Every finding on record at Somerset Nursing and Rehabilitation Facility

Based on interview, record review, and review of the facility's policies, the facility failed to implement the comprehensive person-centered care plan for 1 of 6 sampled residents (Resident (R)1). The findings include: Review of the facility's policy titled, Care Plan Policy, reviewed on [DATE], revealed the facility would develop and implement a person-centered care plan for each resident to include measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Continued review of the facility's policy revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas and risk factors associated with the identified problems. Review of R1's admission Record revealed the facility admitted the resident on [DATE], with diagnoses of osteoporosis, presence of right artificial hip joint, and dementia. Review of R1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed R1 as rarely/never understood. In addition, the facility assessed the resident as severely cognitively cognition. Review further revealed the facility assessed R1's functional status as dependent for bed mobility, toileting, and transfers. Review of R1's Care Plan/Kardex, revised on [DATE], revealed the facility identified a problem for Activities of Daily Living (ADLs) and developed a care plan with a goal to achieve/maintain maximum functional mobility through the next review period. Further review of the Care Plan/Kardex revealed the facility developed an intervention for R1 to use two staff assistance for bed mobility, toileting, and transfers as of [DATE]. Review of the facility's Incident Report dated [DATE], for an incident that occurred at 1:50 PM, involving R1 revealed it was noted by Licensed Practical Nurse (LPN) 1. Continued review revealed State Registered Nurse Aide (SRNA)1 had been providing perineal care for R1 and rolled the resident on to her left side. Per review, when SRNA1 rolled R1 to her left side it caused the resident to roll out of bed and fall to the floor on her right side. Further review revealed LPN 1 noted the root cause (of R1 rolling out of bed) as the resident was rolled too far over causing her to roll out of bed. Review of the Progress Note, dated [DATE] at 2:35 PM, noted by LPN 1, revealed the Nurse Practitioner (NP) had been notified of R1 rolling out of the bed on [DATE]. Review further revealed new orders were received to obtain x-rays of R1's right shoulder, right hip, and right knee. Review of the facility's mobile x-ray report, dated [DATE] at 4:49 PM, revealed the resident had sustained a right femoral diaphyseal fracture (femur shaft fracture) with complete displacement and foreshortening (of the limb). Review of the x-ray report revealed an orthopedics consult was recommended as soon as possible. Review of the Progress Note dated [DATE] at 5:10 PM, documented by LPN 1, revealed the NP had been notified of R1's stat x-ray results and orders were received to send the resident to the hospital for evaluation and treatment. Review of the hospital's x-ray report, dated [DATE] at 6:34 PM, revealed R1 had a comminuted (three or more resulting bone pieces) and moderately displaced mid to distal right femoral shaft fracture. Review of the hospital's surgical progress note dated [DATE], revealed the surgical team repaired R1's hip. Per review, of hospital documentation revealed the resident was deceased on [DATE], while a patient on the hospital's hospice unit. In interview on [DATE] at 1:36 PM, SRNA 1 stated she knew R1 was a two person staff assist, but her partner had been in another room. She stated she thought she would just get R1's care started. However, when she turned the resident, she (R1) rolled out of the bed onto the floor. SRNA 1 stated she had been trained, during her orientation in [DATE] on following resident's Care Plan/Kardex. However, she stated, in the incident involving R1, she had not followed the resident's Care Plan/Kardex. SRNA 1 further stated she found out later R1 sustained a fracture from the fall and she was completely devastated that she had caused an injury to the resident. In interview on [DATE] at 2:14 PM, LPN 1 stated staff were trained on the Care Plan/Kardex during their orientation and updated when there was a change in a resident's condition. She stated R1's Care Plan/Kardex showed the resident was a two person staff assist and had been for quite some time. LPN 1 stated that to her knowledge, there had been no Care Plan changes for R1 on the day of the incident. She explained she had been called into R1's room on the day of the incident by SRNA 1, and upon her arrival to the room the resident was lying on the floor on her right side. LPN 1 stated Unit Manager (UM) 1, who had also been in the room, helped to assess the resident. She stated the Nurse Practitioner (NP) was notified and ordered stat x-rays. She stated the results showed a right femoral head fracture. R1 was sent to the hospital for further evaluation. In interview on [DATE] at 2:49 PM, SRNA 2 stated all staff got orientation to the Kardex information during orientation in both the classroom and on the floor training. She stated any changes to the Kardex were communicated verbally by either the Charge Nurses or Unit Managers. The SRNA stated she was not aware of any changes to R1's Kardex prior to the incident. She stated she was aware R1 was a two person staff assist (on the Kardex). However, SRNA2 stated SRNA 1 started providing care for R1 before she (SRNA 2) got to the room. SRNA 2 stated when she got to R1's room to assist SRNA1, the resident was already lying on the floor and was being assessed by LPN 1 and UM 1. She further stated R1 had been a two person assist for years. In interview on [DATE] at 2:48 PM, UM 1 stated she heard SRNA1 yelling for help (on the day of the incident) and when she got to R1's room, the resident had been lying on the floor. She stated R1 did not appear to be in distress and when LPN 1 arrived in the room, she left to go call the NP and the resident's family. UM 1 explained the NP ordered stat x-rays for R1. She stated as R1 was not in distress, and there had been no obvious injuries assessed, the resident was assisted back to bed with no further issues noted. UM 1 further stated she later saw the x-ray results, which showed R1 had a fracture to the right femoral area. In interview on [DATE] at 3:59 PM, the Infection Preventionist (IP) Nurse, who was also the facility's acting Director of Nursing (DON), stated it was her expectation that Care Plans/Kardex for all staff to follow residents' Care Plan/Kardex when providing care for the residents. She stated she found out about R1's fall during the facility's stand down meeting on [DATE]; however, she was not aware of the resident's fracture until the following morning meeting (on [DATE]). The IP Nurse/acting DON further stated SRNA 1 had not followed R1's Care Plan as the resident was a two person assist with most of her Activities of Daily Living (ADLs). In interview on [DATE] at 4:00 PM, the Administrator stated it was her expectation that staff follow the residents' Care Plans when providing care so accidents/incidents did not occur. She stated she was made aware of R1's fall on [DATE] by UM 1. The Administrator stated she was notified of the x-ray results on [DATE] at 5:12 PM, by the NP, who gave the order to send R1 to the hospital for further evaluation. She stated the Interdisciplinary Team (IDT) met on [DATE] to develop and implement an action plan to prevent another such incident from occurring. The Administrator further stated she was involved in providing a written warning to SRNA 1 for not following R1's Care Plan (as required).

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide each resident with adequate supervision to prevent accidents for 1 of 6 sampled residents (Resident (R)1). R1 sustained a fall with a fracture. The findings include: Review of the facility's policy titled, Falls Policy, reviewed [DATE], revealed the policy was to ensure the facility provided an environment as free from accident hazards as possible, over which the facility had control to prevent avoidable falls/accidents. Review of R1's admission Record revealed the facility admitted the resident on [DATE], with diagnoses of osteoporosis, presence of right artificial hip joint, and dementia. Review of R1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as rarely/never understood. The facility assessed R1 as severely cognitively impaired. Continued review of R1's MDS Assessment revealed the facility additionally assessed the resident's functional status for bed mobility, toileting, and transfers as dependent. Review of R1's Care Plan revised on [DATE], revealed the facility identified a risk problem for Activities of Daily Living (ADLs). The goals included to achieve/maintain maximum functional mobility through the next review period. Continue review of the ADL care plan revealed the facility developed an intervention on [DATE], to use two staff assist for the resident's bed mobility, toileting, and transfers. Review of the facility's Incident Report, dated [DATE], noted by Licensed Practical Nurse (LPN) 1, revealed an incident occurred on that date at 1:50 PM involving R1. Per review, LPN 1 documented State Registered Nurse Aide (SRNA) 1 had been providing perineal care for R1 and rolled the resident to her left side. According to the Report, LPN 1 noted when SRNA 1 rolled R1 to her side it caused the resident to roll out of bed on her right side onto the floor next to the other bed in the room. Continued review of the Report revealed LPN 1 noted the root cause (of R1 rolling out of bed) as the resident was rolled too far over causing her to roll out of bed when staff was providing care. Further review of the Incident Report revealed the predisposing physiological factors noted were weakness and the predisposing situational factors documented as history of falls, and the INTERDISCIPLINARY TEAM (IDT) determined the root cause as the SRNA failed to follow R1's Kardex (The Kardex is the care plan the RNA's use to let them know the resident's care needs). Review of SRNA 1's employee file revealed a written warning, dated [DATE], signed by SRNA 1 and Unit Manager (UM) 1, related to the SRNA failing to follow (R1's) Kardex for specific resident needs. Continued review of the document revealed it had also been signed by the Administrator. Review of R1's Progress Note, dated [DATE] at 2:35 PM, documented by LPN 1, revealed the Nurse Practitioner (NP) and family had been notified of R1 rolling out of the bed on [DATE]. Continued review revealed new orders had been received to obtain x-rays of R1's right shoulder, right hip, and right knee. Review of the facility's mobile x-ray report, dated [DATE] at 4:49 PM, revealed R1 had sustained a right femoral diaphyseal fracture (femur shaft fracture) with complete displacement and foreshortening (of the limb). Further review of the x-ray report revealed an orthopedics consult was recommended as soon as possible. Review of R1's Progress Note, dated [DATE] at 5:10 PM, documented by LPN 1, revealed the NP had been notified of R1's stat x-ray results and orders received to send the resident to the hospital for evaluation and treatment. Continued review of the Progress Note revealed R1's power of attorney (POA) was also notified.Review of the hospital's x-ray report, dated [DATE] at 6:34 PM, revealed R1 had a comminuted (three or more resulting bone pieces) and moderately displaced mid to distal right femoral shaft fracture. Review of the hospital's surgical open reduction and internal fixation (ORIF) progress note, dated [DATE], revealed the surgical team performed an interval realignment of the complete oblique mid to distal femoral shaft fracture components with placement of a long stem plate and screw fixation device. Further review of hospital documentation revealed R1 expired [DATE] (15 days after the incident), while on the hospital's hospice unit. During interview with SRNA 1 on [DATE] at 1:36 PM, she stated she had known R1 was a two person staff assist; however, her partner had been in another resident's room and her partner would join her to finish the resident's care. SRNA 1 stated she was just focused on getting the care started for R1 and never dreamed the resident would roll off the bed. She stated she thought she would just get the care started for R1, but when she turned the resident in the bed, she (R1) rolled out of the bed onto the floor. SRNA 1 explained she had been trained on following a resident's care plan/Kardex during her orientation in [DATE]. She stated in R1's case she had not followed the resident's care plan/Kardex. SRNA 1 further stated she found out later R1 had sustained a fracture from the fall and she was completely devastated that she had caused such an injury to the resident. During interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 2:14 PM, she stated R1's Care Plan/Kardex showed the resident was to be a two person staff assist and had been that way for quite some time. LPN 1 stated prior to the incident involving R1, the nurses never really spot checked the SRNA's to ensure they were following the Care Plan/Kardex. However, she had assisted the SRNA's whenever they asked for assistance. She stated on the day of the incident, she had been called into R1's room by SRNA 1. LPN 1 stated when she got to R1's room, the resident was lying on the floor on her right side and had not appeared to be in distress. She explained that UM 1 had also been in the room and helped assess the resident. LPN 1 stated stat x-rays were ordered by the NP and the results noted a right femoral head fracture. The LPN stated R1 was sent to the hospital for further evaluation by the NP. She further stated staff were trained on following residents' Care Plans/Kardex during orientation and were updated whenever there was a change in a resident's condition. LPN 1 stated that to her knowledge, there had been no Care Plan changes for R1 on the day of the incident. During interview with SRNA 2 on [DATE] at 2:49 PM, she stated she had been aware R1 was a two person staff assist, but on the day of the incident SRNA 1 had started providing care for the resident before she (SRNA 2) had gotten to the resident's room. She stated when she arrived at R1's room to assist SRNA 1, R1 had already been lying on the floor and LPN 1 and UM 1 were already assessing the resident for injuries. SRNA 2 stated R1 had been a two person assist for years. She stated all staff received introduction to the (facility's) Kardex information during their orientation in both the classroom and on the floor training. During interview with UM 1 on [DATE] at 2:48 PM, she stated (on the day of the incident involving R1) she heard SRNA 1 yelling for help and when she got to R1's room the resident was lying on the floor. She stated R1 did not appeared to be in distress. When LPN 1 came to R1's room, she left to go call the NP and the resident's family. UM 1 stated the NP ordered stat x-rays for R1. She stated as R1 had not been in distress, and there had been no obvious injuries observed, the resident was assisted back to bed with no issues noted. UM 1 stated she later saw the x-ray results, which showed a fracture to the right femoral area. She stated prior to the incident involving R1, she had not routinely spot checked the SRNAs to ensure they were providing residents' care as per the Kardex. During interview with Infection Preventionist (IP) Nurse, who was also the facility's acting Director of Nursing (DON), on [DATE] at 3:59 PM, she stated it was her expectation that residents' Care Plans/Kardex were updated for any changes and for all staff to follow the Care Plans/Kardex when providing care for the residents. The IP Nurse/acting DON stated prior to the incident involving R1 she had monitored 10 SRNAs a month regarding perineal care and that the appropriate number of staff were providing that care; however, now the facility was doing audits specifically geared towards staff following the Kardex. She stated she found out about R1's fall during the facility's stand down meeting on [DATE]; however, she was not aware of the resident's fracture until the following morning meeting. The IP Nurse/acting DON said all the information necessary for the SRNAs to provide care for every resident was on the resident's Kardex. She stated any changes made during the shift were communicated by the Unit Managers and/or Charge Nurses to the SRNAs. The IP Nurse/acting DON stated SRNA 1 had not followed the Care Plan for R1 as the resident had been a two person assist with most of her ADLs. During interview with the Administrator on [DATE] at 4:00 PM, she stated it was her expectation for staff to follow the Care Plans when providing care for the residents, so accidents/incidents did not occur in the facility. The Administrator stated staff should always follow the residents' Care Plan and Kardex. She stated if they said assist of two staff; she expected two staff to perform the care. She stated she was made aware of R1's fall on [DATE] by UM 1. She was notified of the x-ray results on that day at 5:12 PM, by the NP, who gave the order to send the resident to the hospital for further evaluation. The Administrator stated the Interdisciplinary Team (IDT) met on [DATE], to develop and implement an action plan to prevent another such incident from occurring. She stated R1 required two staff members to provide her care for toileting, transfers, and bed mobility. The Administrator further stated however, there had only been one staff member present providing care to R1 when the incident occurred. She stated the incident involving R1 would not have occurred if SRNA 1 had followed R1's Care Plan. She additionally explained she had been involved in providing the written warning to SRNA 1 for not following R1's Care Plan, and the SRNA had received re-education on following the care plan.

Based on interview and record review it was determined the facility failed to protect one (1) of seven (7) sampled residents (Resident #2) from sexual abuse. On 05/20/2022, Resident #1 was observed to have his/her hand on Resident #2's bottom area over his/her brief. The findings include: Review of the Facility's Policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed sexual abuse was non-consensual sexual contact of any type with a resident. Further review of the policy revealed willful was defined as an individual acting in a deliberate way; not that the individual must have intended to inflict injury or harm. Review of the Facility's Protocol titled, Elopement/Wander Risk, item one (1), stated It was the expectation that the facility was to ensure that each resident received adequate supervision and assistance to prevent accidents. The Protocol stated, Hourly checks would be performed and documented on each resident who was evaluated to be at risk. Further review of the protocol revealed possible interventions for residents that wandered included frequent monitoring. Record review revealed the facility admitted Resident #1 on 12/23/2021, with diagnoses of Anxiety Disorder, Dementia with Behavioral Disturbance, and Recurrent Depressive Disorders. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview of Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was severely impaired cognitively. Interview with Resident #1's family member, Family Member #1, on 09/27/2022 at 9:18 AM, revealed the facility notified the family member about the incident in May where Resident #1 wandered into another resident's room and touched another resident. Record review revealed the facility admitted Resident #2, on 03/05/2021, with diagnoses of Alzheimer's disease, Anxiety Disorders, Lack of Coordination, and Cognitive Communication Deficit. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident could not participate in the BIMS assessment and was determined the resident was not interviewable Review of the Long-Term Care Facility's-Self-Reported Incident Report, dated 05/20/2022 at 12:30 PM, revealed Resident #1 was observed in room sixty (60) bed one (1) with his/her hand on other residents brief. The facility's 5-day final report of the investigation, signed by the former Administrator, revealed on 05/20/2022, Resident #1 was noted by staff to have his/her hand under Resident #2's bottom. The facility determined no abuse occurred. Review of the facility's investigation file reveals no staff or witness interviews were conducted. In an interview on 09/24/2022 at 6:05 PM, Resident #2's family, Family Member #2, revealed the facility called and told her a resident wandered into Resident #2's room and placed his/her hand on Resident #2's bottom. Per the interview the resident was wearing a brief. Further, the Family Member #2 revealed the resident probably did not remember. Review of the Facility's Self-Reported Incident Report of 05/20/2022 at 12:30 PM, revealed Resident #1 was in Resident #2's room with his/her hand on his/her brief. Further review of the Incident Report revealed Resident #1 was asked what he/she was doing and Resident #1 responded, I don't know. In an interview with State Registered Nursing Assistant (SRNA) #6 on 09/22/2022 at 10:58 AM, revealed Resident #1 was sexually inappropriate with her. She further stated that in May, she assisted another SRNA with Resident #1's roommate, the resident attempted to grab her bum. In an interview on 09/22/2022 at 8:17 AM, with Registered Nurse (RN) #1 revealed said Resident #1 wandered quite a bit. RN #1 stated on 05/20/2022, the aide (unknown) reported Resident #1 was found by Resident #2's bed with his/her hand on the resident's backside, with his/her brief on. Interview on 09/22/2022 at 9:40 AM, revealed the Social Services Director (SSD) said Resident #1 had dementia. Per the interview, the resident was known to be sexually inappropriate with female staff, often observed as groping them. Further interview revealed she referred the resident to have a Psychiatry consult due to the behaviors identified with staff; however, was unaware Resident #1 had touched Resident #2 on his/her bottom. Per the interview, the SSD stated staff should have increased the resident's level of supervision when the resident was being sexually inappropriate with staff. In a subsequent interview on 09/23/2022 at 10:42 AM, the SSD stated abuse was defined as any willful harm to anyone physical, sexual, socially isolating the resident, and verbal. She further stated that the incident, on 05/20/2022, between Resident #1 and Resident #2 could be defined as abuse. She further added that Resident #1 touching Resident #2 on the bottom over his/her brief was inappropriate. In an interview on 09/23/2022 at 1:22 PM, the Director of Nursing (DON) revealed the resident wandered throughout the facility. Further interview revealed the resident should have had interventions in place to prevent episodes of possible abuse. In an interview, on 09/23/2022 at 11:11 AM, the Regional [NAME] President of Operations (RVPO), revealed it was the expectation that residents would not wander into each others rooms. Per the interview, the RVPO stated it was the facility's responsibility to ensure the safety of the residents, adding the residents had the right to be free from abuse. Further interview with the RVPO revealed Resident #2 had the right to be free from inappropriate touching by Resident #1.

Based on observations, interviews, and record reviews, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of seven (7) sampled residents to increase supervision and prevent accidents/incidents related to wandering. On 05/15/2022 Resident #1 wandered into Resident #3's room and attempted to get in bed with him/her causing an unwitnessed fall. The facility failed to revise Resident #1's Care Plan to provide supervision and monitoring to protect Resident #1, as well as, Resident #3 and other residents. On 05/20/2022, Resident #1 wandered into Resident #2's room and touched his/her bottom area over his/her brief. The findings include: The Facility's Policy titled, Care Plan Goals and Objectives, dated 08/01/2013, stated the Care Plan would incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The Policy further stated Goals and Objectives were reviewed and/or revised when there had been a significant change in condition. Review of the facility's policy titled, Care Plans - Comprehensive, dated 08/01/2013, revealed the Comprehensive Care Plan was based on a thorough assessment that included, but was not limited to, the Minimum Data Set (MDS) and was designed to incorporate identified problem areas. The policy stated, Care Plan interventions were designed after careful consideration of the relationship between the residents' problem areas and their causes. Identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident were interdisciplinary processes that required careful data gathering, proper sequencing of events, and complex clinical decision making. The policy also stated, Resident Assessments were ongoing, and the Care Plan would be revised as the residents information and condition changed. The policy further stated, the Care Planning/Interdisciplinary Team was responsible for updating the resident's care plan when desired outcomes were not met or a change in the resident's condition. Review of the facility's policy titled, Care Planning-Interdisciplinary Team, dated 08/20/2020, revealed the facility's care planning/interdisciplinary team were responsible for the development of person-centered individualized Comprehensive Care Plan for each resident. The policy interpretation and implementation section revealed with every residents change in status assessment there would be a Care Plan Conference. Further review of the policy, revealed the Social Worker/Activity Director would make a Care Plan Note in the Resident's Electronic Medical Record (EMR). Review of the facility's protocol titled, Elopement/Wander Risk, item one (1) stated it was the expectation that this facility was to ensure that each resident received adequate supervision and assistance to prevent accidents. The protocol stated, Hourly checks would be performed and documented on each resident who was evaluated to be at risk. The protocol also stated possible interventions for residents that wander included frequent monitoring. Interview with the [NAME] President of Clinical Operations (VP), on 09/29/2022 at 1:29 PM, revealed the protocol, which addressed frequent monitoring, would apply to residents who wandered. Review of the Long-Term Care Facility's - Self-Reported Incident Report, dated 05/20/2022 at 12:30 PM, reported by Licensed Practical Nurse (LPN) #4, revealed Resident #1 was in room sixty (60) bed one (1) with his/her hand on other resident's brief. Review of the facility's five (5)-day final report of the investigation, signed by the former Administrator, revealed on 05/20/2022, Resident #1 was noted by staff to have his/her hand under Resident #2's bottom. Record review revealed the facility admitted Resident #1, on 12/23/2021, with the Diagnoses of Anxiety Disorder, Dementia with Behavioral Disturbance, and Recurrent Depressive Disorders. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #1 to have a BIMS score of six (6), which indicated thee resident was severely impaired cognitively. Record review of Resident #1's care plan related to his/her Behavioral Symptoms Dementia included wandering into others rooms and trying to get in bed with other residents, tickling another resident's feet, sexually inappropriate, touching female employees' chest, and making inappropriate remark's. Resident #1's Care Plan Interventions for these behaviors were: Allow space and re-approach later if resident was resistant to care, Keep environment as calm as possible, Place Stop sign in front of door to decrease wandering into others rooms, Provide distractions from inappropriate behaviors and encourage resident to participate in activities of interest, and redirect resident when he/she exhibits target behaviors. However, continued review of the resident's care plan revealed no interventions to include increased supervision or frequent monitoring to address the resident's wandering . Record review of Resident #1's Minimum Data Set (MDS) assessment, dated 07/05/2022, revealed the resident did not exhibit wandering behavior. In an interview on 09/22/2022 at 10:58 AM, State Registered Nursing Assistant (SRNA) #6 revealed Resident #1 wandered into residents' rooms, mainly at night. The SRNA revealed that on 05/15/2022, the resident was observed in Resident #3's room holding his/her hand after experiencing an unwitnessed fall. In an interview on 09/22/2022 at 8:17 AM, Registered Nurse (RN) #1 stated Resident #1 wandered quite a bit about two (2) or three (3) months ago. RN #1 stated on 05/20/2022, the aide (unknown) reported Resident #1 was found by Resident #2's bed with his/her hand on the resident's backside. Per the interview, RN #1 stated that because the resident expressed such behavior with staff, this would not have been out of character for the resident. In an interview on 09/22/2022 at 9:08 AM, the Former Unit Coordinator revealed Resident #1 had previous falls. The Former Unit Coordinator said that increased supervision and stop-sashes were two things that could be on the Resident #1's Care Plan to address the resident's wandering. The Former Unit Coordinator stated if a resident wandered into another resident's room and tried to get in bed with a resident, his/her expectation of staff, was that they would remove the resident and increase supervision. Further interview revealed the resident's care plan should have been revised to prevent accidents/incidents related to wandering. Interview on 09/22/2022 at 9:40 AM with the Social Services Director (SSD) revealed Resident #1's Care Plan indicated the resident was sexually inappropriate and wandered into residents' rooms. She stated interventions were to place a stop-sash, provide distraction, and redirection. Further interview with the SSD revealed it was the responsibility of nursing to place the resident on increased and/or frequent monitoring. She further stated supervision should have increased. The SSD revealed she was aware of the resident being sexually inappropriate with facility staff, but was unaware of the resident wandering into other residents' rooms nor was she aware the resident touched Resident #2 on his/her bottom. She stated the resident's care plan should have been revised for increased monitoring when the resident was sexually inapposite with staff. In an interview on 09/22/2022 at 2:40 PM Minimum Data Set (MDS) Coordinator #1 said Resident #1 was not a wander risk at this time. She stated the interventions on the resident's care plan were working. Per the interview, the MDS revealed she attended the Interdisciplinary Team (IDT) meetings every morning and they reviewed behaviors and discussed complaints or anything that affects the residents. The MDS Coordinator revealed she recalled the IDT discussing Resident #1 being found to have his/her hand placed on another Resident's brief. The MDS Coordinator said the new interventions put in place related to that incident was a stop-sash on Resident #2's door. Further interview with the MDS revealed the resident was placed on every fifteen (15) minute checks after the incident that occurred on 05/20/2022; however, the resident's care plan was not revised to reflect the interventions. Continued interview with the MDS Coordinator, on 09/22/2022 at 2:40 PM, revealed the facility included an intervention to the resident's care plan to add a stop-sash to the residents' doors, when a concern was identified. The MDS Coordinator #1 stated that when the resident fell , while in Resident #3's room, after wandering into his/her room and making the statement, he/she was attempting to get in bed with the resident, the resident's care plan was not revised with new interventions. She stated the stop-sash was added to the other resident's doorway to keep Resident #1 out of that room. Further interview revealed that the expectation of staff would be that the resident's care plan would be revised and updated to reflect the concerns identified with the residents. In an interview on 09/23/2022 at 1:22 PM with the Director of Nursing (DON), she revealed Resident #1's care plan was revised to include a stop-sash to prevent Resident #1 from wandering into Resident #3's room. Further interview with the DON revealed the facility should have put up a stop sign on all the residents' doors, which may have helped to prevent the resident from wandering into Resident #2's room. Further interview with the DON revealed she did not know what other interventions should have been put in place, other than a twenty-four (24) hour supervision. In an interview, on 09/23/2022 at 11:11 AM, the Regional [NAME] President of Operations (RVPO), revealed it was the expectation that residents would not wander into each others rooms. Per the interview, the RVPO stated it was the facility's responsibility to ensure the safety of the residents. Further interview with the RVPO revealed Resident #2 had the right to be free from inappropriate touching by Resident #1.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to ensure the residents were provided an environment free from accidents or incidents for two (2) of seven (7) sampled residents (Resident #1 and Resident #4). 1. Record review revealed Resident #1 wandered throughout the facility and often went into other female residents' rooms without staff oversight. On [DATE], the resident was observed in Resident #3's room on the floor. Resident #1 expressed to staff he/she was attempting to get into bed with the resident. However, further record review revealed the facility failed to ensure the resident was provided increased supervision after the resident wandered into Resident #3's room and failed to ensure the safety of the resident after his/her unwitnessed fall. 2. Additionally, on [DATE], Resident #1 wandered into Resident #2's room, without the oversight/supervision of staff, and was discovered by staff to have touched Resident #2's bottom area, outside of his/her brief. However, interviews and record review revealed the facility failed to increase the resident's level of supervision after the incident. 3. Furthermore, record review and interviews revealed Resident #4 had a history of wandering into other residents' rooms and a history of unwitnessed falls. Observation on [DATE] at 2:45 PM revealed Resident #4 wandered into room (fifty-eight) 58, which was not the resident's room. Continued observation revealed Resident #4 wandered without staff supervision or staff awareness, which increased the risk of accident and/or injury. The findings include: Review of the Facility's Policy titled, Accident /Incidents, dated [DATE], revealed an accident/injury, regardless of how minor, would be reported to the Director of Nursing (DON) and Administrator and an accident/incident report would be completed on the shift the incident occurred. The Policy also stated an Incident Report would be completed and submitted to the DON. Further review of the policy reveled the facility would provide a safe and healthful environment. Review of the facility's protocol, titled Elopement/Wander Risk Protocol, not dated, revealed it was the expectation that the facility would ensure each resident received adequate supervision and assistance to prevent accidents. Continued review of the protocol revealed an intervention to address residents who wandered was to provide frequent monitoring. 1. Review of the facility's self-reported incident report, dated [DATE], revealed that on [DATE] at 5:29 AM, Registered Nurse (RN) #1 documented Resident #1 was found on the floor, in Resident #3's room, next to his/her bed. Further review revealed Resident #1 stated he/she was trying to get into bed with Resident #3. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with diagnoses to include Anxiety Disorder, Dementia with Behavioral Disturbance, and Recurrent Depressive Disorders. Review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was severely impaired. Record review revealed the facility admitted Resident #1 on [DATE], with diagnoses to include Anxiety Disorder, Dementia with Behavioral Disturbance, and Recurrent Depressive Disorders. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was severely impaired. Review of Resident #1's Care Plan, with no indication of when the care plan was initiated or revised, revealed the resident was care planned for Behavioral Symptoms Dementia to include: wandering into others' rooms and trying to get in bed with other residents, tickling another resident's feet, sexually inappropriate, touching female employees' chest, and making inappropriate remarks. Further review of the resident's care plan; however, did not include interventions to include frequent monitoring, when the resident was assessed to wander, as per the facility's wandering protocol. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE] with diagnoses of Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #3 to have a BIMS score of nine (09), which indicated the resident was moderately cognitively intact. Record review of Resident #3's Care Plan, with no indication of when the care plan was initiated or revised, revealed the Resident was care planned for Impaired Cognitive Thought Process, Argumentative and Hollering out at Staff, Confused, Screaming, Angry Outburst, arguing with another Resident, and Cursing at another Resident. In an interview on [DATE] at 10:58 AM, State Registered Nursing Assistant (SRNA) #6 stated Resident #1 wandered into residents' rooms, mainly at night. The SRNA revealed that on the night of the incident, on [DATE], Resident #1 was found on the floor of Resident #3's room. Continued interview revealed the resident was found holding Resident #3's hand and she assisted the charge nurse with exhorting the resident out of Resident #3's room. In an interview on [DATE] at 8:17 AM, Registered Nurse (RN) #1 stated Resident #1 was found on the floor of Resident #3's room. Further interview with RN #1 revealed the resident reported to her that he/she attempted to get into bed with Resident #3; however, missed the bed and was found sitting on the floor by Resident #3's bed. Per the interview, RN #1 revealed she notified the Director of Nursing (DON) related to the incident. In an interview on [DATE] at 12:41 PM, the Director of Nursing (DON) stated she was not aware of the incident that occurred between Resident #1 and Resident #3. The DON stated she did not recall the incident being discussed in morning interdisciplinary meetings. 2. Record review of the self-reported incident report, dated [DATE], revealed Resident #1 was discovered in Resident #2's room with his/her hand on Resident #2's brief (back side). Further review revealed Resident #1 was asked what he/she was doing and the resident replied, I don't know. Record review revealed the facility admitted Resident #1 on [DATE], with diagnoses to include Anxiety Disorder, Dementia with Behavioral Disturbance, and Recurrent Depressive Disorders. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was severely impaired. Review of Resident #1's Care Plan, with no indication of when the care plan was initiated or revised, revealed the resident was care planned for Behavioral Symptoms Dementia to include: wandering into others' rooms and trying to get in bed with other residents, tickling another resident's feet, sexually inappropriate, touching female employees' chest, and making inappropriate remarks. Further review of the resident's care plan; however, did not include interventions to include frequent monitoring, when the resident was assessed to wander, as per the facility's wandering protocol. Record review revealed the facility admitted Resident #2, on [DATE], with diagnoses to include Alzheimer's disease, Anxiety Disorders, Lack of Coordination, and Cognitive Communication Deficit. Review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #2 with a BIMS score of ninety-nine (99), which indicated the resident unable to complete the interview. Review of Resident #2's Care Plan, with no indication of when the care plan was initiated or revised, revealed the resident was care planned for Cognitive Thought Process Impairment and was very skittish and scared of men. Further review of the resident's care plan revealed the resident was to have only female staff to provide care. In an interview on [DATE] at 8:17 AM, Registered Nurse (RN) #1 revealed that on the date of the incident, [DATE], the aide (unknown) reported Resident #1 was found in Resident #2's room by his/her bed with his/her hand on Resident #2's backside. Per the interview with RN #1, Resident #1 had a habit for grabbing female aides, so this behavior was not out of character for the resident. Interview on [DATE] at 9:18 AM, with Resident #1's family, Family Member #1, revealed the facility notified the family member in May that Resident #1 went into other residents' rooms and was found in a female resident's room where he/she touched another resident. In an interview on [DATE] at 6:05 PM, Resident #2's family, Family Member #2, stated the facility notified the family member that a resident wandered into Resident #2's room and touched him/her on his/her bottom. Per the interview with Family Member #2, she did not believe Resident #2 remembered the incident and believed the facility was keeping a closer eye on the resident that wandered into Resident #2's room. In an interview, on [DATE] at 2:40 PM, with the Minimum Data Set (MDS) Coordinator #1 revealed Resident #1 wandered in May of 2022 and interventions were put in place to prevent unsafe wandering. Per the interview with the MDS Coordinator, she stated the intervention included placing a stop-sash across the door, which was added to the resident's care plan. The MDS Coordinator #1 stated Resident #1 was easily redirected, and the stop-sash worked. In an interview on [DATE] at 9:40 AM, the Social Services Director (SSD) said Resident #1 had dementia and had episodes of being sexually inappropriate with female staff. The SSD stated supervision should have increased after the incidents with staff. Per the interview, the SSD stated the care plan was not updated to include supervision, as it was a nursing measure. Further interview with the SSD revealed she was unaware Resident #1 had touched Resident #2 on his/her bottom over his/her brief on [DATE]. A continued interview with the SSD, on [DATE] at 9:40 AM, revealed she requested the resident to have a psychiatry consult due to the resident being inappropriate with staff. In an interview on [DATE] at 1:22 PM, the Director of Nursing (DON) revealed it was her expectation that interventions would be put in place for the safety of the resident. She further stated that if staff were aware of the residents' wandering behaviors, the behaviors should be care planned to prevent future episodes/incidents. 3. Record review revealed the facility admitted Resident #4 on [DATE], with the Diagnoses of Major Depressive Disorder, Anxiety Disorder, and Delusional Disorders. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #4 with a BIMS score of three (3), which indicated the resident was severely cognitively impaired. Record review of Resident #4's Care Plan, with no indication of when the care plan was initiated or revised, revealed the resident was care planned for Impaired Physical Mobility, Alzheimer's, Dementia, Psychosis, Elopement Risk with Exit Seeking Tendencies, Dementia with Poor Safety Awareness, Yells at Staff, Has Wandered Naked, Hitting/Grabbing/Kicking/Pushing/Scratching and Threatening Staff, Wandering, Yelling at Roommate, Looking for his/her Spouse (spouse was deceased ), Attempting to Feed other Residents and Removed non-skid socks. However, the facility failed to include interventions related to frequent monitoring of the resident as it related to the facility's wandering protocol. Review of Resident #4's medical record, dated [DATE], revealed the resident wandered around the unit without his/her wheelchair or walker and fell without injury noted. Review of the facility's Incident Investigations, dated [DATE], revealed on [DATE], Resident #4 stood up from his/her wheelchair, without brakes locked, and the resident fell backwards on the ground. Continued review revealed a skin tear resulted from the incident. Review of the resident's medical records, dated [DATE] at 10:11 AM, revealed an incident report was completed based on Resident #4's unwitnessed fall without injury on [DATE]. According to the record, Resident #4 spilled water on the floor and slipped on the wet floor. Observation, on [DATE] at 2:45 PM, Resident #4 wandered into room [ROOM NUMBER], which was not his/her room, without staff oversight. Resident #4 appeared confused and wandered to the second bed in the room, by the window. There were two (2) residents in the room in their respective beds. Resident #4 stated, I need food for my husband, paused at the sink for a minute, and wandered out of the room back into the hallway. An observation on [DATE] at 10:50 AM, revealed Resident #4 ducked under the stop-sash across his/her door, stood outside the room, removed the sash and wandered to his/her recliner in his/her room and sat down. In an observation on [DATE] at 10:55 AM, the receptionist replaced the stop-sash on Resident's #4's door. On observation, [DATE] at 11:00 AM, Resident #4 wandered into Resident #8's Room, Room fifty-seven (57), subsequently the Receptionist, went into the room and directed the resident to the nurses' station. In an interview at that time, the Receptionist said she was not a certified assistant and could only do certain tasks. Per the interview, she stated the resident was difficult to redirect at times. In an interview with Resident #8, on [DATE] at 11:05 AM, after Resident #4 wandered into and out of Resident #8's room, he/she said Resident #4 took the stop-sash down and walked into his/her room. Resident #8 stated the resident did not bother him/her but just did not want Resident #4 to fall. In an interview on [DATE] at 10:30 AM, with State Registered Nurse Aide (SRNA) #8, revealed she had observed Resident #4 wandering into other residents' rooms. SRNA #8 stated the intervention in place that prevented wandering was the red stop-sash across the resident's door. Interview on [DATE] at 4:42 PM with SRNA #2 revealed Resident #4 wandered from Station three (3) over to Station one (1), where SRNA #2 was working, and she took the resident back to Station three (3). Continued interview revealed Resident #4 required extra supervision because he/she wandered a lot. SRNA #2 stated she was not required to document or provide additional supervision for the resident. On [DATE] at 11:00 AM, in an interview with Licensed Practical Nurse (LPN) #3 stated Resident #4 often wandered into other residents' rooms. LPN #3 revealed activities sometimes takes Resident #4 to an activity. The LPN revealed Resident #4 had a guard-bracelet that would alarm if he/she got close to the exits. LPN #3 stated the red stop-sash was intended to keep the resident from wandering into residents' rooms. Continued interview with LPN #3 revealed Resident #4 had unwitnessed falls, adding the resident, fell yesterday. In an interview on [DATE] at 8:17 AM, RN#1 said Resident #4 wandered into other resident rooms and was very difficult to redirect. RN #1 revealed that if the resident got fixated on something he/she would not be easily redirected. Continued interview with RN #1 revealed the resident should have been care planned for increased supervision during times of when he/she wondered to assist with the resident's safety. In an interview on [DATE] 9:08 AM, the Former Unit Coordinator/LPN said he/she worked at the facility as Unit Coordinator Coordinator and is now 'as needed' staff. The former Unit Coordinator said Resident #4 wandered but staff tried to redirect when he/she went into resident rooms. He/She said some residents didn't like it, so staff put the stop-sashes up to deter Resident #4. He/She said the resident needed increased supervision- and would have expected staff to increase supervision when Resident #4 wandered. The former Unit Coordinator said, I don't know how we would care plan that. In an interview on [DATE] at 1:32 PM, the Administrator stated she had been the Director of Nursing (DON) of the facility since [DATE] until about two (2) months ago when she became the Administrator. She stated Resident #4 wandered constantly. The Administrator revealed Psychiatry was involved and there should have been interventions on Resident #4's care plan to ensure the safety of the resident while wandering.

Based on interview and record review it was determined the facility failed to review and update the facility assessment when there was a change in facility administration and failed to address the facility's resident population with regards to a resident with bariatric needs. (Refer to F558) The findings included: Review of the Facility Assessment Tool revealed the date of the assessment was 12/07/2020. The assessment did not have the name of the current Administrator or current Director of Nursing (DON) listed as persons who were involved in completing the assessment. Further review of the assessment revealed the section titled Our Resident Profile did not include residents with bariatric needs. Observation of Resident #94 on 08/03/2021 at 10:15 AM and interview with Resident #94 on 08/04/2021 at 1:08 PM revealed the resident did not have a chair in his/her room to allow the resident time out of bed and could only receive bed baths because the facility did not have a shower chair that would accommodate the resident or another means for the resident to shower. Interview with the Rehabilitation Director, on 08/09/2021 at 2:05 PM, revealed Resident #94 required the use of a specialty shower chair due to the resident's condition of a pendulous abdomen. Interview with the DON on 08/11/2021 at 2:58 PM revealed she began as DON of the facility in March of 2021. She stated she had reviewed the Facility Assessment on 07/13/2021 and noted that the administrative staff was not correct. The DON stated she asked at that time if corrections needed to be made to the document. She stated she was told that the Administrator made changes to the document. Further interview with the DON revealed the facility had two (2) residents with bariatric needs and the facility assessment did not address or assess the needs of those residents. Interview with the Administrator on 08/11/2021 at 4:02 PM revealed she had been the administrator of the facility since February 2021. She stated she was aware the Facility Assessment was not current and did not include information about residents with bariatric needs. She stated the updates had not been completed because she thought it was only required annually and therefore would not have been due to be changed until December 2021. The Administrator stated she was unaware the Facility Assessment needed to updated when there were changes at the facility.

Based on observation, interview and review of facility policy, the facility failed to provide a clean comfortable homelike environment. Sinks were observed to be clogged in resident rooms #66 and #68. The hopper flush sinks in the soiled utility rooms on Station one, two and three were not flushing and the water from the sink faucets was dark brown/rust colored. The findings include: A review of the facility maintenance policy titled Maintenance Service dated 08/01/2013 reveled the Maintenance Department was responsible for maintaining the building and equipment in a safe operable manner at all times. A review of the facility work orders/maintenance request on 08/11/2021 revealed no outstanding work orders for non-working or clogged sinks in resident rooms or in soiled utility rooms. Observations of sinks in resident rooms #66 and #68 on 08/03/2021 during the initial tour at 10:30 AM, on 08/04/2021 at 10:40 AM, and on 08/11/2021 at 9:20 AM revealed the sinks were clogged and would not drain water. Observations of the hopper flush sinks in the soiled utility rooms on Station one, two and three on 08/11/2021 at 9:40 AM, revealed the sinks were not working and flushing properly. Brown/rust discolored water came from the faucets when turned on. Interview with the Maintenance Director, on 08/11/2021 at 9:45 AM, revealed maintenance had worked on the sinks in rooms [ROOM NUMBERS] but was not aware the sinks were currently not draining or clogged. Further interview with the Maintenance Director revealed he was not aware the hopper sinks were not working. According to the Maintenance Director, maintenance staff make rounds weekly to identify concerns and had not identified the problems with the sinks (not draining and not working).

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the plan of care for six (6) out of twenty two (22) sampled residents (Residents #1, #41, #59, #69, #96, and #101) related to personal hygiene. Review of the individualized care plans for Residents #1, #41, #59, #69, #96, and #101, revealed the residents were to have a showers twice weekly and bed baths, five (5) days per week, on the days showers were not completed. Review of the bathing documentation, revealed the Resident #1, #41, #59, #69, #96, and #101 were not receiving showers twice weekly. The findings include: Review of the facility's policy titled, Care Plan, Comprehensive, dated 08/01/2013, revealed each care plan was designed and implemented to reflect the resident's wishes regarding care and treatment goals. The policy stated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. 1. Review of the closed record review for Resident #1 revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record further revealed the resident had been discharged from the facility on 07/27/2021. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. The MDS revealed Resident #1 required the extensive assistance of one person for bathing. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #1 with an admitted [DATE], revealed resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:30 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Wednesdays and Saturdays, and would receive a bed bath on all other days. Review of bathing documentation for Resident #1, revealed the resident was to receive a shower on 07/21/2021 and 07/24/2021; however, the documentation revealed the resident had received a bed bath instead. Interview conducted with SRNA #11, on 08/10/21 at 11:04 AM, revealed the Kiosk is where the information was kept regarding the care needs of a resident. The SRNA stated she was required to check the Kiosk before providing care to check for changes. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/24/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in (staff not reporting to work as scheduled). Interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed the care plan and the Kiosk were where the information was kept regarding the care needs of a resident. The SRNA stated she was required to check the Kiosk before providing care to check for changes. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/21/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in. The SRNA stated it had probably been hectic that day. 2. Review of the medical record for Resident #69, revealed the facility had admitted the resident on 05/29/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current quarterly MDS dated [DATE], revealed the resident had been assessed to have BIMS score of twelve (12) which indicated the resident had moderately impaired cognition. The MDS also revealed Resident #69 had been assessed to require the extensive assistance of one staff for bathing. Review of a SRNA care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #69 with an admitted [DATE], revealed resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:35 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Sundays and Thursdays, and would receive a bed bath on all other days. Review of bathing documentation for Resident #69, revealed the resident scheduled to receive a shower on 07/18/2021, 07/25/2021, 08/01/2021, and 08/08/2021; however, the documentation revealed the resident had received a bed bath on those days instead. Observation of Resident #69 on 08/03/2021 at 2:45 PM, revealed the resident was lying in the bed on his/her back. The resident was observed to be clean and well [NAME] with no odors observed. Interview conducted with Resident #69 on 08/03/2021 at 2:45 PM, revealed he/she only got a shower once a week. The resident stated he/she was given a bed bath everyday except the shower day. The resident stated he/she would like to have a shower more often. The resident was not aware why he/she had not been given a shower twice a week. Interview conducted with SRNA #12, on 08/10/2021 at 10:52 AM, revealed she had been responsible for completing a shower for Resident #69 on 08/08/2021. The SRNA stated she could not remember if she had given a bed bath or a shower, but stated if she had documented a bed bath that was what she had done. The SRNA stated she should have completed a shower and could have been call-ins that day. The SRNA stated she was required to check the Kiosk before providing care due to things could have changed. Interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed the care plan and the Kiosk were where the information was kept regarding the care needs of a resident. The SRNA stated she was required to check the Kiosk before providing care to check for changes. The SRNA stated Resident #69 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #69 on 07/18/2021, 07/25/2021, and 08/01/2021 and had no idea why she had given the resident a bed bath instead of a shower. The SRNA stated she should have given Resident #69 a shower instead of a bed bath on those days. 3. Review of the record for Resident #41 revealed the facility admitted the resident on 04/03/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS for Resident #41 with a reference date of 06/03/2021 revealed the resident required the physical assistance of one (1) person for bathing. The comprehensive care plan (undated) included the focus area of ADL deficit related to physical functioning that was dated 04/01/2019 and the goal was for the resident to have ADL care needs met daily. The interventions included staff assistance of one (1) with bathing per schedule and as needed. Review of the computer Kiosk where SRNA's document care revealed Resident #41 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Sundays and Thursdays, and would receive a bed bath on all other days. Interview with the Resident #41 on 08/05/21 at 10:29 AM during the resident council interviews revealed the resident stated it had been a week or two since he/she had received a shower and maybe longer. Review of the shower records for Resident #41 revealed from 07/21/2021 - 08/10/2021, Resident #41 received only one (1) shower on 07/22/2021, and not twice weekly as directed on the care plan. 4. Review of the record for Resident #59 revealed the facility admitted the resident on 01/21/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS with a reference date of 06/22/2021 revealed Resident #59 required physical assistance from one (1) staff person for bathing. Further review of the MDS revealed the resident's BIMS score was three (3) indicating severe cognitive impairment. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan (undated) revealed the resident had ADL self-care performance deficit with a goal for the resident to maintain current level of function in ADL status with a target date of 10/05/2021. The interventions included for staff to assist with bathing. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed Resident #59 was to have a shower twice weekly on Sunday and Thursday with bed baths in between. Further review of the documentation revealed from 07/11/2021 through 08/09/2021, Resident #59 only received four (4) showers (on 07/18/2021, 07/29/2021, 08/02/2021, and 08/05/2021) and did not receive showers twice weekly. 5. Review of the record for Resident #96 revealed the facility admitted the resident on 10/31/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment which was a quarterly assessment with a reference date of 07/12/2021 revealed the resident's BIMS score was fifteen (15) indicating that the resident was cognitively intact. Further review of the MDS revealed the resident required the physical assistance of one (1) staff for bathing. Review of the comprehensive care plan (undated) revealed that the focus area of ADL self care performance deficit related to impaired mobility was initiated on 11/14/2017 with the goal for the resident to be clean and odor free per staff assistance and the interventions included one (1) staff was to assist with bathing. Interview with Resident #96 on 08/05/2021 at 10:02 AM revealed the resident stated he/she was supposed to get two (2) showers per week, but it had been two (2) weeks since he/she had received a shower. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed Resident #96 was to have a shower twice weekly on Tuesday and Friday. Review of the shower records for Resident #96 from 07/21/2021 through 08/10/2021 revealed that only bed baths had been documented for Resident #96 and showers had not been given twice weekly in accordance with the care plan. 6. Review of the record for Resident #101 revealed the facility admitted the resident on 03/05/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS which was a quarterly assessment with a reference date of 07/15/2021 revealed the BIMS score had not been obtained because the resident was rarely/never understood and the assessment further revealed the resident's cognitive skills for decision making were severely impaired. Further review of the MDS assessment revealed Resident #101 was totally dependent on staff for bathing. Review of the comprehensive care plan (undated) revealed that the resident had a ADL self care performance deficit related to confusion, impaired balance and limited mobility. The care plan interventions stated that the resident required total assistance for bathing. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed Resident #59 was to have a shower twice weekly on Wednesday and Saturday. Further review of the shower records for resident #101 from 07/11/2021 through 08/09/2021 revealed the resident received four (4) showers (on 07/14/2021, 07/17/2021, 07/21/2021, and 07/28/2021) and bed bath was recorded for all other days during that time period. The resident did not receive showers twice weekly according to the care plan. Interview conducted with the Director of Nursing (DON), on 08/11/2021 at 2:54 PM, revealed residents were to have showers twice a week unless the resident wanted a shower more often or if the resident refused. The DON stated she had not been aware showers were not being done as required. The DON stated the information regarding when a resident was to be showered as well as the assistance and support required was kept in the Kiosk in the computer. The DON stated the potential concern for a resident not getting a shower twice a week was infection control issues, dignity, and depression. The DON stated SRNAs were required to check the Kiosk before providing care. The DON stated she monitored for implementing the care plan by making rounds daily. The DON stated she had not identified any concerns with staff not following the care plan. Interview conducted with the Administrator, on 08/11/2021 at 4:03 PM, revealed she made rounds daily to ensure residents were being provided with the care they required. The Administrator stated she had not identified any concerns with residents not being provided with the care they required as directed in the care plan. The Administrator stated showers were expected to be done twice a week unless the resident refused.

Based on observation, interview, record review, it was determined the facility failed to ensure six (6) of twenty two (22) sampled residents (Resident #1, #41, #59, #69, #96, and #101) received the necessary care and services to maintain grooming and hygiene. Review of facility bathing documentation, revealed residents were to have received showers twice weekly. However, review of bathing documentation for Residents #1, #41, #59, #69, #96, and #101, revealed the residents were not receiving showers twice weekly. The findings include: Interview conducted with the Corporate Nurse on 08/05/2021 at 11:10 AM, revealed the facility did not have a policy on showers. The Corporate Nurse revealed the expectation was for showers to be completed at least twice weekly unless the resident refused. A bed bath was to be completed on days between showers. The Corporate Nurse stated if the resident wanted a bath more frequently than twice weekly, it would be provided. 1. Review of Resident #1's closed record, revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record further revealed the resident had been discharged by the facility on 07/27/2021. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. The MDS revealed Resident #1 required the extensive assistance of one person for bathing. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #1 with an admitted [DATE], revealed the resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:30 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Wednesdays and Saturdays, and would receive a bed bath on all other days. Review of Resident #1's bathing documentation, revealed the resident was scheduled to receive a shower on 07/21/2021 and 07/24/2021; however, the documentation revealed the resident had received a bed bath instead. An interview conducted with SRNA #11, on 08/10/2021 at 11:04 AM, revealed the Kiosk is where the information was kept regarding the care needs of a resident. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/24/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in (staff not reporting to work as scheduled). An interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed residents were required to be showered twice weekly. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/21/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in. The SRNA stated it had probably been hectic that day. 2. Review of the medical record for Resident #69, revealed the facility had admitted the resident on 05/29/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current quarterly MDS dated [DATE], revealed the resident had been assessed to have BIMS score of twelve (12)which indicated the resident had moderately impaired cognition. The MDS also revealed Resident #69 had been assessed to require the extensive assistance of one staff for bathing. Review of a SRNA care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #69 with an admitted [DATE], revealed resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:35 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Sundays and Thursdays, and would receive a bed bath on all other days. Review of Resident #69's bathing documentation, revealed the resident was scheduled to receive a shower on 07/18/2021, 07/25/2021, 08/01/2021, and 08/08/2021; however, the documentation revealed the resident had received a bed bath on those days instead. Observation of Resident #69 on 08/03/2021 at 2:45 PM, revealed the resident was lying in the bed on his/her back. The resident was observed to be clean and well [NAME] with no odors observed. Interview conducted with Resident #69 on 08/03/2021 at 2:45 PM, revealed he/she only got a shower once a week. The resident stated he/she was given a bed bath everyday except the shower day. The resident stated he/she would like to have a shower more often. The resident was not aware why he/she had not been given a shower twice a week. An interview conducted with SRNA #12, on 08/10/21 at 10:52 AM, revealed she had been responsible for completing a shower for Resident #69 on 08/08/2021. The SRNA stated she could not remember if she had given a bed bath or a shower, but stated if she had documented a bed bath that was what she had done. The SRNA stated she should have completed a shower but could have been call-ins that day. An interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed Resident #69 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #69 on 07/18/2021, 07/25/2021, and 08/01/2021 and had no idea why she had given the resident a bed bath instead of a shower. The SRNA stated she should have given Resident #69 a shower instead of a bed bath on those days. 3. Review of the record for Resident #41 revealed the facility admitted the resident on 04/03/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Resident #41 on 08/05/21 at 10:29 AM during the resident council interviews revealed the resident stated it had been a week or two since he/she had received a shower and maybe longer. Further interviews at the time of the Resident Council interviews revealed Resident #41 stated that certain staff were assigned each day to give showers, but when there were call ins the staff would be pulled to work other areas and the showers would not be given. Observations of the resident during the interview revealed the resident was clean and well groomed with no odors noted. Further review of the MDS for Resident #41 with a reference date of 06/03/2021 revealed the resident required the physical assistance of one (1) person for bathing. The comprehensive care plan (undated) included the focus area of ADL deficit related to physical functioning that was dated 04/01/2019 and the goal was for the resident to have ADL care needs met daily. The interventions included staff assistance of one (1) with bathing per schedule and as needed. Review of the shower records for Resident #41 revealed from 07/21/2021 - 08/10/2021, Resident #41 received one (1) shower. 4. Review of the record for Resident #59 revealed the facility admitted the resident on 01/21/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS with a reference date of 06/22/2021 revealed Resident #59 required physical assistance from one (1) staff person for bathing. Further review of the MDS revealed the resident's BIMS score was three (3) indicating severe cognitive impairment. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan (undated) revealed the resident had ADL self-care performance deficit with a goal for the resident to maintain current level of function in ADL status with a target date of 10/05/2021. The interventions included for staff to assist with bathing. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed from 07/11/2021 through 08/09/2021, Resident #59 only received a shower on 07/18/2021, 07/29/2021, 08/02/2021, and 08/05/2021. Bed baths were documented on all of the other days during that time period. Observation of Resident #59 on 08/03/2021, 08/04/2021, 08/05/2021, 08/06/2021, 08/08/2021, 08/09/2021, and 08/10/2021 revealed the resident was independently ambulatory and appeared clean and well groomed with no odors noted. 5. Review of the record for Resident #96 revealed the facility admitted the resident on 10/31/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment which was a quarterly assessment with a reference date of 07/12/2021 revealed the resident's BIMS score was fifteen (15) indicating that the resident was cognitively intact. Further review of the MDS revealed the resident required the physical assistance of one (1) staff for bathing. Review of the comprehensive care plan (undated) revealed that the focus area of ADL self care performance deficit related to impaired mobility was initiated on 11/14/2017 with the goal for the resident to be clean and odor free per staff assistance and the interventions included one (1) staff was to assist with bathing. Interview with Resident #96 on 08/05/2021 at 10:02 AM revealed the resident stated he/she was supposed to get two (2) showers per week, but it had been two (2) weeks since he/she had received a shower. Resident #96 stated that staff were often pulled from the shower room to the floor and there was not enough staff to provide the showers when that happened. Review of the shower records for Resident #96 from 07/21/2021 through 08/10/2021 revealed that only bed baths had been documented for Resident #96 and no showers had been documented as given. 6. Review of the record for Resident #101 revealed the facility admitted the resident on 03/05/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS which was a quarterly assessment with a reference date of 07/15/2021 revealed the BIMS score had not been obtained because the resident was rarely/never understood and the assessment further revealed the resident's cognitive skills for decision making were severely impaired. Further review of the MDS assessment revealed Resident #101 was totally dependent on staff for bathing. Review of the comprehensive care plan (undated) revealed that the resident had a ADL self care performance deficit related to confusion, impaired balance and limited mobility. The care plan interventions stated that the resident required total assistance for bathing. Review of the shower records for resident #101 from 07/11/2021 through 08/09/2021 revealed the resident received a shower on 07/14/2021, 07/17/2021, 07/21/2021, and 07/28/2021. A bed bath was recorded for all other days during that time period except 07/11/2021, 07/18/2021, 07/22/2021, and 08/06/2021 when not applicable was recorded. Interview with SRNA #14 on 08/11/2021 at 12:51 PM revealed residents get bed baths every day. The SRNA stated that the facility had a shower team that was responsible to give showers each day. She further stated if an aide calls in for the shift, then the aides that were assigned to the resident would then be responsible to give the resident a shower if it is their shower day. SRNA #14 stated when someone calls in that usually leaves them Short handed and the resident may not get a shower, but they always get a bed bath. An interview conducted with the Director of Nursing (DON) on 08/11/2021 at 2:54 PM, revealed residents were to have showers twice a week unless the resident wanted a shower more often or if the resident refused. The DON stated she had not been aware showers were not being done as required. The DON stated the information regarding when a resident was to be showered as well as the assistance and support required was kept in the Kiosk in the computer. The DON stated the potential concern for a resident not getting a shower twice a week was infection control issues, dignity, and depression. The DON stated she had not identified any concerns with staff not showering residents twice weekly. An interview conducted with the Administrator on 08/11/2021 at 4:03 PM, revealed she made rounds daily to ensure residents were being provided with the care they required. The Administrator stated she had not identified any concerns with residents not being provided with the care they required. The Administrator stated showers were expected to be done twice a week unless the resident refused.

Based on observation, interview and record review it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Interviews with residents during the survey revealed that food was often served cold and observations of the tray line on 08/03/2021 during the lunch meal revealed food items on the steam table were not held at the appropriate temperatures. Further observations in the kitchen on 08/03/2021 revealed food items in the refrigerator that were not labeled/dated with the date they were opened. Also, observations of food items in the dry storage area were opened, but not labeled/dated with the date they were opened. The findings include: Review of the facility policy titled Dietary Services (undated) revealed the purpose of the policy was to prevent the contamination of food products and therefore prevent foodborne illness. The policy further stated that steam tables must be able to maintain hot foods at temperatures of 140 degrees Fahrenheit (F) and above. Further review of the facility policy revealed the policy did not address the labeling of food items. Interview with the Administrator, on 08/11/21 at 4:02 PM, revealed it was the expectation that food items be labeled with the date they were opened. 1. Observations in the kitchen on 08/03/2021 at 10:20 AM revealed the lunch meal was on the steam table. Interview with the assistant dietary manager on 08/03/2021 at 11:00 AM revealed the food had been on the steam table since approximately 10:00 AM. Continued observations in the kitchen revealed that staff began plating the lunch meal at 10:55 AM; however, food temperatures were not obtained until prompted by the surveyors. Temperatures of the food on the steam table were as follows: pizza, 161 degrees Fahrenheit (F), pureed pizza - 130 degrees F, mashed potatoes - 161 degrees F, green beans - 155 degrees F, salad - 35 degrees F, pureed ham - 123 degrees F, ham - 165 degrees F, pureed green beans - 151 degrees F, chicken noodle soup - 143 degrees F, cream of chicken soup - 160 degrees F, and tomato soup - 161 degrees F. After the tray cart was loaded, the surveyor prompted the dietary manager to review the temperatures of the foods. The dietary manager then stated that the pureed ham and pureed pizza was too cold. Staff retrieved the four (4) trays that had already been plated with pureed pizza, reheated the pureed pizza to 186 degrees F, and replated the meal. Interviews on 08/03/2021 with Resident #13 at 4:13 PM, Resident #68 at 3:19 PM, and Resident #78 at 4:29 PM, revealed the residents stated meals were often served cold. Observation of the lunch meal tray line service on 08/05/2021 at 10:50 AM revealed staff were in the process of plating the lunch meal. During the observations staff removed the carrots and mashed potatoes that were being served and heated them in the microwave. Interview with the assistant dietary manager on 08/05/2021 at 11:15 AM revealed the steam table was not holding the foods at the appropriate temperatures. She stated the dietary staff add water, but the water evaporates quickly. She stated the problem had been reported, but it had not been fixed. She was unaware when it was reported. Interview with the Dietary Manager (DM) on 08/11/2021 at 1:31 PM revealed she had been the dietary manager for four (4) months. The DM stated she was unaware that there were any concerns with food temperatures until 08/03/2021. The DM further stated it was the expectation that hot foods be served hot and cold foods be served cold. Interview with the Administrator on 08/11/2021 at 4:02 PM revealed that she was not aware that there had been any concerns with cold food or with the steam table. She stated that the residents were vocal about the food and did not like the menu, but she was unaware of any concerns related to the temperature of the food. 2. Observations during the initial tour of the kitchen on 08/03/2021 at 10:20 AM revealed the following food items were in the refrigerator and opened and available for use, but were not labeled with the date that they were opened: a container of prepared macaroni salad, a container of prepared chicken salad, and a can of whipped topping. Further observations in the dry storage area of the kitchen during the initial tour revealed the following items were opened and available for use, but not labeled with the date they were opened: a box of powdered sugar, a bottle of canola oil, a package of sugar sprinkles, a bag of potato chips, a jar of peanut butter, and four (4) loaves of bread. Interview with the Dietary Manager on 08/11/2021 at 1:31 PM revealed it was the expectation all food items available for use in the kitchen be dated when they are opened. She stated she does audits weekly to ensure there are no items that have not been dated when opened. The Dietary Manager stated she had not identified any concerns prior to the survey.

Based on observation, interview, and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #94) received services in the facility with reasonable accommodations of the resident's needs and preferences related to bariatric equipment (Geri Chair and Shower Bed). The findings include: A review of the facility policy for resident equipment titled Equipment Resident Use dated 08/01/2013 revealed the facility would provide routine equipment for the general use of the resident population. A review of the medical record for Resident #94 revealed the facility admitted the resident to the facility on [DATE] with diagnoses, which included Severe [CONDITION(S)] and Abnormalities of Gait and Mobility. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) indicating severe cognitive impairment. Observation of Resident #94 conducted on 08/03/2021 at 10:15 AM revealed the resident was resting in a bariatric bed; however, there was no chair in the resident's room. Interview with Resident #94 on 08/04/2021 at 1:08 PM revealed the resident did not currently have a chair in his/her room. According to the resident, he/she previously had a chair he/she was using to set in when out of bed. However, the facility took the resident's chair, and the resident did not know why. Further interview revealed the resident only received bed baths because the facility did not have chair or means to take the resident to the shower. According to Resident #94, the resident could not recall when the he/she last received a shower and only remembered receiving bed baths. Interview with State Registered Nurse Aide (SRNA) #7, on 08/09/2021 at 1:45 PM, revealed Resident #94 use to have a bariatric chair in his/her room which the resident sat in daily; however, the SRNA stated the chair had not been in the resident's room for a month. Per interview, the SRNA was not sure what happened to the chair. Interview with the Station One Unit Manager, on 08/09/2021 at 1:55 PM, revealed the Unit Manager was not sure where Resident #94's chair was and thought the chair was in the resident's room. According to the Unit Manager, the resident was to be bed bathed only because the resident was not safe in a shower chair. According to the Unit Manager, the Administrator had been talking about using a shower bed for the resident but was not sure if the facility was going to purchase one for the resident. Interview with the Rehabilitation Director, on 08/09/2021 at 2:05 PM, revealed the chair that was being used for Resident #94 was borrowed from another facility and had to be returned on 08/03/2021. The Rehabilitation Director stated a request to purchase a chair for the Resident #94 was awaiting approval. Further interview revealed the Resident had been evaluated in February of 2021 for the use of a shower chair and the resident was not safe to use a shower chair due to the resident's condition of a pendulous abdomen and was to be bed bathed only. Interview with the Director of Nursing, on 08/11/2021 at 2:54 PM, revealed the facility had been working on getting Resident #94 a chair. The facility was trying to find something that would work for the resident and had been looking at a shower bed so the resident could take a shower but did not provide any time period for obtaining the shower bed. According to the DON, a resident not being able to take a shower that wanted to could be a dignity issue Interview with the Administrator, on 08/11/2021 at 4:03 PM, revealed the Administrator was not aware the facility had borrowed equipment from anther facility until 08/03/2021. According to the Administrator, she started at the facility in February of 2021 and was not aware of the need for a chair for Resident #94 . The Administrator stated she would have purchased a chair and the equipment needed to use for Resident #94. Further interview revealed the facility should provide the equipment necessary to care for bariatric residents who required care to meet individual needs and to improve the resident's quality of life.

Based on interview and record review, it was determined the facility failed to protect the rights of one (1) of twenty two (22) sampled residents (Resident #1). Family Member #1 who was also Resident #1's Power of Attorney (POA) verbally requested a copy of the resident's medical records, on 07/29/2021, and the family member signed the request for the medical record, on 07/29/2021. However, the family member did not receive the medical record until 08/03/2021 (3 business days after the initial request). The findings include: Interview on 08/10/2021 at 2:19 PM, with the Administrator revealed the facility did not have a policy related to providing resident medical record copies but used the form, Request for Inspection/Copy of Protected Health Information. A review of this form revealed areas to be filled out stating who requested the medical record, reason for request, and a date line. Interview with Family Member #1 on 08/03/2021 at 2:34 PM, who was also Resident #1's POA, revealed she had come to the facility and requested copies of the resident's medical record and signed the consent on 07/29/2021. The POA stated she had not yet received a copy of Resident #1's medical record. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. Further review revealed Family Member #1 was listed as Resident #1's POA. Review of Request for Inspection/Copy of Protected Health Information for Resident #1, revealed the record had been requested, on 07/29/2021. The record request had been signed, on 07/29/2021 by Resident #1's family. The form had not been signed by a facility representative. Interview conducted on 08/10/21 at 2:19 PM with the Administrator revealed she was responsible for ensuring residents or responsible parties received a copy of the medical record when requested. The Administrator stated she would have the resident or responsible party sign a consent and would then send the consent to the Corporate office for authorization to release the medical record. Once it is approved, the Administrator stated she gives the resident or responsible party a copy of the medical record. The Administrator stated Resident #1's responsible party came in and signed a request for the medical record on 07/29/2021. Per the Administrator, she was notified by corporate to release the medical record on 08/03/2021, and she called the responsible party on 08/03/2021, to come and pick up the medical record. The Administrator stated Family Member #1 had picked up the copy of Resident #1's medical record on 08/04/2021. The Administrator stated she had not been aware the facility was required to provide a written copy of the resident's medical record within two (2) days of the written request.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the resident's physician documented the reason for discharge for one (1) of eleven (11) sampled residents (Resident #1). Resident #1 was discharged from the facility due to the facility not being able to meet the resident's care needs; however, the physician failed to document the specific resident needs the facility could not meet, the facility efforts to meet those needs and/or the specific services the receiving facility could provide to meet the resident needs. The findings include: Review of the facility policy titled Documentation of Transfers/Discharges, dated 08/01/2013, revealed when a resident was transferred or discharged , his or her medical record shall be documented as to the reason why such action was taken. Further review of the policy revealed that should the resident be transferred or discharged for the following reasons: the transfer or discharge was necessary for the resident's welfare, and the resident's needs could not be met in the facility or the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician. Review of Resident #1's medical record revealed the facility admitted the resident on 03/01/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 was discharged from the facility on 03/02/2021. Review of the Nurse's Notes, dated 03/01/2021 at 4:25 PM, revealed the resident was placed on one on one supervision due to behaviors. The nurse's note dated 03/01/2021 at 5:02 PM, revealed the resident was wandering in and out of rooms with staff attempting to redirect. The note further revealed staff were unable to keep the resident's attention very long before he/she started to wander again and wander aimlessly. Further review of the record revealed a physician order, dated 03/01/2021 at 5:32 PM, which stated the facility could transfer the resident back to another facility's memory care unit on 03/02/2021, for the resident's safety. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the medical record revealed no evidence of the physician documented the specific needs the facility could not meet or what attempts were made to meet the resident needs. In addition, the physician documentation did not include the specific service available at the receiving facility to meet the needs of the resident, which could not be met at the facility. Interview with the Administrator, on 03/18/2021 at 4:15 PM, revealed no discharge notice was completed for Resident #1's discharge. Continued interview with the Administrator and Facility Nurse Consultant, on 03/18/2021 at 4:15 PM, revealed they had not identified the lack of physician documentation regarding the discharge.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide a discharge notice to one (1) of eleven (11) sampled residents (Resident #1). Resident #1 was discharged from the facility on 03/02/2021; however, the facility failed to provide a discharge notice to the resident and/or resident's representative. The findings include: Review of the facility's policy, Notice of a Transfer and/or Discharge, dated August 2013, revealed when a resident was transferred or discharged from the facility, the facility would provide notice of the discharge to the resident and/or representative and the notification would be documented in the medical record. Review of Resident #1's medical record revealed the facility admitted the resident on 03/01/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #1 was discharged from the facility on 03/02/2021. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of medical record revealed no evidence the facility provided Resident #1 and/or the resident's representative with a written discharge notice. Interview with the Administrator, on 03/18/2021 at 4:15 PM, revealed no discharge notice was completed for Resident #1's discharge.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to review/revise the comprehensive care plan for two (2) of three (3) sampled residents (Resident #6 and Resident #8). Review of Resident #8's record revealed on 12/14/2020, a cancerous lesion was removed from the resident's scalp. Staff instructions included not removing the dressing and the resident was to return to the physician three (3) days later. However, the resident was not able to keep that appointment and the facility rescheduled the appointment for 12/23/2020 (9 days after the procedure). The facility failed to obtain any further orders related to the wound and failed review/revise the care plan to reflect the delayed treatment. On 12/23/2020, Resident #8 returned to the facility with new wound care orders. However, the facility failed to review/revise the resident's care plan to include the new orders, and staff did not provide the treatment to the resident for five (5) days. On 12/31/2020, Resident #8 was admitted to the hospital and diagnosed with a surgical wound infection. Resident #8 was transferred back to the facility on [DATE] with wound care orders; however, the facility failed to review/revise the resident's care plan to reflect the new orders. Subsequently, the resident did not receive wound care or assessment of the wound until 01/15/2021, when staff at the physicians' office removed the bandage dated 01/06/21. Resident #8 returned to the facility on [DATE] from the Physician's office with orders for the wound dressing to be changed every other day. Although staff updated the care plan to reflect the new orders received on 01/15/2021, staff incorrectly documented the orders on the resident's plan of care, and those wound care orders were not provided to Resident #8, until three (3) days later, on 01/18/2021. In addition, Staff interviews and record review revealed on 12/14/2020, Resident #6 complained of not feeling well and displayed signs/symptoms of COVID-19. However, the facility failed to update the resident's care plan to ensure staff adequately monitored the resident and took appropriate action to notify the resident's physician. On 12/15/2020, staff assessed Resident #1 to have constricted pupils, lethargy and was unresponsive to verbal stimuli. The facility transferred Resident #6 to the hospital via Emergency Medical Services (EMS) and Resident #6 was admitted to the hospital and diagnosed with COVID-19 pneumonia. The findings include: Review of the facility's policy dated 08/01/2013 and titled, Care Plans-Comprehensive, revealed the care-planning team was responsible for the review and updating of care plans when the resident had been readmitted to the facility from a hospital stay. Further review revealed that assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changes. Review of Resident #8's medical record revealed the facility admitted the resident on 09/18/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status Score (BIMS) score of 15, which indicated the resident had no cognitive impairment. Further review revealed the resident required the assistance of two (2) staff for Activities of Daily Living (ADL). Review of a Progress Note for 12/14/2020 at 11:59 AM, revealed Resident #8 returned to the facility at 2:02 PM following an outpatient surgical procedure (basil cell [CONDITION(S)] removal). According to the note, the resident had an incision to the scalp with staples and the wound was covered with [MEDICATION(S)] foam border dressing (dressing designed to provide an antimicrobial environment, absorb drainage, and maintain a moist wound environment). Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's care plan revealed the facility revised the care plan (not dated) to include a focus area of a surgical procedure to remove a basal cell [CONDITION(S)] to the top of the resident's head. The facility's goal was for the skin to improve and not display any signs or symptoms of infection. MDS Coordinator #1 initiated an intervention to keep the dressing in place to the resident's scalp. DO NOT REMOVE DRESSING but may clean around the wound with soap and water. Keep the wound clean and dry every shift. The care plan also stated staff should perform weekly skin assessments and document the results. Interventions to complete a weekly skin assessments and document the assessment in the resident's clinical record was added. The care plan directed staff to notify the resident's physician of any skin integrity changes/decline and that the resident's skin to be observed with each episode of care delivery. Any changes were to be reported to the supervisor for follow-up. However, review of the computerized care plan notes revealed MDS Coordinator #1 revised Resident #8's care plan on 12/23/2020 and entered the date as initiated on 12/14/2020. Interview with MDS Coordinator #1, on 02/01/2021 at 2:45 PM, revealed that the MDS Coordinator updates care plans daily when new orders were received. She stated that new orders were placed in her mailbox before the morning meetings and then discussed in the meeting. The MDS Coordinator stated the care plans were updated during the morning meetings, which occurred five (5) days per week, Monday through Friday. When interviewed why Resident #8's care plan was not updated timely, she responded that the initial wound interventions were in place on 12/14/2020 and that if the MDS Coordinator was unavailable to update the resident's care plan, other staff such as the Director of Nursing (DON) or Unit Coordinators would assist with updates. No other explanation was offered by MDS Coordinator #1 for the delay in updating Resident #8's care plan. Review of Resident #8's Progress Notes, dated 12/16/2021 at 12:35 PM, revealed Licensed Practical Nurse (LPN) #1 contacted Physician #1's office and rescheduled Resident #8's post-operative appointment for 12/23/2020, due to Emergency Medical Services' (EMS) inability to transport the resident to the office on 12/17/2020 for his/her appointment. Further review of Progress Notes revealed no wound treatment orders were obtained by LPN #1 on 12/16/2020, when the appointment was rescheduled and no further documentation was noted that the facility attempted to obtain wound care orders from Physician #1's office. Interview with LPN #1, on 01/28/2021 at 4:15 PM, revealed she called Emergency Medical Services (EMS) on 12/16/2020, to schedule transport for Resident #8's 12/17/2020 follow up appointment and EMS was unable to arrange transport. LPN #1 stated she then contacted Physician #1's office and rescheduled the appointment for 12/23/2020, with the receptionist. Per the LPN, the Physician #1's office did not give further wound care orders or instruct her to change wound care orders when the appointment was changed. However, the LPN stated she did not speak with a nurse at Physician #1's office when the appointment was rescheduled. Review of Resident #8's December Treatment Administration Record (TAR) revealed the initial surgical wound dressing was in place from 12/14/2020 until 12/23/2020, with no dressing change. Weekly Skin Assessment Reports for Resident #8 were requested; however, the facility was unable to provide documentation of a wound assessment for the resident for 12/14/2020 through 12/31/2020. Review of Physician Notes dated 12/23/2020 revealed Resident #8 returned to Physician #1's office for his/her post-operative visit on 12/23/2020. The physician documented that upon examination, the surgical wound to the resident's head measured three (3) centimeters (cm) by 1.5 cm and had ecchymotic (bruising) changes due to an old wound dressing and very foul odor. Further review of the Physician's Notes revealed a follow-up procedure was pathologically indicated to obtain clear margins of non-cancerous tissue. Interview with Physician #1 on 02/01/2021 at 11:30 AM revealed Resident #8 was initially scheduled to return to his office on 12/17/2020 for a post-operative visit, but returned over a week later, on 12/23/2020. He stated during the follow-up visit on 12/23/2020, the wound dressing was old and smelled like road kill. He further stated that it was very evident the dressing had not been changed, stating, The lack of wound care was obvious. Physician #1 stated when facility staff called to reschedule Resident #8's appointment, they should have spoken with a nurse, a Physician Assistant (PA), a Nurse Practitioner (NP), or himself to obtain orders for the surgical site. Continued review of Physician #1's notes revealed Resident #8's surgical wound required daily wet to dry dressings to be initiated on 12/23/2020. According to the physician's note, the facility was notified of the wound care orders and that follow-up surgery was to be scheduled. However, a review of Resident #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, review of the resident's December 2020 TAR revealed no documented evidence that wound care was provided for Resident #8's scalp wound from 12/23/2020 through 12/28/2020. Review of Resident #8's facility progress notes dated 12/28/2020 at 2:04 PM revealed Physician #1's office called the facility to schedule a follow-up surgical procedure for the resident. At that time, LPN #3 obtained orders for a daily wet to dry dressing to be covered with a foam border dressing. Further review revealed the follow-up surgical appointment for Resident #8 was scheduled at the local hospital for 6:00 AM on 01/05/2021. Review of the resident's care plan revealed the care plan was revised with an intervention to provide daily wet to dry dressings. The care plan intervention was not dated. However, a review of the resident's computerized care plan notes revealed the facility did not revise the resident's care plan to reflect the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The revision was completed by MDS Coordinator #2. Continued interview with MDS Coordinator #1, on 02/01/2021 at 2:45 PM, revealed that MDS staff was responsible for updating care plans and updates were based on new orders or treatments received. She also stated that the Unit Coordinators were responsible for entering orders and then MDS staff reviewed them for accuracy before updating care plans. When no orders were entered for Resident #8 on 12/23/2020, the care plan was not revised. Continued review of Resident #8's TAR revealed the facility provided wound care for Resident #8 the next day, 12/29/2020 and on 12/30/2020. However, there was no documented assessment of the resident's scalp wound. Review of Progress Notes dated 12/31/2020 at 12:00 AM revealed Resident #8 was transferred to the local emergency department (ED) for abdominal pain per Physician #3's orders. Review of Resident #8's hospital medical records revealed the resident presented to the ED on 12/31/2020 at 1:21 AM with abdominal pain and staff noted a surgical wound infection of the scalp. According to the ED record, the surgical site appeared to have a necrotic (black, dead tissue) base with gross purulence (pus) at the site of the prior surgery. Physician #1 was consulted on 12/31/2020 and Resident #8 was admitted to the hospital. Continued review of Resident #8's hospital record revealed Resident #8's scalp wound was surgically debrided on 01/02/2021, to remove necrotic tissue with purulence and a tissue culture of the site was obtained. According to the culture report, the wound was positive for Proteus Mirabilis bacteria and Resident #8 was placed on [MEDICATION(S)] 875 mg oral for ten (10) days for infection. Further review revealed Resident #8 was discharged back to the facility on [DATE]. The hospital record revealed that Case Management staff faxed a discharge summary, medication reconciliation record, and treatment orders to the facility on [DATE]. Review of Resident #8's hospital discharge Progress Note dated 01/06/2021 revealed the resident was discharged back to the facility with wound care orders for a moistened [MEDICATION(S)] Blue foam dressing (an antibacterial dressing that assists with the removal of dead and devitalized tissue) to the scalp every 48 hours and cover with a [MEDICATION(S)] dressing (transparent waterproof sterile barrier). Review of nursing progress notes dated 01/06/2021 revealed Resident #8 returned to the facility at 8:30 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress Notes dated 01/08/2021 at 1:03 PM revealed that RN #1 called Physician #1's office to obtain wound care orders for Resident #8. According to the note, an order was obtained to apply a moistened [MEDICATION(S)] Blue dressing every 48 hours and cover with a [MEDICATION(S)] dressing. The note stated that RN #1 completed a dressing change for the resident on 01/08/2021. Further review of Resident #8's computerized care plan revealed the care plan was not revised with the order change for the wound care until 01/15/2021 (11 days after being discharged from the hospital). Review of Resident #8's facility Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of Resident #8's TAR dated 01/15/2021 revealed the facility transcribed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence staff were moistening the [MEDICATION(S)] Blue dressing every day as ordered. Continued review of Resident #8's care plan revealed two (2) separate interventions (not dated) that stated staff were required to apply a [MEDICATION(S)] Blue dressing to the resident head and cover with a [MEDICATION(S)] one time a day every other day. Review of the Resident #8's computerized care plan revealed MDS Coordinator #1 added a care plan intervention on 01/16/2021, dated as initiated on 01/15/2021, for a [MEDICATION(S)] Blue dressing to be changed every 48 hours. However, the care plan did not address moistening the dressing daily. On 01/18/2021, MDS Coordinator #2 added an intervention to moisten [MEDICATION(S)] blue to top of the residents' head and cover with [MEDICATION(S)] and to change every 48 hours. However, again the interventions did not direct staff to moisten the dressing every day. The care plan was not revised to include the correct treatment order until 01/21/2021. Continued interview with LPN #8 on 01/29/2021 at 9:50 AM revealed she recalled the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the Unit Coordinator usually reviewed all orders and entered them into the computer, but stated she entered the orders for Resident #8 on 01/15/2021. She stated she was aware that the dressing should be moistened daily and that it may have been a transcription error. Continued review of Resident #8's TAR revealed no documentation that the resident's dressing was changed on 01/17/2021 as required by physician orders. Interview with RN #4 on 01/29/2021 at 12:20 PM revealed that he cared for Resident #8 on 01/17/2021 from 7:00 AM to 7:00 PM. He stated he did not provide any treatment to the resident's scalp wound on 01/17/2021, nor had he ever treated the wound. He stated a wound care task was not on the resident's TAR for 01/17/2021. Observation on 01/27/2021 at 1:00 PM of Resident #8 scalp wound with facility staff, revealed it measured 4.5 cm in length, 2.5 cm in width and 0.4 cm in depth with the periwound (tissue surrounding the wound) area pink in color and 50% of the wound bed having eschar (dry, or dark scab of dead skin). Staff cleansed the wound with normal saline and sterile 4x4, a [MEDICATION(S)] blue dressing was moistened and applied to wound bed, and was covered with a [MEDICATION(S)] dressing. Further observation revealed staff documented the date, time, staff initials on the dressing. Interview with Resident #8 on 01/26/2021 at 3:35 PM revealed that recently the facility had been providing routine wound care. The resident did not recall how often wound care was provided before, but recalled noticing an odor before the wound was debrided on 01/02/2021. Interview with the Director of Nursing (DON) on 02/01/2021 at 3:40 PM revealed that unit coordinators review all orders for residents in morning meetings and MDS staff updates care plans. She further stated that care plans are revised and updated daily based on new orders and that if MDS is not available to update care plans, herself or unit coordinators will assist when needed. She further stated that nursing staff is expected to continue to attempt to reach a physician for orders or call the Medical Director if unable to reach a physician, and that more initiative should have been taken to obtain orders for Resident #8's wound care. The DON also stated that orders or treatments that on the TAR are expected to be completed by the assigned nurse on that shift. Interview with the Administrator on 02/01/2021 at 4:25 PM revealed that staff are expected to follow all physician orders, review orders, implement care plan interventions, adequately assess wounds and reach a physician to obtain orders when needed. He stated that nursing staff are expected to assess wounds adequately, follow and perform the physician treatment orders, transcribe orders correctly and continue to reach a physician or call the Medical Director if unable to reach a physician. He further stated that the facility ensures orders are reviewed in morning meetings and anytime a resident is readmitted and are reviewed for accuracy by MDS and the Unit Coordinators. He also stated that the care plan revisions and updates are based on new orders and information discussed in the morning meetings. Per the Administrator, the MDS coordinators update care plans daily. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 01/30/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. Review of Resident #6's Comprehensive Care Plan undated, revealed Resident #6 was at risk for contracting COVID-19. However, the care plan failed to indicate how staff were to monitor the resident for the potential infection or what signs/symptoms staff were to be aware of and when to report to the resident's physician if staff suspected the resident had a COVID-19 infection. Review of Resident #6's Progress Notes revealed on 12/14/2020 at 10:42 AM LPN #8 documented that the resident voiced complaints of not feeling well, had a temperature of 100.5 degrees Fahrenheit, an oxygen saturation of 88-89 percent on room air, and diminished lung sounds. Further review revealed the staff attempted to notify the resident's physician of the change in the resident's condition, but the physician did not answer or return the facility's call. Additionally, the facility administered a COVID-19 test to Resident #6 and submitted the test to the laboratory for analysis. However, the facility failed to update the resident's care plan to indicate the resident was complaining of not feeling well and displaying signs and symptoms of an active COVID-19 infection, so staff could more closely monitor the resident and continue to attempt to notify the resident's physician as warranted. Interview with LPN #8 on 01/29/2021 at 9:50 AM revealed she had cared for Resident #6 and completed the documentation on 12/14/2020 during day shift. LPN #8 stated the facility suspected the resident may be infected with COVID-19, but she did not review/revise the resident's care plan because staff did not make changes to resident care plans. Continued review of Resident #6's medical record revealed on 12/15/2020 at 1:30 PM Registered Nurse (RN) #1 assessed Resident #6 to be lethargic, difficult to wake up, have constricted pupils, and be nonresponsive to verbal stimuli. Subsequently, the facility transferred the resident to the hospital by Emergency Medical Services (EMS), and the resident was admitted and diagnosed with COVID-19 pneumonia. Interview with RN #1 on 01/26/2021 at 11:45 AM, revealed she was aware on 12/15/2021, that Resident #6 had not been feeling well for a day or so, but was unaware that the Resident's physician had not been notified. Interview with Minimum Data Set (MDS) Nurse #1 on 02/10/2021 at 2:45 PM revealed she had developed a standardized care-plan for all facility residents related to being at risk for COVID-19 infection in March 2020. However, the MDS Coordinator stated resident care plans were not being reviewed/revised until the resident actually tested positive for the virus, even when the resident was exhibiting signs/symptoms of COVID-19, to ensure staff were aware of the resident's status and were adequately monitoring the resident's condition for deterioration and what actions to take accordingly. Further interview with the MDS nurse confirmed staff nurses did not review/revise resident care plans. She stated care plan revisions were conducted daily Monday-Friday in the morning clinical meetings. Therefore, the MDS coordinator stated Resident #6's care plan should not have been reviewed/revised on 12/14/2020 when the resident experienced a change in condition and staff suspected and tested the resident for a COVID-19 infection. Interview with the DON on 02/01/2021 at 3:40 PM revealed Resident #6's care plan should have been reviewed/revised when a change in his/her condition occurred and the resident was tested for COVID on 12/14/2020. The DON further clarified that resident nursing notes and new resident physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the review was to ensure resident care plans had been updated accurately when the resident experienced a new illness, injury, or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Administrator on 02/01/2021 at 4:25 PM revealed he expected staff to review/revise resident care plans when changes in the resident's condition occurred.

Based on observation, interview, record review, review of facility policy, and review of information from the Cleveland Clinic and woundsource.com, it was determined the facility failed to provide necessary care and services, in accordance with professional standards of practice and facility policy for one (2) of three (3) sampled residents (Resident #8 and Resident #6). Review of Resident #8's record indicated Physician #1 removed a cancerous lesion from the resident's scalp, as an outpatient procedure on 12/14/2020. According to the record, staff were instructed not to remove the surgical dressing, and the resident was instructed to return to the physician's office on 12/17/2020 for a follow up appointment. Due to transportation concerns, the appointment was rescheduled for 12/23/2020; however, the facility failed to obtain further treatment orders for the resident's wound. Additionally, on 12/14/2020, Resident #6 reported feeling sick and was displaying signs and symptoms of a COVID-19 infection. However, the facility failed to ensure a physician was made aware of the resident's condition and failed to ensure the resident received interventions and monitoring in accordance with professional standards to ensure the resident's condition did not decline. Subsequently, on 12/215/2020, Resident #6 became lethargic, unresponsive to verbal stimuli, and have constricted pupils. The facility transferred the resident to the hospital for further evaluation and treatment. The resident was admitted and diagnosed with COVID-19 Pneumonia. The findings include: Review of the facility's policy titled, Wound Protocol, dated February 2019 revealed a weekly pressure ulcer and/or weekly skin alteration assessment (depending on etiology) should be initiated for any resident who had a wound and continued with weekly updates until the wound was healed. Further review of the policy revealed, the Weekly Skin Report should provide a summary of all wounds in the facility and should be reviewed weekly in the Quality of Care Meetings for each resident who was identified as having a wound. According to Cleveland Clinic (an academic medical center, that provides clinical and hospital care and is a leader in research, education and health information), surgical incisions must be kept clean and dry. Proper care of incisions promotes healing, reduces scarring, and reduces the risk of an infection. Cleveland Clinic recommended following physicians' instructions for incision care, including instructions for dressing changes, very carefully. According to woundsource.com, appropriate surgical wound and incision management in the post-operative time period was imperative to prevent complications, including surgical site infection and wound dehiscence. The source stated that preventing incisional infection by appropriate cleansing, skin care, and moisture management was a requisite part of the post-operative plan of care. Review of Resident #8's medical record revealed the facility admitted the resident on 09/18/2020 with diagnoses, which included Cerebral Infarction (stroke) and Type 2 Diabetes Mellitus. Review of Resident #8's Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview of Mental Status Score (BIMS) score of 15, indicating the resident had no cognitive impairment. Further review revealed the resident required the assistance of two (2) staff for Activities of Daily Living (ADL). Review of a Progress Note, dated 12/14/2020 at 11:59 AM, revealed Resident #8 returned to the facility at 2:02 PM following an outpatient surgical procedure (basil cell [CONDITION(S)] removal). According to the note, the resident had an incision to the scalp with staples and the wound was covered with [MEDICATION(S)] foam border dressing (dressing designed to provide an antimicrobial environment, absorb drainage, and maintain a moist wound environment). Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #8's Progress Notes revealed, on 12/16/2020 at 12:35 PM, Licensed Practical Nurse (LPN) #1 documented that she contacted Physician #1's office and rescheduled Resident #8's post-operative appointment for 12/23/2020, due to Emergency Medical Services' (EMS) inability to transport the resident to the 12/17/2020 appointment. Further review of the Progress Notes revealed no wound treatment orders were obtained by LPN #1 on 12/16/2020 when the appointment was rescheduled and no further documentation was noted that the facility attempted to obtain wound care orders from Physician #1's office. Review of Resident #8's December Treatment Administration Record (TAR) revealed the initial surgical wound dressing was in place from 12/14/2020 until 12/23/2020, with no dressing change. Weekly Skin Assessment Reports for Resident #8 were requested. However, the facility was unable to provide documentation of a wound assessment for the resident for 12/14/2020 through 12/31/2020. Review of Physician's Notes dated 12/23/2020, revealed Resident #8 returned to Physician #1's office for his/her post-operative appointment on 12/23/2020. The physician documented that upon examination, the surgical wound to the resident's head had ecchymotic [bruising] changes due to an old wound dressing and very foul odor. Further review of the Physician's Notes revealed a follow-up procedure was pathologically indicated to obtain clear margins of non-cancerous tissue. Interview with Physician #1, on 02/01/2021 at 11:30 AM, revealed when Resident #8 returned for the follow-up visit on 12/23/2020, the surgical wound dressing was old and smelled like road kill. He stated that it was very evident the facility had not changed the dressing stating, The lack of wound care was obvious. Physician #1 stated when facility staff called to reschedule Resident #8's appointment; they should have spoken with nurse, a Physician Assistant (PA), a Nurse Practitioner (NP), or himself to obtain orders for the surgical wound site. Continued review of Physician #1's Notes revealed Resident #8's surgical wound required daily wet to dry dressings to be initiated on 12/23/2020. According to the Physician's Note, the facility was notified of the wound care orders and that follow-up surgery was to be scheduled. However, review of Resident #8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, review of the resident's December 2020 TAR, revealed no documented evidence that wound care was provided for Resident #8's scalp wound from 12/23/2020 through 12/28/2020. In addition, there was no documentation that the facility assessed the wound as required by facility policy in December 2020. Interview with LPN #3, on 01/28/2021 at 12:00 PM, revealed she was responsible for Resident #8's care when he/she came back from the physician's office on 12/23/2020 (exact time unknown). According to LPN #3, Physician #1 did not provide any wound care orders for Resident #8. She stated she left a message at the hospital outpatient surgery center to obtain wound care orders, but did not contact Physician #1's office. She further stated she received no response and she informed the oncoming night shift nurse that the facility was awaiting wound care orders. Interview with LPN #4, on 01/28/2021 at 12:40 PM, revealed she was the oncoming shift nurse, at 7:00 PM on 12/23/2020, and received report from LPN #3. She stated LPN #3 instructed her not to remove Resident #8's dressing and stated she was not informed that the facility was awaiting wound care orders for Resident #8. She stated she did not change the dressing or view/assess Resident #8's wound on 12/23-24/2020. Interview with LPN #7, on 01/28/2020 at 4:50 PM, revealed she cared for Resident #8, on 12/24/2020 from 7:00 PM until 7:00 AM on 12/25/2020. LPN #7 also stated that she did not change the resident's dressing or assess the wound. She stated she was also notified in shift report that staff should not change the dressing and was not notified that the facility was awaiting wound care orders for Resident #8. Interview with LPN #5, on 01/28/2021 at 1:15 PM, revealed she cared for Resident #8, on 12/25/2020 from 7:00 AM to 7:00 PM. She stated that in shift report on 12/25/2020, she was instructed not to remove the wound dressing to Resident #8's scalp; subsequently, she did not provide any treatment or assess the wound. Review of Resident #8's (facility) Progress Note, dated 12/28/2020 at 2:04 PM, revealed Physician #1's office called the facility to schedule a follow-up surgical procedure for the resident. At that time, LPN #3 obtained orders for a daily wet to dry dressing to be covered with a foam border dressing. Further review revealed the follow-up surgical appointment for Resident #8 was scheduled at the local hospital for 6:00 AM on 01/05/2021. Continued review of Resident #8's TAR, revealed the facility provided wound care for Resident #8 the next day, 12/29/2020 and on 12/30/2020. However, there was no documented assessment of the resident's scalp wound. Review of Progress Notes dated 12/31/2020 at 12:00 AM revealed Resident #8 was transferred to the local emergency department (ED) for abdominal pain per Physician #3's orders. Review of Resident #8's hospital medical records revealed the resident presented to the ED on 12/31/2020 at 1:21 AM with abdominal pain and staff noted a surgical wound infection of the scalp. According to the ED record, the surgical site appeared to have a necrotic (black, dead tissue) base with gross purulence (pus) at the site of the prior surgery. Physician #1 was consulted on 12/31/2020 and Resident #8 was admitted to the hospital. Continued review of Resident #8's hospital record revealed Resident #8's scalp wound was surgically debrided on 01/02/2021, to remove the necrotic tissue with purulence and a tissue culture of the site was obtained. According to the culture report, the wound was positive for Proteus Mirabilis bacteria and Resident #8 was placed on [MEDICATION(S)] (antibiotic) 875 mg (milligrams) oral for ten (10) days for infection. Further review revealed Resident #8 was discharged back to the facility on [DATE]. The hospital record revealed that Case Management staff faxed a discharge summary, medication reconciliation record, and treatment orders to the facility on [DATE]. Review of Resident #8's Hospital Discharge Progress Note dated 01/06/2021 revealed the resident was discharged back to the facility with wound care orders for a moistened [MEDICATION(S)] Blue foam dressing (an antibacterial dressing that assists with the removal of dead and devitalized tissue) to the scalp every 48 hours and cover with a [MEDICATION(S)] dressing (transparent waterproof sterile barrier). Review of Nursing Progress Notes dated 01/06/2021, revealed Resident #8 returned to the facility at 8:30 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Advanced Practice Registered Nurse (APRN) on 02/01/2021 at 11:45 AM revealed she treated Resident #8 at the hospital. The APRN stated the facility's lack of wound care led to necrosis of the resident's wound and the subsequent need for debridement. She stated when the resident was discharged from the hospital on 01/06/2021, orders for wound care were provided to the facility in two (2) written forms, the discharge summary and written orders. In addition, she stated she and hospital staff also called the facility and told them about the orders for wound care. However, review of the facility's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of Resident #8's Treatment Administration Record (TAR), revealed no documented evidence wound care was provided for the resident on 01/06/2021 nor on 01/07/2021. Further review revealed there was no documented assessment of Resident #8's wound to the head. Interview with LPN #6, on 01/28/2021 at 1:55 PM, revealed she received Resident #8 back to the facility at 8:30 PM on 01/06/2021. LPN #6 stated she did not remove the dressing nor assess Resident #8's wound, but she did recall the wound care orders were on the discharge paperwork. She further stated the Unit Coordinator, Registered Nurse (RN) #1, who worked day shift, usually reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Progress Notes, dated 01/08/2021 at 1:03 PM, revealed that RN #1 called Physician #1's office to obtain wound care orders for Resident #8. According to the Note, an order was obtained to apply a moistened [MEDICATION(S)] Blue dressing every 48 hours and cover with a [MEDICATION(S)] dressing. The Note stated RN #1 completed a dressing change for the resident on 01/08/2021. Review of a Weekly Wound Care Report, dated 01/08/2021, revealed the first documentation of an assessment of Resident #8's since the surgical procedure on 12/14/2020. Staff documented the wound measured 5.1 cm (centimeters) x 2.5 cm, with granulation (new tissue) and eschar in the mid-anterior region and serosanguinous drainage (clotted or diluted red blood cells. Drainage was thin, and usually light red or pink tinged). Interview with the Unit Coordinator/RN #1, on 01/29/2021 at 11:45 AM, revealed she contacted Physician #1's office on 01/08/2021, to obtain wound care orders for the wound to Resident #8's head. She stated after obtaining orders, she changed the resident's dressing and measured the wound on 01/08/2021. She described the wound dressing as bloody and messy. RN #1 stated as the Unit Coordinator, she was required to review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's TAR, revealed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed RN #1 documented the treatment for 01/08/2021 was provided. However, there was no documented evidence the treatment was provided for the resident on 01/10/2021, 01/12/2021, nor 01/14/2021, as ordered by the physician. Interview with LPN #8, on 01/29/2021 at 9:50 AM, revealed it was the Unit Coordinator's responsibility to review orders when a resident was readmitted and add orders to the resident's TAR. She stated once orders were added to the TAR, it should trigger the computer to put the treatment on a to do task for staff. LPN #8 stated she did not know what happened but the resident's dressing change was not on the staffs' to do list until approximately one week ago. Interview with RN #3, on 01/29/2021 at 11:00 AM, revealed she did not change/treat Resident #8's wound after his/her readmission on 01/06/2021. She stated she did not change any dressings or assess the wound until 01/25/2021. Review of Resident #8's facility Progress Notes, dated 01/15/2021 at 10:48 AM, revealed Resident #8 was transferred to Physician #1's office for a follow-up appointment. Review of Physician #1's Office Notes for Resident #8, dated 01/15/2021, revealed an Advance Practical Registered Nurse (APRN) documented that Resident #8's dressing had a foul odor and the wound measured 5 cm by 2.5 cm by 0.25 cm. Continued interview with the APRN, on 02/01/2021 at 11:45 AM, revealed when Resident #8 came in for the follow-up appointment on 01/15/2021, the resident's dressing had not been changed since the resident was discharged from the hospital. She stated she placed a clean dressing on the resident's wound on 01/06/2021, wrote the date, time, and her initials on the dressing prior to the resident's discharge. According to the APRN, the resident had the same dressing to the wound when he/she returned for the follow-up appointment on 01/15/2021. She further stated on 01/15/2021, the wound had a foul odor, and the facility's 'lack of wound care was unacceptable. Continued review of the APRN's Office Note for 01/15/2021 office visit revealed the APRN wrote orders for the facility to continue to treat Resident #8's wound with a [MEDICATION(S)] Blue. The dressing was required to be moistened daily, changed every 48 hours and covered with a [MEDICATION(S)] dressing. Review of Resident #8's facility Progress Notes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of Resident #8's TAR, dated 01/15/2021, revealed the facility transcribed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the TAR, there was no documented evidence staff were moistening the [MEDICATION(S)] Blue dressing to the resident's head wound every day as ordered. Continued interview with LPN #8, on 01/29/2021 at 9:50 AM, revealed she recalled the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the Unit Coordinator usually reviewed all orders and entered them into the computer, but stated she entered the orders for Resident #8, on 01/15/2021. She stated she was aware that the dressing should be moistened daily and that it may have been a transcription error. Continued review of Resident #8's TAR, revealed no documentation the resident's dressing was changed on 01/17/2021, as required by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RN #4, on 01/29/2021 at 12:20 PM, revealed he cared for Resident #8, on 01/17/2021 from 7:00 AM to 7:00 PM. He stated he did not provide any treatment to the resident's scalp wound on 01/17/2021, nor had he ever treated the wound. He stated a wound care task was not on the resident's TAR for 01/17/2021. Observation on 01/27/2021 at 1:00 PM, of Resident #8 scalp wound with facility staff, revealed staff measured the wound as 4.5 cm in length, 2.5 cm in width and 0.4 cm in depth. The tissue surrounding the wound was pink in color and approximately 50% of the wound bed had a dry, dark scab. Staff were observed to provide treatment to the resident's wound as ordered by the physician. Observation revealed the nurse cleansed the wound with normal saline and sterile 4x4, a [MEDICATION(S)] blue dressing was moistened and applied to the wound bed, and covered with a [MEDICATION(S)] dressing. Further observation revealed staff documented the date, time, and staff initials on the dressing. Interview with Resident #8, on 01/26/2021 at 3:35 PM, revealed that recently the facility had been providing routine wound care. The resident did not recall how often wound care was provided before, but recalled noticing an odor before the wound was debrided on 01/02/2021. Interviews with the APRN, on 02/01/2021 at 11:45 AM, and with Physician #1, on 02/01/2021 at 11:30 AM, revealed the facility's lack of care/failure to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on 02/01/2021 at 3:40 PM revealed Unit Coordinators were required to review all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated that nursing staff was expected to continue to attempt to reach a physician for orders or call the Medical Director if they were unable to reach a physician. She stated nursing staff should have taken more initiative to obtain orders for Resident #8's wound care. The DON further stated that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator on 02/01/2021 at 4:25 PM revealed staff were expected to review and follow all physician orders, to obtain orders when needed, transcribe orders correctly, and to adequately assess wounds. He also stated the MDS Nurses and Unit Coordinators were responsible for reviewing new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #6's medical record revealed the facility admitted the resident on 01/30/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6'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 fourteen (14), indicating the resident was cognitively intact. Review of Resident #6's Progress Notes, dated 12/14/2020 at 10:42 AM, revealed Resident #6 reported to staff he/she was not feeling well. When assessed by Licensed Practical Nurse (LPN) #8, the resident had a body temperature of 100.5 degrees Fahrenheit (98.6 normal), diminished lung sounds, an oxygen saturation of 88-89 percent on room air (95-100 normal), and the resident had a cough. LPN #8 documented the resident assessment, and attempted to notify the physician of the resident's condition, however, she was unable to speak to the physician and left a message. However, the nurse failed to attempt to notify the medical director since the resident's attending physician was not available and did not try to notify the resident's physician again, placing the resident at high risk for rapid deterioration, should the resident be infected with COVID-19. Interview with LPN #8, on 01/29/2021 at 9:50 AM, revealed she had cared for Resident #6 on 12/14/2020, during day shift and the resident complained of being sick and appeared more confused. She stated the resident had abnormal lung sounds and decreased oxygen levels. LPN #8 stated she called the physician's office and left a message for the physician. However, LPN #8 stated the physician never returned her call on 12/14/2020. LPN #8 stated she suspected the resident was infected with COVID-19, and the facility obtained a COVID-19 test, but the results had to be submitted to the laboratory and were not immediately available. Further interview revealed since the nurse was unable to communicate with the physician, she was unable to implement interventions such as oxygen or other measures typically ordered by the physician. In addition, the nurse stated she took no other action to implement resident centered interventions such as increased monitoring of the resident's condition to ensure Resident #6 received appropriate care and services dependent on the resident's assessment, medical condition, and functioning level; such as deep instruction of deep breathing exercises, frequent lung assessment and instruction to the resident/staff to contact the nursing staff immediately of any increased shortness of air, pain or distress. Interview with State Registered Nurse Aide (SRNA) #2, on 01/31/2021 at 8:25 PM, revealed during the day shift on 12/14/2020, Resident #6 acted differently than normal, stated that he/she did not feel well, and did not eat much for lunch, all of which were unusual behaviors for Resident #6. The SRNA stated when the resident's condition was reported to LPN #8, the LPN stated she was already aware of the resident's condition. Interview with Registered Nurse (RN) #1, on 01/26/2021 at 11:45 AM, revealed she cared for Resident #6 on 12/15/2020, during day shift, and was aware the resident had been sick for a day or so. However, RN #1 stated she did not attempt to notify the resident's physician to report the illness or implement other measures to ensure the resident's condition was not actively declining. The RN stated she assessed and obtained the resident's vital signs sometime that morning, and stated they were not that bad, however, the nurse did not document the vital signs, nor did she initiate increased monitoring of the resident's condition. Continued interview with RN #1 and review of Resident #6's medical record, revealed at approximately 1:30 PM, on 12/15/2020, RN #1 assessed Resident #6 to be lethargic, difficult to wake up, unresponsive to verbal stimuli and had constricted pupils. The RN stated she was unable to recall what alerted her to the residents' room, but that she was not performing a scheduled assessment of the resident. RN #1 stated she immediately contacted Emergency Medical Services who transferred Resident #6 to the hospital for further evaluation and treatment. Review of Resident #6's hospital record, revealed the resident presented to the Emergency Department (ED), on 12/15/2020 at approximately 2:05 PM. Further review of the record revealed the hospital admitted the resident, who was subsequently diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing (DON), on 02/01/2021 at 3:40 PM, revealed when the nursing staff assessed Resident #6 on 12/14/2020, to be ill, and exhibiting signs/symptoms of COVID-19, the staff should have ensured contact with a physician. In addition, the DON stated staff should have ensured Resident #6 received person centered care to ensure all action was being taken, as possible, by the facility to prevent an increased risk of a negative outcome for the resident. Interview with the Administrator, on 02/01/2021 at 4:25 PM, revealed his expectation was for staff to notify a physician when a resident's condition warranted, and for staff to ensure the resident was monitored adequately to ensure a decline did not occur if avoidable.

Based on interview, record review, and a review of facility policy, it was determined the facility failed to immediately inform the physician when a significant change in condition occurred for one (1) of three (3) sampled residents (Resident #6). Record review and staff interview, revealed Resident #6 voiced complaints of not feeling well, had abnormal vital signs, and had a decrease in food intake on 12/14/2020. Although staff attempted to notify the Resident's physician of the resident's condition, on 12/14/2020 at 10:42 AM the staff were unable to reach the physician, and the physician never called the facility back after a voice message was left regarding Resident #6. However, there was no documented evidence the facility made any other attempts to notify a physician related to Resident #6's condition until 12/15/2020 at approximately 1:30 PM, when the nurse assessed the resident to be lethargic, constricted pupils, and not responsive to verbal stimuli. Nursing staff contacted Emergency Medical Services and Resident #6 was transferred to the hospital and admitted with COVID-19 Pneumonia. The findings include: Review of the facility's policy titled Change in a Resident's Condition, dated 08/01/2013, revealed staff would promptly notify the resident, the resident's physician, and the resident's representative of changes in the resident's medical and/or mental condition. The policy also stated the resident's attending physician or an on-call physician would be notified when a significant change in the resident's physical, emotional or mental condition occurred. According to the policy a significant change of condition, included a decline in the resident's status that would not normally resolve itself without intervention from staff. Record review revealed the facility admitted Resident #6 on 01/30/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6'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 fourteen (14), indicating the resident was cognitively intact. Review of Resident #6's Progress Notes dated 12/14/2020 at 10:42 AM revealed Licensed Practical Nurse (LPN) #8 documented that the resident's body temperature was 100.5 degrees Fahrenheit (98.6 normal), lungs sounds diminished, and oxygen saturation was 88-89 percent on room air (95-100 normal). The LPN's documentation also revealed the resident informed staff that he/she did not feel good. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with State Registered Nurse Aide (SRNA) #2 on 01/31/2021 at 8:25 PM revealed she cared for Resident #6 during day shift on 12/14/2020. The SRNA stated the resident did not act like his/her normal self and voiced not feeling good to staff. SRNA #2 stated Resident #6 only ate mashed potatoes for lunch on 12/14/2020, which was unusual for the resident. The SRNA reported the concerns to LPN #8. SRNA #2 stated the nurse informed her that she was aware of the resident's condition. Interview with LPN #8 on 01/29/2021 at 9:50 AM revealed she had cared for Resident #6 on 12/14/2020, during day shift. The LPN stated Resident #6 was sick that day and appeared to be more confused. She stated the resident's lung sounds were abnormal, and the resident's oxygen levels were also decreased during her shift. LPN #8 stated she called the physician's office and left a message for the physician. LPN #8 stated Resident #6's physician was difficult to reach at times and staff had no other way of reaching the physician during daytime hours, and had been instructed to leave a message when they called. Continued interview with LPN #8 revealed the physician never returned her call on 12/14/2020. LPN #8 stated she made no further attempts to inform the physician of Resident #6's condition. LPN #8 stated the facility did perform a COVID-19 test on Resident #6 on 12/14/2020, and sent the specimen to the laboratory for analysis. LPN #8 stated she had not been instructed to notify the Medical Director if she was unable to contact the resident's physician. Interview with SRNA #1 on 01/30/2021 at 12:50 PM revealed he cared for Resident #6 during day shift on 12/15/2020. The SRNA stated the resident had decreased food/fluid intake that day for breakfast and lunch. SRNA #1 stated the resident was sleepy and not his/her normal self. The SRNA stated he informed the nurse (unable to recall which nurse), of the resident's condition early in the shift, but was unable to state the exact time. Interview with Registered Nurse (RN) #1 on 01/26/2021 at 11:45 AM revealed she was caring for Resident #6 on 12/15/2020 during day shift. RN #1 stated she was aware the resident had not been feeling well for a day or so. However, RN #1 stated she was not aware that staff had attempted to reach Resident #6's physician on 12/14/2020 to report the resident's illness but was unsuccessful in reaching the physician. Further interview with RN#1 revealed at approximately 1:30 PM, on 12/15/2020, she assessed the resident to be lethargic and difficult to wake up. The RN stated she was unable to recall what alerted her to the residents' room. The RN stated she transferred Resident #6 to the hospital immediately after the assessment. RN #1 stated she had obtained the resident's vital signs prior to 1:30 PM that day; however, she failed to document the vital signs, but stated, They weren't that bad. Further interview revealed RN #1 did not attempt to contact the physician on 12/15/2020 prior to 1:30 PM. Review of Resident #6's medical record revealed on 12/15/2020 at 1:30 PM the resident was lethargic, difficult to wake up, not responsive to verbal stimuli, and had constricted pupils. Staff contacted Emergency Medical Services (EMS) and transferred the resident to the hospital for further evaluation and treatment. Review of Resident #6's hospital record revealed the resident presented to the Emergency Department (ED) on 12/15/2020 at approximately 2:05 PM, and was admitted to the hospital, and subsequently diagnosed with COVID-19 pneumonia. Interview with Resident #6's Physician on 02/01/2021 at 12:25 PM confirmed that facility staff were required to leave a message for her on an answering service during daytime hours. The physician stated she received messages from the facility depending on how effective the system is. However, the physician stated if she had been aware that Resident #6 had an abnormal oxygen level and abnormal lung sounds she would have transferred the resident to the hospital for further evaluation and treatment on 12/14/2020. Interview with the Director of Nursing (DON) on 02/01/2021 at 3:40 PM revealed she was aware that staff were unable to talk to Physician #2 during the daytime hours and were only able to leave a message for the physician. The DON stated Resident #6's Physician might call back on the day the message is left or she might not. However, the DON stated when the nursing staff assessed Resident #6 on 12/14/2020 to have abnormal lung sounds and a decreased oxygen saturation, they should have called the medical director since the resident's physician did not respond in a timely manner. Interview with the Administrator on 02/01/2021 at 4:25 PM revealed he expected staff to notify the resident's physician in a timely manner when the resident's condition warranted. The Administrator also stated if staff were unable to contact the resident's physician, then staff should contact the Medical Director.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to prevent the possible spread of COVID-19. On 12/09/2020, two (2) direct care staff (State Registered Nurse Aide (SRNA) #1 and #2) were observed entering the room of Resident #2 and #7 who were both positive for COVID-19 without donning the appropriate Personal Protective Equipment (a N-95 or higher face mask). The findings include: Review of the facility policy titled, Managing Covid-19 Positive Residents or Residents Under Covid-19 Investigation, undated revealed The resident should be placed in airborne isolation precautions. All staff who enter the resident's room shall don (put on), and doff (take off) the following Personal Protective Equipment: Respirator (N95), Gown, Gloves, Eye Protection. Review of Resident #2's medical record revealed the facility admitted the resident on 09/04/2015, with [DIAGNOSES REDACTED]. Further record review revealed Resident #2 tested positive for COVID-19 on 12/08/2020. Review of Resident #7's medical record revealed the facility admitted the resident on 07/10/2020 with [DIAGNOSES REDACTED]. Further review revealed Resident #7 also tested positive for COVID-19 on 12/08/2020. Observation on 12/09/2020 at 10:34 AM, revealed signage for droplet precautions posted on Resident #2 and #7's doors. The signage stated prior to entry to the room, staff must don a gown, mask, gloves, and face shield. Observation on 12/09/2020 at 10:37 AM, revealed SRNA #1 and SRNA #2 donned a gown, surgical mask, face shield and gloves prior to entering Resident #2 and Resident #7's room (both positive for COVID-19). Interview with SRNA #1, on 12/09/2020 at 10:42 AM, revealed staff were alerted if a resident was on transmission based precautions by the signage posted outside the resident's room door. He stated he was aware that Resident #2 and Resident #7 had tested positive for COVID-19, but was unsure when entering a room of a positive COVID-19 resident, whether a N95 mask or higher level respirator was required. Interview with SRNA #2, on 12/09/2020 at 11:31 AM, revealed she was unaware that Resident #7 and Resident #2 were positive for COVID-19; therefore, did not don a N95. She further revealed she was unaware how often staff received education regarding isolation precautions, but stated they had teachable moments when they were supposed to read information and sign that it was read. Further, according to SRNA #2, she was also providing care for resident on another unit (yellow zone unit) where residents were being monitored for COVID symptoms. Interview with Licensed Practical Nurse (LPN) #1, on 12/09/2020 at 10:48 AM, revealed Resident #2 and Resident #7 were positive for COVID-19; therefore, prior to entry staff must don a N95 mask. She further revealed she notified staff of the positive test results for Resident #2 and #7 immediately after receiving the test results. Interview on 12/09/2020 at 11:42 AM, with the Infection Control Nurse, revealed she expected staff to wear a N95 mask when providing care for a resident who was COVID-19 positive. She further revealed the facility policy stated a N95 must be worn when a resident was positive for COVID-19. Continued interview with the Infection Control Nurse revealed there was a potential for exposure and spread of COVID-19 if staff did not wear the proper mask. Interview with Director of Nursing (DON), on 12/09/2020 at 11:11 AM, revealed staff were expected to wear a N95 or higher level respirator when entering resident rooms who were positive for COVID-19. She stated that the only exception would be if the facility had a shortage of N95 masks; however, she stated the facility did not currently have a mask shortage. Per the DON, if a resident tested positive for the COVID-19 virus, the nurses were responsible to communicate residents' COVID-19 status and the precautions to take when providing care to other staff. The DON stated staff not wearing a N-95 facemask created the potential for spread of COVID-19. Interview with Administrator, on 12/09/2020 at 11:25 AM, revealed he expected staff to wear full personal protective equipment (PPE) which included a gown, gloves, N95 or higher level respirator and face shield to help prevent the spread of COVID-19. He further revealed staff should not enter a resident room with suspected or confirmed COVID-19 without a N95 mask.

Based on interview, record review, and review of facility policy it was determined the facility failed to implement written policies and procedures to ensure allegations of abuse and misappropriation of resident property were investigated for two (2) of sixteen (16) sampled residents (Resident #6 and Resident #7). Interviews and record review revealed Resident #6 alleged that a State Registered Nurse Aide (SRNA) kicked him/her on 08/27/2020. Interviews also revealed Resident #7 alleged that on an unknown date in August 2020, staff had stolen his/her pain medication on more than one occasion; however, the facility failed to investigate the allegations as required. The findings include: Review of the facility policy titled Reporting Abuse to Facility Management, not dated, revealed it was the responsibility of employees, facility consultants, family members, visitors etc., to promptly report any incident or suspected incident of resident neglect or abuse, including misappropriation of resident property, to facility management. The policy stated an immediate investigation of any incidents was to occur and a copy of the investigation findings should be provided to the Administrator. 1. Review of Resident #6's medical record revealed the facility admitted the resident on 03/17/2020 with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident required extensive assistance of two (2) staff members for bed mobility and toileting. The MDS also indicated the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating the resident was cognitively intact. Interview with State Registered Nurse Aide (SRNA) #1 on 09/15/2020 at 5:00 PM revealed on 08/27/2020, she entered Resident #6's room to assist the resident with the evening meal and the resident stated to SRNA #1 that she had kicked him/her. The SRNA stated she immediately reported the allegation to the Director of Nursing (DON). The SRNA stated she was instructed not to enter the resident's room again, and not to mention the allegation in the facility again. SRNA #1 stated the facility never removed her from resident care. Interview with SRNA #2 on 09/15/2020 at 2:15 PM revealed she was present with SRNA #1 on 08/27/2020, and witnessed Resident #6 state that SRNA #1 had kicked him/her. SRNA #2 confirmed that SRNA #1 immediately reported the allegation to the Director of Nursing (DON). Interview with Resident #6 on 09/15/2020 at 12:45 PM revealed the resident denied being kicked, injured, or mistreated in the facility. Interview with the DON on 09/16/2020 at 5:10 PM revealed SRNA #1 reported to her, on or about 08/27/2020, that Resident #6 alleged that she had kicked him/her. The DON stated she spoke with the resident and the resident changed (his/her) story on what had occurred. However, the DON stated she should have investigated the allegation as required. 2. Review of Resident #7's medical record revealed the facility admitted the resident on 08/21/2020 with [DIAGNOSES REDACTED]. Review of Resident #7's Admission MDS dated [DATE] revealed the resident required limited assistance of one (1) staff member for bed mobility and transfers. The facility also assessed the resident to have a BIMS score of eleven (11), indicating the resident had moderate cognitive impairment. Further review of the MDS revealed Resident #7 experienced occasional pain and received pain medication as needed in the facility. Review of Resident #7's physician orders dated August 2020 revealed the physician ordered the resident to receive one (1) [MEDICATION NAME] (narcotic pain medication) 5/325 milligrams (mg) tablet, every six (6) hours as needed for pain. Interview with Resident #7 on 09/14/2020 at 7:45 PM revealed the resident stated staff stole his/her [MEDICATION NAME] pain medication a couple nights in a row. The resident stated he/she had requested pain medication three different times and was told each time that the previous shift had already documented that the medication was administered to him/her previously at 7:00 PM. The resident was unable to recall the specific dates this occurred or the staff members involved. However, Resident #7 stated staff had not administered the pain medication to him/her previously and stated, I've taken that pain medicine a long time and I know what they look like and they took my medicine. Resident #7 stated he/she reported that someone had taken his/her medication on three (3) different occasions before someone done something. Resident #7 stated after the third report, the facility started having the resident to sign when the pain medication was administered and after that, there had been no further problems. Interview with Kentucky Medication Aide (KMA) #1 on 09/16/2020 at 1:05 PM revealed Resident #7 had alleged that staff had not administered his/her narcotic pain medication, even though they documented that they had. The KMA was unable to recall specific dates/times this occurred. However, the KMA stated she did not report the allegations to Administrative staff because the nurses were already aware of the resident's allegations. Interview with Registered Nurse (RN) #1 on 09/16/2020 at 2:00 PM revealed Resident #7 had requested pain medication, and when she informed the resident that staff had documented that it was already administered, the resident denied having already received it. RN #1 was unable to recall the specific dates and times of the occurrences. However, the RN stated she did not report the allegation to Administrative staff as required. Interview with Licensed Practical Nurse (LPN) #1 on 09/16/2020 at 2:10 PM revealed Resident #7 had requested pain medication and when she informed the resident that day shift had already documented that they administered it to him/her, Resident #7 stated he/she had not requested the medication and it had not been given to him/her. LPN #1 went on to say that Resident #7 stated he/she knew what the medication looked like, and he/she had not received it. LPN #1 could not recall the exact date and time of the incident, but the LPN stated she did not report the allegation to Administration as required but should have. However, LPN #1 reported she did report the resident's statements to day shift. Interview with the DON on 09/16/2020 at 5:10 PM revealed when Resident #7 alleged misappropriation of his/her pain medication staff should have immediately reported the resident's concern to Administrative staff. She stated if staff had reported the allegation she would have thoroughly investigated the allegation, including drug screening the staff who worked when the allegations were made. Interview with the Administrator on 09/16/2020 at 6:15 PM revealed staff were required to report all allegations of abuse and misappropriation immediately to ensure timely investigation of the allegations as required by the facility's policies/procedures.

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure allegations of abuse and misappropriation of resident property were reported to state agencies as required for one (1) of sixteen (16) sampled residents. Interviews and record review revealed Resident #6 reported that a State Registered Nurse Aide (SRNA) kicked him/her on 08/27/2020. However, the facility failed to report the allegations to the appropriate State Agencies until 09/06/2020. The findings include: Review of the facility policy titled Reporting Abuse to State Agencies and other Entities/Individuals, not dated, revealed all suspected violations of resident abuse would be immediately reported to appropriate state agencies and other entities or individuals as required by law. Review of Resident #6's medical record revealed the facility admitted the resident on 03/17/2020 with [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating the resident was cognitively intact. Interview with State Registered Nurse Aide (SRNA) #1 on 09/15/2020 at 5:00 PM revealed on 08/27/2020, Resident #6 alleged that I kicked the resident. SRNA #1 stated she reported the allegation to the Director of Nursing (DON) immediately. The SRNA stated she was instructed not to enter the resident's room again, and not to mention the allegation in the facility again. Interview with SRNA #2 on 09/15/2020 at 2:15 PM revealed she witnessed Resident #6 state that SRNA #1 had kicked him/her. SRNA #2 stated the allegation was reported to the DON immediately. Interview with Resident #6 on 09/15/2020 at 12:45 PM revealed the resident denied being kicked or mistreated in the facility. Interview with the Director of Nursing (DON) on 09/16/2020 at 5:10 PM revealed SRNA #1 reported to her, on or about 08/27/2020, that Resident #6 alleged that the SRNA had kicked him/her. The DON stated she spoke with Resident #6 and the resident changed the story. Therefore, the DON stated she did not report the allegation to state agencies as required. Interview with the Administrator on 09/16/2020 at 6:15 PM revealed he was the Abuse Coordinator in the facility and was responsible to ensure all alleged violations were reported to state agencies in a timely manner. The Administrator stated Resident #6's allegation should have been reported to state agencies as required.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) was protected from abuse. On 12/03/19, Resident #17 did not want staff to remove his/her dentures. State Registered Nurse Aide (SRNA) #29 told the resident, If I have to do it you know your (you're) not going to like it. Then, when the resident turned his/her head and stated, Don't do that, SRNA #29 put her fingers in the resident's mouth and attempted to jerk the resident's dentures from his/her mouth. Another staff member intervened and SRNA #29 left the room. Resident #17 cried and stated that his/her mouth hurt as a result of the incident. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/17, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The facility defined abuse as the willful infliction of injury.with resulting physical harm or pain or mental anguish.It includes verbal, sexual, physical & mental abuse. Further review of the facility's policy revealed the facility defined mental abuse as but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Review of a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that SRNA #29 told Resident #17 that she was going to remove the resident's dentures. When the resident refused and turned his/her head, SRNA #29 put her fingers in the resident's mouth and jerked the resident's top dentures halfway out of the resident's mouth. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on [DATE] at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. According to SRNA #29, the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, when she was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Review of SRNA #42's witness statement revealed he was in Resident #17's room on 12/03/19 with SRNA #29 and SRNA #41, when SRNA #29 requested the resident to take out his/her dentures. According to SRNA #42, Resident #17 rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. According to SNRA #42, Resident #17 pulled back and said, Don't do that. SRNA #42 stated he immediately took over for SRNA #29 and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on [DATE] at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on [DATE] at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRNA. SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Interview with Registered Nurse (RN) #8 on [DATE] at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said that Resident #17 wanted to talk to her. Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she completed an oral assessment for Resident #17 and there were no issues noted. RN #8 stated she notified the Director of Nursing (DON) and the resident's Responsible Party (RP) of the incident. Further review of the facility's investigation revealed the Director of Nursing (DON) spoke with Resident #17 on 12/03/19 at 6:25 PM and the resident stated he/she told the girl to quit trying to get (his/her) teeth out that it hurt and the girl stopped. According to the DON's statement, she then asked the resident if the resident thought the girl meant to hurt (the resident) and the resident didn't respond to the question. When the DON asked the resident again, the resident told me to leave (him/her) alone and get out (he/she) just wanted to sleep. Interview with Resident #17's RP on 1[DATE] at 11:44 AM revealed the facility notified her that Resident #17 stated that someone was rough with him/her while taking his/her dentures out. Interview with Resident #17 on 1[DATE] at 10:25 AM revealed he/she had dentures and stated staff cleaned them. According to Resident #17, I had one girl take her finger and jerk my dentures out. I don't know why she had to jerk them out. It was a long time ago and it was only one (1) time. Nobody else has hurt me.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) received the necessary care and assistance to maintain good grooming and personal hygiene. The facility failed to honor Resident #17's preference when providing oral care on 12/03/19, when the resident refused to remove his/her dentures. A State Registered Nurse Aide (SRNA) put her fingers in the resident's mouth and attempted to jerk the resident's teeth from his/her mouth. Resident #17 cried after the incident and reported that his/her mouth hurt. The findings include: Review of the facility's policy, Oral Assessment Protocol, not dated, revealed when oral care needs were identified a plan of care and treatment would be discussed with the resident and/or Responsible Party (RP). Interview with the Administrator on [DATE] at 10:30 AM revealed the facility did not have a policy concerning Activities of Daily Living (ADLs). Review of the medical record revealed the facility admitted Resident #17 on 01/22/19 with [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set ((MDS) dated [DATE] for Resident #17 revealed the facility assessed the resident's Brief Interview for Mental Status (BI[CONDITION]) score to be one (1) which indicated the resident was severely cognitively impaired. Further review of the MDS revealed it was very important for Resident #17 to take care of his/her own personal belongings or things. Interview with the RP on 1[DATE] at 11:44 AM revealed one night the facility called and said an aide had reported Resident #17 had complained that someone was rough with him/her while taking his/her dentures out. The RP explained to the facility staff that Resident #17 liked to sleep with his/her dentures. Interview with Resident #17 on 1[DATE] at 10:25 AM revealed he/she had dentures and stated staff cleans them. Resident #17 stated he/she had one (1) girl take her finger and jerk my dentures out. The resident stated it was a long time ago and nobody else has hurt me. Review of SRNA #42's witness statement from a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that while in Resident #17's room with SRNA #29 and SRNA #41, SRNA #29 requested the resident to take out his/her dentures. SRNA #42 stated the resident rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. He reported that Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. He reported Resident #17 pulled back and said, Don't do that. SRNA #42 reported he immediately took over and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on [DATE] at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on [DATE] at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRNA. SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth, and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on [DATE] at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. SRNA #29 stated that the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, and was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Interview with Registered Nurse (RN) #8 on [DATE] at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said Resident #17 wanted to talk to her. RN #8 revealed Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she did an oral assessment on Resident #17 and there were no issues noted. RN #8 revealed she notified the Director of Nursing (DON) and called the resident's Responsible Party (RP). RN #8 stated the RP told her that Resident #17 liked to sleep with his/her teeth.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) was protected from abuse. On 12/03/19, Resident #17 did not want staff to remove his/her dentures. State Registered Nurse Aide (SRNA) #29 told the resident, If I have to do it you know your (you're) not going to like it. Then, when the resident turned his/her head and stated, Don't do that, SRNA #29 put her fingers in the resident's mouth and attempted to jerk the resident's dentures from his/her mouth. Another staff member intervened and SRNA #29 left the room. Resident #17 cried and stated that his/her mouth hurt as a result of the incident. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/17, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The facility defined abuse as the willful infliction of injury .with resulting physical harm or pain or mental anguish .It includes verbal, sexual, physical & mental abuse . Further review of the facility's policy revealed the facility defined mental abuse as but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Review of a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that SRNA #29 told Resident #17 that she was going to remove the resident's dentures. When the resident refused and turned his/her head, SRNA #29 put her fingers in the resident's mouth and jerked the resident's top dentures halfway out of the resident's mouth. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on 12/18/19 at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. According to SRNA #29, the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, when she was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Review of SRNA #42's witness statement revealed he was in Resident #17's room on 12/03/19 with SRNA #29 and SRNA #41, when SRNA #29 requested the resident to take out his/her dentures. According to SRNA #42, Resident #17 rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. According to SNRA #42, Resident #17 pulled back and said, Don't do that. SRNA #42 stated he immediately took over for SRNA #29 and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRN[NAME] SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said that Resident #17 wanted to talk to her. Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she completed an oral assessment for Resident #17 and there were no issues noted. RN #8 stated she notified the Director of Nursing (DON) and the resident's Responsible Party (RP) of the incident. Further review of the facility's investigation revealed the Director of Nursing (DON) spoke with Resident #17 on 12/03/19 at 6:25 PM and the resident stated he/she told the girl to quit trying to get (his/her) teeth out that it hurt and the girl stopped. According to the DON's statement, she then asked the resident if the resident thought the girl meant to hurt (the resident) and the resident didn't respond to the question. When the DON asked the resident again, the resident told me to leave (him/her) alone and get out (he/she) just wanted to sleep. Interview with Resident #17's RP on 12/17/19 at 11:44 AM revealed the facility notified her that Resident #17 stated that someone was rough with him/her while taking his/her dentures out. Interview with Resident #17 on 12/17/19 at 10:25 AM revealed he/she had dentures and stated staff cleaned them. According to Resident #17, I had one girl take her finger and jerk my dentures out. I don't know why she had to jerk them out. It was a long time ago and it was only one (1) time. Nobody else has hurt me.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) was protected from abuse. On 12/03/19, Resident #17 did not want staff to remove his/her dentures. State Registered Nurse Aide (SRNA) #29 told the resident, If I have to do it you know your (you're) not going to like it. Then, when the resident turned his/her head and stated, Don't do that, SRNA #29 put her fingers in the resident's mouth and attempted to jerk the resident's dentures from his/her mouth. Another staff member intervened and SRNA #29 left the room. Resident #17 cried and stated that his/her mouth hurt as a result of the incident. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/17, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The facility defined abuse as the willful infliction of injury .with resulting physical harm or pain or mental anguish .It includes verbal, sexual, physical & mental abuse . Further review of the facility's policy revealed the facility defined mental abuse as but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Review of a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that SRNA #29 told Resident #17 that she was going to remove the resident's dentures. When the resident refused and turned his/her head, SRNA #29 put her fingers in the resident's mouth and jerked the resident's top dentures halfway out of the resident's mouth. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on 12/18/19 at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. According to SRNA #29, the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, when she was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Review of SRNA #42's witness statement revealed he was in Resident #17's room on 12/03/19 with SRNA #29 and SRNA #41, when SRNA #29 requested the resident to take out his/her dentures. According to SRNA #42, Resident #17 rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. According to SNRA #42, Resident #17 pulled back and said, Don't do that. SRNA #42 stated he immediately took over for SRNA #29 and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRN[NAME] SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said that Resident #17 wanted to talk to her. Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she completed an oral assessment for Resident #17 and there were no issues noted. RN #8 stated she notified the Director of Nursing (DON) and the resident's Responsible Party (RP) of the incident. Further review of the facility's investigation revealed the Director of Nursing (DON) spoke with Resident #17 on 12/03/19 at 6:25 PM and the resident stated he/she told the girl to quit trying to get (his/her) teeth out that it hurt and the girl stopped. According to the DON's statement, she then asked the resident if the resident thought the girl meant to hurt (the resident) and the resident didn't respond to the question. When the DON asked the resident again, the resident told me to leave (him/her) alone and get out (he/she) just wanted to sleep. Interview with Resident #17's RP on 12/17/19 at 11:44 AM revealed the facility notified her that Resident #17 stated that someone was rough with him/her while taking his/her dentures out. Interview with Resident #17 on 12/17/19 at 10:25 AM revealed he/she had dentures and stated staff cleaned them. According to Resident #17, I had one girl take her finger and jerk my dentures out. I don't know why she had to jerk them out. It was a long time ago and it was only one (1) time. Nobody else has hurt me.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) received the necessary care and assistance to maintain good grooming and personal hygiene. The facility failed to honor Resident #17's preference when providing oral care on 12/03/19, when the resident refused to remove his/her dentures. A State Registered Nurse Aide (SRNA) put her fingers in the resident's mouth and attempted to jerk the resident's teeth from his/her mouth. Resident #17 cried after the incident and reported that his/her mouth hurt. The findings include: Review of the facility's policy, Oral Assessment Protocol, not dated, revealed when oral care needs were identified a plan of care and treatment would be discussed with the resident and/or Responsible Party (RP). Interview with the Administrator on 12/18/19 at 10:30 AM revealed the facility did not have a policy concerning Activities of Daily Living (ADLs). Review of the medical record revealed the facility admitted Resident #17 on 01/22/19 with [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set ((MDS) dated [DATE] for Resident #17 revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be one (1) which indicated the resident was severely cognitively impaired. Further review of the MDS revealed it was very important for Resident #17 to take care of his/her own personal belongings or things. Interview with the RP on 12/17/19 at 11:44 AM revealed one night the facility called and said an aide had reported Resident #17 had complained that someone was rough with him/her while taking his/her dentures out. The RP explained to the facility staff that Resident #17 liked to sleep with his/her dentures. Interview with Resident #17 on 12/17/19 at 10:25 AM revealed he/she had dentures and stated staff cleans them. Resident #17 stated he/she had one (1) girl take her finger and jerk my dentures out. The resident stated it was a long time ago and nobody else has hurt me. Review of SRNA #42's witness statement from a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that while in Resident #17's room with SRNA #29 and SRNA #41, SRNA #29 requested the resident to take out his/her dentures. SRNA #42 stated the resident rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. He reported that Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. He reported Resident #17 pulled back and said, Don't do that. SRNA #42 reported he immediately took over and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRN[NAME] SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth, and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on 12/18/19 at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. SRNA #29 stated that the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, and was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said Resident #17 wanted to talk to her. RN #8 revealed Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she did an oral assessment on Resident #17 and there were no issues noted. RN #8 revealed she notified the Director of Nursing (DON) and called the resident's Responsible Party (RP). RN #8 stated the RP told her that Resident #17 liked to sleep with his/her teeth.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) received the necessary care and assistance to maintain good grooming and personal hygiene. The facility failed to honor Resident #17's preference when providing oral care on 12/03/19, when the resident refused to remove his/her dentures. A State Registered Nurse Aide (SRNA) put her fingers in the resident's mouth and attempted to jerk the resident's teeth from his/her mouth. Resident #17 cried after the incident and reported that his/her mouth hurt. The findings include: Review of the facility's policy, Oral Assessment Protocol, not dated, revealed when oral care needs were identified a plan of care and treatment would be discussed with the resident and/or Responsible Party (RP). Interview with the Administrator on 12/18/19 at 10:30 AM revealed the facility did not have a policy concerning Activities of Daily Living (ADLs). Review of the medical record revealed the facility admitted Resident #17 on 01/22/19 with [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set ((MDS) dated [DATE] for Resident #17 revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be one (1) which indicated the resident was severely cognitively impaired. Further review of the MDS revealed it was very important for Resident #17 to take care of his/her own personal belongings or things. Interview with the RP on 12/17/19 at 11:44 AM revealed one night the facility called and said an aide had reported Resident #17 had complained that someone was rough with him/her while taking his/her dentures out. The RP explained to the facility staff that Resident #17 liked to sleep with his/her dentures. Interview with Resident #17 on 12/17/19 at 10:25 AM revealed he/she had dentures and stated staff cleans them. Resident #17 stated he/she had one (1) girl take her finger and jerk my dentures out. The resident stated it was a long time ago and nobody else has hurt me. Review of SRNA #42's witness statement from a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that while in Resident #17's room with SRNA #29 and SRNA #41, SRNA #29 requested the resident to take out his/her dentures. SRNA #42 stated the resident rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. He reported that Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. He reported Resident #17 pulled back and said, Don't do that. SRNA #42 reported he immediately took over and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRN[NAME] SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth, and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on 12/18/19 at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. SRNA #29 stated that the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, and was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said Resident #17 wanted to talk to her. RN #8 revealed Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she did an oral assessment on Resident #17 and there were no issues noted. RN #8 revealed she notified the Director of Nursing (DON) and called the resident's Responsible Party (RP). RN #8 stated the RP told her that Resident #17 liked to sleep with his/her teeth.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to immediately inform the physician when a significant change in condition occurred for one (1) of ten (10) sampled residents (Resident #4). On [DATE] from approximately 3:13 AM until approximately 10:50 AM, Resident #4 yelled out and complained of the external defibrillator (LifeVest) he/she utilized of feeling too tight, complained of being short of breath, yelled for a doctor to come to his/her room, repeatedly asked staff to remove the vest, and had an episode of vomiting. Although staff notified the resident's physician at approximately 8:00 AM on [DATE] that the resident was yelling out and disturbing other residents, the staff failed to inform the physician of the complaints voiced by the resident or that the resident was vomiting. In addition, staff never contacted the resident's physician despite the resident's continuing change in condition and repeated requests for staff to help him/her until approximately 10:50 AM, when the resident's Responsible Party (RP) arrived at the facility and asked staff to help the resident. Resident #4 was assessed by Licensed Practical Nurse (LPN) #2 at the request of the resident's RP. LPN #2 found the resident to be cool to touch, mottled (blotchy red/purple discoloration of the skin, which occurs before death due to the heart's inability to pump blood) from feet to the waist, and was unable to obtain vital signs. Resident #4 was transferred to the hospital and pronounced deceased on [DATE] at 11:40 AM. The facility's failure to ensure the resident's physician was notified when the resident experienced a change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Change in a Resident Condition, dated [DATE], revealed staff would promptly notify the resident's physician and representative of changes in the resident's medical or mental condition. The policy also revealed staff were required to notify the resident's physician when refusal of treatment or medication occurred two (2) or more consecutive times. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #4 also utilized the LifeVest upon admission to the facility. Further review of Resident #4's medical record revealed the facility was not yet required to have completed a Minimum Data Set (MDS) assessment for the resident. However, interview with LPN #2 on [DATE] at 12:25 PM, revealed she admitted Resident #4 to the facility on [DATE]. The LPN stated the resident was alert/oriented, answered her questions appropriately, and made no complaints related to the LifeVest. Review of Resident #4's Admission Nurse's Notes dated [DATE] at 1:15 PM, revealed the resident was alert, verbal, and denied any pain or discomfort upon arrival to the facility. Continued review of Resident #4's Nurse's Notes dated [DATE] at 12:49 AM (approximately 12 hours after admission) revealed Resident #4 was able to make needs known and the resident's LifeVest was in place. Review of Resident #4's Base Line Care Plan dated [DATE] revealed staff identified the resident had concerns related to his/her cardiac and respiratory status. The care plan also revealed the resident had a LifeVest and staff were to monitor, document, and report to the physician signs/symptoms of heart failure and/or dyspnea (shortness of breath). Interview with State Registered Nurse Aide (SRNA) #24 on [DATE] at 6:45 PM revealed she had cared for Resident #4 prior to [DATE] (could not recall exact date), during a twelve (12) -hour shift. SRNA #4 stated the resident was alert/oriented, and voiced no complaints related to the LifeVest. In addition, the SRNA stated Resident #4 exhibited no behaviors such as yelling out or making demands at any time when she cared for him/her. Interview with LPN #1 on [DATE] at 1:30 PM revealed she began caring for Resident #4 on [DATE], at approximately 7:00 PM, and the resident was not exhibiting any behavioral symptoms or complaining of any distress. Although LPN #1 stated she obtained vital signs on Resident #4 at approximately 10:00 PM on [DATE], there was no documented evidence of the vital signs being obtained in the resident's medical record. LPN #1 was unable to recall what the vital signs were, but she stated they were within normal limits, and she had not identified any concerns. However, LPN #1 stated that at approximately 3:00 AM on [DATE], Resident #4 became confused, was complaining that the LifeVest was too tight, stating something was around his/her ankles, and asking staff to remove the vest. LPN #1 stated the resident was pulling and tugging on the vest trying to get it off and continually asking to remove it the remainder of her shift, which ended at 7:00 AM on [DATE]. LPN #1 stated she told the resident to stop bothering the vest and asked him/her throughout the night to lower his/her voice due to disturbing other residents. However, LPN #1 stated she did not notify the resident's physician of the change in the resident's mental and physical condition, or of the resident's complaints related to the LifeVest, because she was not familiar with the resident and did not know if the behavior was normal or not. Further interview with LPN #2 on [DATE] at 12:25 PM revealed LPN #1 reported to her during shift change on [DATE] at approximately 7:00 AM that Resident #4 had yelled out all night. LPN #2 stated when she observed the resident at approximately 8:00 AM on [DATE] she immediately recognized that the resident was acting differently than when he/she was admitted four (4) days earlier. She stated Resident #4 was repeatedly requesting staff to remove the LifeVest, stating it was too tight and that he/she could not breathe. According to LPN #2, Resident #4 was also yelling out, get the doctor in here. LPN #2 stated she informed the resident that he/she had to wear it, because the doctor ordered it. However, LPN #2 did not notify the resident's physician of the resident's change in condition, complaints, or request to see a physician, because she was still assessing other residents and only wanted to call the doctor one time. LPN #2 also stated Resident #4's physician should have been notified of the resident's condition earlier that morning when the resident's change in condition initially occurred, prior to her arrival at the facility. Interview with LPN #3 on [DATE] at 7:30 PM revealed she assisted in providing care to Resident #4 on [DATE] from 7:00 AM to approximately 9:00 AM, and confirmed that the resident was experiencing a change in condition. LPN #3 stated she was familiar with the resident's behavior and demeanor, because she had cared for the resident two (2) days earlier. LPN #3 stated she heard the resident yelling, help me from the hallway, when she arrived on the unit on [DATE] at approximately 7:00 AM. LPN #3 also stated that at approximately 7:45 AM on [DATE], Resident #4 had an episode of vomiting, complained of shortness of breath, and told her that the vest was too tight and asked her to remove it, because he/she could not breathe. LPN #3 stated she called Resident #4's physician and reported that the resident was yelling and screaming and that it was disrupting other residents. LPN #3 acknowledged she failed to inform the physician of the resident's complaints of shortness of breath/distress, vomiting, and complaints that the LifeVest was too tight, because she was in a hurry to leave the facility, due to having a scheduled appointment she needed to attend. Interview with Resident #4's RP on [DATE] at 9:30 AM revealed he arrived at the facility at approximately 10:30 AM on [DATE] and could hear (Resident #4) hollering from the hallway. The RP stated he requested LPN #2 to check the resident, because he knew something was wrong. The RP stated Resident #4 was confused, sweaty, and cold to the touch. The RP stated that LPN #2 told him the resident had been yelling all morning, but the physician had not been called. The RP stated the physician should have been called a long time before I got there and found (him/her) like that. Continued interview with LPN #2 on [DATE] at 12:25 PM revealed when she was called to the resident's room by the RP, Resident #4's color was bad and she was unable to obtain vital signs. The LPN stated the resident's lower extremities were mottled. LPN #2 stated Emergency Medical Services (EMS) was called, and Resident #4 was transported to the hospital. Review of the Emergency Medical Services (EMS) transportation sheet for Resident #4 revealed EMS arrived at the facility on [DATE] at 11:02 AM. Once Resident #4 was loaded into the ambulance, the resident went into [MEDICAL CONDITION] and cardiopulmonary resuscitation (CPR) was initiated. After arrival at the hospital Resident #4 was pronounced deceased at 11:40 AM. Interview with Physician #1 on [DATE] at 8:20 AM revealed he expected staff to inform him when changes in a resident's condition occurred. The physician stated staff should have immediately notified him when Resident #4 complained of shortness of breath, and the LifeVest being too tight. The physician stated he would have ordered Resident #4 be transported to the hospital for further evaluation and treatment. Interviews on [DATE] at 6:20 PM with the Administrator and at 4:45 PM with the Director of Nursing (DON) revealed they expected staff to notify the physician when a change in a resident's condition occurred. Both the Administrator and DON stated staff should have notified Resident #4's Physician of the resident's multiple requests for the LifeVest to be removed and that the resident was complaining of shortness of breath. **The facility alleged that the following actions were implemented to remove Immediate Jeopardy on [DATE]: 1. Interviews with all residents with a Brief Interview for Mental Status (BIMS) score of greater than eight (8) were conducted by Social Services regarding staff treatment, injuries, feeling safe, etc. No concerns were expressed. 2. Unit Managers and licensed nurses conducted skin assessments of all residents with BIMS scores of less than seven (7). Skin checks revealed no negative findings. 3. The Director of Nursing (DON) and Staffing Coordinator interviewed all licensed and unlicensed nursing staff from [DATE] to [DATE], specifically inquiring about concerns with resident care and/or any knowledge of faulty equipment or incidents with patient care. No negative findings were found and no concerns were expressed. 4. Each resident in the facility was assessed by the DON, Assistant Director of Nursing (ADON), or a Unit Manager to assess for any unidentified changes in clinical condition. No new issues were identified. 5. Additionally, all licensed and unlicensed nursing staff that cared for Resident #1 within the last week of his/her stay were interviewed by the Administrator/DON/Nurse Aide Coordinator/VP of Clinical Operations and asked if Resident #1 appeared in any pain when providing care or if they had knowledge of any incident. All answered consistently with no negative findings. 6. The Quality Assurance (QA) Nurse educated all nursing staff (including State Registered Nurse Aides) on mechanical lift procedures and identifying signs of pain in the elderly from [DATE] to [DATE]. 7. After receiving the IJ Notifications, two employees (Employee #1 and Employee #2), who had cared for Resident #2, were suspended until an investigation could be completed. 8. On [DATE], two (2) Hoyer (brand of mechanical lift) lifts were removed from the facility and replaced with two (2) lifts that were the same brand as the majority (Invacare) being utilized at The Center, making the facility use 100% the same full total body lift with the same manufacturer's lift pads available, as recommended. 9. On [DATE], the MDS Assessment Nurses initiated a 100% review and update of each resident's care plan on the required amount of assistance needed. 10. On [DATE], the DON and Nurse Aide Coordinator retrained all staff (licensed and unlicensed) regarding sling size. Further, the sling size was placed on each resident's Kardex/Care Plan by the MDS Assessment Nurse. 11. On [DATE], the DON ensured visual reminders were placed on each mechanical lift that two (2) staff members were required while operating the lift and included specifications from the manufacturer on the sling sizing guide as to what size each color indicated. 12. On [DATE], the facility did not identify any other residents that required a life vest as did Resident #4. 13. On [DATE], The Regional Director of Operations provided in-service/education to the Administrator and the Director of Nursing on the facility's change of condition policy and the requirements related to resident assessment and physician notification by licensed staff when change in a medical condition occurs. Both the Administrator and Director of Nursing completed a post-test with 100% accuracy. 14. On [DATE], the DON/ADON initiated in-service/education to all licensed nurses (on duty) on the facility's policy of change of resident condition, assessing the change in resident status, and associated MD notification. The training also covered care plans (comprehensive) and following resident-centered care plans. This education will be conducted for new hires as well. Any licensed nurses who were unable to attend the required in-service will be immediately educated upon return to work by the DON/ADON. In addition, a sign was posted by the time clock and the DON/Administrator crosschecked the work schedule with the in-service sign-in sheets to assure that only staff that had received the education were allowed to work. This facility does not utilize agency staff. Post-tests were given to licensed staff on change in resident condition, which included assessment of a resident's medical/mental condition, recording the assessment in the medical record, and reporting changes promptly to the MD. A post-test was given to all licensed nurses with 100% accuracy expected before returning to work. 15. On [DATE], the Regional Director of Operations in-serviced/educated the Administrator and Director of Nursing Services on the manufacturer's recommendations for mechanical lifts/lift pads. 16. On [DATE] in-service/education was conducted by the Director of Nursing/ADON on the implementation of the Kardex with all State Registered Nurse Aides (SRNAs) on duty. Specifically, the location of the Kardex, following the Kardex, and requirements for assistance with mobility including transfers, and bed mobility. The education also included immediately reporting a noted change in a resident's condition to the charge nurse. This education will be given to any new hire SRNAs upon orientation. Any SRNA unable to attend the required in-service/education will be immediately educated upon return to work by the DON/ADON. A sign was posted by the time clock and the DON/Administrator crosschecked the work schedule with the in-service sign-in sheet to assure that only staff that had received the education was allowed to work. The facility does not utilize agency staff. All SRNAs took a post-test with 100% accuracy expected before being allowed to return to work. 17. On [DATE], re-education/in-service was provided by the DON to all SRNAs for those immediately on shift in regard to following the SRNA Kardex, both electronic and paper version. In addition, the DON in-serviced on the implementation of the number 2 or more identification label to the right bottom side of the resident's footboard. A post-test was given with 100% accuracy expected. Any employee not in attendance will be educated prior to work by the DON/ADON. An all nursing staff in-service was held on [DATE] to continue this process. Staff are stationed by the time clock each shift with a crosscheck document to assure that no staff member works without first being re-educated. This education will be conducted for all new hire SRNAs and no agency staff are utilized at the facility. Any remaining staff will be educated and deemed competent prior to their next work shift. On [DATE], full SRNA return demonstration on competency regarding electronic and/or Paper Kardex was initiated. One hundred percent accuracy is expected and competency must be established before the SRNA works the next shift. This is being done in conjunction with the SRNA Kardex education provided on [DATE] Any SRNA that was not present for the initial checkoff will be required to do so before their next shift with 100% accuracy. Competency will be completed for any new hires as well. Ongoing checkoffs will be conducted by the SRNA Coordinator prior to the SRNA working. 18. On [DATE], Unit Coordinators, the Physical Therapist, Restorative Nurse, Restorative Nurse Aides, SRNA Coordinator, Director of Nursing, and the Administrator were educated by the safe resident handling consultant authorized by Invacare Lift Company on the following: Sizing of slings according to weight, height, and girth; sling border and color related to size and weight capacity; and safety inspection. Going forward, only these trained individuals will evaluate residents who need mechanical lifts to determine and assign sling sizes. Once the resident's sling size has been assigned, this will be listed on that individual resident's nurse aide Kardex. A post-test was given to the Unit Managers, Restorative Nursing, Director of Nursing, and SRNA Coordinator with 100% accuracy expected. 19. On [DATE], the Director of Nursing initiated education/in-service to all staff nurses and SRNAs regarding their duties, which consisted of identification of how to access the assigned sling size on the SRNA Kardex; the utilization of the correct mechanical lift sling size; the process of assignment, location, and the difference in mechanical lift sling sizes; and the visual reminders on each lift. A post-test will be given to each employee with 100% accuracy expected. Further, any staff not in attendance will be in-serviced by the DON/Administrative Nurses, Physical Therapy, or Restorative Nursing prior to returning to work. A note is posted at the time clock and the DON/ADON crosschecked the schedule to ensure all staff were trained. 20. On [DATE], a Quality Assurance meeting with the Medical Director, Administrator, Director of Nursing, Social Services Director, Unit Coordinators, and Regional Nurse Consultant was conducted. The following were reviewed during this QA meeting: The survey findings as per the IJ notification; the AOC and corresponding action plan; and the ongoing compliance monitoring audits. 21. On [DATE], the facility began having daily meetings (seven days a week) which will include the DON/ADON/Administrator, Licensed Nurses, and Social Services to provide ongoing monitoring of audits and ensuring ongoing compliance with the AOC. 22. On [DATE], the facility initiated a Resident Change of Condition Monitoring Audit. All residents placed on the acute monitoring log will be discussed during the daily meeting and reviewed for the following: evidence of assessment, evidence of physician notification, and a care plan review and the appropriate implementation thereof. A resident change of condition monitoring audit will be conducted by the IDT (including the DON/ADON and/ or Administrator as designated) which includes an assessment of the resident (including vital signs), Physician/Physician on-call/Medical Director notification, resident and family notification, and care plan review. The Audit will be conducted daily for four (4) weeks and presented to Quality Assurance/Performance Improvement (QAPI) for further recommendations. 23. On [DATE], Restorative Nursing conducted a 100% audit of all mechanical lift pads to ensure they were compatible with the mechanical lifts according to manufacturer's recommendations. No concerns were identified. The Mechanical lift sling audit will continue weekly for four (4) weeks, and then monthly with the QAPI process. 24. [ENTITY]ting [DATE], five percent (5%) of care plans (by random selection) are being reviewed one (1) time per week for four (4) weeks for accuracy, specifically with bed mobility, transfers, and toileting. The audit will be conducted by the MDS Coordinator, with 100% accuracy and will then reduce to monthly utilizing the QAPI process. 25. Further, a Quality Assurance meeting was held on [DATE] and [DATE] with the Medical Director, DON, Administrator, Department Directors, and administrative nursing as appropriate. The following Topics were discussed/reviewed: 1. Trainings regarding AOC results of post-test; 2. Ongoing audits and results of the audits conducted; and 3. Ongoing compliance with the AOC. 26. On [DATE], an audit was conducted by the MDS Nurses and the Unit Manager regarding the level of assistance needed for transfers. Further, placement of the 2 or more label was assigned to residents' beds as appropriate. Presence of the 2 or more assistance label on the bed will be audited two (2) times a day by the [ENTITY]/Licensed Nurse and documented on the audit form labeled 2 program compliance check. This audit will be conducted two times a day for two months, and then compliance will be determined by QAPI. Unit Managers will be responsible for updating the list with new admissions and significant changes. This will be monitored by the Director of Nursing. 27. Licensed nurses are auditing daily for utilization of the correct sling size and correct number of staff members present and assisting with mechanical lift transfers. This audit is done once daily on each unit for four (4) weeks. The DON is reporting results of the audit to QA. [ENTITY]s will check every shift for every resident requiring a mechanical lift for the presence of a lift number on each resident's bed. This is documented on the MAR. The MAR is being checked for completeness daily by the Unit Coordinator/DON. Results are reported to QA by the DON. 28. QAPI meetings will be held weekly and as needed with the Medical Director, DON/ADON, Administrator, Social Services, and Administrative Nursing Staff weekly for four (4) weeks as compliance is established and then monthly. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on [DATE], as alleged: 1. Interview with the Social Services Director on [DATE] at 2:50 PM and review of documentation revealed all residents with a BIMS score of eight (8) or greater were interviewed regarding staff treatment during care on [DATE]. No concerns were voiced by residents. 2. Interview with Unit Coordinator #2 on [DATE] and review of skin assessment documentation revealed residents with a BIMS score of seven (7) or less had skin assessments completed on ,[DATE]-,[DATE]. No suspicious injuries were identified. 3. Interview with the Director of Nursing (DON) on [DATE] at 11:54 AM and review of documentation revealed nursing staff was interviewed on ,[DATE]-,[DATE] related to concerns with resident care, any knowledge of faulty equipment, or concerns with resident incidents. No problems were identified. 4. Interviews with the DON on [DATE] at 11:54 AM and on [DATE] with the ADON at 3:40 PM, and review of documentation on resident assessments, revealed all residents were assessed for change in condition on [DATE] with no new issues identified. 5. Interview with the Director of Nursing (DON) on [DATE] at 11:54 AM and review of documentation on staff interviews/statements revealed staff were interviewed between ,[DATE]-,[DATE] regarding care provided for Resident #1. 6. Interview with the Quality Assurance Nurse on [DATE] at 5:25 PM, and review of training documentation, revealed she had completed training with nursing staff related to mechanical lift procedures and identifying signs of pain in the elderly on ,[DATE]-,[DATE]. 7. Interview with the DON on [DATE] at 11:54 AM and the Administrator on [DATE] at 10:45 AM, and review of documentation revealed Employees #1 and #2 were suspended on [DATE]. Both employees returned to work on [DATE] after the facility completed an investigation. 8. Interview with the DON on [DATE] at 11:54 AM and observation of the mechanical lifts in use at the facility on [DATE], [DATE], and [DATE] revealed Invacare lifts were being used by staff to transfer residents. 9. Interview with LPN #12 (MDS Coordinator) on [DATE] at 10:30 AM revealed she and the other MDS Coordinator had reviewed all resident care plans on [DATE]. The MDS Nurse stated they also revised resident care plans during this review related to bed mobility, incontinence care, and mechanical lift use. 10. Interview with the DON on [DATE] at 11:54 AM and with the SRNA Supervisor on [DATE] at 5:10 PM, and review of documentation revealed staff were trained on [DATE] regarding sling size and that the size of sling needed was placed on the resident's care plan. Interviews on [DATE] with SRNA #31 at 11:10 AM, LPN #13 at 3:04 PM, RN #1 at 3:40 PM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM, revealed all had received the above training. Review of Resident #8's Kardex revealed the resident was to be transferred using a mechanical lift and the sling size was listed on the resident's Kardex. 11. Interview with the DON on [DATE] at 11:54 AM and observation of two (2) mechanical lifts on [DATE] revealed the slings had signage that directed two (2) staff member assistance when operating the lift and the lift also had signage including sling color/size. 12. Interview with the DON on [DATE] at 11:54 AM and with the Administrator on [DATE] at 10:45 AM confirmed no other residents currently residing at the facility utilized life vests. 13. Interview with the Regional Director of Operations on [DATE] at 5:00 PM, with the DON on [DATE] at 11:54 AM, and with the Administrator on [DATE] at 10:45 AM, and review of training documentation revealed the Regional Director of Operations had provided education for the Administrator and DON on the facility's Change of Condition Policy and physician notification requirements. Review of tests revealed the Administrator and DON completed post-testing with 100% passing scores. 14. Interview on [DATE] with LPN #13 at 3:04 PM, RN #1 at 3:40 PM, Unit Coordinator #2 at 4:10 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, and with the DON on [DATE] at 11:54 AM, and review of training records revealed the DON had initiated training to all licensed nursing staff on the facility's change of condition policy and physician notification requirements. Review of post-tests revealed staff were tested after the above training. 15. Review of training records and interview with the Regional Director of Operations on [DATE] at 5:00 PM, the DON on [DATE] at 11:54 AM, and the Administrator on [DATE] at 10:45 AM revealed on [DATE], the Regional Director of Operations in-serviced/educated the Administrator and Director of Nursing Services on the manufacturer's recommendations for mechanical lifts/lift pads. Review of tests revealed the Administrator and DON completed post-testing with 100% passing scores. 16. Review of training records and interviews on [DATE] with SRNA #31 at 11:10 AM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #13 at 3:04 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed the DON/ADON educated nursing staff on use of the Kardex (nurse aide care plan). Interview with the DON on [DATE] at 11:54 AM revealed administrative staff observed staff arriving at work at the time clock during shift change and nursing staff were trained and were given post-test with a 100% score prior to working. Review of post-tests revealed staff were tested after the above training. 17. Interview with the DON on [DATE] at 11:54 AM and the Administrator at 10:45 AM revealed nursing staff were initially in-serviced on following the care plan/Kardex on [DATE] and re-educated on [DATE] and [DATE]. Per the DON, return demonstration as to the location of the Kardex was required on [DATE] and [DATE]. Review of training records and interviews on [DATE] with SRNA #31 at 11:10 AM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #13 at 3:04 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed staff were re-educated on use of the Kardex and location with return demonstration of the Kardex location required. Staff stated they were also trained on the number 2 or more identification label to the right bottom side of the footboard. Observation on [DATE] during tour of the facility between 9:40 AM and 10:25 AM, revealed the number 2, or 2L, was observed on the footboard of several residents' beds, including Resident #8's bed which included the signage of 2L (meaning the resident required the assistance of two staff members and a mechanical lift for transfers). 18. Review of training records and interview with the DON on [DATE] at 11:54 AM, the Administrator on [DATE] at 10:45 AM, the SRNA Restorative Aide (SRNA #34) on [DATE] at 10:02 AM, and the SRNA Supervisor on [DATE] at 5:10 PM revealed they all received training by the Invacare Lift Company on sizing of the slings, sling border colors denoting size, etc. Continued interview revealed that all residents who utilized mechanical lifts were measured for the correct sling size and the sling color/size was added to the resident's Kardex. Review of post-tests revealed staff were administered post-tests after the training and all staff passed with 100% accuracy. Review of Resident #8's Kardex revealed the size of the sling and color were listed with the note that the resident was to be transferred via mechanical lift. 19. Interviews on [DATE] with SRNA #31 at 11:10 AM, LPN #13 at 3:04 PM, RN #1 at 3:40 PM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:

Based on interview, record review, and review of the facility's policy it was determined the facility failed to implement the baseline care plan for one (1) of ten (10) sampled residents (Resident #4). Three (3) facility nurses cared for Resident #4 on [DATE], from approximately 3:00 AM until approximately 10:50 AM (approximately eight hours), but failed to implement the resident's plan of care to monitor and report when the resident complained of shortness of breath and difficulty breathing. Subsequently, on [DATE], at approximately 10:50 AM, the resident was found to be cold to the touch, diaphoretic, and staff were unable to obtain the resident's vital signs. Emergency Medical Services (EMS) was notified and the resident was transported to the hospital in [MEDICAL CONDITION] and pronounced deceased at 11:40 AM. The facility's failure to ensure residents' baseline care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Admission Care Plans, dated [DATE], revealed that to ensure a resident's immediate needs were met a preliminary plan of care would be developed within twenty-four (24) hours of the resident's admission. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #4 also utilized an external cardiac defibrillator (LifeVest) upon admission. The facility had not yet completed Resident #4's Admission Minimum Data Set (MDS) assessment. Review of Resident #4's Baseline Care Plan dated [DATE] revealed the care plan identified the resident had cardiac and respiratory problems. The care plan also stated the resident utilized the LifeVest device and staff were required to monitor and report signs and symptoms of heart failure and dyspnea (shortness of breath). Interview with the Director of Nursing on [DATE] at 4:45 PM, revealed the intervention listed on the baseline care plan of reporting any signs/symptoms of heart failure/dyspnea was instructing staff to report the complications to the resident's physician. Review of Nurse's Notes dated [DATE] at approximately 10:50 AM, revealed Resident #4 was found to be cool to touch, with excessive sweating, and the resident had mottling from the waist and to both lower extremities. The Nurse's Note also stated the nurse was unable to obtain the resident's vital signs and EMS was notified, and the resident was transported to the hospital. Interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 7:30 PM, LPN #2 on [DATE] at 12:25 PM, and LPN #1 on [DATE] at 1:30 PM, revealed they had all provided care to Resident #4 on [DATE]. LPN #1 stated at approximately 3:00 AM on [DATE], Resident #4 began repetitively stating that the LifeVest was too tight, that he/she could not breathe, and the resident was attempting to aggressively remove the vest. LPN #2 and LPN #3 stated they both began caring for Resident #4 on [DATE] at approximately 7:00 AM. Both nurses stated that Resident #4 was yelling out for help when they each arrived on the unit and was complaining that the vest was too tight and that he/she could not breathe. The staff stated Resident #4 was yelling out help me and requested to see a physician. However, none of the nurses that cared for Resident #4 on [DATE] from 3:00 AM until approximately 10:50 AM, implemented the resident's plan of care and notified the resident's physician that the resident was short of breath, complaining of dyspnea, or requesting to see a physician. Interview with Resident #4's Responsible Party (RP) on [DATE] at 9:30 AM revealed he arrived at the facility at approximately 10:30 AM on [DATE]. The RP stated he could hear the resident yelling from the hallway. He stated when he arrived at the resident's room, Resident #4 was confused, sweaty, and his/her skin was cold to touch. However, according to the RP, he had to ask a nurse to come to the resident's room to assess him/her. The RP stated that when the nurse arrived at the resident's room, LPN #2 informed the RP that the resident had yelled out all night and morning. Interview with LPN #2 on [DATE] at 12:25 PM, revealed upon assessing Resident #4 at approximately 10:50 AM, the resident's color was bad and she was unable to obtain the resident's vital signs. LPN #2 also stated the resident's skin was cold to the touch and mottled from the waist down. LPN #2 stated EMS was contacted to transport the resident to the hospital. Review of the EMS transportation sheet for Resident #4 revealed EMS arrived at the facility on [DATE] at 11:02 AM, and found Resident #4 unresponsive, pale, cool to touch, and diaphoretic. Further review of the transportation sheet revealed once Resident #4 was placed into the ambulance, the resident went into [MEDICAL CONDITION] and cardiopulmonary resuscitation (CPR) was initiated. Subsequently, Resident #4 was transported to the hospital and pronounced deceased at 11:40 AM on [DATE]. Interview with Physician #1 on [DATE] at 8:20 AM revealed staff should have followed Resident #4's plan of care and notified him when the resident complained of shortness of breath on [DATE]. Interviews on [DATE], with the Administrator at 6:20 PM and with the Director of Nursing (DON) at 4:45 PM, revealed staff had been trained to follow the plan of care for each resident. Further interview revealed staff should have notified Resident #4's Physician when the resident complained of shortness of breath, as outlined in the resident's plan of care. **The facility alleged that the following actions were implemented to remove Immediate Jeopardy on [DATE]: 1. Interviews with all residents with a Brief Interview for Mental Status (BIMS) score of greater than eight (8) were conducted by Social Services regarding staff treatment, injuries, feeling safe, etc. No concerns were expressed. 2. Unit Managers and licensed nurses conducted skin assessments of all residents with BIMS scores of less than seven (7). Skin checks revealed no negative findings. 3. The Director of Nursing (DON) and Staffing Coordinator interviewed all licensed and unlicensed nursing staff from [DATE] to [DATE], specifically inquiring about concerns with resident care and/or any knowledge of faulty equipment or incidents with patient care. No negative findings were found and no concerns were expressed. 4. Each resident in the facility was assessed by the DON, Assistant Director of Nursing (ADON), or a Unit Manager to assess for any unidentified changes in clinical condition. No new issues were identified. 5. Additionally, all licensed and unlicensed nursing staff that cared for Resident #1 within the last week of his/her stay were interviewed by the Administrator/DON/Nurse Aide Coordinator/VP of Clinical Operations and asked if Resident #1 appeared in any pain when providing care or if they had knowledge of any incident. All answered consistently with no negative findings. 6. The Quality Assurance (QA) Nurse educated all nursing staff (including State Registered Nurse Aides) on mechanical lift procedures and identifying signs of pain in the elderly from [DATE] to [DATE]. 7. After receiving the IJ Notifications, two employees (Employee #1 and Employee #2), who had cared for Resident #2, were suspended until an investigation could be completed. 8. On [DATE], two (2) Hoyer (brand of mechanical lift) lifts were removed from the facility and replaced with two (2) lifts that were the same brand as the majority (Invacare) being utilized at The Center, making the facility use 100% the same full total body lift with the same manufacturer's lift pads available, as recommended. 9. On [DATE], the MDS Assessment Nurses initiated a 100% review and update of each resident's care plan on the required amount of assistance needed. 10. On [DATE], the DON and Nurse Aide Coordinator retrained all staff (licensed and unlicensed) regarding sling size. Further, the sling size was placed on each resident's Kardex/Care Plan by the MDS Assessment Nurse. 11. On [DATE], the DON ensured visual reminders were placed on each mechanical lift that two (2) staff members were required while operating the lift and included specifications from the manufacturer on the sling sizing guide as to what size each color indicated. 12. On [DATE], the facility did not identify any other residents that required a life vest as did Resident #4. 13. On [DATE], The Regional Director of Operations provided in-service/education to the Administrator and the Director of Nursing on the facility's change of condition policy and the requirements related to resident assessment and physician notification by licensed staff when change in a medical condition occurs. Both the Administrator and Director of Nursing completed a post-test with 100% accuracy. 14. On [DATE], the DON/ADON initiated in-service/education to all licensed nurses (on duty) on the facility's policy of change of resident condition, assessing the change in resident status, and associated MD notification. The training also covered care plans (comprehensive) and following resident-centered care plans. This education will be conducted for new hires as well. Any licensed nurses who were unable to attend the required in-service will be immediately educated upon return to work by the DON/ADON. In addition, a sign was posted by the time clock and the DON/Administrator crosschecked the work schedule with the in-service sign-in sheets to assure that only staff that had received the education were allowed to work. This facility does not utilize agency staff. Post-tests were given to licensed staff on change in resident condition, which included assessment of a resident's medical/mental condition, recording the assessment in the medical record, and reporting changes promptly to the MD. A post-test was given to all licensed nurses with 100% accuracy expected before returning to work. 15. On [DATE], the Regional Director of Operations in-serviced/educated the Administrator and Director of Nursing Services on the manufacturer's recommendations for mechanical lifts/lift pads. 16. On [DATE] in-service/education was conducted by the Director of Nursing/ADON on the implementation of the Kardex with all State Registered Nurse Aides (SRNAs) on duty. Specifically, the location of the Kardex, following the Kardex, and requirements for assistance with mobility including transfers, and bed mobility. The education also included immediately reporting a noted change in a resident's condition to the charge nurse. This education will be given to any new hire SRNAs upon orientation. Any SRNA unable to attend the required in-service/education will be immediately educated upon return to work by the DON/ADON. A sign was posted by the time clock and the DON/Administrator crosschecked the work schedule with the in-service sign-in sheet to assure that only staff that had received the education was allowed to work. The facility does not utilize agency staff. All SRNAs took a post-test with 100% accuracy expected before being allowed to return to work. 17. On [DATE], re-education/in-service was provided by the DON to all SRNAs for those immediately on shift in regard to following the SRNA Kardex, both electronic and paper version. In addition, the DON in-serviced on the implementation of the number 2 or more identification label to the right bottom side of the resident's footboard. A post-test was given with 100% accuracy expected. Any employee not in attendance will be educated prior to work by the DON/ADON. An all nursing staff in-service was held on [DATE] to continue this process. Staff are stationed by the time clock each shift with a crosscheck document to assure that no staff member works without first being re-educated. This education will be conducted for all new hire SRNAs and no agency staff are utilized at the facility. Any remaining staff will be educated and deemed competent prior to their next work shift. On [DATE], full SRNA return demonstration on competency regarding electronic and/or Paper Kardex was initiated. One hundred percent accuracy is expected and competency must be established before the SRNA works the next shift. This is being done in conjunction with the SRNA Kardex education provided on [DATE] Any SRNA that was not present for the initial checkoff will be required to do so before their next shift with 100% accuracy. Competency will be completed for any new hires as well. Ongoing checkoffs will be conducted by the SRNA Coordinator prior to the SRNA working. 18. On [DATE], Unit Coordinators, the Physical Therapist, Restorative Nurse, Restorative Nurse Aides, SRNA Coordinator, Director of Nursing, and the Administrator were educated by the safe resident handling consultant authorized by Invacare Lift Company on the following: Sizing of slings according to weight, height, and girth; sling border and color related to size and weight capacity; and safety inspection. Going forward, only these trained individuals will evaluate residents who need mechanical lifts to determine and assign sling sizes. Once the resident's sling size has been assigned, this will be listed on that individual resident's nurse aide Kardex. A post-test was given to the Unit Managers, Restorative Nursing, Director of Nursing, and SRNA Coordinator with 100% accuracy expected. 19. On [DATE], the Director of Nursing initiated education/in-service to all staff nurses and SRNAs regarding their duties, which consisted of identification of how to access the assigned sling size on the SRNA Kardex; the utilization of the correct mechanical lift sling size; the process of assignment, location, and the difference in mechanical lift sling sizes; and the visual reminders on each lift. A post-test will be given to each employee with 100% accuracy expected. Further, any staff not in attendance will be in-serviced by the DON/Administrative Nurses, Physical Therapy, or Restorative Nursing prior to returning to work. A note is posted at the time clock and the DON/ADON crosschecked the schedule to ensure all staff were trained. 20. On [DATE], a Quality Assurance meeting with the Medical Director, Administrator, Director of Nursing, Social Services Director, Unit Coordinators, and Regional Nurse Consultant was conducted. The following were reviewed during this QA meeting: The survey findings as per the IJ notification; the AOC and corresponding action plan; and the ongoing compliance monitoring audits. 21. On [DATE], the facility began having daily meetings (seven days a week) which will include the DON/ADON/Administrator, Licensed Nurses, and Social Services to provide ongoing monitoring of audits and ensuring ongoing compliance with the AOC. 22. On [DATE], the facility initiated a Resident Change of Condition Monitoring Audit. All residents placed on the acute monitoring log will be discussed during the daily meeting and reviewed for the following: evidence of assessment, evidence of physician notification, and a care plan review and the appropriate implementation thereof. A resident change of condition monitoring audit will be conducted by the IDT (including the DON/ADON and/ or Administrator as designated) which includes an assessment of the resident (including vital signs), Physician/Physician on-call/Medical Director notification, resident and family notification, and care plan review. The Audit will be conducted daily for four (4) weeks and presented to Quality Assurance/Performance Improvement (QAPI) for further recommendations. 23. On [DATE], Restorative Nursing conducted a 100% audit of all mechanical lift pads to ensure they were compatible with the mechanical lifts according to manufacturer's recommendations. No concerns were identified. The Mechanical lift sling audit will continue weekly for four (4) weeks, and then monthly with the QAPI process. 24. [ENTITY]ting [DATE], five percent (5%) of care plans (by random selection) are being reviewed one (1) time per week for four (4) weeks for accuracy, specifically with bed mobility, transfers, and toileting. The audit will be conducted by the MDS Coordinator, with 100% accuracy and will then reduce to monthly utilizing the QAPI process. 25. Further, a Quality Assurance meeting was held on [DATE] and [DATE] with the Medical Director, DON, Administrator, Department Directors, and administrative nursing as appropriate. The following Topics were discussed/reviewed: 1. Trainings regarding AOC results of post-test; 2. Ongoing audits and results of the audits conducted; and 3. Ongoing compliance with the AOC. 26. On [DATE], an audit was conducted by the MDS Nurses and the Unit Manager regarding the level of assistance needed for transfers. Further, placement of the 2 or more label was assigned to residents' beds as appropriate. Presence of the 2 or more assistance label on the bed will be audited two (2) times a day by the [ENTITY]/Licensed Nurse and documented on the audit form labeled 2 program compliance check. This audit will be conducted two times a day for two months, and then compliance will be determined by QAPI. Unit Managers will be responsible for updating the list with new admissions and significant changes. This will be monitored by the Director of Nursing. 27. Licensed nurses are auditing daily for utilization of the correct sling size and correct number of staff members present and assisting with mechanical lift transfers. This audit is done once daily on each unit for four (4) weeks. The DON is reporting results of the audit to QA. [ENTITY]s will check every shift for every resident requiring a mechanical lift for the presence of a lift number on each resident's bed. This is documented on the MAR. The MAR is being checked for completeness daily by the Unit Coordinator/DON. Results are reported to QA by the DON. 28. QAPI meetings will be held weekly and as needed with the Medical Director, DON/ADON, Administrator, Social Services, and Administrative Nursing Staff weekly for four (4) weeks as compliance is established and then monthly. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on [DATE], as alleged: 1. Interview with the Social Services Director on [DATE] at 2:50 PM and review of documentation revealed all residents with a BIMS score of eight (8) or greater were interviewed regarding staff treatment during care on [DATE]. No concerns were voiced by residents. 2. Interview with Unit Coordinator #2 on [DATE] and review of skin assessment documentation revealed residents with a BIMS score of seven (7) or less had skin assessments completed on ,[DATE]-,[DATE]. No suspicious injuries were identified. 3. Interview with the Director of Nursing (DON) on [DATE] at 11:54 AM and review of documentation revealed nursing staff was interviewed on ,[DATE]-,[DATE] related to concerns with resident care, any knowledge of faulty equipment, or concerns with resident incidents. No problems were identified. 4. Interviews with the DON on [DATE] at 11:54 AM and on [DATE] with the ADON at 3:40 PM, and review of documentation on resident assessments, revealed all residents were assessed for change in condition on [DATE] with no new issues identified. 5. Interview with the Director of Nursing (DON) on [DATE] at 11:54 AM and review of documentation on staff interviews/statements revealed staff were interviewed between ,[DATE]-,[DATE] regarding care provided for Resident #1. 6. Interview with the Quality Assurance Nurse on [DATE] at 5:25 PM, and review of training documentation, revealed she had completed training with nursing staff related to mechanical lift procedures and identifying signs of pain in the elderly on ,[DATE]-,[DATE]. 7. Interview with the DON on [DATE] at 11:54 AM and the Administrator on [DATE] at 10:45 AM, and review of documentation revealed Employees #1 and #2 were suspended on [DATE]. Both employees returned to work on [DATE] after the facility completed an investigation. 8. Interview with the DON on [DATE] at 11:54 AM and observation of the mechanical lifts in use at the facility on [DATE], [DATE], and [DATE] revealed Invacare lifts were being used by staff to transfer residents. 9. Interview with LPN #12 (MDS Coordinator) on [DATE] at 10:30 AM revealed she and the other MDS Coordinator had reviewed all resident care plans on [DATE]. The MDS Nurse stated they also revised resident care plans during this review related to bed mobility, incontinence care, and mechanical lift use. 10. Interview with the DON on [DATE] at 11:54 AM and with the SRNA Supervisor on [DATE] at 5:10 PM, and review of documentation revealed staff were trained on [DATE] regarding sling size and that the size of sling needed was placed on the resident's care plan. Interviews on [DATE] with SRNA #31 at 11:10 AM, LPN #13 at 3:04 PM, RN #1 at 3:40 PM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM, revealed all had received the above training. Review of Resident #8's Kardex revealed the resident was to be transferred using a mechanical lift and the sling size was listed on the resident's Kardex. 11. Interview with the DON on [DATE] at 11:54 AM and observation of two (2) mechanical lifts on [DATE] revealed the slings had signage that directed two (2) staff member assistance when operating the lift and the lift also had signage including sling color/size. 12. Interview with the DON on [DATE] at 11:54 AM and with the Administrator on [DATE] at 10:45 AM confirmed no other residents currently residing at the facility utilized life vests. 13. Interview with the Regional Director of Operations on [DATE] at 5:00 PM, with the DON on [DATE] at 11:54 AM, and with the Administrator on [DATE] at 10:45 AM, and review of training documentation revealed the Regional Director of Operations had provided education for the Administrator and DON on the facility's Change of Condition Policy and physician notification requirements. Review of tests revealed the Administrator and DON completed post-testing with 100% passing scores. 14. Interview on [DATE] with LPN #13 at 3:04 PM, RN #1 at 3:40 PM, Unit Coordinator #2 at 4:10 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, and with the DON on [DATE] at 11:54 AM, and review of training records revealed the DON had initiated training to all licensed nursing staff on the facility's change of condition policy and physician notification requirements. Review of post-tests revealed staff were tested after the above training. 15. Review of training records and interview with the Regional Director of Operations on [DATE] at 5:00 PM, the DON on [DATE] at 11:54 AM, and the Administrator on [DATE] at 10:45 AM revealed on [DATE], the Regional Director of Operations in-serviced/educated the Administrator and Director of Nursing Services on the manufacturer's recommendations for mechanical lifts/lift pads. Review of tests revealed the Administrator and DON completed post-testing with 100% passing scores. 16. Review of training records and interviews on [DATE] with SRNA #31 at 11:10 AM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #13 at 3:04 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed the DON/ADON educated nursing staff on use of the Kardex (nurse aide care plan). Interview with the DON on [DATE] at 11:54 AM revealed administrative staff observed staff arriving at work at the time clock during shift change and nursing staff were trained and were given post-test with a 100% score prior to working. Review of post-tests revealed staff were tested after the above training. 17. Interview with the DON on [DATE] at 11:54 AM and the Administrator at 10:45 AM revealed nursing staff were initially in-serviced on following the care plan/Kardex on [DATE] and re-educated on [DATE] and [DATE]. Per the DON, return demonstration as to the location of the Kardex was required on [DATE] and [DATE]. Review of training records and interviews on [DATE] with SRNA #31 at 11:10 AM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #13 at 3:04 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed staff were re-educated on use of the Kardex and location with return demonstration of the Kardex location required. Staff stated they were also trained on the number 2 or more identification label to the right bottom side of the footboard. Observation on [DATE] during tour of the facility between 9:40 AM and 10:25 AM, revealed the number 2, or 2L, was observed on the footboard of several residents' beds, including Resident #8's bed which included the signage of 2L (meaning the resident required the assistance of two staff members and a mechanical lift for transfers). 18. Review of training records and interview with the DON on [DATE] at 11:54 AM, the Administrator on [DATE] at 10:45 AM, the SRNA Restorative Aide (SRNA #34) on [DATE] at 10:02 AM, and the SRNA Supervisor on [DATE] at 5:10 PM revealed they all received training by the Invacare Lift Company on sizing of the slings, sling border colors denoting size, etc. Continued interview revealed that all residents who utilized mechanical lifts were measured for the correct sling size and the sling color/size was added to the resident's Kardex. Review of post-tests revealed staff were administered post-tests after the training and all staff passed with 100% accuracy. Review of Resident #8's Kardex revealed the size of the sling and color were listed with the note that the resident was to be transferred via mechanical lift. 19. Interviews on [DATE] with SRNA #31 at 11:10 AM, LPN #13 at 3:04 PM, RN #1 at 3:40 PM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed they had attended an in-service regarding how to utilize the Kardex to ensure residents were transferred appropriately and regarding the sling size a resident required. Observation of two (2) mechanical lifts on [DATE] revealed the slings had signage that directed two (2) staff members were required when operating the lift. The lift also had signage including the sling color/size. Review of post-tests revealed a test was administered to staff after the training and all staff had to pass the test with 100% accuracy before they were allowed to work. 20. Review of QA Meeting Minutes and interviews on [DATE] at 5:25 PM with the QA Nurse, on [DATE] with the ADON at 3:40 PM and Unit Coordinator #2 at 4:10 PM, and on [DATE] with the DON at 11:54 AM and the Administrator at 10:45 AM revealed a QA meeting was held on [DATE] with the Medical Director on the survey findings, the AOC and the corresponding action plan, and ongoing audits. 21. Review of the AM Meeting documentation and interview on [DATE] with the Social Services Director at 2:50 PM, the SRNA Supervisor at 5:10 PM, the MDS Coordinator at 10:30 AM, the ADON at 3:40 PM, and Unit Coordinator #2 at 4:10 PM, and interviews on [DATE] with the DON at 11:54 AM and the Administrator at 10:45 AM revealed AM meetings were held seven (7) days per week. During the meeting, the following was discussed: 24-hour report, acute monitoring log, resident orders, nurse's notes, etc. Care plans were also updated/revised as needed during the meeting, per staff interviews. 22. Review of QA audits and interview with the DON on [DATE] at 11:54 AM revealed daily audits were being completed for residents placed on the acute monitoring log. The audit included verifying evidence of an assessment, physician notification, care plan review, and the appropriate implementation thereof. 23. Review of QA audits and interview with SRNA #34 (Restorative Nursing) revealed she had completed 100% of the sling audits on [DATE] and weekly audits were also completed. The SRNA stated there had been a couple of slings removed for minor tearing/fraying. Interview with the Administrator on [DATE] at 10:45 AM revealed the results of the audits came to her and were discussed in the weekly QA meetings. 24. Review of Audit documentation and interview with the MDS Coordinator on [DATE] at 10:30 AM revealed she had participated in completing a 100% audit of all resident care plans on [DATE]. She stated 5% of the care plans were audited weekly. Interview with the Administrator on [DATE] at 10:45 AM, revealed the results of the audits came to her and were discussed in the weekly QA meetings. 25. Review of the Quality Assurance meeting minutes and interviews on [DATE] with the DON at 11:54 AM and the Administrator at 10:45 AM, revealed a QA meeting was held with the Medical Director, participating via phone, regarding staff trainings in regard to the results of the post-test, and ongoing audits. 26. Review of QA audits and interview on [DATE] with the MDS Coordinator at 10:30 AM, RN #1 (Unit Coordinator #3) at 3:40 PM, and Unit Coordinator #2 at 4:10 PM revealed audits were conducted on the level of assistance required for resident transfers. Staff were also auditing that a number 2 or 2L was on the footboard of the resident's bed. Interview with the DON on [DATE] at 11:54 AM, revealed she received and reviewed the audit on resident assistance needed with the number on the bed. All audits go to the weekly QA meeting. 27. Review of QA audits and interview on [DATE] with the ADON at 3:40 PM, and Unit Coordinator #2 at 4:10 PM, and interviews on [DATE] with the DON at 11:54 AM and the Administrator at 10:45 AM revealed licensed nurses were auditing daily for utilization of the correct sling size and correct number of staff members present and assisting. Interview with the DON on [DATE] at 11:54 AM revealed she received and reviewed the audit on resident assistance needed with the number on the bed. All audits go to the weekly QA meeting. Further interview and audit review revealed an audit was completed daily to ensure the nurses and Medication Aides were checking tha

Based on observation, interview, record review, and review of facility video surveillance footage, investigations, and the care plan policy, it was determined the facility failed to develop/implement a comprehensive person-centered care plan for three (3) of ten (10) sampled residents (Resident #1, Resident #2, and Resident #7). The facility assessed Resident #1 to require total assistance of two (2) staff members for bed mobility and toileting, and two (2) staff members for mechanical lift transfers; however, review of his/her comprehensive care plan and State Registered Nurse Aide (SRNA) Kardex revealed the amount of assistance the resident was assessed to require was not addressed. Interview with SRNA #19 revealed she had provided incontinence care to Resident #1 unassisted on [DATE] at which time Resident #1 sustained a bruise to the left side of his/her forehead. In addition, interview with SRNA #12 revealed she had provided care to Resident #1 without the assistance of a second staff member during the night shift of ,[DATE]-,[DATE] (the night before Resident #1 was found unresponsive). Resident #1 was found unresponsive on [DATE] at approximately 8:00 AM and was transported to the Emergency Department (ED). While at the ED, Resident #1 was diagnosed with [REDACTED]. The facility's failure to ensure residents' care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to implement Resident #2's comprehensive care plan when transferring the resident on [DATE]. The facility developed interventions that required two (2) staff members to transfer the resident utilizing a mechanical lift; however, on [DATE] review of video surveillance footage revealed a SRNA took a mechanical lift into Resident #2's room and approximately ten (10) minutes later exited with the lift and linen/garbage. Further, the facility assessed Resident #7 to require the extensive assistance of two (2) staff members for bed mobility and toileting; however, the resident's care plan and Kardex did not provide specific instructions to staff on the amount of staff assistance required to assist the resident with bed mobility and incontinence care. In addition, the facility assessed Resident #7 to be at risk for falls and developed care plan interventions for two (2) staff persons to provide extensive assistance with transfers. On [DATE], SRNA #25 transferred Resident #7 from bed to a wheelchair without the assistance of a second staff person as required by the resident's care plan. The resident became weak, started to fall, and the SRNA lowered the resident to the floor. Later, on [DATE], the resident was transferred to the hospital for evaluation and diagnosed with [REDACTED]. The findings include: Review of the facility's policy, Using the Care Plan, dated [DATE], revealed the care plan should be used in developing the resident's daily care routines and would be available to staff who had the responsibility for providing care or services to the resident. The policy stated that the nurse supervisor and/or charge nurse was responsible for developing the nurse aide's daily/weekly work assignment sheets and/or flow sheets (Kardex) from the care plan. The policy further stated the daily care and documentation must be consistent with the resident's care plan. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #1 was a full code (required CPR if needed). Review of a PT (Physical Therapy) Evaluation and Plan of Care dated [DATE] revealed Resident #1 was referred due to nursing staff reporting a change in transfers and assessment of transfers. Prior to the assessment on [DATE], Resident #1 required maximum assistance of two (2) staff persons for bed mobility and transfers. The functional mobility assessment stated Resident #1 was unable to follow commands to complete bed mobility due to advancing symptoms of dementia, therefore the resident was not a candidate for bed mobility training due to his/her inability to carry over and follow through with instructions. According to the PT Treatment Encounter Note dated [DATE], PT #1 assessed Resident #1 for the use of a mechanical lift with transfers. Record review revealed PT #1 documented that Resident #1 would now utilize a mechanical lift for transfers due to his/her fall risk, did not assist staff with transfers, and the resident was unable to follow commands. Review of a PT Discharge Summary dated [DATE], revealed a functional skills assessment that stated the resident was dependent with chair/bed-to-chair transfers, lying to sitting on the side of bed, sitting to standing, toilet transfer, rolling left and right, and sitting to lying. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to be severely cognitively impaired and never/rarely made decisions. Continued review of Resident #1's MDS assessment revealed the facility assessed the resident to require total assistance of two (2) staff persons for bed mobility, transfers, dressing, bathing, and toileting. Further review of the MDS revealed that Resident #1 required staff assistance to stabilize with surface-to-surface transfers. According to the MDS, Resident #1 had not sustained any falls since his/her last assessment. Review of Resident #1's comprehensive care plan dated [DATE], revealed the facility identified that the resident required assistance with Activities of Daily Living (ADL) and developed interventions that included staff assisting Resident #1 with dressing, grooming, hygiene, showers, and bathing. In addition, review of a care plan revised on [DATE] revealed the facility developed an intervention to provide incontinence care for the resident every two (2) hours and as needed. Further review of Resident #1's care plan revealed the facility identified that the resident had the potential for impaired physical mobility related to a [DIAGNOSES REDACTED]. According to the care plan, on [DATE], the facility developed an intervention for staff to utilize a mechanical lift for safe staff transfers of the resident. The care plan also stated staff were required to provide supportive care/assistance with mobility as needed. Further review of Resident #1's care plan revealed that although the facility identified that the resident required assistance with ADLs (including incontinence care, transfers, and mobility), there was no documented evidence that the facility addressed how many staff members were required to assist the resident safely. Review of Resident #1's SRNA Kardex (a guide for resident care) revealed the Kardex did not address the number of staff required to assist the resident with transferring in a mechanical lift, nor the number of staff that the resident required for assistance with incontinence care or bed mobility. Interviews with SRNA #6 on [DATE] at 12:16 PM, SRNA #12 on [DATE] at 6:32 PM, and SRNA #18 on [DATE] at 1:14 PM revealed Resident #1 was dependent on two (2) staff persons for bed mobility and incontinence care. However, according to SRNAs #12 and #18, they had provided incontinence care for the resident without the assistance of a second staff person in the past. However, even though review of the Physical Therapy and MDS assessments revealed the resident was dependent on two (2) staff persons for ADLs, interviews with Registered Nurse (RN) #2 on [DATE] at 10:02 AM, Unit Coordinator (UC) #1 on [DATE] at 2:16 PM, and the Director of Nursing (DON) on [DATE] at 4:52 PM, revealed one staff member could assist Resident #1 at times. RN #2 stated one person could provide incontinence care if they utilized a draw sheet to keep the resident on his/her side. According to the Unit Coordinator, on some days the resident could assist staff with care and on those days one (1) person could provide care. Review of a Resident Accident/Incident Report dated [DATE] at 3:15 PM, revealed staff rolled Resident #1 onto his/her side and the resident bumped the left side of his/her forehead on the side rail sustaining a bruise above the left eyebrow. Further review of the accident/incident report revealed the causative factor was that the resident often moved his/her head attempting to talk to staff when staff provided care. Continued review revealed the recommendation/action taken was to replace tender care pads on the side rails and ensure padding was in place at all times when care was provided. Further review revealed there was no documented evidence that the facility identified any concerns with Resident #1's care during the investigation. However, interview with SRNA #19 on [DATE] at 1:48 PM revealed Resident #1 had an incontinence episode and she provided incontinence care for the resident alone, without the assistance of another staff member. SRNA #19 stated she was unaware of the amount of assistance Resident #1 required with care. She stated she did not have an assignment sheet (Kardex) and was not given the information during report from the previous shift. Continued interview with SRNA #19 revealed she did not think to ask for help when providing care to Resident #1 since she was just changing the resident. Interview with RN #2 on [DATE] at 10:02 AM revealed she was assigned to care for Resident #1 on [DATE]. She stated SRNA #18 and SRNA #19 reported to her that while providing incontinence care, Resident #1 bumped his/her forehead on the bed rail and sustained a bruise. She stated she was not aware that SRNA #19 was providing care to Resident #1 without assistance. Interview with Unit Coordinator (UC) #1 on [DATE] at 2:16 PM revealed that even though she believed one (1) to two (2) staff persons could provide bed mobility and incontinence care for the resident, she had reviewed the accident/incident report to ensure all the documentation was present. Further interview revealed she did not identify that on [DATE], Resident #1 sustained an injury to his/her forehead after one (1) SRNA provided care to the resident instead of two (2) staff persons that the facility assessed the resident to require. Interview with the Director of Nursing (DON) on [DATE] at 4:52 PM, revealed that she was not aware that SRNA #19 was providing care to Resident #1 without assistance when the resident sustained [REDACTED]. She stated SRNA #19 should have had another person with her when she provided incontinence care to Resident #1. Continued review of Resident #1's medical record revealed four (4) days later, on [DATE] at 8:05 AM, RN #2 documented that upon entering Resident #1's room, the resident's skin was very pale, the resident's eyes were open, and (he/she) was not responding or talking. RN #2 documented that Resident #1 had dementia, and previously talked using short words and/or phrases, and often answered questions inappropriately. The assessment stated the resident's respirations were shallow, his/her skin was warm and clammy to touch, lung sounds noted with rhonchi and auditory gurgling, a faint pulse was detected, and the resident's oxygen saturation was [AGE] percent (%) on room air (normal is ,[DATE]%). Resident #1's pulse was documented at 66 beats per minute (bpm) (normal heart rate is ,[DATE]) and his/her blood pressure was ,[DATE] (normal range is 90-,[DATE]-[AGE].) The Nurse's Note stated that RN #2 notified Physician #4 and received an order to transfer the resident to the Emergency Department (ED). Further review revealed Resident #1's Responsible Party was also notified of the resident's change in condition. Review of Resident #1's Emergency Medical Services (EMS) Run Report dated [DATE], revealed at 8:11 AM, the EMS crew arrived at Resident #1's room and the resident was unresponsive but breathing, with audible rales (crackling/rattling sounds in the lungs). Further review of the EMS Report revealed EMS placed a non-rebreather oxygen mask on Resident #1 and administered oxygen at 15 liters per minute (lpm). Once the resident was in the ambulance, EMS staff suctioned the resident's airway, which cleared the rales, and placed the resident on a cardiac monitor, which showed a heart rate of [AGE] bpm. Continued review revealed the resident began to have agonal breathing (gasping, abnormal pattern of labored breathing) and was assisted with a bag valve mask (BVM) (also called an ambu bag, which is a handheld device commonly used to provide positive pressure ventilation to patients who are not breathing adequately) and a nasopharyngeal airway (a tube inserted into the nasal passageway to secure an open airway) was inserted into the resident's left nostril and supportive care was provided throughout the resident's transport. Further review of the run report revealed the resident did not require intubation (placement of a tube into the resident's windpipe to provide breathing for the individual) or sedation during transport to the hospital. The resident's care was transferred to staff at the ED. Review of the ED record revealed Resident #1 arrived at the hospital at 8:29 AM with a chief complaint of cardiorespiratory arrest. The resident was found unresponsive by staff at a local nursing facility and was transported to the ED by EMS. The ED record stated that EMS reported that the resident went apneic and was provided oxygen via BVM. At 8:36 AM Resident #1 was intubated and at 9:55 AM Resident #1's pulse was undetected and CPR was initiated. According to the ED record, after emergency medications were administered, Resident #1's heart started beating again. Continued review of Resident #1's ED record revealed a computed tomography (CT) scan (a series of x-ray images taken from different angles that provides more detailed information than a plain x-ray) of the chest was ordered at 10:30 AM. Review of the results of the CT scan of the chest electronically signed by Physician #5 at 12:50 PM on [DATE], revealed the resident had bilateral hazy predominantly ground glass alveolar opacities and increased interstitial most likely [MEDICAL CONDITIONS]. The results further revealed that Resident #1 had an acute mild compression fracture of T11 ([MEDICATION NAME] vertebrae in the back) and age indeterminate (possibly old) mild compression fracture of T8, T9, and T10. Continued review of Resident #1's medical record revealed the ED Physician ordered a CT scan of the resident's abdomen and pelvis with contrast at 11:28 AM on [DATE] because Resident #1 was unresponsive, septic (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), and an elevated white blood cell count (indicative of infection). Review of the CT results revealed a large amount of hemorrhage (blood) throughout the right iliacus muscle with moderate hemorrhage into the inferior aspect of the silhouette, a large amount of extra-peritoneal hemorrhage bilaterally and interiorly in the pelvis, and moderate hemorrhage in the right obturator muscle (moderate to large amount of bleeding in the right pelvis/hip area). Further review revealed the resident had a right comminuted acetabular fracture involving the acetabular roof, posterior column, anterior column, anterior wall, and extending superiorly into the mid iliac bone (fractures of the socket portion of the hip and fractured pelvis); right superior and inferior pubic rami fractures (bones in the bottom-most portion of the pelvis); acute comminuted (splintered) left femoral head/neck junction fracture with extension into the intertrochanteric region (highest part of the thigh (femur) bone); acute moderate superior and inferior endplate compression fractures of L1 and T11 (lumbar and [MEDICATION NAME] spine fracture) with dense [MEDICAL CONDITION]; and age indeterminate anterior column compression fractures of L2-L5 (lumbar spine fractures). Continued review of the radiology report revealed Resident #1 had multiple acute fractures with large extra-peritoneal hemorrhage bilaterally (bleeding in the abdomen); and hemorrhage into the iliopsoas muscle (pelvic muscle) on the right and obturator muscle (hip muscle). Interview with SRNA #12 on [DATE] at 6:32 PM revealed she was assigned to Resident #1 on the night shift of [DATE]. She stated Resident #1 required total assistance of two (2) staff persons with care; however, that night she provided care to the resident by herself because other staff members were busy. Further interview with SRNA #12 revealed she had provided care to Resident #1 unassisted on more than one (1) occasion and nothing had ever happened to the resident. Continued interview with SRNA #12 revealed nothing occurred when she provided care to Resident #1 that would have caused injuries to the resident. Interview with RN #3 on [DATE] at 6:53 PM, revealed she was assigned to Resident #1 on the night shift of [DATE]. RN #3 stated she was not aware that SRNA #12 provided care to Resident #1 during her shift unassisted. However, if Resident #1 was already in bed one (1) person could provide incontinence care and bed mobility for him/her. Interview with the DON on [DATE] at 4:52 PM revealed she had investigated Resident #1's injuries and had not identified that SRNA #12 provided care for Resident #1 during night shift of [DATE] unassisted. According to the DON, staff should provide the amount of assistance that each resident was assessed to require with ADL care. However, the DON then stated that some residents required one (1) or two (2) staff for care depending upon the time of day. She stated during day time hours some residents may only need one (1) person to assist with care and then at night the same resident may require two (2) staff persons with the same care, even though the resident was assessed to require either a one or two (2) -person assist. However, the DON stated that resident care plans did not specify the amount of assistance a resident required during day time hours versus nighttime hours. She stated she did not know why Resident #1's care plan did not specify the amount of assistance required with transfers, toileting, or bed mobility. Interview with the Administrator on [DATE] at 6:22 PM, revealed she had not identified that Resident #1 received care from SRNA #12 unassisted on the night shift of [DATE] (the night before the resident was found unresponsive). She stated staff were expected to provide the amount of assistance that a resident was assessed to require. Interview with Physician #5 on [DATE] at 12:45 PM revealed he reviewed the radiology reports of Resident #1 and believed the fractures were acute (had occurred within the last two to three days). Continued review of Resident #1's hospital record revealed the resident was pronounced dead at the hospital on [DATE] at 3:06 PM. Review of a preliminary autopsy report dated [DATE] at 9:00 AM revealed a preliminary [DIAGNOSES REDACTED]. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed to have a BIMS score of five (5), indicating the resident was severely cognitively impaired and was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident to require the extensive assistance of two (2) staff persons for bed mobility and total assistance of two (2) staff persons for transfers and toileting. Review of Resident #2's comprehensive care plan initially dated [DATE], and a review of Resident #2's SRNA Kardex, revealed on [DATE] the facility identified that the resident had impaired physical mobility and developed an intervention for two (2) staff persons to transfer the resident utilizing a mechanical lift. Review of facility video surveillance footage from [DATE] revealed at approximately 10:04 PM, Resident #2 was sitting in a wheelchair in the hallway when SRNA #23 transported the resident to his/her room. SRNA #23 then exited the resident's room and re-entered with a mechanical lift alone, with no other staff. SRNA #23 closed Resident #2's door and was in the resident's room with a mechanical lift for approximately ten (10) minutes before exiting the resident's room with the mechanical lift. Interview with SRNA #23 on [DATE] at 2:06 PM and on [DATE] at 12:39 PM confirmed she assisted Resident #2 to bed on [DATE] during night shift. She stated she was aware that Resident #2 required the use of a mechanical lift for transfers and that two (2) staff persons were required to assist the resident when utilizing a lift. After reviewing the video footage from [DATE] with SRNA #23, she stated that she may have transferred Resident #2 with the mechanical lift by herself. Further interview with SRNA #23 revealed Resident #2 required two (2) staff persons for incontinence care; however, she provided incontinence care to Resident #2 unassisted. Interview with the DON on [DATE] at 4:52 PM revealed she had reviewed the facility's video surveillance footage for [DATE] through [DATE] and had not identified that SRNA #23 had taken a mechanical lift into Resident #2's room by herself. She stated the mechanical lift was not to be used by less than two (2) staff persons when transferring a resident. Interview with the Administrator on [DATE] at 6:22 PM revealed she had not identified that SRNA #23 had taken a mechanical lift into Resident #2's room during the night shift of [DATE], even though she stated she had reviewed the video footage. She stated that no one should be transferred with a mechanical lift while only one (1) person was present. 3. Review of Resident #7's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to require the extensive assistance of two (2) staff persons for transfers, bed mobility, and toilet use. According to the assessment, the resident had a Brief Interview for Mental Status score of fifteen (15), which indicated the resident was cognitively intact. The facility assessed the resident to be frequently incontinent of urine. Resident #7 was observed at a local hospital on [DATE] at 1:40 PM. The resident was in bed with his/her eyes closed using a bi-pap machine (machine that delivers pressurized air through a mask to the patient's airway). Review of Resident #7's Comprehensive Care Plan and Nurse Aide Care Plan/Kardex revealed the facility identified that the resident was a fall risk due to impaired mobility and incontinence with a goal for the resident to not experience falls through the next review. The facility developed interventions that included two (2) staff persons assisting the resident for safe transfers and to always use a gait belt. Review of the Incident Report and Nurse's Notes dated [DATE] at 2:30 PM, revealed a State Registered Nurse Aide (SRNA) was transferring Resident #7 from the bed to a wheelchair when the resident lost balance and got weak in the knees and the SRNA lowered the resident to the floor. Per the Nurse's Notes, staff assessed the resident and the resident had no pain or discomfort. However, further review revealed on [DATE] at 5:43 PM, the resident complained of a lot of pain and discomfort to right hip. The resident was sent to the hospital and diagnosed with [REDACTED]. Interview with SRNA #25 on [DATE] at 11:38 AM revealed she and SRNA #26 were assigned to care for Resident #7 on [DATE]. SRNA #25 stated she assisted Resident #7 out of bed and with getting dressed without the assistance of a second staff person at approximately 10:00 AM on [DATE], prior to the resident going to Bingo. SRNA #25 stated she also transferred the resident back to bed after Bingo by herself. SRNA #25 stated at approximately 1:45 PM, Resident #7 requested to get up for afternoon Bingo. The SRNA stated she used the gait belt to assist the resident when standing. Per the SRNA, while she was adjusting the resident's clothing, the resident got weak and slid down the SRNA's leg to the floor. The SRNA stated she believed that Resident #7 only required one (1) person to assist with transfers. According to SRNA #25, all staff transferred the resident prior to the incident alone, without a second staff person's assistance. Per SRNA #25, she had been recently trained regarding checking the resident's care plan or Kardex prior to providing care. The SRNA stated she had failed to check the Kardex prior to transferring Resident #7. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 10:02 AM revealed she had cared for Resident #7 on [DATE]. The LPN stated that prior to the incident she as well as other staff believed the resident only required one staff member to assist the resident with transfers. However, she stated when she was doing the paperwork to send the resident to the hospital, she noticed the resident required two (2) staff persons for transfers. She stated she told all staff working to be sure to transfer Resident #7 with two (2) staff persons assisting. Further review of Resident #7's Kardex revealed one (1) to two (2) staff persons should assist Resident #7 with toileting needs in bed depending on the level of incontinence care needed. Further review revealed the Kardex directed that one (1) staff member should assist the resident with bed mobility when rolling side to side, and two (2) staff members should assist the resident when pulling the resident up in bed. Interview with SRNA #5 on [DATE] at 6:30 PM, with SRNA #35 at 6:20 PM, and SRNA #29 at 5:40 PM revealed if the resident's Kardex stated one (1) to two (2) staff persons were required to assist a resident with incontinence care or bed mobility, they would use two (2) staff persons as it would be safer. However, interview on [DATE] at 6:45 PM with SRNA #12, SRNA #6 at 4:00 PM, SRNA #32 at 6:58 PM, SRNA #33 at 6:50 PM, and SRNA #30 at 4:35 PM revealed if the resident's Kardex stated that one (1) to two (2) staff persons were required for incontinence care or bed mobility, the nurse aide would use their judgement as to how many staff persons were needed to assist the resident. Interview with the Director of Nursing (DON) on [DATE] at 9:20 AM and on [DATE] at 11:54 AM revealed the clinical team discussed the cause of Resident #7's fall as possibly being due to the incorrect number of staff assisting the resident and due to the resident getting weak during transfer. The DON stated the care plan should be developed using information from the MDS and that the care plan interventions should match the MDS regarding the assistance the resident required. The DON stated she did not know why Resident #7's care plan and Kardex interventions were not consistent with the resident's MDS assessment. Per the DON, the care plan should not say one to two staff assistance, it should be specific. Interview with the Administrator on [DATE] at 3:32 PM and on [DATE] at 11:54 AM revealed on [DATE] Unit Manager #2 reported that SRNA #25 had transferred Resident #7 by herself. The Administrator stated SRNA #25 thought Resident #7 was a one (1) -person assist for transfers and did not verify (by looking at the Kardex) the amount of assistance needed prior to transferring the resident. **The facility alleged that the following actions were implemented to remove Immediate Jeopardy on [DATE]: 1. Interviews with all residents with a Brief Interview for Mental Status (BIMS) score of greater than eight (8) were conducted by Social Services regarding staff treatment, injuries, feeling safe, etc. No concerns were expressed. 2. Unit Managers and licensed nurses conducted skin assessments of all residents with BIMS scores of less than seven (7). Skin checks revealed no negative findings. 3. The Director of Nursing (DON) and Staffing Coordinator interviewed all licensed and unlicensed nursing staff from [DATE] to [DATE], specifically inquiring about concerns with resident care and/or any knowledge of faulty equipment or incidents with patient care. No negative findings were found and no concerns were expressed. 4. Each resident in the facility was assessed by the DON, Assistant Director of Nursing (ADON), or a Unit Manager to assess for any unidentified changes in clinical condition. No new issues were identified. 5. Additionally, all licensed and unlicensed nursing staff that cared for Resident #1 within the last week of his/her stay were interviewed by the Administrator/DON/Nurse Aide Coordinator/VP of Clinical Operations and asked if Resident #1 appeared in any pain when providing care or if they had knowledge of any incident. All answered consistently with no negative findings. 6. The Quality Assurance (QA) Nurse educated all nursing staff (including State Registered Nurse Aides) on mechanical lift procedures and identifying signs of pain in the elderly from [DATE] to [DATE]. 7. After receiving the IJ Notifications, two employees (Employee #1 and Employee #2), who had cared for Resident #2, were suspended until an investigation could be completed. 8. On [DATE], two (2) Hoyer (brand of mechanical lift) lifts were removed from the facility and replaced with two (2) lifts that were the same brand as the majority (Invacare) being utilized at The Center, making the facility use 100% the same full total body lift with the same manufacturer's lift pads available, as recommended. 9. On [DATE], the MDS Assessment Nurses initiated a 100% review and update of each resident's care plan on the required amount of assistance needed. 10. On [DATE], the DON and Nurse Aide Coordinator retrained all staff (licensed and unlicensed) regarding sling size. Further, the sling size was placed on each resident's Kardex/Care Plan by the MDS Assessment Nurse. 11. On [DATE], the DON ensured visual reminders were placed on each mechanical lift that two (2) staff members were required while operating the lift and included specifications from the manufacturer on the sling sizing guide as to what size each color indicated. 12. On [DATE], the facility did not identify any other residents that required a life vest as did Resid

Based on interview, record review, and review of facility policy, it was determined the facility failed to provide appropriate treatment and care for one (1) of ten (10) sampled residents (Resident #4). On [DATE] at approximately 3:13 AM, Resident #4 exhibited symptoms of confusion, increased agitation, and yelling out for help. In addition, the resident told staff that the external cardiac defibrillator (LifeVest) that he/she was wearing was too tight and asked staff repeatedly to remove the device. However, staff failed to thoroughly assess and address the resident's medical condition. Subsequently, Resident #4 continued to yell out for assistance for the remainder of the night. At 9:02 AM on [DATE], staff documented that Resident #4 was yelling constantly for someone to help him/her, and told staff he/she could not breathe. However, staff continued to fail to assess the resident's medical condition, and at approximately 10:50 AM on [DATE], after Resident #4's Responsible Party (RP) summoned the nurse to the resident's room, the resident was observed to be cool to touch, and mottled (blotchy red/purple discoloration of the skin, which occurs before death due to the heart's inability to pump blood) from his/her feet to waist. In addition, the nurse was unable to obtain the resident's vital signs. Emergency Medical Services (EMS) was called to the facility to transport Resident #4 to the hospital. However, the resident went into [MEDICAL CONDITION] after being placed into the ambulance and was pronounced deceased at the hospital on [DATE] at 11:40 AM. The facility's failure to ensure that residents received appropriate treatment and care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on [DATE] at 4:30 PM revealed the facility did not have a policy that directed staff when to conduct a nursing assessment. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. In addition, Resident #4 utilized the LifeVest when admitted to the facility. Due to Resident #4 having resided in the facility only four (4) days, the facility had not completed a Minimum Data Set (MDS) assessment for the resident. However, interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 12:25 PM revealed she admitted Resident #4 into the facility on [DATE]. LPN #4 stated the resident was alert, oriented, and able to answer questions appropriately during the admission process. The LPN also stated Resident #4 was talkative and pleasant when he/she was admitted to the facility. Review of Nurses' Notes dated [DATE] at approximately 10:50 AM, revealed LPN #2 documented that the resident was cool to touch, with excessive sweating, and his/her skin was mottled from feet to waist. Further review revealed staff was unable to obtain vital signs and EMS was notified. LPN #2 documented that Resident #4 lost consciousness as emergency staff entered his/her room. The documentation also revealed that as emergency staff transferred the resident onto the stretcher he/she had excessive vomiting of a dark red/brown substance. Interview with LPN #1 on [DATE] at 1:30 PM, revealed she was assigned to care for Resident #4 on [DATE] from 7:00 PM until 7:00 AM on [DATE]. LPN #1 stated she assessed Resident #4 on [DATE] at approximately 10:00 PM and identified no concerns with the resident. The LPN stated she did obtain the resident's vital signs. However, she failed to document the vital signs and could not recall what they were, but stated they were within normal limits. According to LPN #1, at approximately 3:00 AM on [DATE], Resident #4 had become confused and was repetitively stating that something was around his/her ankles, and was aggressively trying to remove the LifeVest, stating it was too tight. Continued interview with LPN #1 revealed the resident continued to ask staff to remove the vest and attempted to remove it himself/herself during the remainder of her shift. However, LPN #1 stated she did not assess the resident when the change in the resident's behavior occurred, or at any time after that, despite the resident continuing to complain of being in distress from 3:00 AM until approximately 7:00 AM (four hours), when her shift ended. LPN #1 stated she had never cared for Resident #4 prior to [DATE], and was not sure if the resident's behavior was normal for the resident or not. Continued interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 12:25 PM revealed she received shift report from LPN #1 on [DATE] at approximately 7:00 AM and LPN #1 informed her that Resident #4 had yelled out the biggest part of the night. LPN #2 stated she observed the resident at approximately 8:00 AM on [DATE] and stated the resident was definitely different. LPN #2 stated Resident #4 requested that she remove the LifeVest, that it was too tight, and the resident stated, I can't breathe, get the doctor in here. Further interview revealed LPN #2 stated she told the resident that the physician had ordered the LifeVest, and he/she had to wear it. However, further interview with LPN #2 revealed she failed to assess the resident's medical condition at that time, failed to conduct a skin assessment of the resident, failed to obtain the resident's vital signs, failed to obtain the resident's oxygen saturation level, and failed to provide any type of comforting measures to the resident. Interview with LPN # 3 on [DATE] at 7:30 PM revealed she assisted in providing care to Resident #4 on [DATE] from 7:00 AM until approximately 9:00 AM. LPN #3 stated when she arrived on the unit on [DATE], at approximately 7:00 AM, she could hear Resident #4 yelling help me from the hallway. The LPN stated she immediately recognized that was an unusual behavior for the resident, because she had cared for him/her two (2) days earlier. LPN #3 stated LPN #1 informed her that the resident had not slept, stating the resident had yelled out most of the night. Further interview with LPN #3 revealed that at approximately 8:00 AM on [DATE], Resident #4 had an episode of vomiting, complained of being short of breath, and told her that the LifeVest was too tight and asked her to remove it. Although LPN #3 stated that the resident's behavior was abnormal and she knew the behavior was unusual for the resident, she did not physically assess the resident, did not perform a skin assessment of the resident, did not listen to the resident's heart/lungs, did not obtain the resident's oxygen saturation, and did not obtain the resident's vital signs. The only assessment conducted by the LPN was to place two fingers between the resident and the vest, and told the resident that it did not feel too tight. Interview with Resident #4's RP on [DATE] at 9:30 AM, revealed he arrived at the facility at approximately 10:30 AM on [DATE] and stated, I could hear (Resident #4) hollering from the hallway and I knew something was wrong. The RP stated Resident #4 was confused, sweaty, and was cold to the touch. The RP stated he rang the resident's call light and when no one came, he went to the nurses' station and asked LPN #2 what was wrong with the resident. LPN #2 informed the RP that the resident had been yelling all morning. The RP stated at that time he requested LPN #2 to come to the resident's room. Further interview with LPN #2 on [DATE] at 12:25 PM revealed Resident #4's RP asked her to go the resident's room on [DATE] at approximately 10:50 AM. LPN #2 stated Resident #4's color was bad and even though the resident was awake, she was unable to obtain any vital signs. LPN #2 stated Resident #4's skin was cold to touch, and mottled from the resident's feet to waist. LPN #2 stated staff called Emergency Medical Services (EMS) and transferred the resident to the hospital. Review of the EMS transportation sheet for Resident #4 dated [DATE], revealed they arrived at the facility at 11:02 AM, and found Resident #4 unresponsive, pale, cool to touch, and diaphoretic. According to EMS documentation, the resident's pulse was weak, and they initiated oxygen to the resident at 11:03 AM. Continued review of the EMS documentation revealed after Resident #4 was placed into the ambulance for transport, the resident became pulseless and stopped breathing while still in the facility's parking lot. EMS documentation revealed cardiopulmonary resuscitation (CPR) was initiated at 11:05 AM and the resident was intubated (tube placed into the airway) at approximately 11:13 AM. EMS transported the resident to the hospital. Review of Resident #4's hospital record revealed the resident arrived at the hospital at 11:30 AM. Hospital documentation revealed Resident #4 had no pulse/respirations, had fixed and dilated pupils, and CPR was in progress upon arrival. Further review of the record revealed Resident #4 was pronounced deceased at 11:40 AM. Interview with the Director of Nursing (DON) on [DATE] at 4:45 PM revealed staff were trained to assess facility residents when a change in condition occurred or the resident expressed distress or discomfort. The DON stated that at a minimum a physical assessment should include a thorough observation of the resident and the nurse should obtain vital signs and perform other relevant assessment dependent on the situation. Interview with the Administrator on [DATE] at 6:20 PM revealed she expected staff to conduct a thorough nursing assessment any time a resident experienced a change in condition, or made complaints such as difficulty breathing, or reported being in distress. The Administrator stated as soon as Resident #4 began to complain on [DATE], staff should have assessed the resident and taken appropriate action based on that assessment. Interview with Physician #1 on [DATE] at 8:20 AM, revealed he expected staff to assess a resident when a change in their condition occurred. The physician also stated Resident #4's ejection fraction (measures the percent of blood leaving the heart when it contracts) was extremely low, and staff should have immediately assessed the resident's medical condition when the resident began displaying a change in behavior, stating he/she could not breathe, and verbalizing distress. **The facility alleged that the following actions were implemented to remove Immediate Jeopardy on [DATE]: 1. Interviews with all residents with a Brief Interview for Mental Status (BIMS) score of greater than eight (8) were conducted by Social Services regarding staff treatment, injuries, feeling safe, etc. No concerns were expressed. 2. Unit Managers and licensed nurses conducted skin assessments of all residents with BIMS scores of less than seven (7). Skin checks revealed no negative findings. 3. The Director of Nursing (DON) and Staffing Coordinator interviewed all licensed and unlicensed nursing staff from [DATE] to [DATE], specifically inquiring about concerns with resident care and/or any knowledge of faulty equipment or incidents with patient care. No negative findings were found and no concerns were expressed. 4. Each resident in the facility was assessed by the DON, Assistant Director of Nursing (ADON), or a Unit Manager to assess for any unidentified changes in clinical condition. No new issues were identified. 5. Additionally, all licensed and unlicensed nursing staff that cared for Resident #1 within the last week of his/her stay were interviewed by the Administrator/DON/Nurse Aide Coordinator/VP of Clinical Operations and asked if Resident #1 appeared in any pain when providing care or if they had knowledge of any incident. All answered consistently with no negative findings. 6. The Quality Assurance (QA) Nurse educated all nursing staff (including State Registered Nurse Aides) on mechanical lift procedures and identifying signs of pain in the elderly from [DATE] to [DATE]. 7. After receiving the IJ Notifications, two employees (Employee #1 and Employee #2), who had cared for Resident #2, were suspended until an investigation could be completed. 8. On [DATE], two (2) Hoyer (brand of mechanical lift) lifts were removed from the facility and replaced with two (2) lifts that were the same brand as the majority (Invacare) being utilized at The Center, making the facility use 100% the same full total body lift with the same manufacturer's lift pads available, as recommended. 9. On [DATE], the MDS Assessment Nurses initiated a 100% review and update of each resident's care plan on the required amount of assistance needed. 10. On [DATE], the DON and Nurse Aide Coordinator retrained all staff (licensed and unlicensed) regarding sling size. Further, the sling size was placed on each resident's Kardex/Care Plan by the MDS Assessment Nurse. 11. On [DATE], the DON ensured visual reminders were placed on each mechanical lift that two (2) staff members were required while operating the lift and included specifications from the manufacturer on the sling sizing guide as to what size each color indicated. 12. On [DATE], the facility did not identify any other residents that required a life vest as did Resident #4. 13. On [DATE], The Regional Director of Operations provided in-service/education to the Administrator and the Director of Nursing on the facility's change of condition policy and the requirements related to resident assessment and physician notification by licensed staff when change in a medical condition occurs. Both the Administrator and Director of Nursing completed a post-test with 100% accuracy. 14. On [DATE], the DON/ADON initiated in-service/education to all licensed nurses (on duty) on the facility's policy of change of resident condition, assessing the change in resident status, and associated MD notification. The training also covered care plans (comprehensive) and following resident-centered care plans. This education will be conducted for new hires as well. Any licensed nurses who were unable to attend the required in-service will be immediately educated upon return to work by the DON/ADON. In addition, a sign was posted by the time clock and the DON/Administrator crosschecked the work schedule with the in-service sign-in sheets to assure that only staff that had received the education were allowed to work. This facility does not utilize agency staff. Post-tests were given to licensed staff on change in resident condition, which included assessment of a resident's medical/mental condition, recording the assessment in the medical record, and reporting changes promptly to the MD. A post-test was given to all licensed nurses with 100% accuracy expected before returning to work. 15. On [DATE], the Regional Director of Operations in-serviced/educated the Administrator and Director of Nursing Services on the manufacturer's recommendations for mechanical lifts/lift pads. 16. On [DATE] in-service/education was conducted by the Director of Nursing/ADON on the implementation of the Kardex with all State Registered Nurse Aides (SRNAs) on duty. Specifically, the location of the Kardex, following the Kardex, and requirements for assistance with mobility including transfers, and bed mobility. The education also included immediately reporting a noted change in a resident's condition to the charge nurse. This education will be given to any new hire SRNAs upon orientation. Any SRNA unable to attend the required in-service/education will be immediately educated upon return to work by the DON/ADON. A sign was posted by the time clock and the DON/Administrator crosschecked the work schedule with the in-service sign-in sheet to assure that only staff that had received the education was allowed to work. The facility does not utilize agency staff. All SRNAs took a post-test with 100% accuracy expected before being allowed to return to work. 17. On [DATE], re-education/in-service was provided by the DON to all SRNAs for those immediately on shift in regard to following the SRNA Kardex, both electronic and paper version. In addition, the DON in-serviced on the implementation of the number 2 or more identification label to the right bottom side of the resident's footboard. A post-test was given with 100% accuracy expected. Any employee not in attendance will be educated prior to work by the DON/ADON. An all nursing staff in-service was held on [DATE] to continue this process. Staff are stationed by the time clock each shift with a crosscheck document to assure that no staff member works without first being re-educated. This education will be conducted for all new hire SRNAs and no agency staff are utilized at the facility. Any remaining staff will be educated and deemed competent prior to their next work shift. On [DATE], full SRNA return demonstration on competency regarding electronic and/or Paper Kardex was initiated. One hundred percent accuracy is expected and competency must be established before the SRNA works the next shift. This is being done in conjunction with the SRNA Kardex education provided on [DATE] Any SRNA that was not present for the initial checkoff will be required to do so before their next shift with 100% accuracy. Competency will be completed for any new hires as well. Ongoing checkoffs will be conducted by the SRNA Coordinator prior to the SRNA working. 18. On [DATE], Unit Coordinators, the Physical Therapist, Restorative Nurse, Restorative Nurse Aides, SRNA Coordinator, Director of Nursing, and the Administrator were educated by the safe resident handling consultant authorized by Invacare Lift Company on the following: Sizing of slings according to weight, height, and girth; sling border and color related to size and weight capacity; and safety inspection. Going forward, only these trained individuals will evaluate residents who need mechanical lifts to determine and assign sling sizes. Once the resident's sling size has been assigned, this will be listed on that individual resident's nurse aide Kardex. A post-test was given to the Unit Managers, Restorative Nursing, Director of Nursing, and SRNA Coordinator with 100% accuracy expected. 19. On [DATE], the Director of Nursing initiated education/in-service to all staff nurses and SRNAs regarding their duties, which consisted of identification of how to access the assigned sling size on the SRNA Kardex; the utilization of the correct mechanical lift sling size; the process of assignment, location, and the difference in mechanical lift sling sizes; and the visual reminders on each lift. A post-test will be given to each employee with 100% accuracy expected. Further, any staff not in attendance will be in-serviced by the DON/Administrative Nurses, Physical Therapy, or Restorative Nursing prior to returning to work. A note is posted at the time clock and the DON/ADON crosschecked the schedule to ensure all staff were trained. 20. On [DATE], a Quality Assurance meeting with the Medical Director, Administrator, Director of Nursing, Social Services Director, Unit Coordinators, and Regional Nurse Consultant was conducted. The following were reviewed during this QA meeting: The survey findings as per the IJ notification; the AOC and corresponding action plan; and the ongoing compliance monitoring audits. 21. On [DATE], the facility began having daily meetings (seven days a week) which will include the DON/ADON/Administrator, Licensed Nurses, and Social Services to provide ongoing monitoring of audits and ensuring ongoing compliance with the AOC. 22. On [DATE], the facility initiated a Resident Change of Condition Monitoring Audit. All residents placed on the acute monitoring log will be discussed during the daily meeting and reviewed for the following: evidence of assessment, evidence of physician notification, and a care plan review and the appropriate implementation thereof. A resident change of condition monitoring audit will be conducted by the IDT (including the DON/ADON and/ or Administrator as designated) which includes an assessment of the resident (including vital signs), Physician/Physician on-call/Medical Director notification, resident and family notification, and care plan review. The Audit will be conducted daily for four (4) weeks and presented to Quality Assurance/Performance Improvement (QAPI) for further recommendations. 23. On [DATE], Restorative Nursing conducted a 100% audit of all mechanical lift pads to ensure they were compatible with the mechanical lifts according to manufacturer's recommendations. No concerns were identified. The Mechanical lift sling audit will continue weekly for four (4) weeks, and then monthly with the QAPI process. 24. [ENTITY]ting [DATE], five percent (5%) of care plans (by random selection) are being reviewed one (1) time per week for four (4) weeks for accuracy, specifically with bed mobility, transfers, and toileting. The audit will be conducted by the MDS Coordinator, with 100% accuracy and will then reduce to monthly utilizing the QAPI process. 25. Further, a Quality Assurance meeting was held on [DATE] and [DATE] with the Medical Director, DON, Administrator, Department Directors, and administrative nursing as appropriate. The following Topics were discussed/reviewed: 1. Trainings regarding AOC results of post-test; 2. Ongoing audits and results of the audits conducted; and 3. Ongoing compliance with the AOC. 26. On [DATE], an audit was conducted by the MDS Nurses and the Unit Manager regarding the level of assistance needed for transfers. Further, placement of the 2 or more label was assigned to residents' beds as appropriate. Presence of the 2 or more assistance label on the bed will be audited two (2) times a day by the [ENTITY]/Licensed Nurse and documented on the audit form labeled 2 program compliance check. This audit will be conducted two times a day for two months, and then compliance will be determined by QAPI. Unit Managers will be responsible for updating the list with new admissions and significant changes. This will be monitored by the Director of Nursing. 27. Licensed nurses are auditing daily for utilization of the correct sling size and correct number of staff members present and assisting with mechanical lift transfers. This audit is done once daily on each unit for four (4) weeks. The DON is reporting results of the audit to QA. [ENTITY]s will check every shift for every resident requiring a mechanical lift for the presence of a lift number on each resident's bed. This is documented on the MAR. The MAR is being checked for completeness daily by the Unit Coordinator/DON. Results are reported to QA by the DON. 28. QAPI meetings will be held weekly and as needed with the Medical Director, DON/ADON, Administrator, Social Services, and Administrative Nursing Staff weekly for four (4) weeks as compliance is established and then monthly. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on [DATE], as alleged: 1. Interview with the Social Services Director on [DATE] at 2:50 PM and review of documentation revealed all residents with a BIMS score of eight (8) or greater were interviewed regarding staff treatment during care on [DATE]. No concerns were voiced by residents. 2. Interview with Unit Coordinator #2 on [DATE] and review of skin assessment documentation revealed residents with a BIMS score of seven (7) or less had skin assessments completed on ,[DATE]-,[DATE]. No suspicious injuries were identified. 3. Interview with the Director of Nursing (DON) on [DATE] at 11:54 AM and review of documentation revealed nursing staff was interviewed on ,[DATE]-,[DATE] related to concerns with resident care, any knowledge of faulty equipment, or concerns with resident incidents. No problems were identified. 4. Interviews with the DON on [DATE] at 11:54 AM and on [DATE] with the ADON at 3:40 PM, and review of documentation on resident assessments, revealed all residents were assessed for change in condition on [DATE] with no new issues identified. 5. Interview with the Director of Nursing (DON) on [DATE] at 11:54 AM and review of documentation on staff interviews/statements revealed staff were interviewed between ,[DATE]-,[DATE] regarding care provided for Resident #1. 6. Interview with the Quality Assurance Nurse on [DATE] at 5:25 PM, and review of training documentation, revealed she had completed training with nursing staff related to mechanical lift procedures and identifying signs of pain in the elderly on ,[DATE]-,[DATE]. 7. Interview with the DON on [DATE] at 11:54 AM and the Administrator on [DATE] at 10:45 AM, and review of documentation revealed Employees #1 and #2 were suspended on [DATE]. Both employees returned to work on [DATE] after the facility completed an investigation. 8. Interview with the DON on [DATE] at 11:54 AM and observation of the mechanical lifts in use at the facility on [DATE], [DATE], and [DATE] revealed Invacare lifts were being used by staff to transfer residents. 9. Interview with LPN #12 (MDS Coordinator) on [DATE] at 10:30 AM revealed she and the other MDS Coordinator had reviewed all resident care plans on [DATE]. The MDS Nurse stated they also revised resident care plans during this review related to bed mobility, incontinence care, and mechanical lift use. 10. Interview with the DON on [DATE] at 11:54 AM and with the SRNA Supervisor on [DATE] at 5:10 PM, and review of documentation revealed staff were trained on [DATE] regarding sling size and that the size of sling needed was placed on the resident's care plan. Interviews on [DATE] with SRNA #31 at 11:10 AM, LPN #13 at 3:04 PM, RN #1 at 3:40 PM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM, revealed all had received the above training. Review of Resident #8's Kardex revealed the resident was to be transferred using a mechanical lift and the sling size was listed on the resident's Kardex. 11. Interview with the DON on [DATE] at 11:54 AM and observation of two (2) mechanical lifts on [DATE] revealed the slings had signage that directed two (2) staff member assistance when operating the lift and the lift also had signage including sling color/size. 12. Interview with the DON on [DATE] at 11:54 AM and with the Administrator on [DATE] at 10:45 AM confirmed no other residents currently residing at the facility utilized life vests. 13. Interview with the Regional Director of Operations on [DATE] at 5:00 PM, with the DON on [DATE] at 11:54 AM, and with the Administrator on [DATE] at 10:45 AM, and review of training documentation revealed the Regional Director of Operations had provided education for the Administrator and DON on the facility's Change of Condition Policy and physician notification requirements. Review of tests revealed the Administrator and DON completed post-testing with 100% passing scores. 14. Interview on [DATE] with LPN #13 at 3:04 PM, RN #1 at 3:40 PM, Unit Coordinator #2 at 4:10 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #10 at 5:30 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, and with the DON on [DATE] at 11:54 AM, and review of training records revealed the DON had initiated training to all licensed nursing staff on the facility's change of condition policy and physician notification requirements. Review of post-tests revealed staff were tested after the above training. 15. Review of training records and interview with the Regional Director of Operations on [DATE] at 5:00 PM, the DON on [DATE] at 11:54 AM, and the Administrator on [DATE] at 10:45 AM revealed on [DATE], the Regional Director of Operations in-serviced/educated the Administrator and Director of Nursing Services on the manufacturer's recommendations for mechanical lifts/lift pads. Review of tests revealed the Administrator and DON completed post-testing with 100% passing scores. 16. Review of training records and interviews on [DATE] with SRNA #31 at 11:10 AM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #13 at 3:04 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed the DON/ADON educated nursing staff on use of the Kardex (nurse aide care plan). Interview with the DON on [DATE] at 11:54 AM revealed administrative staff observed staff arriving at work at the time clock during shift change and nursing staff were trained and were given post-test with a 100% score prior to working. Review of post-tests revealed staff were tested after the above training. 17. Interview with the DON on [DATE] at 11:54 AM and the Administrator at 10:45 AM revealed nursing staff were initially in-serviced on following the care plan/Kardex on [DATE] and re-educated on [DATE] and [DATE]. Per the DON, return demonstration as to the location of the Kardex was required on [DATE] and [DATE]. Review of training records and interviews on [DATE] with SRNA #31 at 11:10 AM, SRNA #6 at 4:00 PM, Unit Coordinator #2 at 4:10 PM, SRNA #30 at 4:35 PM, the ,[DATE] House Supervisor at 4:44 PM, LPN #13 at 3:04 PM, LPN #10 at 5:30 PM, SRNA #29 at 5:40 PM, RN #2 at 5:45 PM, RN #6 at 6:05 PM, SRNA #35 at 6:20 PM, SRNA #5 at 6:30 PM, SRNA #12 at 6:45 PM, SRNA #33 at 6:50 PM, and SRNA #32 at 6:58 PM revealed staff were re-educated on use of the Kardex and location with return demonstration of the Kardex location required. Staff stated they were also trained on the number 2 or more identification label to the right bottom side of the footboard. Observation on [DATE] during tour of the facility between 9:40 AM and 10:25 AM, revealed the number 2, or 2L, was observed on the footboard of several residents' beds, including Resident #8's bed which included the signage of 2L (meaning the resident required the assistance of two staff members and a mechanical lift for transfers). 18. Review of training records and interview with the DON on [DATE] at 11:54 AM, the Administrator on [DATE] at 10:45 AM, the SRNA Restorative Aide (SRNA #34) on [DATE] at 10:02 AM, and the SRNA Supervisor on [DATE] at 5:10 PM revealed they all received training by the Invacare Lift Company on sizing of the slings, sling border colors denoting size, etc. Continued interview revealed that all residents who utilized mechanical lifts were measured for the correct sling size and the sling color/size was added to the resident's Kardex. Review of post-tests revealed staff were administered post-tests after the training and all staff passed with 100% accuracy. Review of Resident #8's Kardex reveale

Based on observation, interview, record review, review of a facility investigation, review of the facility's policies and procedures, and review of mechanical lift/sling user manuals/instructions, it was determined the facility failed to have an effective system to provide supervision to prevent accidents for three (3) of ten (10) sampled residents (Resident #1, Resident #2, and Resident #7) and fifty-four (54) residents who utilized a mechanical lift (a device used to move individuals who are unable to stand on their own). The facility assessed Resident #1 to require total assistance of two (2) staff persons for bed mobility and toileting, and two (2) staff persons for mechanical lift transfers. However, interview with State Registered Nurse Aide (SRNA) #19 revealed she provided incontinence care to Resident #1 on [DATE] without assistance and Resident #1 hit his/her head against the bed side rail and sustained a bruise above his/her left eyebrow. Further, during the night shift of ,[DATE]-,[DATE], SRNA #12 stated she provided care to Resident #1 during her entire twelve (12) -hour shift unassisted. On [DATE] at approximately 7:53 AM, staff found Resident #1 in bed unresponsive. Resident #1 was transported to the local Emergency Department (ED) where he/she required CPR (cardiopulmonary resuscitation) and intubation (a breathing tube to provide breaths for the resident). The resident was also diagnosed with [REDACTED]. Resident #1 expired at the hospital on [DATE] at 3:06 PM. The facility conducted an investigation, but determined that there was no evidence Resident #1 sustained any injuries at the facility. However, a review of the resident's preliminary autopsy report dated [DATE] at 9:00 AM revealed a preliminary [DIAGNOSES REDACTED]. In addition, the autopsy revealed the resident also had fractures of the proximal right humerus (large bone of the upper arm in the shoulder area) and posterior right first and second ribs (portion of the ribs that curve around to the back). The report also stated Resident #1 had fractures of the sternum and multiple bilateral anterolateral ribs (ribs in the chest) that were (possibly resuscitation related). The facility's failure to ensure residents remained free from accident hazards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655 and F656), and 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to ensure staff transferred Resident #2 via a mechanical lift safely. Review of Resident #2's care plan revealed the resident required two (2) staff persons to transfer the resident utilizing a mechanical lift. However, review of the facility's video footage for [DATE] at approximately 10:04 PM, revealed State Registered Nurse Aide (SRNA) #23 took a mechanical lift into Resident #2's room and shut the door. Approximately ten (10) minutes later at 10:14 PM, SRNA #23 exited Resident #2's room and discarded dirty linens/supplies in a cart across the hallway. SRNA #23 was then observed to re-enter Resident #2's room and exit his/her room with a mechanical lift by herself. Furthermore, the facility failed to ensure mechanical lifts were utilized safely according to the manufacturer's instructions. Observation revealed the facility utilized Invacare Reliant brand pads/slings to transfer residents via a mechanical lift, which were safe to use for two (2) of the five (5) mechanical lifts that the facility utilized. Observation of the other three (3) lifts utilized by the facility and review of the manufacturer's instructions for the lifts revealed Invacare Reliant Brand pads/slings utilized by the facility were not compatible and use was not recommended by the manufacturer. In addition, interviews with direct care staff revealed they were not knowledgeable related to ensuring the correct sized pad/sling was utilized for residents that required the use of a mechanical lift for transfers. The facility also failed to ensure two (2) staff persons transferred Resident #7 as required by the resident's care plan. On [DATE], one (1) SRNA transferred Resident #7 from the bed to a wheelchair in the resident's room. The resident became weak, and the SRNA lowered the resident to the floor. Approximately one hour later, the resident complained of pain. The facility transferred the resident to the hospital for evaluation and the resident was diagnosed with [REDACTED]. The findings include: Review of the facility's Accidents and Incidents - Investigating and Reporting Policy, dated [DATE], revealed all accidents or incidents involving residents occurring on the facility's premises would be investigated and reported to the Administrator. Review of the facility's Transfers and Mechanical Lifts Use/Care policy, undated, revealed two (2) staff persons were required to use a mechanical lift. The policy also stated that two (2) staff persons were required to reposition a dependent resident. Review of the Employee Safety Mechanical Lift Audit form, undated, revealed staff were to obtain assistance from appropriate staff when using a mechanical lift for transfers. Interview with Physical Therapist (PT) #1 on [DATE] at 12:23 PM revealed utilizing mechanical lifts always required a minimum of two (2) staff persons for use because one (1) person had to maneuver the lift and one (1) person had to guide the resident to ensure the resident was safely transferred with the lift and to avoid injuries of the residents. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], and the resident had [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #1 was a Full Code (required CPR if needed). Review of Resident #1's Physical Therapy (PT) Treatment Encounter Note dated [DATE], revealed PT #1 assessed Resident #1 for the use of a mechanical lift with transfers. PT #1 documented that Resident #1 would now utilize a mechanical lift for transfers due to his/her fall risk, inability to assist staff with transfers, and the resident's inability to follow commands. Review of a PT Discharge Summary dated [DATE], revealed a functional skills assessment that stated Resident #1 was dependent on staff during chair/bed-to-chair transfers, lying to sitting on side of bed, sitting to standing, toilet transfer, rolling left and right, and sitting to lying. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to be severely cognitively impaired and never/rarely made decisions. Continued review of Resident #1's MDS assessment revealed the facility assessed the resident to be totally dependent on two (2) staff persons for bed mobility, transfers, dressing, bathing, and toileting. Further review of the MDS revealed that Resident #1 required staff assistance to stabilize with surface-to-surface transfers. According to the MDS, Resident #1 had not sustained any falls since his/her last assessment. Review of Resident #1's comprehensive care plan dated [DATE], revealed the facility identified that the resident required assistance with Activities of Daily Living (ADL) and developed interventions that included staff assisting Resident #1 with dressing, grooming, hygiene, showers, and bathing. In addition, review of a care plan revised on [DATE], revealed the facility developed an intervention to provide incontinence care for the resident every two (2) hours and as needed. Further review of Resident #1's care plan revealed the facility identified that the resident had the potential for impaired physical mobility related to a [DIAGNOSES REDACTED]. According to the care plan, on [DATE], the facility developed an intervention for staff to utilize a mechanical lift for safe staff transfers of the resident. The care plan also stated staff were required to provide supportive care/assistance with mobility as needed. Further review of Resident #1's care plan revealed that although the facility identified that the resident required assistance with ADLs, the care plan did not specify how many staff persons were needed to safely provide care for the resident. Review of Resident #1's SRNA Kardex (a guide for resident care) revealed the Kardex did not address the number of staff required to assist the resident with transferring in a mechanical lift, nor the number of staff that the resident required for assistance with incontinence care or bed mobility. Review of a Resident Accident/Incident Report dated [DATE] at 3:15 PM, revealed staff rolled Resident #1 onto his/her side and the resident bumped the left side of his/her forehead on the side rail sustaining a bruise above the left eyebrow. Interview with SRNA #19 on [DATE] at 1:48 PM revealed on [DATE] she was assisting Resident #1 with care, alone, when the incident occurred. She stated it was her first day working at the facility and she was assisting SRNA #18 with resident care. She stated that SRNA #18 was on lunch break when Resident #1 had an incontinence episode and she provided incontinence care alone, without the assistance of SRNA #18. She stated she rolled the resident onto his/her side to change the resident's bed linens when the resident slightly hit his/her head on the bed rail. SRNA #19 stated she was unaware of the number of staff that were required to care for Resident #1. She stated she did not have a Kardex/assignment sheet and was not told the amount of assistance that the resident needed during shift report. Continued interview with SRNA #19 revealed she did not think to ask for help when providing care to Resident #1 since she was just changing the resident. Interview with SRNA #18 on [DATE] at 1:14 PM revealed SRNA #19 had been assisting her with resident care that night but while she was on break, SRNA #19 provided incontinence care for Resident #1 and the resident hit his/her head on the side rail of the bed. She further stated she was aware that Resident #1 required two (2) staff persons to provide incontinence care and bed mobility. SRNA #18 stated SRNA #19 was providing care to Resident #1 by herself when the incident occurred and it was reported to Registered Nurse (RN) #2. In addition, she stated sometimes other staff persons were busy at times and she had provided care to the resident unassisted, but it was hard to do. However, further review of the Resident Accident/Incident Report for Resident #1 dated [DATE], revealed the causative factor for the injury was because the resident often moved his/her head when staff provided care attempting to talk to staff. Continued review revealed the recommendation/action taken was to replace the tender care pads on the resident's side rails and ensure padding was in place at all times when care was provided. There was no documented evidence that the facility identified/addressed during the investigation that one staff member was assisting the resident with care when the injury occurred. Continued review of Resident #1's medical record revealed four (4) days later, on [DATE] at 8:05 AM, RN #2 documented that upon entering Resident #1's room, the resident's skin was very pale, the resident's eyes were open, and (he/she) was not responding or talking. RN #2 documented that Resident #1 had dementia, and previously talked using short words and/or phrases, and often answered questions inappropriately. The assessment stated the resident's respirations were shallow, his/her skin was warm and clammy to touch, lung sounds were noted with rhonchi and auditory gurgling, a faint pulse was detected, and the resident's oxygen saturation was [AGE] percent (%) on room air (normal is ,[DATE]%). Resident #1's pulse was documented at 66 beats per minute (bpm) (normal heart rate is ,[DATE]) and his/her blood pressure was ,[DATE] (normal range is 90-,[DATE]-[AGE]). The Nurse's Note stated that RN #2 notified Physician #4 and received an order to transfer the resident to the ED. Further review revealed Resident #1's responsible party was also notified of the resident's change in condition. Further review of Resident #1's medical record revealed that at 8:07 AM on [DATE] RN #2 called Emergency Medical Services (EMS) and at 8:15 AM Resident #1 was out of the facility via EMS and a report of the resident's condition was called to the local ED. Continued review revealed RN #2 documented that the resident left the facility with a pulse and respirations, and the resident was cleaned after having a large bowel movement prior to EMS arriving at the facility. Interview with SRNA #6 on [DATE] at 12:16 PM revealed the first time she saw Resident #1 on [DATE] was at approximately 7:55 AM, when she delivered the resident's breakfast meal. She stated the resident's skin was gray and the resident was gasping for air. She stated RN #2 was across the hall in another resident's room and she yelled for her to come to Resident #1's room. The SRNA stated RN #2 immediately went to Resident #1's room and assessed the resident. She stated the resident was usually counting and moving his/her arms around when she entered the resident's room. During continued interview SRNA #6 stated staff utilized a mechanical lift to transfer the resident, which required two (2) staff persons, and the resident required two (2) staff persons to provide incontinence care and bed mobility. She further stated that the resident was only transferred with the mechanical lift when staff showered the resident and the last time the resident received a shower was on [DATE], two (2) days before the resident was found unresponsive. SRNA #6 stated she was not aware of the resident falling or any incidents that could have caused injuries to the resident. Interview with RN #2 on [DATE] at 10:02 AM revealed she was assigned to provide care for Resident #1 on [DATE]. She stated she had not been in Resident #1's room on the morning of [DATE], until SRNA #6 reported that something was wrong with Resident #1. She stated she entered Resident #1's room and the resident's skin was really pale, respirations were shallow, the resident was making gurgling sounds, and was unresponsive. She stated LPN #4 notified EMS that Resident #1 was unresponsive and she gathered the necessary paperwork to transport the resident to the ED. RN #2 stated that Resident #1 did not have any bruising or injuries upon assessment except for discoloration to the forehead from hitting his/her head on the bed side rail on [DATE]. She stated the resident's skin looked great. RN #2 stated she remained in Resident #1's room until the resident was transferred out of the facility. She stated the resident did not show any signs of pain with movement; however, the RN previously stated the resident was unresponsive. According to RN #2, Resident #1 was dependent on two (2) staff persons for activities of daily living (ADLs) and utilized a mechanical lift for transfers. However, she stated one (1) person could provide incontinence care to Resident #1 if they utilized a draw sheet to keep the resident turned onto his/her side. Further interview with RN #2 revealed the only time staff transferred the resident out of bed was on his/her shower day. RN #2 stated she was not aware of anything that had occurred with Resident #1 on previous shifts that could have injured the resident. She stated the resident had not sustained a fall in a long time and did not attempt to get out of bed or roll over in bed unassisted. Interview with Unit Coordinator (UC) #1 on [DATE] at 2:16 PM revealed she was at her desk working on [DATE] when SRNA #7 came to the desk to verify Resident #1's code status. She stated LPN #4 called 911 and announced a code to Resident #1's room. She stated she ran to Station 1 to obtain the crash cart and she and the DON went to Resident #1's room. She stated RN #2 and the MDS Coordinator were in Resident #1's room, and the resident was unresponsive, but breathing. She stated the resident's respirations were shallow, pulse was faint, and the resident had a large bowel movement, when they rolled the resident to his/her side. UC #1 stated EMS arrived and she left Resident #1's room so they could work with Resident #1. Interview with the MDS Coordinator on [DATE] at 3:13 PM revealed she was going outside when she heard a Code Blue called for Resident #1. She stated she went to Resident #1's room and RN #2 was in the room assessing the resident. The MDS Coordinator stated she could hear the resident gurgling and was trying to get Resident #1 to respond. She stated Resident #1's oxygen saturation was low, an oxygen mask was placed on the resident, and his/her oxygen saturation began to increase. She stated when turning the resident to his/her side the resident had a bowel movement, so she assisted with cleaning the resident and EMS arrived. She stated Resident #1 did not have any bruising or redness to his/her skin except for a fading bruise to his/her forehead. Further, according to the MDS Coordinator, Resident #1 did not exhibit any signs of pain when he/she was moved. She stated the resident did not moan or groan; however, the MDS Coordinator stated the resident was also unresponsive. Review of Resident #1's EMS Run Report dated [DATE], revealed at 8:04 AM, the facility contacted them regarding an unconscious resident. At 8:11 AM, the EMS crew arrived at Resident #1's room to find Resident #1 lying in bed, unresponsive but breathing, with audible rales (crackling/rattling sounds in the lungs). Further review of the EMS Report revealed EMS placed a non-rebreather oxygen mask on Resident #1 and administered oxygen at 15 liters per minute (lpm). The resident was transferred onto a stretcher, secured for transport, and loaded onto the ambulance. Further review revealed EMS staff suctioned the resident's airway, which cleared the rales. EMS placed the resident on a cardiac monitor and the resident had a sinus rhythm (no abnormal heartbeats) of [AGE] bpm. Continued review revealed the EMS crew attempted to obtain intravenous (IV) access two (2) times in case emergency medications were required; however, they were unsuccessful. The resident was observed to begin agonal breathing (gasping, abnormal pattern of labored breathing) and was assisted with a bag valve mask (BVM) (also called an ambu bag, which is a handheld device commonly used to provide positive pressure ventilation to patients who are not breathing adequately). The run report stated a nasopharyngeal airway (NPA) (a tube inserted into the nasal passageway to secure an open airway) was inserted into the resident's left nostril and supportive care was provided throughout the resident's transport. Further review of the run report revealed the resident did not require intubation (placement of a tube into the resident's windpipe to provide breathing for the individual) or sedation during transport to the hospital and the resident's care was transferred to staff at the ED. Interview with Emergency Medical Technician (EMT) #1 on [DATE] at 1:19 PM revealed when he arrived at the resident's room, the resident was lying in bed and staff were cleaning the resident after a bowel movement. He stated the resident was breathing, but had audible rales. EMT #1 stated he provided supportive care to the resident during transport to the ED; however, cardiopulmonary resuscitation (CPR) was not administered or required. Review of the ED record revealed Resident #1 arrived at the hospital at 8:29 AM on [DATE] in cardiorespiratory arrest. The ED record stated that the resident was found unresponsive by staff at a local nursing facility and was transported to the ED by EMS. EMS reported that the resident became apneic (stopped breathing) and oxygen was provided via BVM. At 8:36 AM, Resident #1 was intubated and at 9:55 AM Resident #1's pulse could not be detected and a Code Blue was called and CPR was initiated. Review of the Code Blue Documentation for Resident #1 revealed at 9:58 AM on [DATE], CPR was initiated due to Resident #1's cardiac rhythm being in asystole (the heart stopped beating). The resident received medications to stimulate a heartbeat and at 10:04 AM, Resident #1 had sinus [MEDICAL CONDITION](increased heart rate). Continued review of Resident #1's ED record revealed a computed tomography (CT) scan (a series of x-ray images taken from different angles that provides more detailed information than a plain x-ray) of the chest was ordered at 10:30 AM. Review of the results of the CT scan of the chest electronically signed by Physician #5 at 12:50 PM on [DATE], revealed the resident had bilateral hazy predominantly ground glass alveolar opacities and increased interstitial most likely [MEDICAL CONDITIONS]. The results further revealed that Resident #1 had an acute mild compression fracture of T11 ([MEDICATION NAME] vertebrae in the back) and age indeterminate (possibly old) mild compression fracture of T8, T9, and T10. Continued review of Resident #1's medical record revealed the ED Physician ordered a CT scan of the abdomen and pelvis with contrast at 11:28 AM on [DATE] because Resident #1 was unresponsive, septic (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), and an elevated white blood cell count (indicative of infection). Review of the CT results revealed a large amount of hemorrhage (blood) throughout the right iliacus muscle with moderate hemorrhage into the inferior aspect of the silhouette, a large amount of extra-peritoneal hemorrhage bilaterally and anteriorly in the pelvis, and moderate hemorrhage in the right obturator muscle (moderate to large amount of bleeding in the right pelvis/hip area). Further review revealed the resident had a right comminuted acetabular fracture involving the acetabular roof, posterior column, anterior column, anterior wall, and extending superiorly into the mid iliac bone (fractures of the socket portion of the hip and fractured pelvis); right superior and inferior pubic rami fractures (bones in the bottom-most portion of the pelvis); acute comminuted (splintered) left femoral head/neck junction fracture with extension into the intertrochanteric region (highest part of the thigh (femur) bone); acute moderate superior and inferior endplate compression fractures of L1 and T11 (lumbar and [MEDICATION NAME] spine fracture) with dense [MEDICAL CONDITION]; and age indeterminate anterior column compression fractures of L2-L5 (lumbar spine fractures). Continued review of the radiology report revealed Resident #1 had multiple acute fractures with large extra-peritoneal hemorrhage bilaterally (bleeding in the abdomen); and hemorrhage into the iliopsoas muscle (pelvic muscle) on the right and obturator muscle (hip muscle). Review of an ED Patient Note dated [DATE] at 12:32 PM revealed RN #4 contacted the nursing facility and spoke with RN #2, the RN who cared for Resident #1 prior to his/her transfer to the ED, to clarify how Resident #1 was found at the nursing facility and to update staff of the resident's condition. RN #4 documented that RN #3 reported that Resident #1 was found in bed and was pale, cool, and unresponsive. RN #3 denied any falls or abnormal events occurring in the past twenty-four (24) hours. Review of a facility Nursing Progress Note dated [DATE] at 12:35 PM, revealed RN #2 documented that she received a phone call from the ED Nurse inquiring about how Resident #1 was found at the facility. RN #2 stated the resident was found lying in bed, his/her skin was very pale, respirations were very shallow, and his/her pulse was palpable, and the resident was not talking. She further documented that the ED Nurse was attempting to determine what had occurred prior to finding the resident unresponsive because the resident had multiple fractures to his/her back, pelvis, and hips. Furthermore, RN #2 documented that she informed the ED Nurse that Resident #1 never got up and had not sustained any recent falls. According to the Nursing Progress Note, RN #2 reported the phone conversation to the DON. Continued review of Nursing Progress Notes revealed on [DATE] at 12:50 PM, RN #2 documented that she called the ED Nurse back to clarify that the earlier conversation was about the correct resident, Resident #1, because the resident had not sustained any falls and did not have any injuries prior to his/her transport to the ED other than fading discoloration above his/her left eye. Even though documentation revealed Resident #1 was not responding when he/she was transferred to the ED, RN #2 stated she reported to the ED Nurse that the resident did not grimace or voice pain prior to leaving the facility and stated that there were three (3) nurses at the resident's bedside prior to his/her transfer to the ED. Further review revealed the ED Nurse reported that the resident stopped breathing while in transit with EMS, had coded several times since he/she arrived at the ED, and was admitted to the Intensive Care Unit (ICU). Review of Resident #1's Patient Note dated [DATE] at 1:48 PM revealed staff at the hospital notified the Cabinet for Health and Family Services of Resident #1's multiple fractures and at 2:07 PM the state regulatory agency (State Survey Agency) was notified. Review of an Inpatient Progress Note dated [DATE] at 3:05 PM revealed that nursing staff notified the physician that Resident #1 was bradycardic (low heart rate) and going into asystole (heart was stopping). The resident's family was at the resident's bedside, and upon exam the resident did not respond to verbal or physical stimuli. The note stated that Resident #1 was absent from heart and breath sounds, his/her pupils were fixed and dilated, and no motor response stimulation. Resident #1 was pronounced dead at 3:06 PM. Interview with RN #4 on [DATE] at 11:35 AM revealed she was working in the ED on [DATE] when Resident #1 arrived via EMS. She stated she did not observe anything on Resident #1 that would have alerted her that Resident #1 had any injuries. She stated Resident #1's heart stopped beating while in the ED and she assisted with chest compressions while standing beside the resident's bed. RN #4 stated that Physician #2 ordered CT scans and she transported the resident for the scans while on their way to ICU. RN #4 stated when the radiology reports were reviewed, it was discovered that the resident had numerous fractures. She stated she called the nursing facility and spoke with RN #2 to see if anything had happened to Resident #1 at the nursing facility that could have caused his/her injuries; however, she stated RN #2 denied any knowledge of anything that would have caused the numerous fractures and bleeding. Further interview with RN #4 revealed that nothing had happened in the ED that would have caused the fractures or hemorrhaging. Interview with RN #5 on [DATE] at 12:02 PM revealed she was assigned to care for Resident #1 when he/she arrived at the ED on [DATE]. She stated she did not observe any bruising or injuries to Resident #1. RN #5 stated CPR was performed for the resident in the ED. She stated chest compressions were performed at bedside and the resident's heart started back. Further interview with RN #5 revealed Physician #2 ordered a CT scan that showed the resident had numerous fractures. She further stated that Resident #1 did not sustain any falls while in the ED, and that RN #4 called the nursing facility to determine if the resident had sustained any falls or injuries prior to his/her transfer to the ED. Review of a preliminary autopsy report dated [DATE] at 9:00 AM revealed Resident #1 had a preliminary [DIAGNOSES REDACTED]. Pelvic and bilateral retroperitoneal soft tissue (abdominal area that includes the bowel, pancreas, kidneys, and adrenal glands) hemorrhage; fractures of the proximal right humerus (the upper part of the long bone of the upper arm), right acetabulum (the socket of the hipbone), iliac bone (a pelvic bone), and pubic bone (a pelvic bone); left femoral head (hip area of the upper leg bone); and posterior right first and second ribs. The report also stated Resident #1 had fractures of the sternum and multiple bilateral anterolateral ribs (possibly resuscitation related). Further review of the report revealed a history that Resident #1 was found unresponsive in his/her bed at the nursing facility at which time he/she was transported to the hospital and diagnosed with [REDACTED]. Interview with SRNA #6 on [DATE] at 12:16 PM and [DATE] at 11:55 AM, SRNA #9 on [DATE] at 12:59 PM and [DATE] at 11:39 AM, SRNA #14 on [DATE] at 9:41 AM, Restorative Aide #1 on [DATE] at 11:29 AM, LPN #8 on [DATE] at 1:14 PM, SRNA #17 on [DATE] at 10:54 AM, SRNA #11 on [DATE] at 3:33 PM, [ENTITY] #1 on [DATE] at 3:14 PM, SRNA #12 on [DATE] at 6:32 PM, and RN #3 on [DATE] at 6:53 PM revealed they provided care for Resident #1 on [DATE], [DATE], and/or [DATE] and denied that the resident sustained [REDACTED]. SRNA #6, SRNA #9, SRNA #14, and Restorative Aide #1 stated they assisted with transferring Resident #1 via a mechanical lift to/from bed or to/from a shower bed on [DATE], but denied that any injury occurred during the transfers. Continued interview with SRNA #12 on [DATE] at 6:32 PM revealed she was assigned to care for Resident #1 on the night shift of [DATE]. She stated there was no change in Resident #1's condition and the resident was counting numbers as usual. Further interview with SRNA #12 revealed she was aware that Resident #1 required total assistance of two (2) staff persons for care; however, that night she provided care to the resident by herself because other staff members were busy. Further interview with SRNA #12 revealed she had provided care to Resident #1 unassisted on more than one (1) occasion and nothing had ever happened to the resident. She stated if anything occurred when she was caring for Resident #1 she would have reported it to the nurse. Continued interview with SRNA #12 revealed nothing occurred when she provided care to Resident #1 on her shift that would have caused injuries to the resident. Interview with SRNA #23 on [DATE] at 2:06 PM and on [DATE] at 12:39 PM revealed during the night of ,[DATE]-,[DATE], she did not assist SRNA #12 with Resident #1's care and SRNA #12 did not ask for assistance. Interview with RN #3 on [DATE] at 6:53 PM revealed she was also assigned to care for Resident #1 on the night shift of [DATE]. She stated the resident did not act any different than usual. She stated the last time she saw Resident

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) was protected from abuse. On 12/03/19, Resident #17 did not want staff to remove his/her dentures. State Registered Nurse Aide (SRNA) #29 told the resident, If I have to do it you know your (you're) not going to like it. Then, when the resident turned his/her head and stated, Don't do that, SRNA #29 put her fingers in the resident's mouth and attempted to jerk the resident's dentures from his/her mouth. Another staff member intervened and SRNA #29 left the room. Resident #17 cried and stated that his/her mouth hurt as a result of the incident. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/17, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The facility defined abuse as the willful infliction of injury .with resulting physical harm or pain or mental anguish .It includes verbal, sexual, physical & mental abuse . Further review of the facility's policy revealed the facility defined mental abuse as but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Review of a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that SRNA #29 told Resident #17 that she was going to remove the resident's dentures. When the resident refused and turned his/her head, SRNA #29 put her fingers in the resident's mouth and jerked the resident's top dentures halfway out of the resident's mouth. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on 12/18/19 at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. According to SRNA #29, the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, when she was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Review of SRNA #42's witness statement revealed he was in Resident #17's room on 12/03/19 with SRNA #29 and SRNA #41, when SRNA #29 requested the resident to take out his/her dentures. According to SRNA #42, Resident #17 rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. According to SNRA #42, Resident #17 pulled back and said, Don't do that. SRNA #42 stated he immediately took over for SRNA #29 and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRNA. SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said that Resident #17 wanted to talk to her. Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she completed an oral assessment for Resident #17 and there were no issues noted. RN #8 stated she notified the Director of Nursing (DON) and the resident's Responsible Party (RP) of the incident. Further review of the facility's investigation revealed the Director of Nursing (DON) spoke with Resident #17 on 12/03/19 at 6:25 PM and the resident stated he/she told the girl to quit trying to get (his/her) teeth out that it hurt and the girl stopped. According to the DON's statement, she then asked the resident if the resident thought the girl meant to hurt (the resident) and the resident didn't respond to the question. When the DON asked the resident again, the resident told me to leave (him/her) alone and get out (he/she) just wanted to sleep. Interview with Resident #17's RP on 12/17/19 at 11:44 AM revealed the facility notified her that Resident #17 stated that someone was rough with him/her while taking his/her dentures out. Interview with Resident #17 on 12/17/19 at 10:25 AM revealed he/she had dentures and stated staff cleaned them. According to Resident #17, I had one girl take her finger and jerk my dentures out. I don't know why she had to jerk them out. It was a long time ago and it was only one (1) time. Nobody else has hurt me.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) was protected from abuse. On 12/03/19, Resident #17 did not want staff to remove his/her dentures. State Registered Nurse Aide (SRNA) #29 told the resident, If I have to do it you know your (you're) not going to like it. Then, when the resident turned his/her head and stated, Don't do that, SRNA #29 put her fingers in the resident's mouth and attempted to jerk the resident's dentures from his/her mouth. Another staff member intervened and SRNA #29 left the room. Resident #17 cried and stated that his/her mouth hurt as a result of the incident. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/17, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. The facility defined abuse as the willful infliction of injury .with resulting physical harm or pain or mental anguish .It includes verbal, sexual, physical & mental abuse . Further review of the facility's policy revealed the facility defined mental abuse as but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Review of a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that SRNA #29 told Resident #17 that she was going to remove the resident's dentures. When the resident refused and turned his/her head, SRNA #29 put her fingers in the resident's mouth and jerked the resident's top dentures halfway out of the resident's mouth. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on [DATE] at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. According to SRNA #29, the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, when she was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Review of SRNA #42's witness statement revealed he was in Resident #17's room on 12/03/19 with SRNA #29 and SRNA #41, when SRNA #29 requested the resident to take out his/her dentures. According to SRNA #42, Resident #17 rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. According to SNRA #42, Resident #17 pulled back and said, Don't do that. SRNA #42 stated he immediately took over for SRNA #29 and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on [DATE] at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on [DATE] at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRNA. SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Interview with Registered Nurse (RN) #8 on [DATE] at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said that Resident #17 wanted to talk to her. Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she completed an oral assessment for Resident #17 and there were no issues noted. RN #8 stated she notified the Director of Nursing (DON) and the resident's Responsible Party (RP) of the incident. Further review of the facility's investigation revealed the Director of Nursing (DON) spoke with Resident #17 on 12/03/19 at 6:25 PM and the resident stated he/she told the girl to quit trying to get (his/her) teeth out that it hurt and the girl stopped. According to the DON's statement, she then asked the resident if the resident thought the girl meant to hurt (the resident) and the resident didn't respond to the question. When the DON asked the resident again, the resident told me to leave (him/her) alone and get out (he/she) just wanted to sleep. Interview with Resident #17's RP on 1[DATE] at 11:44 AM revealed the facility notified her that Resident #17 stated that someone was rough with him/her while taking his/her dentures out. Interview with Resident #17 on 1[DATE] at 10:25 AM revealed he/she had dentures and stated staff cleaned them. According to Resident #17, I had one girl take her finger and jerk my dentures out. I don't know why she had to jerk them out. It was a long time ago and it was only one (1) time. Nobody else has hurt me.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) received the necessary care and assistance to maintain good grooming and personal hygiene. The facility failed to honor Resident #17's preference when providing oral care on 12/03/19, when the resident refused to remove his/her dentures. A State Registered Nurse Aide (SRNA) put her fingers in the resident's mouth and attempted to jerk the resident's teeth from his/her mouth. Resident #17 cried after the incident and reported that his/her mouth hurt. The findings include: Review of the facility's policy, Oral Assessment Protocol, not dated, revealed when oral care needs were identified a plan of care and treatment would be discussed with the resident and/or Responsible Party (RP). Interview with the Administrator on 12/18/19 at 10:30 AM revealed the facility did not have a policy concerning Activities of Daily Living (ADLs). Review of the medical record revealed the facility admitted Resident #17 on 01/22/19 with [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set ((MDS) dated [DATE] for Resident #17 revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be one (1) which indicated the resident was severely cognitively impaired. Further review of the MDS revealed it was very important for Resident #17 to take care of his/her own personal belongings or things. Interview with the RP on 12/17/19 at 11:44 AM revealed one night the facility called and said an aide had reported Resident #17 had complained that someone was rough with him/her while taking his/her dentures out. The RP explained to the facility staff that Resident #17 liked to sleep with his/her dentures. Interview with Resident #17 on 12/17/19 at 10:25 AM revealed he/she had dentures and stated staff cleans them. Resident #17 stated he/she had one (1) girl take her finger and jerk my dentures out. The resident stated it was a long time ago and nobody else has hurt me. Review of SRNA #42's witness statement from a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that while in Resident #17's room with SRNA #29 and SRNA #41, SRNA #29 requested the resident to take out his/her dentures. SRNA #42 stated the resident rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. He reported that Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. He reported Resident #17 pulled back and said, Don't do that. SRNA #42 reported he immediately took over and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRNA. SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth, and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on 12/18/19 at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. SRNA #29 stated that the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, and was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said Resident #17 wanted to talk to her. RN #8 revealed Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she did an oral assessment on Resident #17 and there were no issues noted. RN #8 revealed she notified the Director of Nursing (DON) and called the resident's Responsible Party (RP). RN #8 stated the RP told her that Resident #17 liked to sleep with his/her teeth.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of sixteen (16) sampled residents (Resident #17) received the necessary care and assistance to maintain good grooming and personal hygiene. The facility failed to honor Resident #17's preference when providing oral care on 12/03/19, when the resident refused to remove his/her dentures. A State Registered Nurse Aide (SRNA) put her fingers in the resident's mouth and attempted to jerk the resident's teeth from his/her mouth. Resident #17 cried after the incident and reported that his/her mouth hurt. The findings include: Review of the facility's policy, Oral Assessment Protocol, not dated, revealed when oral care needs were identified a plan of care and treatment would be discussed with the resident and/or Responsible Party (RP). Interview with the Administrator on [DATE] at 10:30 AM revealed the facility did not have a policy concerning Activities of Daily Living (ADLs). Review of the medical record revealed the facility admitted Resident #17 on 01/22/19 with [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set ((MDS) dated [DATE] for Resident #17 revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be one (1) which indicated the resident was severely cognitively impaired. Further review of the MDS revealed it was very important for Resident #17 to take care of his/her own personal belongings or things. Interview with the RP on 1[DATE] at 11:44 AM revealed one night the facility called and said an aide had reported Resident #17 had complained that someone was rough with him/her while taking his/her dentures out. The RP explained to the facility staff that Resident #17 liked to sleep with his/her dentures. Interview with Resident #17 on 1[DATE] at 10:25 AM revealed he/she had dentures and stated staff cleans them. Resident #17 stated he/she had one (1) girl take her finger and jerk my dentures out. The resident stated it was a long time ago and nobody else has hurt me. Review of SRNA #42's witness statement from a Resident Abuse Investigation Report Form dated 12/03/19 revealed SRNA #42 reported that while in Resident #17's room with SRNA #29 and SRNA #41, SRNA #29 requested the resident to take out his/her dentures. SRNA #42 stated the resident rolled his/her eyes and turned his/her head away when SRNA #29 asked for his/her dentures. He reported that SRNA #29 stated to the resident, If I have to do it you know your (you're) not going to like it. He reported that Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. He reported Resident #17 pulled back and said, Don't do that. SRNA #42 reported he immediately took over and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Interview with SRNA #42 on [DATE] at 10:45 AM confirmed he was in Resident #17's room with SRNA #29 and SRNA #41 on 12/03/19. He stated after they assisted the resident with incontinence care, SRNA #29 asked for the resident's dentures. He stated Resident #17 rolled his/her eyes and turned his/her head. SRNA #29 then stated to the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 revealed Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away from SRNA #29. SRNA #42 revealed he intervened and asked the resident if he could have his/her dentures, and the resident allowed SRNA #42 to remove his/her dentures. SRNA #42 stated SRNA #29 then left the room and he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Review of SRNA #41's witness statement dated 12/03/19 revealed she was in Resident #17's room with SRNA #42 and SRNA #29 when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. She reported Resident #17 told SRNA #29 not to do it, and proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Interview with SRNA #41 on [DATE] at 5:50 PM revealed she did not think SRNA #29 was trying to abuse Resident #17; however, SRNA #29 was intimidating the resident. SRNA #41 stated the resident did not want his/her dentures removed and rolled his/her eyes and turned his/her head. However, SRNA #29 stated, You know you won't like it if I have to take them out, and stuck two (2) fingers in the resident's mouth and tried to flip them out. She stated the resident did not try to bite the SRNA. SRNA #41 stated SRNA #42 then intervened and took over. According to SRNA #41, Resident #17 was upset and SRNA #42 stayed with the resident and talked to the resident to calm him/her down. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to SRNA #29, and tried to bite the SRNA's fingers. SRNA #29 admitted that she put her fingers in the resident's mouth, and told the resident that she was going to brush and soak the dentures. Interview with SRNA #29 on [DATE] at 4:10 PM revealed on 12/03/19 she was doing her last rounds and she told Resident #17 that she was going to remove his/her dentures. SRNA #29 stated that the resident tried smacking her away, and when she was trying to get them out, the resident tried to bite her finger. She stated that she explained to the resident that his/her daughter wanted his/her dentures out to have them brushed and allowed to soak. According to SRNA #29, Resident #17 told her to go ahead and take them. The SRNA stated the resident's dentures fit well and created suction that made them difficult to remove. SRNA #29 stated she left the room and went to the next room, and was told she needed to leave the facility. SRNA #29 stated looking back now she should have stopped and got a nurse when she saw that the resident was getting agitated. Interview with Registered Nurse (RN) #8 on [DATE] at 5:30 PM revealed SRNA #42 came to her on 12/03/19 and said Resident #17 wanted to talk to her. RN #8 revealed Resident #17 told her That girl got my teeth, and my mouth hurts. RN #8 revealed she did an oral assessment on Resident #17 and there were no issues noted. RN #8 revealed she notified the Director of Nursing (DON) and called the resident's Responsible Party (RP). RN #8 stated the RP told her that Resident #17 liked to sleep with his/her teeth.

Based on observation, interview, record review, and a review of facility policy, it was determined the facility failed to assess/treat pain for one (1) of ten (10) sampled residents (Resident #5). On 07/29/19, at approximately 4:15 PM, Resident #5 complained of pain to the left leg when staff were assisting the resident to bed. However, staff failed to assess/treat the resident's pain. Staff documented that the resident had pain during the night shift on 07/29-30/19; there was no documented evidence that staff assessed Resident #5 to determine the possible cause of the pain nor treated the resident's pain; and failed to notify the resident's physician of the complaints of pain on 07/29/19 in accordance with the facility's policy. Further, staff administered Tylenol to Resident #5 on 07/30/19 at approximately 8:00 AM due to pain; however, the facility failed to assess the cause of the pain or determine whether the medication was effective. Interviews with staff revealed the resident continued to have pain on 07/30/19 and was diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled, Pain Protocol, (not dated) revealed staff would assess each resident's pain level during routine medication or care delivery every shift utilizing a numeric or geriatric pain scale. Further review revealed the assessment would be recorded daily (even though it should be assessed every shift) on the resident's Medication Administration Record [REDACTED]. According to the policy, Communication to the physician, when pain is not controlled, will occur to collaborate for the resident to find the best way to change treatments and plan of care. Review of Resident #5's medical record revealed the facility admitted the resident on 06/09/10 with [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), which indicated Resident #5 was interviewable. Review of Resident #5's physician orders [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #4 on 08/07/19 at 7:40 PM revealed she assisted Licensed Practical Nurse (LPN) #4 and Certified Occupational Therapy Assistant (COTA) #1 with getting Resident #5 into bed on 07/29/19 at approximately 4:00 PM, after she found the resident's lower body off the bed. The SRNA stated when COTA #1 moved Resident #5's legs into bed, the resident cursed loudly and complained of pain to his/her left lower extremity. SRNA #4 stated she never witnessed the LPN assess the resident's pain even though the resident continued to complain of pain until the SRNA left the resident's room. Interview with COTA #1 on 08/06/19 at 2:10 PM revealed he assisted SRNA #4 and LPN #4 in getting Resident #5 in bed on 07/29/19. He stated, After we moved the resident, he/she complained of pain in his/her left leg. The COTA stated he never observed nursing staff assess the resident after he/she complained of pain on 07/29/19. Review of Resident #5's MAR indicated [REDACTED]. However, interview with Licensed Practical Nurse (LPN) #4 on 08/07/19 at 2:00 PM revealed she did not assess Resident #5 after he/she complained of pain to determine the source of the pain. LPN #4 stated, Looking back I should have assessed Resident #5 and should have notified someone of (his/her) complaints of pain. According to the LPN, when COTA #1 picked up the resident's legs and placed them back onto the bed, the resident stated, That hurt, don't touch me. Further review of Resident #5's MAR indicated [REDACTED]. However, there was no evidence that Resident #5 received physician-ordered Tylenol during the night shift of 07/29/19 at 7:00 PM until 07/30/19 at 7:00 AM, nor was there any documentation that the source of the resident's pain was assessed. Interview with LPN #5 on 08/11/19 at 10:00 PM revealed she did not recall caring for Resident #5 and did not recall whether the resident had pain on 07/29/19. Continued review of Resident #5's MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Interview with [ENTITY] #1 on 08/07/19 at 3:40 PM revealed at approximately 8:00 AM on 07/30/19, Resident #5 stated I need some Tylenol; that big old boy picked my legs up and threw them in the bed and it's hurt me ever since. [ENTITY] #1 stated she administered [MEDICATION NAME] 500 mg for the resident's complaints of pain. However, there was no documented evidence that staff assessed the resident's pain to determine the cause, or reassessed the resident to determine whether the Tylenol was effective. Interview with SRNA #2 on 08/07/19 at 3:00 PM revealed he cared for Resident #5 during the 7:00 AM to 7:00 PM shift on 07/30/19. The SRNA stated he and another SRNA transferred Resident #5 via a mechanical lift on 07/30/19 (unable to recall time) to the shower room. SRNA #2 stated the resident constantly complained of pain that day. He stated the resident's complaints of pain were reported to a nurse (unable to recall whom) and the nurse informed the SRNA that she was aware of the resident's pain. SRNA #2 also stated, No one told us there were tests ordered for Resident #5, or that they should not get the resident out of bed until the nurse sent the resident to the hospital. Review of Resident #5's Physical Therapy Notes dated 07/30/19, revealed the resident was transported to the Therapy Department on 07/30/19 (time not included in documentation). According to the documentation, the resident complained to the therapist of pain in the knee and thigh area to the LLE (left lower extremity), which the resident rated 8 on a 0-10 pain scale. Therapy documentation also revealed therapy staff reported Resident #5's pain to a charge nurse who is aware of the resident's pain and stated x-rays are scheduled for today. Interview with LPN #2 on 08/08/19 at 12:25 PM revealed she cared for Resident #5 during the 7:00 AM to 7:00 PM shift on 07/30/19. The LPN stated she was aware that Resident #5 complained of pain on 07/30/19 and also stated that after she got the x-ray results and was going to transfer the resident to the hospital, they had (the resident) in the shower room and I could hear (the resident) yelling out in pain. However, there was no documented evidence that the LPN administered medication to treat the resident's pain. Review of Resident #5's Nurse's Notes dated 07/30/19 at 4:50 PM, revealed the resident left the facility for further evaluation and treatment at a local hospital. Review of an incident report dated 07/30/19 revealed at 9:40 AM on 07/30/19, Resident #5 was attempting to climb out of bed and stated I'm going to get R-Tech bus to go to the hospital to get an x-ray of my knee due to complaints of left knee pain. Further review of the incident report revealed the resident's physician was notified of the change in condition on 07/30/19 and an x-ray was ordered related to the resident's complaints of pain. Review of Resident #5's hospital record dated 07/30/19 revealed the resident was triaged at a local hospital at 5:07 PM due to complaints of left knee pain. Resident #5 reported a constant aching pain and stated that nothing lessened his/her discomfort. Review of an Emergency Department Note revealed Resident #5 reported that an incident had occurred at the facility the day before, and he/she has been having pain ever since. According to the hospital record, Resident #5 was admitted on [DATE] at 9:15 PM with a [DIAGNOSES REDACTED]. During interview with Resident #5 on 08/07/19 at 2:30 PM, the resident stated, The bearded boy in Therapy hit me in the leg and broke it last week. The resident stated, My leg killed me all night and all day until they got me over to the hospital, after he knocked me on my ass. Resident #5 also stated, I told them I hurt and they still took me all over this place, with me telling them I was hurting. Interview with Resident #5's Power of Attorney (POA) on 08/09/19 at 12:35 PM revealed the facility called him on 07/30/19 to notify him that the resident was complaining of pain to his/her left leg and was being transferred to the hospital. The POA stated he met Resident #5 at the hospital and when he arrived, Resident #5 was hurting bad and told him that his/her leg had killed (the resident) all night and all day. Interview with the Director of Nursing (DON) on 08/21/19 at 4:45 PM revealed staff should have assessed Resident #5 when he/she complained of pain and provided medication for pain, if needed, on 07/29/19. The DON also stated she was not aware that Resident #5 had been transported to Therapy or that the resident had ongoing complaints of pain on 07/30/19. The DON stated staff should not have moved the resident while he/she continued to complain of pain, or while diagnostic tests results were still pending.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to notify the physician when one (1) of three (3) sampled residents (Resident #1) refused care and a physician's order was not followed. Interviews with staff revealed they were unable to remove an ACE wrap/splint to Resident #1's left leg and assess the resident's skin because the resident had pain and refused care. Staff also stated that even when the ACE wrap/splint was removed, they were unable to assess behind the resident's knee because the resident had contractures (unable to extend the leg). However, the facility failed to notify the resident's physician that skin assessments could not be conducted. On 10/26/18, Resident #1 was transferred to the hospital where a Stage IV pressure ulcer was discovered to the left popliteal area (area of the leg behind the left knee). The resident was admitted to the hospital to be treated with intravenous (IV) antibiotics and wound treatments for the infected pressure ulcer. The facility's failure to ensure the physician was notified when orders were unable to be followed has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/01/18, and determined to exist on 09/26/18 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F686). The facility was notified of the Immediate Jeopardy on 11/01/18. An acceptable Allegation of Compliance was received on 11/07/18, which alleged removal of the Immediate Jeopardy on 11/06/18. The State Survey Agency determined the Immediate Jeopardy was removed on 11/06/18, prior to exit on 11/08/18, 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 (F657), and 42 CFR 483.25 Quality of Care (F686), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Change in a Resident's Condition policy, dated 08/01/13, revealed the nurse supervisor/charge nurse would notify the resident's attending physician or on-call physician when the resident refused a treatment or medication for two (2) or more consecutive times. Review of the medical record revealed the facility admitted Resident #1 on 12/06/10, and the resident had [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderate cognitive impairment. The MDS further revealed Resident #1 had limited range of motion in both lower extremities and was dependent on two (2) or more staff members for activities of daily living. According to the MDS assessment, Resident #1 did not have any pressure ulcers. Review of Resident #1's Hospital Emergency Department (ED) Discharge Record dated 09/23/18 revealed the resident was diagnosed with [REDACTED]. The resident was transferred back to the facility with an ACE (elastic bandage) wrap to the left knee/distal femur area, and to follow up with another physician in three (3) to five (5) days. Review of an Orthopedic Physician's Note dated 09/26/18 revealed Resident #1 was nonambulatory and had severe contractures. Further review revealed a splint was placed on the left leg. There were no orders for treatment to the left leg until 10/05/18, when Resident #1's Attending Physician gave an order to wrap left leg with ace bandage daily as resident tolerates. Monitor skin when ace bandage is on every shift for left femur fx (fracture). Interview on 10/31/18 at 10:45 AM with Registered Nurse (RN) #2, who was the Unit Manager, revealed she obtained the physician's order on 10/05/18, for treatment to the resident's left leg. RN #2 stated the order was obtained to ensure staff monitored the resident's skin due to the risk of skin breakdown related to the usage of a splint and ace bandage. However, interviews with Licensed Practical Nurse (LPN) #1 on 10/30/18 at 12:45 PM, LPN #2 on 10/30/18 at 1:30 PM, and LPN #4 on 10/30/18 at 1:45 PM revealed they did not remove the ACE wrap and assess Resident #1's skin because the resident had pain/contractures to the leg and often refused to allow staff to touch his/her leg. LPN #1 and LPN #3 stated the purpose of assessing the resident's skin was to ensure the resident did not have pressure ulcers or problems with circulation from the splint. Further interview with the LPNs revealed they did not notify the resident's physician that the resident refused care and that they were unable to provide care as ordered. Interview with Registered Nurse (RN) #1 on 10/30/18 at 5:30 PM, revealed she had not been able to remove the ACE wrap from Resident #1's left leg to assess the resident's skin since the weekend of 10/13/18 and 10/14/18. She stated when she was unable to unwrap the resident's leg or visualize the skin under the splint/ACE wrap, she would place her fingers under the ACE wrap to feel for moisture/drainage or open areas. RN #1 further stated she was only able to see behind the resident's left knee at times. RN #1 stated she did not report the inability to complete the skin assessments of the left leg as ordered to her supervisor or to the resident's physician. Interview with State Registered Nurse Aide (SRNA) #1 on 10/30/18 at 4:00 PM, and SRNA #2 on 10/30/18 at 4:05 PM revealed they provided care to Resident #1 frequently and had never helped/assisted with removing/applying the splint or ACE wrap to the resident's leg. SRNA #2 further stated she had not observed anyone remove the bandage from the resident's leg. Review of Resident #1's Progress Notes dated 10/05/18 through 10/26/18 revealed no documentation that Resident #1 refused to allow staff to remove the ACE wrap/splint. In addition, there was no documentation that staff were unable to complete skin assessments of the resident's left leg as ordered, or that the physician was notified that they could not be conducted. Review of a Progress Note dated 10/26/18 revealed Resident #1 was transferred to the hospital due to vomiting blood. Review of the Hospital Emergency Department (ED) record dated 10/26/18 revealed upon assessment at the ED, staff removed the ACE wrap/splint to the resident's leg and found an infected decubitus (pressure ulcer) to the posterior popliteal area of the left knee (the sunken area behind the knee). Further review revealed the resident was admitted for further evaluation of the infected pressure ulcer and acute [MEDICAL CONDITION]. Observation of Resident #1 on 10/31/18 at 8:15 AM revealed the resident remained at the hospital and did not respond to questions. Further review of the resident's hospital record revealed the resident was being treated with Intravenous antibiotics and treatment to the pressure ulcer. According to a surgical note, the need for possible surgery to debride the ulcer (removal of the dead/infected tissue) would be re-evaluated after chemical treatment to the pressure ulcer. Interview with the Director of Nursing (DON) on 10/31/18 at 11:00 AM revealed the goal of the order to unwrap the ACE bandage to Resident #1's leg was to assess the skin. The DON stated staff should have notified her and the resident's physician that they were unable to conduct skin assessments. Interview with the Administrator on 10/31/18 at 1:25 PM, revealed when she became aware a wound had been discovered on Resident #1's leg in the ED, an investigation was initiated. She stated she determined that staff were feeling under the ACE wrap for a wound/drainage, but were not able to see the area behind the left knee. She stated staff should have notified the resident's physician of the inability to perform the skin assessments. Interview with the Advanced Practice Registered Nurse (APRN) on 11/01/18 at 2:30 PM, revealed she signed the 10/05/18 order to assess Resident #1's skin every shift. She stated the intent of the order was to ensure comfort and the skin assessments were ordered to monitor for any skin breakdown, irritation, or sores. The APRN stated she would have expected facility staff to notify either her or the primary physician if the resident refused treatment or if staff were unable to perform treatment. However, the APRN stated they were not notified of any concerns with providing the treatment to Resident #1 as ordered. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 11/06/18: 1. Resident #1 no longer resides in the facility. 2. On 10/26/18 and 10/27/18 all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed by the Social Services Director concerning the care they received in the facility, if their call lights were being answered timely, if nurses were monitoring the condition of their skin, and if they had any other concerns they wished to discuss. There were no concerns voiced by the residents. 3. A head-to-toe assessment was completed on all residents as of 11/01/18, with particular attention to residents with fractures, contractures, and orthotic devices. The assessments were conducted by the Unit Coordinator, Minimum Data Set (MDS) Coordinator, Charge Nurses, or Clinical Care Coordinator. Any skin concerns were reported to the physician and addressed by the Interdisciplinary Team (IDT). 4. The care plans for all residents with contractures or fractures, or who require an orthotic device were reviewed and revised as necessary by the MDS Coordinators on 10/28/18. 5. The MDS Coordinator will update care plans daily during the morning meeting when reviewing the 24-hour report, acute monitoring log, and physician orders. 6. The Director of Nursing (DON) provided education related to performing skin assessments and conducting Braden Scale assessments to all licensed staff beginning on 10/27/18 and continuing through 11/01/18 until all staff had received the education. The licensed staff were required to complete a post test at the conclusion of the education. In addition, a wound care company, independent of the facility, provided additional education on pressure ulcer prevention for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) on 11/05/18. 7. The Unit Coordinator will bring the Twenty-four (24) Hour Report, Acute Monitoring Log, and Physician Orders to the morning meetings to ensure that any changes in a resident's condition or a resident's consistent refusal of care have been reported to the family and physician. The morning meetings will be conducted seven (7) days a week, until substantial compliance is achieved. 8. The DON reviewed family and physician notification requirements with licensed staff on 11/02/18 and 11/05/18. 9. The Corporate Nurse Consultant re-educated the DON, MDS Staff, Unit Coordinators, and Clinical Coordinators on developing person-centered care plans. The education was initiated on 10/31/18 and completed on 11/03/18. 10. Therapy representatives educated all nursing staff on positioning, contracture management, and management of orthotic devices on 11/02/18 and 11/05/18. 11. All nursing assistants were trained by the Nurse Aide Coordinator and Clinical Care Coordinator on contracture management and examination of skin during routine care beginning on 10/27/18 and continuing through 11/05/18, until all staff had received the education. 12. The DON or a designated RN will conduct Quality Assurance (QA) audits daily utilizing the Complicated Skin Risks, Contractures, Fractures and Devices audit tool on all residents who have a contracture, fracture, or an orthotic device. The audits will address the following, and continue until substantial compliance is achieved: A) Ensure all risk factors for skin breakdown have been identified. B) Ensure nursing documentation of skin assessments is being performed daily when a device is in place. C) Ensure observations of any devices or skin breakdown match the nursing documentation. D) Identify any barriers which could impact the ability to provide care to the resident. If barriers are identified has the physician has been notified. E) Ensuring the resident's care plan reflects the interventions for the device that is in place. 13. The Quality Assurance Performance Improvement (QAPI) Committee began meeting weekly on 10/29/18. The Immediate Jeopardy citation, the audits being conducted, education provided to staff, and post test results were discussed. Weekly QAPI meetings will continue for four (4) weeks and then monthly for six (6) months. Results of the audits and any follow-up required will be presented to the QA Committee by the DON. The QA Committee consists of the Medical Director, Administrator, DON, Social Services Director, Activities Director, Minimum Data Set (MDS) Coordinator, Dietary Director, and the Unit Coordinators. ****The State Survey Agency determined Immediate Jeopardy was removed on 11/06/18 based on the following: 1. Review of Resident #1's closed medical record revealed the resident was discharged from the facility on 10/26/18. 2. Review of facility documentation and interview with the Social Services Director (SSD) on 11/08/18 at 10:15 AM revealed interviews with residents with a BIMS score above eight (8) were conducted on 10/27/18. The questions were related to care, complaints, and assessment of skin/pain. Review of the documented interviews revealed the SSD interviewed fifty-nine (59) residents and received no concerns or complaints regarding resident care. 3. Review of documentation and interviews conducted on 11/08/18 at 2:10 PM with the DON, at 12:58 PM with RN #4 and Unit Manager (UM) #1, at 9:55 AM with MDS Coordinator #1, and at 9:15 AM with RN #2 revealed all residents received a head-to-toe skin assessment between 10/27/18 and 11/01/18. The skin assessment focused on contractures, pressure areas, and any orthotic device in use. The DON stated no new pressure areas were identified. 4. Review of documentation and interview with MDS Coordinator #1 on 11/08/18 at 9:55 AM revealed the care plans of residents with contractures or fractures, or who require an orthotic device were reviewed and revised as necessary on 10/27/18 and 10/28/18. 5. Review of documentation and interview with MDS Coordinator #1 on 11/08/18 at 9:55 AM, revealed she attended the morning meetings every day and care plans were also updated in the meetings as necessary. 6. Review of documentation and interview with the DON on 11/08/18 at 2:10 PM, revealed that education on skin assessments and ensuring the physician was aware of any skin changes was provided to licensed nurses on 10/27/18 - 11/01/18. Licensed nurses completed a post test after the training which they had to pass before returning to work. According to the DON, all staff passed the post test. Copies of the post tests were reviewed with no concerns identified. Further review of documentation revealed a wound care company provided training on pressure ulcer prevention. Interviews on 11/08/18 with the DON at 2:10 PM, UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, and LPN #4 at 3:10 PM, revealed the above trainings were provided. 7. Review of documentation and interview with the Administrator on 11/08/18 at 3:28 PM revealed the facility held morning meetings seven (7) days per week. The Administrator stated Twenty-Four (24) Hour Reports, the Acute Monitoring Book, and Physician's Orders were reviewed during the meetings. The Administrator stated they also check to ensure physician notification has been completed as necessary. Interviews on 11/08/18 with the DON at 2:10 PM, RN #5 at 12:43 PM, the SSD at 10:15 AM, and RN #2 at 9:15 AM revealed they all had attended the morning meetings daily where they reviewed the Twenty-Four (24) Hour Reports, the Acute Monitoring Book, Physician's Orders, and Physician Notifications. 8. Review of documentation and interview with the DON on 11/08/18 at 2:10 PM revealed that education on physician notification was provided to licensed nurses on 10/27/18 - 11/01/18. Interviews on 11/08/18 with UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, and LPN #4 at 3:10 PM revealed training on physician notification was provided. 9. Review of documentation revealed education was provided by the Corporate Nurse Consultant on the care plan process on 10/31/18 - 11/03/18. Interviews on 11/08/18 with the MDS Coordinator at 9:55 AM, RN #5 at 12:43 PM, the DON at 2:10 PM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, and RN #2 at 9:15 AM revealed they received training on the care plan process. 10. Review of documentation revealed the Therapy Department provided education to all nursing staff on contractures, positioning, and management of orthotic devices. 11. Review of documentation revealed all nursing assistants were trained by the Nurse Aide Coordinator and Clinical Care Coordinator on contracture management and examination of skin during routine care. These trainings were completed by 11/05/18. Interviews on 11/08/18 with the DON at 2:10 PM, UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, SRNA #7 at 1:14 PM, SRNA #3 at 2:00 PM, SRNA #2 at 12:45 PM, SRNA #6 at 1:25 PM, LPN #4 at 3:10 PM, SRNA #5 at 2:55 PM, and SRNA #4 at 3:00 PM revealed the above training was provided. The staff interviewed were able to describe what trainings were provided and what skin conditions or refusal of care needed to be reported to the charge nurse. 12. Interview with the DON on 11/08/18 at 2:10 PM and review of the QA Audit Complicated Skin Risks, Contractures, Fracture and Devices revealed the DON completed audits on all residents with contractures, fractures, or orthotic devices. The DON stated she reviewed the areas on the audit form for each resident which included: A) That all risk factors for skin breakdown had been identified. B) The nursing staff had documented checking skin under any orthotic device daily. C) Nursing audits matched observations. D) Identification of any barriers that could impact care or skin assessments, and notification of physician if any barriers were identified. E) Ensuring the care plan had the appropriate intervention for the particular device in place. Further interview with the DON, MDS Coordinator #1, RN #5, and RN #2 revealed the 24-hour Report, Acute Monitoring Log, and physician orders were reviewed in the Morning Meetings held daily. They all stated the care plans were updated in the meeting if needed. 13. Interview with the DON on 11/08/18 at 2:10 PM, revealed a QAPI meeting was held on 10/29/18. The DON stated the Immediate Jeopardy citation, all audits being conducted, education performed, and post tests completed were reviewed. The DON stated the QAPI meetings will continue for four (4) weeks and then monthly for six (6) months. Interview with the Medical Director on 11/08/18 at 3:25 PM revealed he attended the weekly QA meetings and had provided education on pressure sores to facility staff.

Based on observation, interviews, record review, and review of the facility's policy, it was determined the facility failed to revise the comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 sustained a distal femur (the knee area of the upper leg bone) [MEDICAL CONDITION] leg on 09/23/18. An ACE (elastic bandage) bandage was applied to the resident's leg. On 09/26/18, an orthopedic surgeon placed a splint on the resident's leg and wrapped the leg with an ACE bandage. Further, on 10/05/18, the resident's Attending Physician wrote an order to remove the ACE wrap daily, as tolerated by the resident, and to inspect the resident's skin every shift. However, the facility failed to revise the resident's care plan when the resident sustained [REDACTED]. Subsequently, the facility failed to assess the resident's skin. On 10/26/18, during an Emergency Department (ED) visit for vomiting blood, ED staff found an infected Stage IV pressure ulcer to the area behind the resident's left knee. The resident was admitted to the hospital for intravenous (IV) antibiotics and wound treatments to the infected pressure ulcer. The facility's failure to ensure care plans were revised with interventions to prevent pressure ulcers has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/01/18, and determined to exist on 09/26/18 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F686). The facility was notified of the Immediate Jeopardy on 11/01/18. An acceptable Allegation of Compliance was received on 11/07/18, which alleged removal of the Immediate Jeopardy on 11/06/18. The State Survey Agency determined the Immediate Jeopardy was removed on 11/06/18, prior to exit on 11/08/18, 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 (F657), and 42 CFR 483.25 Quality of Care (F686), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Care Plan policy, dated 08/01/13, revealed assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. The policy also revealed the resident's care plan was designed to reflect currently recognized standards of practice for problem areas and conditions. Observation of Resident #1 at an acute care hospital on [DATE] at 8:15 AM, revealed the resident was lying in bed and did not open his/her eyes or respond to questions. Review of Resident #1's medical record revealed the facility admitted the resident on 12/06/10 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident had moderate cognitive impairment. The MDS also revealed the resident was totally dependent on two (2) or more staff members to complete activities of daily living and had limited range of motion in the lower extremities and one upper extremity. Further review of the assessment revealed the resident was at risk for developing pressure ulcers, but did not have any pressure ulcers when the assessment was conducted. Review of the care plan for Resident #1 dated 08/14/18 revealed the facility developed a care plan to address the resident's risk for skin breakdown, with interventions that included conducting weekly skin assessments and reporting any red or open areas. Review of a Hospital Emergency Department Discharge Record, dated 09/23/18, revealed Resident #1 sustained a non-displaced [MEDICAL CONDITION] left femur. Further review revealed Resident #1 was transported back to the facility with an ACE wrap to the left knee/distal femur area. However, there was no documented evidence that the facility revised the resident's care plan with interventions that directed staff how to care for the resident's left leg. Review of an Orthopedic Physician's Note dated 09/26/18 revealed the resident was seen due to a left leg femur fracture that the resident sustained [REDACTED].#1 to wear a splint. Again, there was no documented evidence that the facility revised the resident's care plan with interventions that directed staff how to care for the resident's left leg after the splint was applied. Review of the physician's orders [REDACTED]. Further review of Resident #1's care plan revealed no documented evidence that the facility revised the care plan with an intervention to monitor the resident's skin every shift as ordered by the resident's physician, and no documented evidence that the facility identified the potential for skin impairment (pressure ulcers) related to usage of a splint/ACE wrap. Review of Resident #1's acute care hospital record revealed the resident was transferred to the hospital on [DATE], because the resident was vomiting blood. Upon assessment in the Emergency Department, an infected pressure ulcer was found to the popliteal area of the left leg (sunken area of the leg behind the left knee). Review of the assessment of the pressure ulcer revealed it was a Stage IV (extends into muscle and other structures, e.g. tendon, fascia, and bone) pressure ulcer that measured 6.4 centimeters (cm) in length (head to toe), 2 cm wide, and 0.3 cm deep. The wound also had tunneling (channels extending from the wound beneath the skin) at 8 o'clock that measured 4.2 cm deep and at 9 o'clock that measured 2.4 cm deep. The pressure ulcer also contained necrotic (dead, black) tissue. Further review revealed Resident #1 was admitted to the hospital for further evaluation and treatment of [REDACTED]. According to the hospital record, Resident #1 remained at the hospital and continued to receive dressings to the pressure ulcer and IV antibiotics. Interviews with Licensed Practical Nurse (LPN) #1 on 10/30/18 at 12:45 PM, LPN #2 on 10/30/18 at 1:30 PM, and LPN #4 on 10/30/18 at 1:45 PM revealed they did not remove the ACE wrap/splint and assess Resident #1's left leg prior to the resident being transferred to the hospital on [DATE]. In addition, interview with Registered Nurse (RN) #1 on 10/30/18 at 5:30 PM revealed she had not been able to remove the ACE wrap from Resident #1's left leg to assess the resident's skin since the weekend of 10/13/18 and 10/14/18, due to pain in the resident's leg. Interviews with State Registered Nurse Aide (SRNA) #1 on 10/30/18 at 4:00 PM, and SRNA #2 on 10/30/18 at 4:05 PM revealed they had never helped/assisted with removing/applying the splint or ACE wrap to the resident's leg. SRNA #2 further stated she had not observed anyone remove the bandage from the resident's leg. Interview with MDS Coordinators #1 and #2 on 10/31/18 at 9:40 AM revealed Resident #1's care plan should have been revised on 09/23/18, with interventions regarding assessing the resident's leg, when the resident sustained [REDACTED].#1 or #2 could state why the 10/05/18 physician's orders [REDACTED]. Interview with the Administrator on 10/31/18 at 1:25 PM, revealed the facility should have developed a care plan for Resident #1 that addressed the resident's [DIAGNOSES REDACTED]. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 11/06/18: 1. Resident #1 no longer resides in the facility. 2. On 10/26/18 and 10/27/18 all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed by the Social Services Director concerning the care they received in the facility, if their call lights were being answered timely, if nurses were monitoring the condition of their skin, and if they had any other concerns they wished to discuss. There were no concerns voiced by the residents. 3. A head-to-toe assessment was completed on all residents as of 11/01/18, with particular attention to residents with fractures, contractures, and orthotic devices. The assessments were conducted by the Unit Coordinator, Minimum Data Set (MDS) Coordinator, Charge Nurses, or Clinical Care Coordinator. Any skin concerns were reported to the physician and addressed by the Interdisciplinary Team (IDT). 4. The care plans for all residents with contractures or fractures, or who require an orthotic device were reviewed and revised as necessary by the MDS Coordinators on 10/28/18. 5. The MDS Coordinator will update care plans daily during the morning meeting when reviewing the 24-hour report, acute monitoring log, and physician orders. 6. The Director of Nursing (DON) provided education related to performing skin assessments and conducting Braden Scale assessments to all licensed staff beginning on 10/27/18 and continuing through 11/01/18 until all staff had received the education. The licensed staff were required to complete a post test at the conclusion of the education. In addition, a wound care company, independent of the facility, provided additional education on pressure ulcer prevention for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) on 11/05/18. 7. The Unit Coordinator will bring the Twenty-four (24) Hour Report, Acute Monitoring Log, and Physician order [REDACTED]. refusal of care have been reported to the family and physician. The morning meetings will be conducted seven (7) days a week, until substantial compliance is achieved. 8. The DON reviewed family and physician notification requirements with licensed staff on 11/02/18 and 11/05/18. 9. The Corporate Nurse Consultant re-educated the DON, MDS Staff, Unit Coordinators, and Clinical Coordinators on developing person-centered care plans. The education was initiated on 10/31/18 and completed on 11/03/18. 10. Therapy representatives educated all nursing staff on positioning, contracture management, and management of orthotic devices on 11/02/18 and 11/05/18. 11. All nursing assistants were trained by the Nurse Aide Coordinator and Clinical Care Coordinator on contracture management and examination of skin during routine care beginning on 10/27/18 and continuing through 11/05/18, until all staff had received the education. 12. The DON or a designated RN will conduct Quality Assurance (QA) audits daily utilizing the Complicated Skin Risks, Contractures, Fractures and Devices audit tool on all residents who have a contracture, fracture, or an orthotic device. The audits will address the following, and continue until substantial compliance is achieved: A) Ensure all risk factors for skin breakdown have been identified. B) Ensure nursing documentation of skin assessments is being performed daily when a device is in place. C) Ensure observations of any devices or skin breakdown match the nursing documentation. D) Identify any barriers which could impact the ability to provide care to the resident. If barriers are identified has the physician has been notified. E) Ensuring the resident's care plan reflects the interventions for the device that is in place. 13. The Quality Assurance Performance Improvement (QAPI) Committee began meeting weekly on 10/29/18. The Immediate Jeopardy citation, the audits being conducted, education provided to staff, and post test results were discussed. Weekly QAPI meetings will continue for four (4) weeks and then monthly for six (6) months. Results of the audits and any follow-up required will be presented to the QA Committee by the DON. The QA Committee consists of the Medical Director, Administrator, DON, Social Services Director, Activities Director, Minimum Data Set (MDS) Coordinator, Dietary Director, and the Unit Coordinators. ****The State Survey Agency determined Immediate Jeopardy was removed on 11/06/18 based on the following: 1. Review of Resident #1's closed medical record revealed the resident was discharged from the facility on 10/26/18. 2. Review of facility documentation and interview with the Social Services Director (SSD) on 11/08/18 at 10:15 AM revealed interviews with residents with a BIMS score above eight (8) were conducted on 10/27/18. The questions were related to care, complaints, and assessment of skin/pain. Review of the documented interviews revealed the SSD interviewed fifty-nine (59) residents and received no concerns or complaints regarding resident care. 3. Review of documentation and interviews conducted on 11/08/18 at 2:10 PM with the DON, at 12:58 PM with RN #4 and Unit Manager (UM) #1, at 9:55 AM with MDS Coordinator #1, and at 9:15 AM with RN #2 revealed all residents received a head-to-toe skin assessment between 10/27/18 and 11/01/18. The skin assessment focused on contractures, pressure areas, and any orthotic device in use. The DON stated no new pressure areas were identified. 4. Review of documentation and interview with MDS Coordinator #1 on 11/08/18 at 9:55 AM revealed the care plans of residents with contractures or fractures, or who require an orthotic device were reviewed and revised as necessary on 10/27/18 and 10/28/18. 5. Review of documentation and interview with MDS Coordinator #1 on 11/08/18 at 9:55 AM, revealed she attended the morning meetings every day and care plans were also updated in the meetings as necessary. 6. Review of documentation and interview with the DON on 11/08/18 at 2:10 PM, revealed that education on skin assessments and ensuring the physician was aware of any skin changes was provided to licensed nurses on 10/27/18 - 11/01/18. Licensed nurses completed a post test after the training which they had to pass before returning to work. According to the DON, all staff passed the post test. Copies of the post tests were reviewed with no concerns identified. Further review of documentation revealed a wound care company provided training on pressure ulcer prevention. Interviews on 11/08/18 with the DON at 2:10 PM, UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, and LPN #4 at 3:10 PM, revealed the above trainings were provided. 7. Review of documentation and interview with the Administrator on 11/08/18 at 3:28 PM revealed the facility held morning meetings seven (7) days per week. The Administrator stated Twenty-Four (24) Hour Reports, the Acute Monitoring Book, and physician's orders [REDACTED]. The Administrator stated they also check to ensure physician notification has been completed as necessary. Interviews on 11/08/18 with the DON at 2:10 PM, RN #5 at 12:43 PM, the SSD at 10:15 AM, and RN #2 at 9:15 AM revealed they all had attended the morning meetings daily where they reviewed the Twenty-Four (24) Hour Reports, the Acute Monitoring Book, physician's orders [REDACTED]. 8. Review of documentation and interview with the DON on 11/08/18 at 2:10 PM revealed that education on physician notification was provided to licensed nurses on 10/27/18 - 11/01/18. Interviews on 11/08/18 with UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, and LPN #4 at 3:10 PM revealed training on physician notification was provided. 9. Review of documentation revealed education was provided by the Corporate Nurse Consultant on the care plan process on 10/31/18 - 11/03/18. Interviews on 11/08/18 with the MDS Coordinator at 9:55 AM, RN #5 at 12:43 PM, the DON at 2:10 PM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, and RN #2 at 9:15 AM revealed they received training on the care plan process. 10. Review of documentation revealed the Therapy Department provided education to all nursing staff on contractures, positioning, and management of orthotic devices. 11. Review of documentation revealed all nursing assistants were trained by the Nurse Aide Coordinator and Clinical Care Coordinator on contracture management and examination of skin during routine care. These trainings were completed by 11/05/18. Interviews on 11/08/18 with the DON at 2:10 PM, UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, SRNA #7 at 1:14 PM, SRNA #3 at 2:00 PM, SRNA #2 at 12:45 PM, SRNA #6 at 1:25 PM, LPN #4 at 3:10 PM, SRNA #5 at 2:55 PM, and SRNA #4 at 3:00 PM revealed the above training was provided. The staff interviewed were able to describe what trainings were provided and what skin conditions or refusal of care needed to be reported to the charge nurse. 12. Interview with the DON on 11/08/18 at 2:10 PM and review of the QA Audit Complicated Skin Risks, Contractures, Fracture and Devices revealed the DON completed audits on all residents with contractures, fractures, or orthotic devices. The DON stated she reviewed the areas on the audit form for each resident which included: A) That all risk factors for skin breakdown had been identified. B) The nursing staff had documented checking skin under any orthotic device daily. C) Nursing audits matched observations. D) Identification of any barriers that could impact care or skin assessments, and notification of physician if any barriers were identified. E) Ensuring the care plan had the appropriate intervention for the particular device in place. Further interview with the DON, MDS Coordinator #1, RN #5, and RN #2 revealed the 24-hour Report, Acute Monitoring Log, and physician orders [REDACTED]. They all stated the care plans were updated in the meeting if needed. 13. Interview with the DON on 11/08/18 at 2:10 PM, revealed a QAPI meeting was held on 10/29/18. The DON stated the Immediate Jeopardy citation, all audits being conducted, education performed, and post tests completed were reviewed. The DON stated the QAPI meetings will continue for four (4) weeks and then monthly for six (6) months. Interview with the Medical Director on 11/08/18 at 3:25 PM revealed he attended the weekly QA meetings and had provided education on pressure sores to facility staff.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide care to prevent pressure ulcers for one (1) of three (3) sampled residents (Resident #1). Resident #1 sustained a pathological fracture to the left femur on 09/23/18, and was treated with a splint and ACE (brand name for an elastic bandage) wrap to the left leg. The facility failed to assess Resident #1's skin under the splint/ACE wrap and failed to identify and treat a pressure ulcer to the area of the leg behind the left knee. The pressure ulcer was not identified until staff from an acute care hospital identified the pressure ulcer on 10/26/18, when the facility transferred the resident to the hospital due to blood in his/her emesis (vomit). The hospital assessed the pressure ulcer as a Stage IV (the ulcer extends into muscle and other structures, e.g. tendon, fascia, and bone) and the resident was admitted to the hospital for intravenous (IV) antibiotics and treatments to the infected pressure ulcer. The facility's failure to ensure residents received care to prevent pressure ulcers has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/01/18, and determined to exist on 09/26/18 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F686). The facility was notified of the Immediate Jeopardy on 11/01/18. An acceptable Allegation of Compliance was received on 11/07/18, which alleged removal of the Immediate Jeopardy on 11/06/18. The State Survey Agency determined the Immediate Jeopardy was removed on 11/06/18, prior to exit on 11/08/18, 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 (F657), and 42 CFR 483.25 Quality of Care (F686), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Protocol for Early Intervention to Prevent Skin Breakdown, undated, revealed for residents identified as at risk for skin breakdown there should be a daily inspection of all skin surfaces. Review of the medical record revealed the facility admitted Resident #1 on 12/06/10 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was moderately cognitively impaired. The MDS also revealed the resident was totally dependent on two (2) or more staff members to complete activities of daily living. Further review of the MDS revealed Resident #1 had limited range of motion in one (1) upper extremity and both lower extremities. The assessment revealed the resident was at risk to develop pressure ulcers, but did not have any pressure ulcers when the assessment was conducted. Review of the care plan for Resident #1 dated 08/14/18 revealed the resident had no skin breakdown (pressure ulcers). The facility identified the resident was at risk for pressure ulcers and developed interventions that included conducting weekly skin assessments and reporting any red or open areas to the resident's physician. Review of a Hospital Emergency Department Discharge Record, dated 09/23/18, revealed Resident #1 was transported to the Emergency Department (ED) on 09/23/18, after a popping sound was heard on 09/22/18 while the resident was being turned and repositioned. The resident complained of pain in the left knee and presented to the ED with minor swelling and discoloration to the knee. Further review revealed the resident was diagnosed with [REDACTED]. Resident #1 was transported back to the facility with an ACE wrap to the left knee/distal femur area. Instructions from the ED were to administer Tylenol/[MEDICATION NAME] for pain, fall precautions, and to follow up with a physician in three (3) to five (5) days. However, there were no instructions on how to care for the resident's leg. Review of an Orthopedic Physician's Note dated 09/26/18 revealed Resident #1 sustained a left supracondylar femur fracture (break at the knee) on 09/22/18. The Note stated the patient was nonambulatory and had severe contractures. Further review of the Note revealed a splint was applied to the resident's left leg, but no orders were given on how to care for the resident's leg while utilizing the splint. Further review of Resident #1's medical record revealed there was no physician's order regarding treatment of [REDACTED]. Monitor skin when ace bandage is on every shift for left femur fx (fracture). Review of the comprehensive care plan for Resident #1 revealed the facility revised the resident's Altered Cardiac Output care plan on 10/05/18, with an intervention to wrap the resident's left leg with an ace bandage daily as tolerated. However, the order regarding monitoring the resident's skin every shift was not added to the care plan. Further review revealed no documented evidence that the facility revised Resident #1's care plan related to the leg fracture or developed interventions to monitor the resident's skin related to the splint/ace wrap. Review of Progress Notes for Resident #1, dated 10/05/18 through 10/26/18, revealed no documentation that Resident #1 refused/did not tolerate the ACE wrap or that staff were unable to follow the physician's orders for monitoring the resident's skin every shift. Review of Resident #1's weekly skin assessments dated 09/01/18, 09/08/18, 09/14/18, 09/22/18, 10/12/18, and 10/19/18 revealed staff documented that the resident had no skin impairment/pressure ulcers. Review of the weekly skin assessment documentation for 10/12/18 revealed Registered Nurse (RN) #1 documented that the resident's left leg had a splint with an ACE wrap. Further review revealed on 10/18/18, RN #4 also documented that the splint and ACE wrap were on the resident's left leg. Continued review of Resident #1's Progress Notes dated 10/26/18 at 8:30 AM, revealed the resident had an episode of vomiting with blood clots and trace amounts of bright red blood noted in the emesis. The facility transferred the resident to the Emergency Department at 8:45 AM on 10/26/18. Review of the Hospital ED Record dated 10/26/18, revealed the resident was transferred to the ED due to hematemesis (vomiting of blood). The review also revealed upon assessment, the resident was found to have an infected decubitus (pressure ulcer) to the posterior popliteal area of the left knee (the sunken area behind the knee). Further review revealed the resident was admitted to the hospital for further evaluation of the infected pressure ulcer with physician orders for intravenous (IV) antibiotics to treat the infected ulcer. Review of a surgical consultation note, dated 10/26/18, revealed a treatment of [REDACTED]. According to the surgical note, the need for possible surgery to debride the ulcer (removal of the dead/infected tissue) would be re-evaluated after chemical debridement of the ulcer with the Dakin's solution. According to the hospital record, Resident #1 remained at the hospital and continued to receive IV antibiotics and treatments to the pressure ulcer. Interview with the Wound Care Certified (WCC) Nurse at the hospital on [DATE] at 8:15 AM, and review of the WCC's Progress Note dated 10/26/18, revealed she assessed the pressure ulcer behind Resident #1's left knee (popliteal area) on 10/26/18 at 3:44 PM. She stated the wound was a Stage IV pressure ulcer that measured 6.4 centimeters (cm) in length (head to toe), 2 cm wide, and 0.3 cm deep. The wound also had tunneling (channels extending from the wound beneath the skin) at 8 o'clock that measured 4.2 cm deep and at 9 o'clock that measured 2.4 cm deep. The WCC Nurse stated the pressure ulcer had necrotic (dead) tissue. Further interview with the WCC Nurse revealed the pressure ulcer was caused by the medical device (splint with ACE bandage), and had been present for more than five (5) days, probably even longer due to the extent of the tunneling. She also stated skin assessments would have been the key to prevention and/or early detection of the wound. Interview with State Registered Nurse Aide (SRNA) #1 on 10/30/18 at 4:00 PM and SRNA #2 on 10/30/18 at 4:05 PM revealed they were frequently assigned to provide care for Resident #1 and were knowledgeable that the resident had a splint/ACE wrap to the left leg. The SRNAs stated they provided no care to the resident's left leg and were never asked to help or assist with the splint/ACE wrap to the left leg. SRNA #2 further stated she had not observed staff removing/applying the ACE wrap. Interview with Licensed Practical Nurse (LPN) #1 on 10/30/18 at 12:45 PM, revealed she was working when Resident #1 came back from the ED on 09/23/18, with a [DIAGNOSES REDACTED]. She stated there was an ACE wrap to the resident's left leg, but there were no physician orders regarding treatment to the leg. LPN #1 stated that after the resident returned from the appointment with the orthopedic surgeon on 09/26/18 the resident had a splint and an ACE bandage; however, an order was not written to monitor the resident's leg until 10/05/18. According to LPN #1, the physician's order required staff to assess the resident's skin for redness or breakdown, and to ensure the dressing (ACE wrap) was not binding. However, LPN #1 stated that staff were not able to remove the ACE wrap and assess the resident's leg because the resident complained of pain when the leg was touched. LPN #1 further stated that even if the wrap was removed, she would not have been able to visualize the resident's left popliteal area (behind the knee) because the resident had contractures. The LPN stated Resident #1 had medication to treat pain and did not consider notifying the resident's physician that the resident could not tolerate skin assessments. Interview with LPN #2 on 10/30/18 at 1:30 PM, revealed she had difficulty removing the ACE wrap from the resident's left leg because the resident had pain upon movement of the leg. LPN #2 stated she was never able to visualize the back of the left knee because the resident's leg was contracted. Interview with LPN #4 on 10/30/18 at 1:45 PM, revealed the purpose for removing the ACE wrap/splint to Resident #1's leg was to be able to assess the resident's skin. LPN #4 stated she had not been able to completely unwrap/rewrap and remove the splint from Resident #1's left leg since approximately 09/26/18 or 09/27/18. LPN #4 stated she had not been able to assess the resident's skin to the left leg since then because the resident complained of pain when attempts were made to remove the splint. Interview with Registered Nurse (RN) #1 on 10/30/18 at 5:30 PM, revealed she had only been able to unwrap the resident's left leg and assess the skin approximately four (4) times, with the last time being the weekend of 10/13/18 and 10/14/18 (RN #1 completed the weekly skin assessment on 10/12/18). RN #1 stated at times she was able to see the area behind the left knee. She further stated that when she was not able to unwrap or visualize the resident's skin, she would place her fingers under the ACE wrap to feel for moisture/drainage or open areas, and had not identified any problems. On 10/30/18 at 5:40 PM, an interview was attempted with RN #4, the nurse who completed Resident #1's weekly skin assessment on 10/19/18, which was the last skin assessment prior to the resident being transferred to the hospital. However, RN #4 did not answer and did not return the phone call. Interview with RN #2 on 10/31/18 at 10:45 AM, revealed she was the Unit Coordinator where Resident #1 resided. She stated she obtained the physician's order to remove the ACE bandage and assess the skin every shift, and the intent was to ensure the resident's skin was assessed. She further stated that Resident #1 utilizing a splint and ACE wrap to the leg increased the resident's potential for skin breakdown and circulatory problems. RN #2 stated she was responsible for monitoring to ensure skin assessments were completed. The RN stated she had not received any reports from staff of the inability to remove the ACE wrap and conduct a skin assessment of Resident #1's left leg and assumed the skin assessments were being completed as ordered. Interview with the Director of Nursing (DON) on 10/31/18 at 11:00 AM, revealed the goal of the order to unwrap the bandage from Resident #1's leg was to assess the resident's skin to ensure no pressure ulcers were developing and to ensure the splint and ACE wrap were not impairing the resident's circulation. She stated she was not aware staff were not assessing Resident #1's skin until she spoke with staff following the discovery of the wound in the Emergency Department on 10/26/18. The DON stated staff told her they were unable to remove the ACE wrap completely from the resident's left leg and were unable to visualize the left popliteal area. Further interview with the DON revealed staff should have reported the inability to perform the skin assessment to her and to the resident's physician. Interview with the Administrator on 10/31/18 at 1:25 PM, revealed the ED staff notified her when they discovered Resident #1's pressure ulcer, and an investigation was initiated. She stated that upon investigation it was revealed staff were feeling under the ACE wrap for any wounds or drainage, but they were not able to see the area behind the left knee. She further added that the inability to perform the skin assessment should have been reported to a supervisor and the resident's physician. Observation of Resident #1 at an acute care hospital on [DATE] at 8:15 AM, revealed the resident was lying in bed with his/her eyes closed. The resident responded, What, when his/her name was called, but did not open his/her eyes and gave no response to questions. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 11/06/18: 1. Resident #1 no longer resides in the facility. 2. On 10/26/18 and 10/27/18 all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed by the Social Services Director concerning the care they received in the facility, if their call lights were being answered timely, if nurses were monitoring the condition of their skin, and if they had any other concerns they wished to discuss. There were no concerns voiced by the residents. 3. A head-to-toe assessment was completed on all residents as of 11/01/18, with particular attention to residents with fractures, contractures, and orthotic devices. The assessments were conducted by the Unit Coordinator, Minimum Data Set (MDS) Coordinator, Charge Nurses, or Clinical Care Coordinator. Any skin concerns were reported to the physician and addressed by the Interdisciplinary Team (IDT). 4. The care plans for all residents with contractures or fractures, or who require an orthotic device were reviewed and revised as necessary by the MDS Coordinators on 10/28/18. 5. The MDS Coordinator will update care plans daily during the morning meeting when reviewing the 24-hour report, acute monitoring log, and physician orders. 6. The Director of Nursing (DON) provided education related to performing skin assessments and conducting Braden Scale assessments to all licensed staff beginning on 10/27/18 and continuing through 11/01/18 until all staff had received the education. The licensed staff were required to complete a post test at the conclusion of the education. In addition, a wound care company, independent of the facility, provided additional education on pressure ulcer prevention for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) on 11/05/18. 7. The Unit Coordinator will bring the Twenty-four (24) Hour Report, Acute Monitoring Log, and Physician Orders to the morning meetings to ensure that any changes in a resident's condition or a resident's consistent refusal of care have been reported to the family and physician. The morning meetings will be conducted seven (7) days a week, until substantial compliance is achieved. 8. The DON reviewed family and physician notification requirements with licensed staff on 11/02/18 and 11/05/18. 9. The Corporate Nurse Consultant re-educated the DON, MDS Staff, Unit Coordinators, and Clinical Coordinators on developing person-centered care plans. The education was initiated on 10/31/18 and completed on 11/03/18. 10. Therapy representatives educated all nursing staff on positioning, contracture management, and management of orthotic devices on 11/02/18 and 11/05/18. 11. All nursing assistants were trained by the Nurse Aide Coordinator and Clinical Care Coordinator on contracture management and examination of skin during routine care beginning on 10/27/18 and continuing through 11/05/18, until all staff had received the education. 12. The DON or a designated RN will conduct Quality Assurance (QA) audits daily utilizing the Complicated Skin Risks, Contractures, Fractures and Devices audit tool on all residents who have a contracture, fracture, or an orthotic device. The audits will address the following, and continue until substantial compliance is achieved: A) Ensure all risk factors for skin breakdown have been identified. B) Ensure nursing documentation of skin assessments is being performed daily when a device is in place. C) Ensure observations of any devices or skin breakdown match the nursing documentation. D) Identify any barriers which could impact the ability to provide care to the resident. If barriers are identified has the physician has been notified. E) Ensuring the resident's care plan reflects the interventions for the device that is in place. 13. The Quality Assurance Performance Improvement (QAPI) Committee began meeting weekly on 10/29/18. The Immediate Jeopardy citation, the audits being conducted, education provided to staff, and post test results were discussed. Weekly QAPI meetings will continue for four (4) weeks and then monthly for six (6) months. Results of the audits and any follow-up required will be presented to the QA Committee by the DON. The QA Committee consists of the Medical Director, Administrator, DON, Social Services Director, Activities Director, Minimum Data Set (MDS) Coordinator, Dietary Director, and the Unit Coordinators. ****The State Survey Agency determined Immediate Jeopardy was removed on 11/06/18 based on the following: 1. Review of Resident #1's closed medical record revealed the resident was discharged from the facility on 10/26/18. 2. Review of facility documentation and interview with the Social Services Director (SSD) on 11/08/18 at 10:15 AM revealed interviews with residents with a BIMS score above eight (8) were conducted on 10/27/18. The questions were related to care, complaints, and assessment of skin/pain. Review of the documented interviews revealed the SSD interviewed fifty-nine (59) residents and received no concerns or complaints regarding resident care. 3. Review of documentation and interviews conducted on 11/08/18 at 2:10 PM with the DON, at 12:58 PM with RN #4 and Unit Manager (UM) #1, at 9:55 AM with MDS Coordinator #1, and at 9:15 AM with RN #2 revealed all residents received a head-to-toe skin assessment between 10/27/18 and 11/01/18. The skin assessment focused on contractures, pressure areas, and any orthotic device in use. The DON stated no new pressure areas were identified. 4. Review of documentation and interview with MDS Coordinator #1 on 11/08/18 at 9:55 AM revealed the care plans of residents with contractures or fractures, or who require an orthotic device were reviewed and revised as necessary on 10/27/18 and 10/28/18. 5. Review of documentation and interview with MDS Coordinator #1 on 11/08/18 at 9:55 AM, revealed she attended the morning meetings every day and care plans were also updated in the meetings as necessary. 6. Review of documentation and interview with the DON on 11/08/18 at 2:10 PM, revealed that education on skin assessments and ensuring the physician was aware of any skin changes was provided to licensed nurses on 10/27/18 - 11/01/18. Licensed nurses completed a post test after the training which they had to pass before returning to work. According to the DON, all staff passed the post test. Copies of the post tests were reviewed with no concerns identified. Further review of documentation revealed a wound care company provided training on pressure ulcer prevention. Interviews on 11/08/18 with the DON at 2:10 PM, UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, and LPN #4 at 3:10 PM, revealed the above trainings were provided. 7. Review of documentation and interview with the Administrator on 11/08/18 at 3:28 PM revealed the facility held morning meetings seven (7) days per week. The Administrator stated Twenty-Four (24) Hour Reports, the Acute Monitoring Book, and Physician's Orders were reviewed during the meetings. The Administrator stated they also check to ensure physician notification has been completed as necessary. Interviews on 11/08/18 with the DON at 2:10 PM, RN #5 at 12:43 PM, the SSD at 10:15 AM, and RN #2 at 9:15 AM revealed they all had attended the morning meetings daily where they reviewed the Twenty-Four (24) Hour Reports, the Acute Monitoring Book, Physician's Orders, and Physician Notifications. 8. Review of documentation and interview with the DON on 11/08/18 at 2:10 PM revealed that education on physician notification was provided to licensed nurses on 10/27/18 - 11/01/18. Interviews on 11/08/18 with UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, and LPN #4 at 3:10 PM revealed training on physician notification was provided. 9. Review of documentation revealed education was provided by the Corporate Nurse Consultant on the care plan process on 10/31/18 - 11/03/18. Interviews on 11/08/18 with the MDS Coordinator at 9:55 AM, RN #5 at 12:43 PM, the DON at 2:10 PM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, and RN #2 at 9:15 AM revealed they received training on the care plan process. 10. Review of documentation revealed the Therapy Department provided education to all nursing staff on contractures, positioning, and management of orthotic devices. 11. Review of documentation revealed all nursing assistants were trained by the Nurse Aide Coordinator and Clinical Care Coordinator on contracture management and examination of skin during routine care. These trainings were completed by 11/05/18. Interviews on 11/08/18 with the DON at 2:10 PM, UM #1 at 12:58 PM, MDS Coordinator #1 at 9:55 PM, RN #2 at 9:15 AM, LPN #7 at 8:57 AM, LPN #6 at 10:45 AM, LPN #5 at 12:25 PM, RN #5 at 12:43 PM, SRNA #7 at 1:14 PM, SRNA #3 at 2:00 PM, SRNA #2 at 12:45 PM, SRNA #6 at 1:25 PM, LPN #4 at 3:10 PM, SRNA #5 at 2:55 PM, and SRNA #4 at 3:00 PM revealed the above training was provided. The staff interviewed were able to describe what trainings were provided and what skin conditions or refusal of care needed to be reported to the charge nurse. 12. Interview with the DON on 11/08/18 at 2:10 PM and review of the QA Audit Complicated Skin Risks, Contractures, Fracture and Devices revealed the DON completed audits on all residents with contractures, fractures, or orthotic devices. The DON stated she reviewed the areas on the audit form for each resident which included: A) That all risk factors for skin breakdown had been identified. B) The nursing staff had documented checking skin under any orthotic device daily. C) Nursing audits matched observations. D) Identification of any barriers that could impact care or skin assessments, and notification of physician if any barriers were identified. E) Ensuring the care plan had the appropriate intervention for the particular device in place. Further interview with the DON, MDS Coordinator #1, RN #5, and RN #2 revealed the 24-hour Report, Acute Monitoring Log, and physician orders were reviewed in the Morning Meetings held daily. They all stated the care plans were updated in the meeting if needed. 13. Interview with the DON on 11/08/18 at 2:10 PM, revealed a QAPI meeting was held on 10/29/18. The DON stated the Immediate Jeopardy citation, all audits being conducted, education performed, and post tests completed were reviewed. The DON stated the QAPI meetings will continue for four (4) weeks and then monthly for six (6) months. Interview with the Medical Director on 11/08/18 at 3:25 PM revealed he attended the weekly QA meetings and had provided education on pressure sores to facility staff.

Based on interview, record review, accident/incident report review, and a review of the facility's Changes in Resident's Condition or Status policy/procedure it was determined the facility failed to ensure the resident's physician was notified of a significant change in condition for one of three sampled residents (Resident #1). Resident #1 experienced a non-witnessed fall on 09/21/11 and was assessed by the facility at 4:05 AM to have sustained no injuries. However, on 09/21/11, at 10:00 AM, the facility assessed the resident and noted the resident had a dark purple/red discoloration to the right hand/lower arm area and the resident also complained of pain. The facility failed to notify Resident #1's physician of the change in the resident's condition. Documented assessments revealed Resident #1 continued to have discoloration, [MEDICAL CONDITION], and pain to the right upper extremity and was diagnosed on [DATE] by an orthopedic surgeon to have a right distal radius fracture. (Refer to F309.) The findings include: A review of the facility's Changes In A Resident's Condition or Status policy/procedure (dated 01/09/03) revealed Nursing Services would notify the resident's attending physician when the resident was involved in an accident or incident that involved injury, when the resident experienced a significant change in physical status, or when there was a need to significantly alter the resident's treatment. The facility admitted Resident #1 to the facility on [DATE]. Documentation revealed the resident had fallen at home and sustained fractures to the left humerus and femur that required surgical intervention. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed the resident to be cognitively impaired and to be at risk for falls. Resident #1's Comprehensive Care Plan dated 8/15/11 revealed the facility assessed the resident to have a potential for alteration in comfort related to the resident's history of falls and fractures. A review of an Accident/Incident report dated 09/20/11, at 4:05 AM, revealed Resident #1 was found on the floor after an apparent fall. Documentation revealed facility staff assessed the resident and noted the resident had sustained no injuries. A review of the incident report and nurse's notes dated 09/20/11, at 8:00 AM, indicated Resident #1's physician was contacted by telephone and notified of the resident's "no injury fall." A review of documentation in the nurse's notes revealed on 09/21/11, at 10:00 AM, Resident #1 complained of pain to the right hand/lower arm, was "guarding" the area, and the resident's right hand/wrist was "dark purple/red" in color. However the facility failed to notify Resident #1's physician of the assessment or the resident's complaints of pain. Continued review of the medical record revealed on 09/21/11, at 9:00 PM, Resident #1 complained of pain in his/her right hand/wrist when he/she attempted to make a fist. In addition, documentation revealed the resident's right hand/wrist was [MEDICAL CONDITION] and discolored. An interview conducted with Licensed Practical Nurse (LPN) #1 on 11/22/11, at 4:55 PM, revealed she had been assigned to provide care to Resident #1 on 09/21/11. According to the LPN, Resident #1 complained of pain to his/her right hand/wrist area on 09/21/11 and the resident's right hand/wrist was [MEDICAL CONDITION] and discolored. LPN #1 stated Resident #1 had not previously complained of pain in the right hand/wrist and acknowledged the resident had experienced a change in condition. However, LPN #1 stated Resident #1 could "move" his/her right hand/wrist "fine" and could "pick stuff up" therefore she did not notify the resident's physician of the change in the resident's condition at that time. According to LPN #1, Resident #1 had a follow-up appointment scheduled on 09/22/11 with the orthopedic surgeon who had treated and surgically repaired the resident's left humerus and femur fractures, and assumed the surgeon would evaluate the right hand/wrist area at that time. In addition, LPN #1 stated she notified the Director of Nursing (DON) of Resident #1's complaints of pain and the discolored area to his/her hand/wrist (unable to state date and time). Documentation in the medical record on 09/22/11, at 8:00 AM, and interview conducted with LPN #2 on 11/22/11, at 5:35 PM, revealed Resident #1 complained of pain and guarded the right extremity, and the right extremity was noted to be [MEDICAL CONDITION]. Based on documentation, the resident had a follow-up appointment that day (09/22/11) with the orthopedic surgeon and the surgeon would evaluate the resident's right arm. However, nurse's notes dated 09/22/11, at 2:00 PM, revealed Resident #1 had been transported to the follow-up appointment with the orthopedic surgeon but the appointment had been rescheduled for 09/27/11, and the resident was not assessed by the physician. LPN #2 stated she was aware Resident #1 had not received an evaluation or treatment of [REDACTED].#1 could wait until the appointment on 09/27/11 to have the right hand/lower arm evaluated. Documentation on 9/22/11, at 9:00 PM, in the resident's medical record revealed LPN #3 had noted Resident #1's right extremity was discolored, the resident complained of pain to the right extremity, and the LPN administered pain medication to the resident. Interview with LPN #3 on 11/22/11, at 6:30 PM, revealed he "assumed the doctor had been notified" and was aware of the area on Resident #1's right wrist/arm, and took no further action. Further review of documentation revealed entries on 09/23/11, 09/24/11, 09/25/11, 09/26/11, and 09/27/11, that Resident #1 had continued to have [MEDICAL CONDITION], discoloration, and complaints of pain to his/her right hand/wrist, however, the facility staff failed to notify the physician of the resident's change in condition. The DON confirmed in interview on 11/22/11, at 5:00 PM, that she was notified of the area on Resident #1's right hand/wrist (unable to state date or time) and had "looked" at the area. The DON stated when she observed Resident #1's right hand/wrist, the area was discolored and [MEDICAL CONDITION], but because the resident was walking in the hallway with the use of a walker, and since the resident was not complaining of pain, she did not feel further intervention was warranted. The DON stated she was unaware Resident #1 had complained of pain on several other occasions. However, after a review of the assessment in the resident's medical record conducted on 09/21/11, at 10:00 AM, by facility staff, the DON stated Resident #1's physician "should have been called" at that time. An interview was conducted on 11/23/11, at 9:20 AM, with Resident #1's attending physician. The physician confirmed he had been notified on 09/20/11 that Resident #1 had fallen and reportedly had not sustained an injury. However, the physician stated he had not been notified that Resident #1's hand/arm had been [MEDICAL CONDITION] or discolored, or that the resident had complained of pain. The physician stated he should "absolutely" have been notified of the change in Resident #1's condition so appropriate evaluation and treatment could have been performed timely. A review of documentation from Resident #1's office visit on 09/27/11 and interview with the orthopedic surgeon on 11/23/11, at 11:00 AM, revealed Resident #1 complained of right wrist pain during the follow-up appointment with the orthopedic surgeon on 09/27/11, and subsequent x-rays obtained on 09/27/11 revealed the resident had a minimally displaced radius [MEDICAL CONDITION] extremity.

Based on interview, record review, accident/incident report review, a review of facility policies, and documentation received from a physician's office, it was determined the facility failed to ensure necessary care and services were provided for one of three sampled residents (Resident #1) in order to maintain the resident's physical well-being. Resident #1 sustained a fall on 09/20/11 and was assessed by the facility to have no injuries. However, from 09/21/11 through 09/27/11, Resident #1 complained of pain to the right hand/wrist and/or was assessed by the facility to have dark purple/red discoloration to the area. The facility failed to seek further evaluation or treatment for [REDACTED].#1's right hand/wrist, the resident was diagnosed with [REDACTED].) The findings include: A review of the facility's Falls Follow Up Protocol (undated) revealed each resident who experienced a fall would be assessed for complications from the fall for 24 hours, with the findings documented in the medical record. However, the protocol did not direct staff on what actions were to be taken if an abnormal finding or complication was found. The facility admitted Resident #1 on 08/01/11, after the resident had sustained a severe fall at home, was hospitalized , and underwent surgery for [REDACTED]. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be cognitively impaired and at risk for falls. A review of Resident #1's Comprehensive Care Plan dated 08/15/11 revealed the facility assessed the resident to have a potential for alteration in comfort related to the resident's history of falls and fractures. A review of Nursing Notes and an Accident/Incident Report, both dated 09/20/11, revealed on 09/20/11, at 4:05 AM, staff observed Resident #1 on the floor in the hallway as a result of an apparent fall. The facility assessed Resident #1 to have no injuries as a result of the apparent fall. An interview on 11/22/11, at 4:55 PM, with Licensed Practical Nurse (LPN) #1 and review of documentation in Resident #1's record dated 09/21/11, at 10:00 AM, revealed facility staff noted Resident #1's right hand/wrist had a dark purple/red discoloration and the resident complained of pain when the area was touched. LPN #1 stated prior to this time Resident #1 had not complained of pain nor had [MEDICAL CONDITION] or discoloration to the right extremity and therefore had not exhibited a change in condition. The LPN stated she was aware the resident had sustained a fall on 09/20/11 and had notified the Director of Nursing (DON) (unable to recall date and time) of the discoloration, [MEDICAL CONDITION], and the resident's complaints of pain to the right hand/wrist. Based on an assessment on 09/21/11, at 9:00 PM, Resident #1 continued to have [MEDICAL CONDITION] and discoloration of the right hand/wrist and complained of pain when he/she attempted to make a fist. Continued review of documentation and an interview conducted with LPN #2 on 11/22/11, at 5:35 PM, revealed on 09/22/11, at 8:00 AM, Resident #1 had [MEDICAL CONDITION], complained of pain, and guarded the right extremity. The entry also revealed the resident had a follow-up appointment that day (09/22/11) with the orthopedic surgeon and the surgeon would evaluate the resident's right arm at that time. However, documentation revealed the resident was transported to the physician's appointment but the physician was unable to assess the resident and the appointment was rescheduled for 09/27/11. Continued interview with LPN #2 revealed she was aware when Resident #1 returned to the facility on [DATE] and that the resident had received no evaluation or treatment of [REDACTED]."did not think it was an emergency." Per interview she thought Resident #1 could wait to have the right extremity evaluated by the orthopedic surgeon on 09/27/11, six days after resident #1 started complaining of pain and [MEDICAL CONDITION] and discoloration was noted to the resident's right hand/wrist. In addition, documentation on 09/22/11, at 9:00 PM, revealed LPN #3 noted Resident #1 had discoloration of the right extremity, complained of pain, and pain medication was administered. Interview with LPN #3 on 11/22/11, at 6:30 PM, revealed he "assumed the doctor had been notified" and was aware of the area on Resident #1's right wrist/arm, and the LPN took no further action. Review of the nurse's notes revealed entries on 09/23/11, at 8:30 AM, of [MEDICAL CONDITION], purple discoloration to the extremity, and complaints of pain, and at 8:00 PM, of discoloration. Further review of Resident #1's nurse's notes revealed entries on 09/24/11, 09/25/11, 09/26/11, and 09/27/11, which continued to describe the [MEDICAL CONDITION] and discoloration of the resident's right hand/wrist. An interview with the DON on 11/22/11, at 5:00 PM, revealed she had been notified of the area on Resident #1's right hand/wrist and had "looked" at the area, however, the DON was unable to recall the date or time. The DON stated because Resident #1 was able to move his/her right extremity, utilize a walker by grasping/holding onto it, and had not complained of pain, "nothing alerted me that anything else needed to be done." However, after a review of documentation in Resident #1's record the DON stated she was unaware the resident had complained of pain to the right hand/wrist prior to reviewing the documentation. An interview with Resident #1's attending physician on 11/23/11, at 9:00 AM, revealed he should have been notified of Resident #1's change in condition so evaluation and treatment could have been provided timely. A review of nurse's notes dated 09/27/11, at 12:30 PM, revealed Resident #1 was transported to the orthopedic surgeon's appointment for the follow-up visit related to the prior left-sided fractures. A review of documentation from the physician's office revealed Resident #1 complained of right wrist pain during the evaluation, and subsequent x-rays obtained on 09/27/11 revealed the resident had a minimally displaced radius [MEDICAL CONDITION] extremity.