediacy is removed beginning on 03/30/16, then for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. At that time based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QAPI meeting will be completed by the SCC, Director of Clinical Programs, the Regional Vice President of Operations, or member or regional staff weekly and daily by telephone until removal of immediacy beginning 03/30/16, then every other week for four (4) weeks, then monthly. Audits to be reviewed but not limited to morning clinical meeting, pain, change in condition, x-rays and SBARs. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the facility's investigation revealed the Director of Nursing (DON) reported the allegation related to an injury of unknown origin for Resident #1 to the state agencies on 03/22/16 and initiated an investigation to include the following: a) Review of the SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated 03/20/16, revealed Resident # 1 was assessed to have left hip/leg tenderness. Further review of the SBAR Form revealed Resident #1's Physician was notified of the hip/leg tenderness on 03/21/16 at 5:45 PM; and an order was obtained for a hip x-ray. Review of the SBAR Communication Form further revealed Resident #1's family was notified of the hip/leg tenderness on 03/21/16. Review of the results of the left hip x-ray, dated read by the Radiologist and faxed on 03/21/16 at 11:15 PM, revealed the x-ray was positive for an acute complete slightly displaced left intertrochanteric fracture. Review of the SBAR Communication Form, dated 03/22/16 at 6:00 PM, revealed Resident #1's Physician was notified of the [MEDICAL CONDITION] and an order was obtained to send the resident to the emergency room for evaluation and treatment. Further review of the SBAR Communication Form revealed Resident #1's family was notified of the [MEDICAL CONDITION] on 03/22/16. Review of the facility's investigation revealed the DON was notified of the fracture by the Charge Nurse on 03/22/16. Furth

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) sampled residents (Resident #1) related to pain. On 03/20/16, Certified Nurse Aides (CNAs) that were caring for Resident #1 reported to licensed nursing staff that the resident was in pain when they assisted him/her for the evening meal and with turning, repositioning, and changing. Resident #1 was assessed by licensed nursing staff to have tenderness to the left hip/leg. However, the resident's physician was not notified of the resident's pain until 03/21/16 at 5:45 PM, approximately twenty-four (24) hours after initial report of pain. an order for [REDACTED]. Even though licensed nursing staff was aware the hip x-ray showed the resident had a [MEDICAL CONDITION] hip, Resident #1's physician was not notified of the [MEDICAL CONDITION] until 03/22/16 at 6:00 PM (approximately nineteen hours after the x-ray results were faxed to the facility). As a result, the resident continued to have pain that was untreated. The facility's failure to ensure each resident was monitored/assessed and provided necessary care and services was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/20/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514). The facility was notified of the Immediate Jeopardy on 03/30/16. An acceptable Allegation of Compliance was received on 04/07/16 which alleged removal of the Immediate Jeopardy on 04/07/16. A partial extended survey was conducted on 04/11-12/16. The State Survey Agency determined the Immediate Jeopardy was removed on 04/07/16 as alleged, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Change in Condition, not dated, revealed the facility staff should assess any change in condition through direct observation and physical examination. Further review of the policy revealed if the change in condition does not appear to be life threatening, the SBAR Communication Form should be utilized and the physician should be contacted. Review of the facility's policy titled Pain Management, not dated, revealed if the resident had pain the resident's pain should be assessed, an SBAR (Situation, Background, Assessment, and Recommendation) Communication Form should be utilized, and the resident's physician should be notified. Review of Resident #1's medical record revealed the facility admitted the resident on 03/12/12, with [DIAGNOSES REDACTED]. Review of the resident's most recent Quarterly Minimum Data Set (MDS) assessment, dated 02/12/16, revealed the resident was cognitively impaired and required extensive assistance with all activities of daily living (ADLs). Review of Resident #1's plan of care, dated 07/10/15, revealed the resident experiences pain. Further review of the plan of care revealed the resident had the following interventions for pain: administer Tylenol (a non-narcotic pain medication) as ordered, position for comfort, and administer [MEDICATION NAME] (a narcotic pain medication) as ordered. Review of Resident #1's physician's orders [REDACTED].) hours as needed for pain. Review of Resident #1's Medication Administration Record [REDACTED]as needed basis during the month of March. Further review of the MAR indicated [REDACTED]. Review of Resident #1's SBAR Communication Form, dated 03/20/16 and not timed, revealed the resident was assessed to have tenderness to the left hip/leg. However, further review of the form revealed the resident's physician was not notified until 03/21/16 at 5:45 PM and an order for [REDACTED]. Review of Resident #1's hip x-ray results, dated 03/21/16, revealed an acute complete slightly displaced left intratrochanteric fracture ([MEDICAL CONDITION]). Review of Resident #1's SBAR Communication Form, dated 03/22/16 at 6:00 PM, revealed the physician was notified of the results of the hip x-ray which showed a [MEDICAL CONDITION] hip and the results of the knee x-ray which showed arthritis. Continued review of the SBAR Form revealed the physician gave an order for [REDACTED]. Interviews on 03/28/16 with CNA #1 at 10:57 AM and CNA #4 at 3:57 PM revealed on 03/20/16 the CNAs positioned Resident #1 up for the evening meal and the resident was in pain (moaned when the staff positioned him/her up). The interviews further revealed the CNAs reported that the resident was in pain to Licensed Practical Nurse (LPN) #3. Interviews on 03/28/16 with CNA #6 at 4:08 PM and CNA #7 at 10:44 PM revealed on the evening of 03/20/16 Resident #1 was in pain. The resident attempted to push the staff's hands away, and moaned when moved and when staff touched his/her left hip. The CNAs stated they reported to LPN #3 that the resident was in pain. Interviews on 03/28/16 with CNA #3 at 3:43 PM and CNA #5 at 4:04 PM, and on 03/29/16 with CNA #8 at 9:42 AM, CNA #9 at 9:45 AM, and CNA #10 at 10:03 AM revealed the CNAs had provided care for Resident #1 from the evening of 03/20/16 through 03/22/16. The CNAs stated Resident #1 continued to be in pain (attempted to push the staff's hands away, moaned when moved and when staff touched his/her left hip) with turning, repositioning, and incontinence care and would attempt to swat at and push staff away when staff attempted to turn, change, and reposition the resident. The staff stated they reported the resident's pain to the licensed nursing staff (LPN #1, LPN #2, and LPN #5). Interview on 03/29/16 at 10:10 AM with LPN #3 revealed on the evening of 03/20/16, the CNAs providing care for Resident #1 did report the resident was in pain when they assisted the resident to sit up for dinner and when the resident was turned, repositioned, and changed. The interview further revealed she assessed Resident #1 at approximately 4:00 AM and assessed the resident to have tenderness in the left hip/leg area. LPN #3 completed a SBAR Communication Form related to the resident's hip/leg tenderness. LPN #3 stated she did not notify the doctor of the resident's hip/leg tenderness and passed the SBAR Form on to the day shift nurse. Interview with LPN #1 at 03/28/16 at 1:19 PM and on 03/30/16 at 11:10 AM revealed she provided care for Resident #1 on 03/21/16 but was not aware the resident was having hip pain. The LPN stated she asked the resident if he/she had pain, but she did not assess the resident for pain or contact the resident's physician. Further interview with LPN #1 revealed she was assigned to care for Resident #1 on 03/22/16 and had observed the resident's hip x-ray results around mid-morning, which revealed the resident's left hip was fractured. However, the LPN stated she did not notify the physician of the results of the x-ray because it didn't click that the resident's hip was fractured. Continued interview revealed the CNAs caring for Resident #1 reported around lunchtime that the resident had bruising and [MEDICAL CONDITION] to the left knee and the area was assessed and the resident was noted to grimace with movement of the left leg. LPN #1 stated another nurse notified the physician of the issue with the resident's knee and an order was obtained for an x-ray of the knee. Interview on 03/28/16 at 2:39 PM with LPN #2 revealed she received the SBAR Communication Form related to Resident #1's hip/leg tenderness on the morning of 03/21/16 from the night shift nurse. The interview further revealed Resident #1 had a history of [REDACTED]. Further interview revealed she contacted the resident's physician close to the end of her shift at around 6:00 PM related to the resident's hip/leg tenderness and an order was obtained for a hip x-ray. Interview on 03/30/16 at 8:15 AM with the mobile x-ray company Dispatch Coordinator revealed Resident #1's hip x-ray was obtained on 03/21/16 at 10:25 PM and was read by the radiologist and the results were faxed to the facility at 11:15 PM. Interview on 03/29/16 at 11:29 PM with LPN #5 revealed he provided care for Resident #1 on the evening/night of 03/21/16 and he asked the resident if he/she was in any pain and the resident denied being in pain (shook head no). The interview further revealed he was aware the resident had an order for [REDACTED]. Interviews on 03/30/16 with the Director of Nursing (DON) at 1:16 PM and the Administrator at 1:36 PM revealed Resident #1's pain should have been thoroughly assessed by licensed nursing staff and the resident's physician should have been notified immediately of the resident's pain and the [MEDICAL CONDITION]. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/07/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The facility Director of Nursing (DON) reported the allegation of the Injury of unknown origin on Resident #1 to the Office of Inspector General on 03/22/16. The facility DON initiated the initial investigation on 03/22/16 to include: a) Staff assessed Resident #1 for injury on 03/20/16 after complaints of pain were reported to the Charge Nurse by the Certified Nurse Aide (CNA) caring for the resident. The Charge Nurse assessed the resident and found the resident had tenderness to palpation of the left hip with no outward signs of such as swelling, bruising, or deformity. The staff notified Resident #1's Physician on 03/21/16, and orders were received to obtain an x- ray of the left hip. Resident #1's left hip x-ray results were noted to be positive for an acute complete slightly displaced left intertrochanteric fracture and the resident was sent to the emergency roiagnom on [DATE]. Resident #1's family was notified by the Charge Nurse on 03/21/16 and again on 03/22/16. Facility staff notified the DON and the Administrator on 03/22/16. Resident #1 was assessed by the Charge Nurse on 03/22/16 for any signs and symptoms of abuse and none were noted. 2) Resident #1's Attending Physician was notified on 03/22/16 by the Charge Nurse and orders were given for an in-house x-ray for the left knee. The x-ray results were obtained on 03/22/16 showing Resident #1's bones were osteogenic with mild [MEDICAL CONDITION] changes. 3) All residents were assessed for any signs and symptoms of abuse/neglect on 03/22/16 by the DON, Staff Development Coordinator (SDC), and the Unit Manager to ensure the current residents felt safe, that they were being treated well and felt that staff was caring for them appropriately, by questions that included: 1.) Has anyone been rough with you when providing care? 2.) Has anyone yelled at you? 3.) Do you have any concerns? No concerns were noted. 4) On 03/23/16, the Signature Care Consultant (SCC) conducted an education with the Nursing Administration Team to include but not limited to the DON, Unit Manager, SDC, and MDS Coordinator; and the Restorative Nurse Manager on the abuse policy. Six Nursing Administration staff was educated. The SCC performed the training face to face in order to facilitate discussion and questions and to include examples of abuse. A post-test on abuse was administered and 100% score obtained, if managers did not score 100% on post-test, the manager was immediately re-educated and the post-test was re-administered. The SCC continued the process until all managers obtained 100% score on the post-tests. All post-tests were reviewed for compliance by the SCC. The facility does not use agency staffing. The Administrator and DON were responsible for ensuring staff members were educated prior to returning to work. 5) Once the Nursing Administration Team received their education and completed post-test on abuse, they were reassigned to educate the staff on abuse on 03/22/16. The Nursing Administrative Team performed the training with facility staff face to face in order to facilitate discussion and questions and to include examples. The facility will continue the training until all nursing staff and therapy staff is educated. The staff that had not worked as of 03/26/16 will receive education prior to returning to work on abuse. 95 % of the staff had received the training as of 04/01/16. Facility nursing staff on Family Medical Leave of Absence (FMLA), Medical Leave or vacation will be educated prior to returning to work. Staff members will not return to work until education has been provided, post-test completed with a score of 100%. If the staff member did not achieve a score of a 100% on the post-test, the staff member will be re-educated on the policy and given the post-¿test again. The process will continue until the staff member achieves 100% score on the post-test. 6) Residents with a Brief Interview for Mental Status (BIMS) score of greater than 8 were interviewed by the DON, Unit Manager or Social Services Director, for any abuse/neglect concerns to ensure that current residents felt safe; that they were being treated well; and felt the staff was caring for them appropriately, which started on 03/22/16 and was completed on 03/23/16. There were no concerns voiced. 7) Residents with a BIMS score less than 8 were physically assessed by the DON, Unit Managers, or MDS Nurses for any signs and symptoms of abuse/neglect on 03/22/16 and 03/23/16. Staff completed skin assessments for these residents and no concerns were identified. 8) The Administrator and/or Signature Care Consultant (SCC) reviewed the resident assessments for abuse that included the questionnaires for residents with BIMS scores of 8 or greater and skin assessments for residents with a BIMS score less than 8 on 03/23/16. No concerns were identified. 9) On 03/23/16, the Director of Nursing (DON) reviewed x-rays for the month. The physician was notified of abnormal x-rays of other residents for the month of March. A total of 7 x-rays (including two for Resident #1) were performed in March 2016. Six (6) x-rays were abnormal and 1 x-ray was normal. With review of the audit, concern was identified that physician notification of abnormal x-rays was not always done timely. One abnormal chest x-ray notification to physician varied from two (2) minutes to five (5) hours. The facility initiated education with the licensed nurses regarding physician notification and change of condition. See #13, #15, and #16. 10) Nursing staff completed pain assessments on current residents every shift from 03/23/16 through 03/26/16 and any issues were addressed. The staff identified no concerns with residents not receiving pain medication as requested. The SCC and Director of Clinical Programs reviewed these assessments and validated that the assessments were complete and no concerns identified as it related to assessment, pain management or physician notification. 11) Beginning on 03/23/16 the Interdisciplinary Team (IDT) reviewed in the morning clinical meeting telephone orders, SBARs, 24 Hour Report and medical records of residents to ensure timely notification to physician occurred and any changes in resident pain was addressed timely and x-rays were completed, results obtained timely, reported to physician timely and care plans were updated. The SCC or Director of Clinical Programs has been attending this meeting since 04/01/16 and assisting with medical record review, care plan review, providing oversight and consultation. 12) Daily, beginning 04/01/16, until immediacy is lifted, a stand down meeting will occur in the afternoon around 3:00 PM where the DON, Unit Manager, Restorative Nurse Manager and or MDS Coordinator will report on the status of residents for the day and follow up for MD notification, documentation in the medical record, SBARs, Stop and Watch, pain and or x ray reports and updating of care plans was occurring. The SCC or Director of Clinical Programs will attend this meeting to provide oversight and consultation of physician notification, updating care plans, pain assessments and documentation. 13) Beginning on 03/23/16, licensed nurses were educated regarding physician notification and changes in residents' condition by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work by the facility. The facility will not allow staff members to return to work until education has been provided. The education included notifying the physician of all changes in residents' condition as it occurs throughout the shift. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 14) Beginning on 03/23/16, licensed nurses were educated on pain management and assessing residents for pain by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16, will receive education prior to returning to work by the facility. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included performing pain assessments. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 15) Beginning on 03/23/16, licensed nurses were educated on documentation by the DON, SDC, Unit Manager, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included documenting notification to the physician and change in conditions. The initial education was initiated on 03/23/16 and the post-test was not administered until re-education was initiated on 03/30/16. 16) Beginning on 03/30/16 licensed nurses were educated by the DON, SDC, Unit Manager, MDS Coordinator and/or the Restorative Nurse Manager on assessing for pain, the facility's pain policy, 24 hour report, pain management, lab policy and lab tracking log, and documentation in the medical record and updating care plans. The education the facility staff was provided included pain assessments, pain policy, assessing for pain, assessing for new, worsening and different pain, assessing for pain includes range of motion (ROM) if that is where the pain is originating from, use of the Wong Baker pain form, 24 hour report policy, updating care plans, notification to the physician for any change in condition, completing SBAR for change in resident condition and nurse assessing after Stop and Watch, is received, follow up documentation for change in condition, and lab tracking form to be completed and checked daily. The Stop and Watch is an extra tool (along with verbally reporting) to remind staff to tell the charge nurse if there is a change in a resident. The staff was trained that a life threatening event/change of condition, will be immediately reported verbally to a licensed nurse and other change of conditions will be reported by Stop and Watch and verbally. The staff was trained when a staff member recognizes a change of condition in a resident that is not a life threatening event, they obtain a Stop and Watch form (located throughout the facility) fill out the Stop and Watch form by either checking one of the boxes or writing in the change of condition. Then the staff member gives the form to a licensed nurse along with verbally telling them of the Stop and Watch. The licensed nurse then assesses/evaluates the resident, completes an SBAR/Nurse's Note if there is a change of condition, and notifies the physician immediately. 17) Beginning on 03/30/16 current staff (all departments) was educated by the DON, SDC, Unit Manager, MDS Coordinator, and/or the Restorative Nurse Manager, completing a Stop and Watch form for a change in the resident's condition. When a staff member fills out a Stop and Watch form and feels that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. The current staff (all departments) has been trained by the DON and or SDC on the Stop and Watch process. The DON and Administrator are accessible 24 hours a day, their phone numbers are posted throughout the facility in each department. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note if there is a change of condition and notify the physician immediately. Beginning 04/01/16, a member of the Nursing Administration Team to include but not limited have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting, Stop and Watch forms are addressed with the nurse and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. Beginning the evening of 04/06/16, Department Heads including but not limited to Dietary Director, Housekeeping/Laundry Supervisor, Quality of Life Director (QOL); and the Nursing Administration Team to include but not limited to the DON, Unit Manager, Staff Development Coordinator (SDC), MDS Coordinator and the Restorative Nurse Manager will round at the end of each shift and ensure with staff that if a Stop and Watch has been completed or if any verbal reports of change of condition have been reported to the licensed nurse that the change in condition has been addressed, until immediacy has been lifted. Once the Department Managers have talked with their staff, if a Stop and Watch or verbal communication was given to a licensed nurse, the Department Managers will then go to a member of the Nursing Administration Team (to include but not limited to the DON, Unit Managers, Staff Development Coordinator (SDC), and MDS Coordinators and the Restorative Nurse Manager) and communicate verbally that there was a Stop and Watch completed or a verbal report of a change of condition on a resident, until immediacy is lifted. A carbon copy of the Stop and Watch will be given to the DON when completed. The DON or member of the Nursing Administration Team will review the carbon copies of the Stop and Watch and verify with the charge nurses they have been addressed every shift until immediacy has been lifted. The Nursing Administration team member will then go to the charge nurse assigned to the resident that had a Stop and Watch completed or verbal report given regarding a change of condition and verify that the change of condition has been addressed by the charge nurse by an assessment/evaluation, having a SBAR or nurse's note completed, physician notification, orders followed and care plans updated. The Department Managers that included the Dietary Director, Quality of Life Director, Housekeeping/ Laundry Supervisor, DON and the Administrator were educated on this process on 04/06/16 by the Director of Clinical Programs. The results will be discussed in the Quality Assurance and Performance Improvement (QAPI) meeting. At that time based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 18) Facility education included physician notification immediately for change of condition of a resident. When facility staff was provided re-education, a post-test was administered to the licensed nursing staff on pain, change of condition, physician notification, charting and documentation and lab tracking. 99% of full and part time staff have completed the education. One employee was on vacation and was mailed a certified letter regarding education needing to be completed before returning to work. 63% of prn staff members have received the training and the remaining have been mailed a certified letter regarding education needing to be completed before returning to work. 19) Beginning on 03/29/16 education was initiated for current staff (all departments) on the Stop and Watch process which includes completing a Stop and Watch form with a change in condition and giving the form to the charge nurse. Any staff member can complete a Stop and Watch and give to the charge nurse. If a staff member fills out a Stop and Watch and finds that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note, if there is a change in condition and notify the physician within an hour. Beginning 04/01/16, a member of the Nursing Administration Team have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. 20) The facility will continue education until current staff is educated on the process. Staff not educated by 04/01/16 will be educated before they return to work. Staff on FMLA, Medical Leave or vacation will be educated prior to returning to work and staff members will not return to work until education has been provided. 21) A nurse from the regional team or corporate office has been available since 03/22/16 and onsite since 03/30/16. The nurse(s) from the regional team or home office are assisting with pain assessments, performing chart audits, and providing oversight and consultation. 22) On 03/31/16, current residents' charts were audited by the Nursing Administration Team, for the past thirty (30) days reviewing pain, change in condition and physician notification. The chart audits looked for the following; incomplete documentation, physician notification not being done and care plans updated. No concerns were identified with physician notification. Twelve (12) care plans were updated. One care plan was updated for an ADL improvement. Two (2) care plans were updated for impaired skin integrity, redness under breast and a rash. One care plan was updated for abnormal labs, positive [MEDICAL CONDITION]. One care plan was updated for [MEDICAL CONDITION] in leg and transfer to hospital. Two (2) care plans were updated for initiating of antibiotics. One care plan was updated for anticoagulant therapy changes. One care plan was updated for insulin changes. One care plan was updated for blood pressure medication changes. One care plan was updated for skin integrity, self-inflicted scratches. One care plan was updated for cataract surgery. 23) On 03/23/16 the SCC; and again on 04/01/16 the SCC and Director of Clinical Programs audited care plans of current residents with fractures to ensure they were updated and current. On 03/23/16, the care plan of Resident # 1 was not updated, the resident was in the hospital and the facility was awaiting his/her return to update the care plan. On 04/01/16, the SCC and/or Director of Clinical Programs reviewed current residents with fractures, care plans for pain, and change in condition. No issues were identified. 24) Beginning daily on 03/31/16, a member of the Nursing Administration will conduct visits on five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. Any issues identified will be addressed with an SBAR being completed and physician notification. Results of audits will be discussed in the QAPI meeting. 25) Beginning daily on 04/01/16, ten (10) residents' charts will be audited by the Nursing Administration Team for physician notification being completed, change in condition (including updating care plans) being addressed by completion of SBAR, care plans being updated and documentation being present, until immediacy is lifted. Then five (5) charts per day five (5) days a week will be checked for two (2) weeks; and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery; results of audits will be discussed in the QAPI meeting. 26) On 04/01/16, current residents' care plans were audited by SCC, Director of Clinical Programs, Clinical Reimbursement Coordinator, and the MDS Coordinator to ensure current residents' care plans with pain were updated and accurate, and residents with fractures care plans were updated and accurate. There were three (3) residents in the facility with fractures; Resident #1's care plan has been updated for his/her fracture and pain on 03/28/16 upon his/her return from the hospital. The other two (2) care plans were current. 27) Administrative oversight of the facility will be completed by the VP of Operations, Signature Care Consultant (SCC), and the Director of Clinical Programs daily until removal of immediacy beginning 03/23/16, then weekly for four (4) weeks, then monthly to ensure the above audits were completed and any concerns were addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the Stop and Watch, SBARs/Nurse's Notes for change in condition and care plans occurs daily by the SCC or Director of Clinical Programs along with attending the morning clinical meeting and daily stand down meeting where the Stop and Watch, SBARs and pain assessments are reviewed. 28) Ongoing pain assessments every shift will be completed by the charge nurses and reviewed daily in the morning clinical meeting until immediacy is lifted, looking for new, worsening or different pain. Any issues will be addressed at time of discovery. Beginning 04/0

Based on interview, record review, and review of the facility's policy it was determined the facility failed to maintain clinical records for one (1) of three (3) sampled residents (Resident #1) that were complete and accurate in accordance with accepted professional standards and practices. Review of Resident #1's Nurse's Notes revealed no documented evidence the resident was assessed for pain or was experiencing pain until 03/22/16 at 12:30 PM at which time a licensed nurse documented the resident grimaced when his/her left leg was moved. Review of the Medication Administration Record [REDACTED]. Further interviews with the CNAs revealed the information was reported to the licensed nursing staff. The facility's failure to ensure each resident had an accurate clinical record was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/20/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514). The facility was notified of the Immediate Jeopardy on 03/30/16. An acceptable Allegation of Compliance was received on 04/07/16 which alleged removal of the Immediate Jeopardy on 04/07/16. A partial extended survey was conducted on 04/11-12/16. The State Survey Agency determined the Immediate Jeopardy was removed on 04/07/16 as alleged, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Charting and Documentation, not dated, revealed services provided to the resident or any change in the resident's medical condition shall be documented in the resident's medical record. Review of the facility's Pain Management policy, not dated, revealed if the resident had pain, the resident's pain should be assessed, an SBAR (Situation, Background, Assessment, and Recommendation) Communication Form should be utilized, and the resident's physician should be notified. Review of Resident #1's medical record revealed the facility admitted the resident on 03/12/12, with [DIAGNOSES REDACTED]. Review of the resident's most recent Quarterly Minimum Data Set (MDS) assessment, dated 02/12/16, revealed the resident was cognitively impaired and required extensive assistance from staff for all activities of daily living. Further review of the record revealed a Care Plan, dated 07/10/15, which stated the resident experienced pain with interventions to decrease the resident's pain that included giving pain medication as ordered. Review of Resident #1's Nurse's Notes, dated 03/22/16 at 12:30 PM, revealed the resident was noted to have bruising and [MEDICAL CONDITION] to the left knee and the resident grimaced when the leg was moved. Review of Resident #1's MAR, dated March 2016, revealed there was no documented evidence that the resident experienced pain during the month of March 2016. Review of Resident #1's SBAR Communication Form, dated 03/20/16 and not timed, revealed the resident was assessed to have tenderness to the left hip/leg. Interviews on 03/28/16 with CNA #1 at 10:57 AM, CNA #3 at 3:43 PM, CNA #4 at 3:57 PM, CNA #5 at 4:04 PM, CNA #6 at 4:08 PM, and CNA #7 at 10:44 PM, and on 03/29/16 with CNA #8 at 9:42 PM, CNA #9 at 9:45 AM, and CNA #10 at 10:03 AM revealed the CNAs that had provided care for Resident #1 from the evening of 03/20/16 through 03/22/16 revealed Resident #1 exhibited signs of pain (moaned when moved and when staff touched his/her left hip) with turning, repositioning, and incontinence care and would attempt to swat at and push staff away. The staff stated they reported the resident's pain to the licensed nursing staff. Interview on 03/29/16 at 10:10 AM with Licensed Practical Nurse (LPN) #3 revealed the CNAs caring for Resident #1 on 03/20/16 reported that the resident was in pain (moaning when moved, touching his/her left hip and pushing the staff away) with turning, repositioning, and when the resident was changed. LPN #3 stated she assessed the resident at approximately 4:00 AM and the resident had tenderness to the left hip/leg area. The interview further revealed the LPN completed an SBAR Communication Form related to the resident's pain and passed the form on the day shift nurse to follow up. LPN #3 denied Resident #1 was in pain when she had completed the routine pain assessment earlier in the shift. Interview with LPN #1 at 03/28/16 at 1:19 PM and on 03/30/16 at 11:10 AM revealed she provided care for Resident #1 on 03/21/16, but was not aware the resident was having hip pain when the resident was turned, repositioned, and changed. She stated she asked the resident if he/she had pain, but she did not do a physical assessment to check for pain and did not document that the resident was having pain. Interview with LPN #2 on 03/28/16 at 2:39 PM revealed LPN #3 (the night shift nurse) had passed Resident #1's SBAR Form on to her, which stated the resident's complaints of left hip/leg tenderness. LPN #2 stated she assessed the resident and did not find the resident to be in pain. Continued interview with LPN #2 revealed she denied she did a physical assessment to assess for the resident's pain. Interview on 03/29/16 at 11:29 AM with LPN #5 revealed he provided care to Resident #1 on the evening/night of 03/21/16 and was informed in report that the resident was having some hip pain when he/she was moved by staff and an x-ray had been ordered. The interview further revealed LPN #5 asked Resident #1 if he/she was having any pain and the resident denied having pain and acted normal and therefore he did not document pain for the resident. LPN #5 denied he attempted to perform a physical assessment on the resident's leg or hip to assess for pain. Interviews on 03/30/16 with the Director of Nursing at 1:16 PM and the Administrator at 1:36 PM revealed Resident #1's pain should have been thoroughly assessed by licensed nursing staff and documented if the staff assessed the resident to be in pain. The interview further revealed the licensed nursing staff should have attempted to turn and reposition the resident to adequately assess for the resident's pain. Continued interview with the DON revealed she felt like the staff did not feel like the resident was in pain or the pain would have been documented. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/07/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The facility Director of Nursing (DON) reported the allegation of the Injury of unknown origin on Resident #1 to the Office of Inspector General on 03/22/16. The facility DON initiated the initial investigation on 03/22/16 to include: a) Staff assessed Resident #1 for injury on 03/20/16 after complaints of pain were reported to the Charge Nurse by the Certified Nurse Aide (CNA) caring for the resident. The Charge Nurse assessed the resident and found the resident had tenderness to palpation of the left hip with no outward signs of such as swelling, bruising, or deformity. The staff notified Resident #1's Physician on 03/21/16, and orders were received to obtain an x- ray of the left hip. Resident #1's left hip x-ray results were noted to be positive for an acute complete slightly displaced left intertrochanteric fracture and the resident was sent to the emergency roiagnom on [DATE]. Resident #1's family was notified by the Charge Nurse on 03/21/16 and again on 03/22/16. Facility staff notified the DON and the Administrator on 03/22/16. Resident #1 was assessed by the Charge Nurse on 03/22/16 for any signs and symptoms of abuse and none were noted. 2) Resident #1's Attending Physician was notified on 03/22/16 by the Charge Nurse and orders were given for an in-house x-ray for the left knee. The x-ray results were obtained on 03/22/16 showing Resident #1's bones were osteogenic with mild [MEDICAL CONDITION] changes. 3) All residents were assessed for any signs and symptoms of abuse/neglect on 03/22/16 by the DON, Staff Development Coordinator (SDC), and the Unit Manager to ensure the current residents felt safe, that they were being treated well and felt that staff was caring for them appropriately, by questions that included: 1.) Has anyone been rough with you when providing care? 2.) Has anyone yelled at you? 3.) Do you have any concerns? No concerns were noted. 4) On 03/23/16, the Signature Care Consultant (SCC) conducted an education with the Nursing Administration Team to include but not limited to the DON, Unit Manager, SDC, and MDS Coordinator; and the Restorative Nurse Manager on the abuse policy. Six Nursing Administration staff was educated. The SCC performed the training face to face in order to facilitate discussion and questions and to include examples of abuse. A post-test on abuse was administered and 100% score obtained, if managers did not score 100% on post-test, the manager was immediately re-educated and the post-test was re-administered. The SCC continued the process until all managers obtained 100% score on the post-tests. All post-tests were reviewed for compliance by the SCC. The facility does not use agency staffing. The Administrator and DON were responsible for ensuring staff members were educated prior to returning to work. 5) Once the Nursing Administration Team received their education and completed post-test on abuse, they were reassigned to educate the staff on abuse on 03/22/16. The Nursing Administrative Team performed the training with facility staff face to face in order to facilitate discussion and questions and to include examples. The facility will continue the training until all nursing staff and therapy staff is educated. The staff that had not worked as of 03/26/16 will receive education prior to returning to work on abuse. 95 % of the staff had received the training as of 04/01/16. Facility nursing staff on Family Medical Leave of Absence (FMLA), Medical Leave or vacation will be educated prior to returning to work. Staff members will not return to work until education has been provided, post-test completed with a score of 100%. If the staff member did not achieve a score of a 100% on the post-test, the staff member will be re-educated on the policy and given the post-¿test again. The process will continue until the staff member achieves 100% score on the post-test. 6) Residents with a Brief Interview for Mental Status (BIMS) score of greater than 8 were interviewed by the DON, Unit Manager or Social Services Director, for any abuse/neglect concerns to ensure that current residents felt safe; that they were being treated well; and felt the staff was caring for them appropriately, which started on 03/22/16 and was completed on 03/23/16. There were no concerns voiced. 7) Residents with a BIMS score less than 8 were physically assessed by the DON, Unit Managers, or MDS Nurses for any signs and symptoms of abuse/neglect on 03/22/16 and 03/23/16. Staff completed skin assessments for these residents and no concerns were identified. 8) The Administrator and/or Signature Care Consultant (SCC) reviewed the resident assessments for abuse that included the questionnaires for residents with BIMS scores of 8 or greater and skin assessments for residents with a BIMS score less than 8 on 03/23/16. No concerns were identified. 9) On 03/23/16, the Director of Nursing (DON) reviewed x-rays for the month. The physician was notified of abnormal x-rays of other residents for the month of March. A total of 7 x-rays (including two for Resident #1) were performed in March 2016. Six (6) x-rays were abnormal and 1 x-ray was normal. With review of the audit, concern was identified that physician notification of abnormal x-rays was not always done timely. One abnormal chest x-ray notification to physician varied from two (2) minutes to five (5) hours. The facility initiated education with the licensed nurses regarding physician notification and change of condition. See #13, #15, and #16. 10) Nursing staff completed pain assessments on current residents every shift from 03/23/16 through 03/26/16 and any issues were addressed. The staff identified no concerns with residents not receiving pain medication as requested. The SCC and Director of Clinical Programs reviewed these assessments and validated that the assessments were complete and no concerns identified as it related to assessment, pain management or physician notification. 11) Beginning on 03/23/16 the Interdisciplinary Team (IDT) reviewed in the morning clinical meeting telephone orders, SBARs, 24 Hour Report and medical records of residents to ensure timely notification to physician occurred and any changes in resident pain was addressed timely and x-rays were completed, results obtained timely, reported to physician timely and care plans were updated. The SCC or Director of Clinical Programs has been attending this meeting since 04/01/16 and assisting with medical record review, care plan review, providing oversight and consultation. 12) Daily, beginning 04/01/16, until immediacy is lifted, a stand down meeting will occur in the afternoon around 3:00 PM where the DON, Unit Manager, Restorative Nurse Manager and or MDS Coordinator will report on the status of residents for the day and follow up for MD notification, documentation in the medical record, SBARs, Stop and Watch, pain and or x ray reports and updating of care plans was occurring. The SCC or Director of Clinical Programs will attend this meeting to provide oversight and consultation of physician notification, updating care plans, pain assessments and documentation. 13) Beginning on 03/23/16, licensed nurses were educated regarding physician notification and changes in residents' condition by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work by the facility. The facility will not allow staff members to return to work until education has been provided. The education included notifying the physician of all changes in residents' condition as it occurs throughout the shift. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 14) Beginning on 03/23/16, licensed nurses were educated on pain management and assessing residents for pain by the DON, SDC, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16, will receive education prior to returning to work by the facility. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included performing pain assessments. The initial education was initiated on 03/23/16 and post-tests were not administered until re-education was initiated on 03/30/16. 15) Beginning on 03/23/16, licensed nurses were educated on documentation by the DON, SDC, Unit Manager, and/or SCC. Education will be continued until current licensed nursing staff is educated and staff not working as of 03/26/16 will receive education prior to returning to work. Licensed nursing staff on FMLA, Medical Leave or vacation will be educated prior to returning to work. The facility will not allow staff members to return to work until education has been provided. The education included documenting notification to the physician and change in conditions. The initial education was initiated on 03/23/16 and the post-test was not administered until re-education was initiated on 03/30/16. 16) Beginning on 03/30/16 licensed nurses were educated by the DON, SDC, Unit Manager, MDS Coordinator and/or the Restorative Nurse Manager on assessing for pain, the facility's pain policy, 24 hour report, pain management, lab policy and lab tracking log, and documentation in the medical record and updating care plans. The education the facility staff was provided included pain assessments, pain policy, assessing for pain, assessing for new, worsening and different pain, assessing for pain includes range of motion (ROM) if that is where the pain is originating from, use of the Wong Baker pain form, 24 hour report policy, updating care plans, notification to the physician for any change in condition, completing SBAR for change in resident condition and nurse assessing after Stop and Watch, is received, follow up documentation for change in condition, and lab tracking form to be completed and checked daily. The Stop and Watch is an extra tool (along with verbally reporting) to remind staff to tell the charge nurse if there is a change in a resident. The staff was trained that a life threatening event/change of condition, will be immediately reported verbally to a licensed nurse and other change of conditions will be reported by Stop and Watch and verbally. The staff was trained when a staff member recognizes a change of condition in a resident that is not a life threatening event, they obtain a Stop and Watch form (located throughout the facility) fill out the Stop and Watch form by either checking one of the boxes or writing in the change of condition. Then the staff member gives the form to a licensed nurse along with verbally telling them of the Stop and Watch. The licensed nurse then assesses/evaluates the resident, completes an SBAR/Nurse's Note if there is a change of condition, and notifies the physician immediately. 17) Beginning on 03/30/16 current staff (all departments) was educated by the DON, SDC, Unit Manager, MDS Coordinator, and/or the Restorative Nurse Manager, completing a Stop and Watch form for a change in the resident's condition. When a staff member fills out a Stop and Watch form and feels that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. The current staff (all departments) has been trained by the DON and or SDC on the Stop and Watch process. The DON and Administrator are accessible 24 hours a day, their phone numbers are posted throughout the facility in each department. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note if there is a change of condition and notify the physician immediately. Beginning 04/01/16, a member of the Nursing Administration Team to include but not limited have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting, Stop and Watch forms are addressed with the nurse and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. Beginning the evening of 04/06/16, Department Heads including but not limited to Dietary Director, Housekeeping/Laundry Supervisor, Quality of Life Director (QOL); and the Nursing Administration Team to include but not limited to the DON, Unit Manager, Staff Development Coordinator (SDC), MDS Coordinator and the Restorative Nurse Manager will round at the end of each shift and ensure with staff that if a Stop and Watch has been completed or if any verbal reports of change of condition have been reported to the licensed nurse that the change in condition has been addressed, until immediacy has been lifted. Once the Department Managers have talked with their staff, if a Stop and Watch or verbal communication was given to a licensed nurse, the Department Managers will then go to a member of the Nursing Administration Team (to include but not limited to the DON, Unit Managers, Staff Development Coordinator (SDC), and MDS Coordinators and the Restorative Nurse Manager) and communicate verbally that there was a Stop and Watch completed or a verbal report of a change of condition on a resident, until immediacy is lifted. A carbon copy of the Stop and Watch will be given to the DON when completed. The DON or member of the Nursing Administration Team will review the carbon copies of the Stop and Watch and verify with the charge nurses they have been addressed every shift until immediacy has been lifted. The Nursing Administration team member will then go to the charge nurse assigned to the resident that had a Stop and Watch completed or verbal report given regarding a change of condition and verify that the change of condition has been addressed by the charge nurse by an assessment/evaluation, having a SBAR or nurse's note completed, physician notification, orders followed and care plans updated. The Department Managers that included the Dietary Director, Quality of Life Director, Housekeeping/ Laundry Supervisor, DON and the Administrator were educated on this process on 04/06/16 by the Director of Clinical Programs. The results will be discussed in the Quality Assurance and Performance Improvement (QAPI) meeting. At that time based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. 18) Facility education included physician notification immediately for change of condition of a resident. When facility staff was provided re-education, a post-test was administered to the licensed nursing staff on pain, change of condition, physician notification, charting and documentation and lab tracking. 99% of full and part time staff have completed the education. One employee was on vacation and was mailed a certified letter regarding education needing to be completed before returning to work. 63% of prn staff members have received the training and the remaining have been mailed a certified letter regarding education needing to be completed before returning to work. 19) Beginning on 03/29/16 education was initiated for current staff (all departments) on the Stop and Watch process which includes completing a Stop and Watch form with a change in condition and giving the form to the charge nurse. Any staff member can complete a Stop and Watch and give to the charge nurse. If a staff member fills out a Stop and Watch and finds that the charge nurse has not addressed the issue he/she is to call the DON or Administrator. Change in a resident includes but is not limited to new, worsening, or different pain. The charge nurse will then assess/evaluate the resident including assessing/evaluating for change in condition including but not limited to pain. The charge nurse will then complete an SBAR/Nurse's Note, if there is a change in condition and notify the physician within an hour. Beginning 04/01/16, a member of the Nursing Administration Team have been in the facility 24 hours a day, checking at minimum every 45 minutes to 1 hour with the nurses and other staff in the facility on changes in residents' conditions, pain monitoring including assessing pain, physician notification, documentation and charting and that care plans are updated. No concerns have been identified. No concerns of Stop and Watch forms being filled out by staff and not being addressed have been identified. 20) The facility will continue education until current staff is educated on the process. Staff not educated by 04/01/16 will be educated before they return to work. Staff on FMLA, Medical Leave or vacation will be educated prior to returning to work and staff members will not return to work until education has been provided. 21) A nurse from the regional team or corporate office has been available since 03/22/16 and onsite since 03/30/16. The nurse(s) from the regional team or home office are assisting with pain assessments, performing chart audits, and providing oversight and consultation. 22) On 03/31/16, current residents' charts were audited by the Nursing Administration Team, for the past thirty (30) days reviewing pain, change in condition and physician notification. The chart audits looked for the following; incomplete documentation, physician notification not being done and care plans updated. No concerns were identified with physician notification. Twelve (12) care plans were updated. One care plan was updated for an ADL improvement. Two (2) care plans were updated for impaired skin integrity, redness under breast and a rash. One care plan was updated for abnormal labs, positive [MEDICAL CONDITION]. One care plan was updated for [MEDICAL CONDITION] in leg and transfer to hospital. Two (2) care plans were updated for initiating of antibiotics. One care plan was updated for anticoagulant therapy changes. One care plan was updated for insulin changes. One care plan was updated for blood pressure medication changes. One care plan was updated for skin integrity, self-inflicted scratches. One care plan was updated for cataract surgery. 23) On 03/23/16 the SCC; and again on 04/01/16 the SCC and Director of Clinical Programs audited care plans of current residents with fractures to ensure they were updated and current. On 03/23/16, the care plan of Resident # 1 was not updated, the resident was in the hospital and the facility was awaiting his/her return to update the care plan. On 04/01/16, the SCC and/or Director of Clinical Programs reviewed current residents with fractures, care plans for pain, and change in condition. No issues were identified. 24) Beginning daily on 03/31/16, a member of the Nursing Administration will conduct visits on five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. Any issues identified will be addressed with an SBAR being completed and physician notification. Results of audits will be discussed in the QAPI meeting. 25) Beginning daily on 04/01/16, ten (10) residents' charts will be audited by the Nursing Administration Team for physician notification being completed, change in condition (including updating care plans) being addressed by completion of SBAR, care plans being updated and documentation being present, until immediacy is lifted. Then five (5) charts per day five (5) days a week will be checked for two (2) weeks; and then five (5) charts per week for two (2) weeks. Any issues identified will be addressed at the time of discovery; results of audits will be discussed in the QAPI meeting. 26) On 04/01/16, current residents' care plans were audited by SCC, Director of Clinical Programs, Clinical Reimbursement Coordinator, and the MDS Coordinator to ensure current residents' care plans with pain were updated and accurate, and residents with fractures care plans were updated and accurate. There were three (3) residents in the facility with fractures; Resident #1's care plan has been updated for his/her fracture and pain on 03/28/16 upon his/her return from the hospital. The other two (2) care plans were current. 27) Administrative oversight of the facility will be completed by the VP of Operations, Signature Care Consultant (SCC), and the Director of Clinical Programs daily until removal of immediacy beginning 03/23/16, then weekly for four (4) weeks, then monthly to ensure the above audits were completed and any concerns were addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the Stop and Watch, SBARs/Nurse's Notes for change in condition and care plans occurs daily by the SCC or Director of Clinical Programs along with attending the morning clinical meeting and daily stand down meeting where the Stop and Watch, SBARs and pain assessments are reviewed. 28) Ongoing pain assessments every shift will be completed by the charge nurses and reviewed daily in the morning clinical meeting until immediacy is lifted, looking for new, worsening or different pain. Any issues will be addressed at time of discovery. Beginning 04/01/16 a member of the Nursing Administration Team have been in the facility 24 hours a day, checking every at minimum every 45 minutes to one hour with the nurses and other staff in the facility on changes in residents conditions, pain monitoring including assessing pain, physician notification, documentation and charting and that care plans are updated. No concerns have been identified. 29) A QA meeting was held on 03/30/16 with the Medical Director (by phone), Administrator, DON, Unit Manager, Restorative Nurse Manager, SCC, MDS Coordinator and Social Services Director reviewing the occurrence of Resident # 1's fracture and the steps that have been put in place. 30) A QAPI meeting will be held weekly until immediacy is removed beginning on 03/30/16, then for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. At that time based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the QAPI meeting will be completed by the SCC, Director of Clinical Programs, the Regional Vice President of Operations, or member or regional staff weekly and daily by telephone until removal of immediacy beginning 03/30/16, then every other week for four (4) weeks, then monthly. Audits to be reviewed but not limited to morning clinical meeting, pain, change in condition, x-rays and SBARs. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the facility's investigation revealed the Director of Nursing (DON) reported the allegation related to an injury of unknown origin for Resident #1 to the state agencies on 03/22/16 and initiated an investigation to include the following: a) Review of the SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated 03/20/16, revealed Resident # 1 was assessed to have left hip/leg tenderness. Further review of the SBAR Form revealed Resident #1's Physician was notified of the hip/leg tenderness on 03/21/16 at 5:45 PM; and an order was obtained for a hip x-ray. Review of the SBAR Communication Form further revealed Resident #1's family was notified of the hip/leg tenderness on 03/21/16. Review of the results of the left hip x-ray, dated read by the Radiologist and faxed on 03/21/16 at 11:15 PM, revealed the x-ray was positive for an acute complete slightly displaced left intertrochanteric fracture. Review of the SBAR Communication Form, dated 03/22/16 at 6:00 PM, revealed Resident #1's Physician was notified of the [MEDICAL CONDITION] and an order was obtained to send the resident to the emergency room for evaluation and treatment. Further review of the SBAR Communication Form revealed Resident #1's family was notified of the [MEDICAL CONDITION] on 03/22/16. Review of the facility's investigation revealed the DON was notified of the fracture by the Charge Nurse on 03/22/16. Further review of the facility's investigation revealed Resident #1 was assessed for signs and symptoms of abuse on 03/22/16 and none we