Every finding on record at Stanton Nursing and Rehabilitation Center

Based on interview, record review, and review of facility policy, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff for one (Resident (R) 1) of 22 sampled residents. Abuse was substantiated when staff yelled at R1 and hooked a back scratcher on the resident's bottom lip to pull on the resident's mouth. The findings include: Review of the facility's policy titled Abuse Prohibition Standard of Practice, revision date 07/2022, revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of R1's admission record revealed the facility admitted R1 on 06/14/2022, with diagnoses of neurogenic bowel, neuromuscular dysfunction of bladder, other psychoactive substance abuse with unspecified psychoactive substance-induced disorder, and unspecified viral hepatitis C without hepatic coma. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2025, revealed a Brief Interview for Mental Status (BIMS) score of 13/15, indicating R6 was cognitively intact. Per the MDS, R1 displayed no behaviors. Review of R6's Electronic Health Record (EHR) on 04/22/2025, revealed a Miscellaneous Note, dated 02/08/2025 at 3:17 AM, which stated that R6 displayed some aggression towards staff at 10 PM, with the note stating that R6 threw water on staff. Further review of the Miscellaneous Note revealed no information as to what might have led to this incident. Review of a facility investigation, dated 02/10/2025 at 10:00 AM and completed by the former Director of Nursing (DON), revealed that on the evening of 02/07/2025, R1 was asleep in his bed when he was abruptly awakened by two Certified Nursing Assistants ((CNA) 4 and CNA5), who were standing over his bed, talking loudly and attempting to wake him up. Per the investigation, CNA4 took R6's bamboo back scratcher from his over-bed table and lightly touched his lip. CNA4 may have also brushed R6's stomach with the back scratcher. R6 was startled, and when he felt the backscratcher on his lip, he threw a half-filled cup of water on CNA4. Continued review of the investigation revealed CNA4 then left R6's room and brought CNA5 into the room to scold him for the water he threw on CNA4. CNA4 told R6 she was going to report him for his actions. Licensed Practical Nurse (LPN) 3 was standing at R6's doorway during this time. Per the investigation, LPN3, CNA4, and CNA5 claimed they tried to wake R6 up because he appeared to be unresponsive. LPN3 told CNA4 and CNA5 to stop after R6 woke up. The facility's investigation showed that, based on the information provided by R6 regarding CNA4, the facility substantiated the allegation of abuse. During an interview on 04/22/2025 at 11:34 AM, R6 stated LPN3 came into his room [ROOM NUMBER] minutes prior to the incident because R6's roommate was on intravenous (IV) antibiotics, and while in the room, LPN3 said, hey to R6. R6 continued that, when the incident occurred, he had been asleep but woke up when CNA4 took his back scratcher and hooked it on the bottom of his lip, pulled at his mouth, and was hollering at him. Then, he woke up and slung the cup of water on CNA4. R6 stated when he woke up, CNA4 and CNA5 were on the left side of his bed with LPN3 at the foot of his bed. Further interview with R6 revealed CNA4's actions made him mad. During an interview with CNA5 on 04/22/2025 at 2:31PM, CNA5 stated R6's call light went off and CNA4 answered it. CNA5 stated CNA4 tried to ask R6 if he needed anything, but he would not wake up, and that's when CNA4 got me. We tried to scratch his belly and forehead, smacked the bed, hollered at him, and he still wouldn't wake up. CNA5 stated that when R6 did wake up, he threw water on CNA4. CNA5 indicated that when trying to wake a resident, she would normally say their name two to three times and rub on the resident's leg, and if that does not work, she will get another staff member. During an interview on 04/23/2025 at 3:38PM, LPN3 stated prior to the incident, she was hanging R6's roommate's IV and she woke R6 up while she changed the IV. LPN3 stated she was at the nurses' desk when CNA5 came to her and stated that they were unable to wake R6 up. When she got there, CNA4 had the back scratcher in her hand and R6 stated I'm tired of getting picked on by these girls. Attempts to contact CNA4 on 04/22/2025 at 2:27PM and 04/23/2025 at 12:36PM, were unsuccessful, as the call could not be completed as dialed. Attempts to contact the former Director of Nursing (DON) on 04/24/2025 at 9:29AM and 04/24/2025 at 2:09PM were also unsuccessful, as the voice mailbox could not accept any more messages. Interview with the former Administrator on 04/24/2025 at 9:33AM, revealed he was the Administrator at the time of this incident. The former Administrator described the incident in which abuse was substantiated as, It was just one aide aggravating a resident, also stating that There was no injury at all. Continued interview with the former Administrator revealed his statement that CNA4 and R6 had some playfulness prior to that incident, and I think they thought it was funny. He did not elaborate on what playfulness was or what his expectations were. Further interview with the Administrator revealed that the facility failed to report the incident to the State Survey Agency or other required agencies (Refer to F609.)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an alleged violation involving abuse was reported immediately, but not later than two hours, for one (Resident (R)1) of four residents reviewed for abuse, out of a total sample of 22 residents. Staff failed to immediately report an allegation of abuse to the Administrator, as well as the State Survey Agency (SSA) and Adult Protective Services (APS). The findings include: Review of the facility's policy titled Abuse Prohibition Standard of Practice, revision date 07/2022, revealed alleged violation(s) will be reported to the Administrator and/or designee immediately. Further review revealed alleged violations were to be reported to the SSA and APS. However, the policy did not include the time frames specified in the regulation. Review of a facility investigation dated 02/10/2025 at 10:00 AM, and which was completed by the former Director of Nursing (DON), revealed that on the evening of 02/07/2025, R1 was asleep in his bed when he was abruptly awakened by two Certified Nursing Assistants ((CNA) 4 and CNA5), who were standing over his bed, talking loudly and attempting to wake him. Per the investigation, CNA4 took R6's bamboo back scratcher from his over-bed table and lightly touched his lip and may have also brushed R6's stomach with the back scratcher. R6 was startled, and when he felt the backscratcher on his lip, and he threw a half-filled cup of water on CNA4. Continued review of the investigation revealed CNA4 then left R6's room and brought CNA5 into the room to scold the resident for the water he threw on CNA4. CNA4 told R6 she was going to report him for his actions. The facility's investigation concluded, that based on information provided by R6 regarding CNA4, abuse was substantiated. (Refer to F600.). Further review of the facility investigation revealed the initial allegation of abuse was not received by the Administrator until 02/10/2025 at 10:00 AM, three days after the incident occurred. In addition, once the Administrator was notified of the allegation, the facility failed to immediately notify the SSA, as the Office of Inspector General was not notified until 02/10/2025 at 2:57 PM. During an interview with CNA5 on 04/22/2025 at 2:31PM, she said that after the incident on 02/07/2025, she texted Unit Manager (UM)1 about the incident. CNA5 stated she no longer had the texts, and did not remember specifically what she texted to UM1. However, she indicated that the report to the UM was more about the resident throwing water on CNA4, rather than the suspected abuse in which the CNA pulled the resident's lip with the backscratcher and yelled at him. During an interview with LPN3 on 04/23/2025 at 3:38PM, she confirmed that CNA5 texted UM1 what happened, and UM1 said OK, figure out what's going on in the morning. During an interview with UM1 on 04/24/2025 at 10:41AM, UM1 stated CNA5 texted her in the middle of the night, and she did not see the text until she woke up the next morning. Further interview with UM1 revealed that she sent a message to the former DON, and he said the resident was just mad, that's not anything. Continued interview with UM1 revealed she expected her staff to call her and keep calling until she was awake. During an interview with the former Administrator on 04/24/2025 at 9:33AM, he confirmed that he did not receive the report until a couple days after the incident. The former Administrator stated, It was just one aide aggravating a resident. The former Administrator stated that once he was aware of the allegation, he had two hours to report it to OIG, However, the SSA was not notified of the abuse allegation until almost five hours after the Administrator was made aware of it. The Administrator confirmed that the facility had not reported the abuse allegation to APS, saying that he was under the impression OIG informed APS. Continued interview with the Administrator revealed staff were supposed to notify the Administrator or the Director of Nursing (DON) immediately, and that was specified in the abuse policy of the facility.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the physician was notified when a change in condition occurred for one (1) of three (3) sampled residents, Resident #2. On 01/28/2022, State Registered Nursing Assistant (SRNA) #2 observed Resident #2 to have an open area on his/her right lower calf. SRNA #2 immediately reported the change in condition to Licensed Practical Nurse (LPN) #1. LPN #1 assessed the wound on Resident #2's lower right leg and provided wound care to the area. However, LPN #1 failed to notify Resident #2's physician of the open area to the resident's lower leg. Furthermore, LPN #1 failed to notify facility management of the open area until 02/01/2022, when the State Surveyor observed the wound to Resident #2's lower right leg. The findings include: Review of the facility's policy titled, Change of Condition Standard Practice dated July 2020, revealed facility staff were to immediately consult the resident's physician, nurse practitioner, or physician assistant. Further review revealed staff were to also immediately notify the resident representative when a significant change occurred in the resident's physical status. Review of the facility's policy titled, Skin Care Standard of Practice dated July 2020, revealed upon identification of a skin/wound impairment the nurse would notify the physician and obtain orders for treatment. Continued review revealed the nurse was to document the change of condition for the resident on the facility's 24-hour Report, and notify the Nurse Manager of the change in the resident's skin condition. Observation of Resident #2 on 02/01/2021 at 12:50 PM, revealed the resident lying on his/her bed, on a bariatric mattress without a sheet covering it. Continued observation revealed Registered Nurse (RN) #1 attempted to remove a gauze dressing from Resident #2's lower leg; however the dressing was stuck to the resident's leg. Observation revealed Wound Nurse #1 entered Resident #2's room and sprayed the gauze dressing with normal saline spray and removed the dressing from the resident's leg. Interview with Wound Nurse #1, at the time of observation, revealed she stated she had not been aware Resident #2 had an open wound on his/her leg. She further stated the dressing she removed from Resident #2's leg had been there for a few days. Wound Nurse #1 stated she would have assessed the area, notified the physician and obtained a treatment order. Interview with Resident #2 on 02/01/2021 at 12:50 PM, at the time of observation, revealed on 01/28/2022, he/she had been lying on the bed without a sheet covering his/her bariatric mattress. Continued interview revealed when Resident #2 attempted to move his/her legs, and his/her right leg was stuck to the uncovered bariatric mattress. Resident #2 stated when he/she pulled his/her leg up off the mattress; it tore the skin off his/her right lower leg. Further interview revealed Resident #2 had not reported the open area on his/her right lower leg to staff. Resident #2 further revealed; however, on 01/28/2022 LPN #1 cleansed the injured area on his/her right lower leg, and placed a dry dressing over the open area. The resident additionally stated no other staff had assessed, or provided treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's medical record revealed the facility admitted the resident on 08/27/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #2 as cognitively intact as indicated by a Brief Interview for Mental Status (BIMS) score of fifteen (15). Further review of the MDS revealed the facility also assessed the resident to have functional limitation in range of motion to the lower bilateral extremities. Additionally, review revealed the facility assessed Resident #2 to require assistance of two (2) or more staff for toileting and bed mobility. Review of the Comprehensive Care Plan dated 08/27/2019 for Resident #2 revealed the facility had care planned the resident for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the care plan revealed goals which included the resident avoiding prolonged pressure to his/her skin; and for the reoccurring Venous Ulcer to his/her right lower extremity to be free from signs/symptoms of infection. Further review of the care plan revealed the goals and interventions included staff to float the resident's heels on pillows while he/she was in bed. Review of the facility's weekly skin assessments for Resident #2 dated 12/15/2021, 12/23/2021, 12/30/2021, 01/06/2022, 01/13/2022, 01/20/2022, and 01/27/2022 revealed the documentation noted the resident's skin was intact. Review of the facility's Wound Notes for Resident #2 revealed on 10/14/2021 the resident had a reoccurring Venous Wound on his/her right leg measuring six (6) centimeters (cm) by three (3) cm with moderate drainage. Review of the Wound Notes dated 12/11/2021, revealed the Wound Specialist had noted the Venous Wound on Resident #2's right lower leg was resolved. Further review of the 12/11/2021 Note revealed staff were to continue the current treatment orders for the wound on the resident's right lower leg for one (1) additional week for preventative measures. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/01/2022 at 2:00 PM, with SRNA #2 revealed she had been assigned to Resident #2's care on 01/28/2022. She revealed on that date she had been performing incontinence care for Resident #2, and noticed blood on the resident's lower right leg. Further interview revealed she immediately reported the blood and an open area on Resident #2's right lower leg to LPN #1. Interview on 02/03/2022 at 2:05 PM, with SRNA #4 revealed on 01/28/2022, 01/29/2022, and 01/30/2022, she had been assigned to Resident #2's care from 7:00 PM to 7:00 AM. Continued interview revealed on 01/28/2022, she and SRNA #2 had been providing perineal care for Resident #2 when she observed blood on the resident's right lower leg, which LPN was notified of. She stated LPN #1 came to Resident #2's room, and placed an abdominal pad over the open wound then wrapped it with a gauze dressing. Further interview revealed on 01/29/2022, Resident #2 had a chux underneath his/her right lower leg which the SRNA removed and replaced with a bath blanket. SRNA #4 further stated there had been a dark brown drainage on the chux she removed from under Resident #2's right lower leg on 01/29/2022. In addition, she revealed she had not attempted to move Resident #2's leg on 01/30/2022, because that caused the resident to yell out in pain when his/her legs were moved. Interview on 02/01/2022 at 2:35 PM, with LPN #1, revealed on 01/28/2022 at the end of her shift, approximately 7:00 PM, SRNA #2 called her to Resident #2's room. Per LPN #1's interview, SRNA #2 told her she had observed blood on the resident's right lower leg while performing perineal care. Continued interview revealed LPN #1 stated she assessed the area on Resident #2's right lower leg and observed the right calf as red; however, did not observe an open area to the resident's calf. She stated she cleansed the area with Dermal Wound Cleanser (normal saline cleanser), covered the area with an abdominal pad (a highly absorbent pad), and wrapped the calf area with a gauze dressing. LPN #1 stated she reported the skin impairment she had observed to Unit Manager (UM) #1 prior to leaving at the end of her shift. Further interview revealed LPN #1 had not called the resident's physician to report the red area and treatment provided. Interview revealed LPN #1 had not documented the treatment she provided in Resident #2's medical record and had not completed an Incident Report regarding the reddened area. An additional interview on 02/09/2022 at 2:32 PM, with LPN #1 revealed she had not known where the bloody drainage was coming from on Resident #2's right calf area, and the right calf area had only been red, not open. LPN #1 further stated therefore, she had not notified the physician. Interview with UM #1 on 02/01/2022 at 2:50 PM revealed she had not been notified by any staff of an open wound to Resident #2's right lower leg until 02/01/2022, when the wound was identified by the State Surveyor. Interview on 02/01/2022 at 2:07 PM, with Physician #1 and Nurse Practitioner #1 revealed they had not been notified of any red or open areas on Resident #2's legs. They stated however, they should have been notified when facility staff identified the change in Resident #2's skin. Interview on 02/02/2022 at 2:16 PM, with LPN #2, who had been assigned as Resident #2's nurse on 01/29/2022 and 01/30/2022, revealed she had not received any information about an open area on Resident #2's right lower leg in report from other nurses, nor from any of the SRNA's. Interview with the Wound Nurse, on 02/02/2022 at 2:55 PM, revealed she was assigned to Resident #2's care on 01/29/2022 and 01/30/2022. The Wound Nurse stated Resident #2 had experienced an open wound on his/her right lower leg previously in October 2021. Continued interview revealed however, the previous wound had healed in December 2021. Further interview revealed staff had not informed her Resident #2 currently had an open area to his/her right lower leg. Interview on 02/02/2022 at 2:31 PM, with the Director of Nursing (DON) revealed the SRNAs were trained to report any new skin impairment issues or changes in a resident's condition to the nurse. Continued interview revealed the nurse was responsible for notifying the physician when changes occurred in a resident's skin integrity. Further interview revealed the DON stated if a nurse observed a new area on a resident's skin, which was not opened, and had blood observed around the area, her expectation was for the nurse to assess where the blood was coming from and notify the physician.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide the necessary care and services, in accordance with professional standards of practice and facility policy for one (1) of three (3) sampled residents, Resident #2. Interview with Resident #2, on 02/01/2022 at 12:50 PM, revealed on 01/28/2022, when attempting to move his/her right leg, the leg had been stuck to the mattress which had not been covered. Observation of Resident #2, at the time of interview, revealed the resident was currently lying on the bed with no sheet covering the bariatric mattress he/she was lying on. Registered Nurse (RN) #1 attempted to remove a gauze dressing from Resident #2's lower right leg on 02/01/2022; however, the dressing was stuck to the resident's leg. When RN #1 was finally able to remove the dressing, a fourteen (14) centimeter (cm) by seven (7) cm open area was observed to Resident #2's right lower calf. The wound had a large amount of bloody drainage with a large amount of blood on the one (1) pillow and two (2) towels the resident's leg had been resting on. State Registered Nurse Assistant (SRNA) #2 and #4 reported they noticed blood on Resident #2's right lower leg on 01/28/2022 when providing perineal care, and reported that information to Licensed Practical Nurse (LPN) #1. Interview with LPN #1 revealed she was notified by SRNA #2 of blood on Resident #2's right lower leg. She stated she had not observed an open area to Resident #2's lower leg, just bloody drainage. She stated she did not contact the physician or document her observations of the area. Review of Resident #2's medical record revealed no documented evidence the resident's physician was ever contacted or notified of the area on the resident's right lower leg. Furthermore, review revealed no documented evidence the wound was assessed and treated. The findings include: Interview with the Administrator on 02/09/2022 at 11:00 AM, revealed the facility had no policy related to handling and/or storage of bed linens and did not have a policy related to when bed linens were to be changed. Review of the facility's policy titled, Change of Condition Standard Practice, dated July 2020, revealed facility staff would immediately consult the resident's physician, nurse practitioner, or physician assistant, and the resident's representative when a significant change occurred in the resident's physical status. Review of the facility's policy titled, Skin Care Standard of Practice dated July 2020, revealed upon identification of a skin/wound impairment the nurse would notify the physician and obtain orders for treatment. Continued review revealed the nurse would document the change of condition on the facility's 24-hour Report, and notify the Nurse Manager of the change in the resident's skin condition. Further review of the policy revealed a nurse would be assigned to stage and measure the resident's wounds to maintain continuity of progression of wound healing. Review of Resident #2's medical record revealed the facility admitted the resident on 08/27/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #2 to have functional limitation in range of motion of the lower bilateral extremities, and to require two (2) plus person assist for bed mobility and toileting. Review of Resident #2's Comprehensive Care Plan dated 08/27/2019, revealed the resident had been care planned for [CONDITION(S)], Type 2 Diabetes, and as at high risk for skin breakdown. Continued review of the care plan revealed goals for the resident to avoid prolonged pressure to the skin. Further review revealed goals and interventions which included the reoccurring Venous Ulcer to Resident #2's right lower extremity would be free from signs/symptoms of infection, and staff were to float his/her heels on pillows while in bed. Review of the facility's weekly skin assessments for Resident #2 dated 12/15/2021, 12/23/2021, 12/30/2021, 01/06/2022, 01/13/2022, 01/20/2022, and 01/27/2022 revealed the resident's skin had been noted as intact. Review of the facility's wound notes for Resident #2 revealed on 10/14/2021 the resident had been assessed to have a reoccurring Venous Wound on his/her right leg measuring six (6) cm by three (3) cm with moderate drainage. Continued review of the wound notes revealed on 12/11/2021, the Wound Specialist noted the wound on Resident #2's right lower leg as resolved. Further review revealed facility staff were to continue with the current orders for treatment one (1) week for preventative measures. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 02/01/2022 at 12:50 PM, of Resident #2 revealed the resident was lying on the bed's bariatric mattress with no sheet covering the mattress. Interview with Resident #2, at the time of observation, revealed on 01/28/2022 the resident had been lying on his/her bed mattress which had also had no sheet on it that day. Resident #2 stated when he/she attempted to move his/her legs on the uncovered mattress, his/her right leg stuck to the mattress. Continued interview revealed when Resident #2 pulled his/her right leg off the uncovered mattress, the skin was torn off his/her right lower leg. Resident #2 revealed he/she had not told staff of the open area which resulted to his/her right lower leg. Further interview revealed on 01/28/2022, LPN #1 cleansed the open area on his/her lower right leg, and placed a dry dressing over the open area. Resident #2 further revealed however, since 01/28/2022 no other staff had assessed, or provided treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #2 revealed he/she had not had any sheets covering his/her mattress for approximately two (2) weeks. Interview with State Registered Nurse Assistant (SRNA) #2 on 02/01/2022 at 2:00 PM, revealed she had been assigned to Resident #2's care on 01/27/2022, 01/28/2022, and 01/29/2022. She stated Resident #2 did not have a sheet on his/her bed mattress on all three (3) of the nights she had provided care for him/her. Continued interview revealed on 01/27/2022, she had noticed Resident #2 had bloody drainage on the pillow which had been placed under his/her right leg to float it off the mattress; however, she had not seen any open areas on the resident's leg. SRNA #2 stated she placed two (2) towels over the pillow under Resident #2's leg on 01/27/2022. Interview revealed when she worked on 01/28/2022, the towels had been removed and Resident #2's bloody drainage had increased. Further interview revealed she placed a chux (protective pad) on Resident #2's pillow under his/her right leg, and notified LPN #1 of the bloody drainage she had seen. Further interview revealed LPN #1 placed a pad under Resident #2's right lower leg when she was notified of the drainage. Interview with SRNA #4, on 02/03/2022 at 2:05 PM, revealed she had been assigned to Resident #2's care on 01/28/2022, 01/29/2022, and 01/30/2022. She stated when she came onto shift Resident #2 did not have a sheet on his/her mattress and she would put on a sheet on the mattress. Continued interview revealed however, when she returned to work the next night for her shift, the sheet would be gone from Resident #2's mattress. SRNA #4 revealed on 01/28/2022 she and SRNA #2 provided perineal care for Resident #2 and they had observed a small amount of dark drainage coming from his/her right leg. Per interview, SRNA #4 stated SRNA #2 notified LPN #1 of the drainage, and the LPN placed an abdominal pad under Resident #2's right lower leg. Interview revealed on 01/29/2022, when SRNA #4 returned to work, she placed a sheet on Resident #2's mattress, and observed the resident to have a chux under his/her right leg which the SRNA removed. SRNA #4 stated she placed a bath blanket under Resident #2's leg to save the sheet from being soiled. SRNA #4 revealed she had not seen any blood draining from Resident #2's leg, on 01/30/2022; however, she stated she had not moved the resident's legs because the resident screamed when staff attempted to move his/her legs. Further interview with SRNA #4 revealed she had trouble getting sheets for Resident #2's mattress and had reported that information to the nurses. SRNA #4 further revealed Resident #2 was a heavy wetter (incontinent of urine) and needed the bed sheets changed often; however, the facility did not always have sheets available to replace the ones removed. Interview on 02/01/2022 at 2:35 PM, with Licensed Practical Nurse (LPN) #1 revealed on 01/28/2022, at the end of her shift (approximately 7:00 PM), SRNA #2 called her to Resident #2's room because the SRNA had observed blood on the resident's right lower leg when performing perineal care. LPN #1 stated she assessed the area on Resident #2's right lower leg and observed the right calf area to be red; however, she had not observed an open area to the resident's calf. Continued interview revealed she cleansed the red area with Dermal Wound Cleanser, covered the area with an abdominal pad, and wrapped the area with a gauze dressing. She stated she reported the skin impairment she had observed on Resident #2's right lower leg to Unit Manager (UM) #1 prior to leaving when her shift ended. LPN #1 revealed however, she had not called the resident's physician, filled out an Incident Report, or documented the wound treatment she had provided for Resident #2 in the medical record. Additional interview with LPN #1 on 02/09/2022 at 2:32 PM, revealed she had not known where the bloody drainage was coming from on Resident #2's right lower leg. LPN #2 stated the area on the resident's right calf was red and was not open at the time of her observation, and therefore she had not notified the physician. Interview on 02/02/2022 at 2:16 PM, with LPN #2 revealed she had been assigned as Resident #2's nurse on 01/29/2022 and 01/30/2022. She stated she had not performed any skin assessments of Resident #2 when she was scheduled to work on 01/29/2022 and 01/30/2022. She further stated she had not received any information regarding an open area on Resident #2's right lower leg in report from other nurses or from any of the SRNA's. Interview on 02/03/2022 at 8:23 PM, with LPN #4 revealed she had been assigned as Resident #2's nurse on 01/30/2022 during the night shift. She stated she had not been aware Resident #2 had any open areas on 01/30/2022, when assigned to his/her care. Further interview revealed the facility did not have enough sheets for its bariatric beds. Interview with State Registered Nurse Assistant (SRNA) #5, on 02/03/2022 at 2:40 PM, revealed staff did run out of sheets to place on residents' bariatric beds and just had to wait until laundry brought some out for use. SRNA #5 revealed Resident #2 was a heavy wetter and had to have his/her bed sheets changed two (2) to (3) times a shift. Interview with the Unit Manager (UM) #1, on 02/01/2022 at 2:50 PM, revealed she had not been made aware of an open wound on Resident #2's right lower leg until 02/01/2022, after the area was identified by the State Surveyor. UM #1 denied being notified of the area by LPN #1 in 01/28/2022. The UM stated if she had been notified she would have assessed the area, called the physician and obtained orders to treat the wound. Interview with Physician #1 and Nurse Practitioner (NP) #1, on 02/01/2022 at 2:07 PM, revealed they had not been notified of any open areas on Resident #2's legs. They stated however, they should have been notified when the facility staff identified the change in Resident #2's skin. The NP stated she observed the area on 02/01/2022 after being notified of the area, and gave treatment orders to facility staff. Interview with the Wound Nurse, on 02/02/2022 at 2:55 PM, revealed she had not been aware Resident #2 had an open wound on his/her right leg. She stated if she had known about the wound, she would have had the Wound Doctor assess and order treatments for the wound. She further stated the dressing she removed from Resident #2's leg on 02/01/2022 had been there for a few days. The Wound Nurse stated the nurse who first observed the area should have filled out an incident report and notified the physician. Interview with the Director of Nursing (DON) on 02/02/2022 at 2:31 PM, revealed she assisted with Resident #2's care on 01/29/2022, and was the resident's nurse on 01/30/2022. She stated she had not been aware Resident #2 had a wound or that the resident had not had sheets on his/her bed. Continued interview revealed the SRNA's called her all the time for sheets, which were locked in the emergency linen closet. She stated there was a key to the locked closet on the medication cart; however, she did not know if staff knew about the key. She stated there should always be sheets on all residents' beds. Further interview with the DON revealed staff were expected to report new or worsened skin issues and to contact the physician. She further stated she expected all open skin wounds to be measured and documented. The DON further stated when the area on Resident #2's lower leg was found the physician should have been notified and a treatment obtained.

Based on observation, and interview it was determined the facility failed to ensure residents were provided necessary housekeeping services to maintain a clean, sanitary, and comfortable bed for two (2) of three (3) sampled residents, Resident #2 and Resident #3. Observation revealed Resident #2 and Resident #3 were lying on their beds with no sheet covering their bariatric mattresses. The findings include: Interview with the Administrator on 02/09/2022 at 11:00 AM, revealed the facility did not have a policy related to handling/storage of bed linens and did not have a policy related to when bed linens were to be changed. Observation on 02/01/2022 at 12:50 PM, of Resident #2 revealed the resident lying on the bed which had a bariatric mattress without sheets covering the mattress. Interview with Resident #2 on 02/01/2022 at 12:50 PM, revealed the resident had not had any sheets on his/her mattress for approximately two (2) weeks. Observation on 02/01/2022 at 1:10 PM, of Resident #3 revealed the resident was lying on the bed which had a bariatric mattress without a sheet covering the mattress. Interview with Resident #3, on 02/01/2022 1:10 PM, revealed the resident had not had any sheets on his/her bed in the last two (2) days. Resident #3 revealed this was the second time he/she had not had sheets on his/her bed for over two (2) days since being admitted to the facility four (4) months ago. Observation on 02/01/2022 at 4:00 PM, of linen closets on the facility's South Hall and North Halls revealed five (5) fitted bariatric sheets present for use on the South Hall, and four (4) fitted bariatric sheets present for use on the North Hall. Observation of the facility's laundry room on 02/01/2022 at 4:20 PM, revealed the facility had four (4) fitted bariatric sheets present in that area. Interview with State Registered Nursing Assistant (SRNA) #2 on 02/01/2022 at 2:00 PM, revealed she worked on 01/27/2022, 01/28/2022, 01/29/2022. SRNA #2 revealed on all three of those nights when she started her shift, Resident #2 had not had a sheet in place to cover his/her bariatric mattress. Interview with SNRA #4, on 02/03/2022 at 2:05 PM, revealed she worked on 01/28/2022, 01/29/2022, 01/30/2022. SRNA #4 stated on all three (3) of those nights when she started her shift, Resident #2 had not had a sheet on his/her bed to cover the bariatric mattress. Further interview revealed Resident #2 was a heavy wetter and the resident's sheets had to be changed two (2) to three (3) times per shift. Further interview revealed she had trouble obtaining sheets for Resident #2's bariatric mattress in the past, and had reported that information to the nursing staff. Interview with SRNA #5, on 02/03/2022 at 2:40 PM, revealed Resident #2 was a heavy wetter and had to have his/her sheets changed often during a shift. SRNA #5 revealed when they ran out of sheets for residents' bariatric beds, staff would check the linen closet on the other hall; however, that closet would also be out of bariatric sheets. Further interview revealed SRNA #5 had reported not having bariatric sheets for use on residents' bariatric beds to laundry staff; however, had to wait to replace the sheets on the residents' beds until laundry staff brought the clean bariatric sheets for staff to use. SRNA #5 further stated she was not aware the facility had an emergency linen closet. Interview with Licensed Practical Nurse (LPN) #2, on 02/02/2022 at 2:16 PM, and LPN #4 on 02/03/2022 at 8:23 PM, revealed they were both aware of staff not having enough bariatric sheets for use on the residents' bariatric beds. Interview with the Housekeeping Supervisor, on 02/01/2022 at 4:00 PM, revealed he ordered towels and bed linens monthly. He revealed; however, the last few orders the facility received had only contained towels and washcloths. Continued interview revealed he was unable to say if he had ordered linens or not, or if they had just not been sent. The housekeeper went on to state that due to budget constraints it was difficult to obtain all the necessary supplies required for the housekeeping department. Interview with the Director of Nursing (DON), on 02/02/2022 at 2:31 PM, revealed the facility had an emergency linen closet which was locked at all times from staff. The DON stated she only lived ten (10) minutes from the facility if staff needed extra bariatric sheets from the emergency linen closet. The DON further revealed she did not know if all staff knew the facility had the emergency linen closet. The DON stated it was not acceptable for residents to lie on an uncovered mattresses. However, the DON stated she conducted no monitoring to ensue linens were available. Interview with the Administrator, on 02/02/2022 at 3:00 PM, revealed she had only been the Administrator in the building since 02/01/2022, and was not aware of the problem with facility linens.

Based on interview, record review and policy review, the facility failed to ensure that an allegation of abuse/mistreatment was reported immediately to the administrator and failed to ensure that the allegation was reported to the appropriate state agencies for one (1) of one eighteen (18) sampled residents (Resident #31). On 03/19/2021, Resident #31 reported to Licensed Practical Nurse (LPN) #1 that someone had jumped on the resident (spoke in a harsh manner toward the resident). The LPN failed to immediately report the allegation to the administrator. Further, the facility failed to have evidence that the allegation was reported to the appropriate agencies. The findings include: Review of the facility policy titled Abuse Prohibition Standard of Practice, with a revision date of May 2020, revealed the purpose of the policy was to ensure reporting and investigating of alleged violations. The policy further stated that alleged violations would be reported to the administrator immediately and that the administrator would oversee the center in conducting an internal investigation. Observation of and interview with Resident #31 on 04/20/2021 at 11:10 AM revealed the resident was sitting on the side of the bed in his/her room. The resident stated that he/she had been at the facility a little over a month and that approximately two (2) weeks after arriving at the facility, a nurse had been rude to him/her and had talked mean to the resident. The resident stated that facility staff had discussed the incident with him/her and that he/she had not seen the staff person since the incident. The resident went on to say that, he/she felt safe in the facility, was not harmed by the incident, and had no further concerns. Review of the medical record for Resident #31 revealed the facility admitted the resident on 03/02/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes revealed no notes related to the incident that Resident #31 reported. Further review of the record for Resident #31 revealed an admission Minimum Data Set (MDS) assessment with a reference date of 03/04/2021. The assessment noted that Resident #31's Brief Interview for Mental Status (BIMS) score was 14 indicating that the resident's cognition was intact. Review of a Grievance/Concern Form dated 03/19/2021 revealed Resident #31 reported to LPN #1 that a woman came in [his/her] room and jumped on [him/her]. The grievance/concern form further stated that Resident #31 reported that the woman came to his/her room twice and the woman was wearing a red shirt. The form stated that the resident indicated that the woman that Resident #31 was referring to was not LPN #1, State Registered Nursing Assistant (SRNA) #1, or SRNA #2. The form further noted that Registered Nurse (RN) #1 was assigned to investigate the concern. The summary of the investigation noted that RN #1 spoke with Resident #31 and the resident denied having any issues or anything that caused him/her distress and when the resident was asked about the previous evening, the resident stated, it was good. The summary of the investigation further noted that a search of the building during the previous shift found no female wearing red. Under the portion of the form that stated Resolution of Grievance/Concern, RN #1 signed the form and noted that the grievance/concern was not confirmed and no issues were found. The date of the resolution was 03/19/2021. The Grievance/Concern Form further noted that the resident was notified of the resolution on 03/22/2021 through a meeting. Further review of the information provided regarding the incident revealed no evidence that the incident was reported to the State Survey Agency or Adult Protective Services. Interview with LPN #1 on 04/22/2021 at 10:24 AM revealed that she was working when Resident #31 made the statement that someone had jumped on the resident. LPN #1 stated that the incident occurred late, approximately 11:00 PM or 12:00 AM. She stated that she went into the resident's room and the resident reported the incident. LPN #1 stated she asked the resident to describe the woman and she said the woman was wearing a red shirt. LPN #1 stated she brought all of the staff that were working to Resident #31 and asked if it was any of the staff working and the resident reported that it was not any staff working. LPN #1 stated that she did not report the incident immediately because Resident #31 has episodes of confusion at times and LPN #1 did not think anything really happened. LPN #1 further stated that she did not look at any residents to see if they were wearing red shirts or ask any other residents about the incident. Interview with RN #1 on 04/22/2021 at 10:43 AM revealed she was the unit manager for the unit where Resident #31 resided. RN #1 stated she remembered that LPN #1 reported the incident to her in the morning on 03/19/2021 when she arrived at the facility at approximately 7:30 or 8:00 AM. She stated that LPN #1 works evening shift and the incident had occurred sometime during the night shift while LPN #1 was on duty. RN #1 stated she told LPN #1 to fill out a grievance form related to the incident. RN #1 stated she asked LPN #1 to clarify what jumped on meant and that it had been a verbal incident and that the person that did it was wearing red. RN #1 stated that LPN #1 told her that she checked with all of the staff that was working during the evening and no one was wearing red and the resident had said it was not any of the staff that were working. RN #1 stated that she then went and spoke to the resident and the resident did not recall or report an incident. RN #1 stated that she then went to the Director of Nursing (DON) and reported the incident to her when the DON arrived at the facility between 8:00 AM and 8:30 AM. Interview with the DON on 04/22/2021 at 10:58 AM revealed she was familiar with the incident but she did not investigate the incident. The DON stated that the expectation for the staff was that any allegation of abuse, which includes verbal abuse, would be reported immediately to the administrator or to the DON. Interview with the Social Services Director (SSD) on 04/22/21 at 11:22 AM revealed she spoke to Resident #31 on 03/19/2021 after becoming aware that the resident reported an incident. The SSD stated that the resident did not recall the incident. She stated that she reported that information back to the administrator. The SSD stated she then spoke to the resident again on 03/22/2021 and notified the resident of the resolution of the grievance. Interview with the Administrator on 04/22/2021 at 11:09 AM revealed she was the abuse coordinator for the facility and was responsible for investigating and reporting allegations of abuse. The Administrator stated that when she arrived at the facility on the morning of 03/19/2021, the grievance form was on her desk. The Administrator stated that when she reviewed the grievance, she felt like they needed more information so she requested that the SSD speak with Resident #31. The Administrator stated that the SSD reported that the resident did not recall the incident. The Administrator stated that if the nurse felt like there was an allegation of abuse, then it should be reported to her immediately. The Administrator stated that she spoke to LPN #1 and because she found no staff that met the description given by Resident #31, she did not feel there was an allegation of abuse and therefore did not report it to the State Survey Agency and Adult Protective Services. The Administrator stated she did not know if LPN #1 had interviewed any other residents regarding the incident.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's physician ordered the resident to utilize a [CONDITION(S)] (Bilevel Positive Air Pressure) machine when sleeping; however, observation and interviews with staff revealed the resident was utilizing a [CONDITION(S)] (Continuous Positive Air Pressure) machine instead of a [CONDITION(S)] machine. The findings include: Review of the facility's policies and interview with the Director of Nursing (DON) on 04/22/2021 at 3:10 PM revealed the facility had no policy on [CONDITION(S)]/[CONDITION(S)] machines or on respiratory care. Interview with Administrator on 04/22/2021 at 4:57 PM revealed the facility had no policy on following physician orders. Observation of Resident #5 on 04/22/20 revealed Resident #5 in bed using a [CONDITION(S)] machine. The [CONDITION(S)] machine in use was a Res Med Air sense 10 with settings of 6.7 pressure. An interview was attempted with the resident; however, the resident was very hard of hearing. The resident did state he/she used the machine when he/she napped. Review of Resident #5 medical record revealed the facility last readmitted the resident on 02/07/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of ten (10) out of fifteen (15) indicating the resident has moderate cognitively impairment. Review of the Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders for [CONDITION(S)] settings were IPAP (Inspiratory Positive Air Pressure) 16 cm EPAP (Expiratory Positive Air Pressure) 8 cm rate of 24/min and FIO2 (Fraction of Inspired Oxygen) 24%. Interview with Licensed Practical Nurse (LPN) #2, on 04/21/2021 at 3:36 PM, revealed Resident #5 currently utilized a C-PAP machine with settings of 6.7 pressure. However, the LPN stated the current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated an outside respiratory company had set up the resident's [CONDITION(S)] machine. She stated she did not question the discrepancy between the [CONDITION(S)] verses the [CONDITION(S)] machine. Interview with LPN #3, on 04/22/2021 at 11:32 AM, revealed an outside respiratory company comes to the facility to set up resident respiratory machines. The LPN stated I check the machine to make sure it's working, that's all. LPN #3 stated Resident #5 currently was using a C-PAP machine. However, LPN #3 stated Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated Resident #5 dealt with her own machine. and that she did not questioned the order. The LPN stated Respiratory set up the machine and checked it monthly. Interview with Customer Service Representative at Specialized Service (with the respiratory company) on 04/22/21 at 11:32 AM , revealed a Respiratory Therapist set up the resident's [CONDITION(S)] machines. Interview with Respiratory Therapist via phone on 04/22/2021 at 1:50 PM revealed the process for setting up oxygen involves receiving an order in the cooperate office and they tell us what to do. We do [CONDITION(S)], C-PAP or whatever needs to be done. We do monthly checks unless the resident needs something else. The Respiratory Therapist stated the C-PAP gives continuous one positive pressure where [CONDITION(S)] gives two, an inhale pressure and an exhale pressure. Regarding Resident #5, the Therapist stated I did not initially set up the C-PAP machine but have been seeing Resident #5 since December 2020. The Therapist stated since the COVID pandemic she would stand at the resident's doors to check to complete the monthly checks. She stated she had not checked Resident #5's machine. The Therapist was asked If Resident #5 was on C-PAP or [CONDITION(S)] and the Therapist stated she was currently not for sure but would try and get order from cooperate office. Interview with Resident #5's Physician, on 04/22/21 at 2:41 PM, revealed Resident #5 should be on [CONDITION(S)] machine with settings of Peep (Positive and Expiratory Pressure) 8 Respiratory Rate 24, and FIO2 24. The Physician stated this is what Resident was discharged with from his/her pulmonologist. The Physician revealed Resident #5's pulmonologist is no longer at the facility. Interview with DON on 04/22/21 at 3:10 PM revealed when a resident needs oxygen, we get an order from the physician and contact the oxygen company. The company will then set the oxygen up. Don't really know if staff know the difference between [CONDITION(S)]/[CONDITION(S)]. The DON stated will have to interview staff to see. Respiratory therapist is supposed to be here today. The DON stated staff are expected to follow physician orders. The DON stated he/she did not know why the respiratory company set up a [CONDITION(S)] instead of [CONDITION(S)] for Resident #5. The DON stated Respiratory Therapist comes in monthly to check on Residents oxygen. Continued interview with the Respiratory Therapist on 04/22/21 at 4:16 PM revealed that Resident #5 is currently on auto pap ([CONDITION(S)] Machine) with a setting of 6-16. The Therapist stated that when the resident goes to sleep the machine will give pressure from 6-16. The Therapist stated The machine will give the resident what is needed. When therapist was questioned whether auto pap was the same as [CONDITION(S)], therapist revealed auto pap is not [CONDITION(S)]. The Therapist stated she took Resident #5 as a Patient in December of 2020 but had not reviewed her/his machine due to COVID. The Respiratory Therapist revealed there was no progress notes or documentation related to the [CONDITION(S)] machine. Interview with Regional Director of Operation on 04/22/2021 at 4:17 PM revealed the facility has been using the respiratory company since 2018. The Director stated there is no contract with this company. Interview with Education Manager on 04/22/2021 at 5:31 revealed she was not aware that Resident #5 was on the wrong type of respiratory machine, ([CONDITION(S)] instead of [CONDITION(S)]). Interview with Administrator on 04/22/21 at 6:00 PM revealed the facility depended on Respiratory to make sure correct oxygen was given to our residents. Per the Administrator, the facility expectation was for staff to follow physician orders. The Administrator stated I was not aware that respiratory was not looking at the [CONDITION(S)]/[CONDITION(S)] machine. I expect all staff to be educated on respiratory basis training. Nursing staff was not really trained on oxygen.

Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan related to use of a [CONDITION(S)] (Bilevel Positive Air Pressure) machine for one (1) of eighteen (18) sampled residents (Resident #5). Resident #5 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the facility failed to include the use of the [CONDITION(S)] machine on the resident's plan of care. The findings include: Review of the facility's policies revealed that there was no Comprehensive Care Plan policy. Interview with Administrator on 04/22/2021 at 1:22 PM revealed the facility had no policy related to respiratory care. The Administrator stated the facility developed resident care plans following the Resident Assessment Instrument (RAI) process. Review of Resident #5 medical record revealed the facility last readmitted the resident on 02/07/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of ten (10) out of fifteen (15) indicating the resident has moderate cognitively impairment. Review of the Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders for [CONDITION(S)] settings were IPAP (Inspiratory Positive Air Pressure) 16 cm EPAP (expiratory Positive Air Pressure) 8 cm rate of 24/min and FIO2 (Fraction of Inspired Oxygen) 24%. Review of Resident #5's care plan revealed the facility had not addressed the resident's Obstructive Sleep Apnea or the use of the [CONDITION(S)] machine. Observation of Resident #5 on 4/22/21 at 10:57 AM revealed Resident #5 was resting in bed utilizing a [CONDITION(S)] (Continuous Positive Air Pressure) machine instead of a [CONDITION(S)] machine. Interview with LPN #3, on 04/22/2021 at 11:32 AM, revealed an outside respiratory company comes to the facility to set up resident respiratory machines. The LPN stated I check the machine to make sure it's working, that's all. LPN #3 stated Resident #5 currently was using a C-PAP machine. However, LPN #3 stated Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Education Manager on 04/22/21 at 5:31 PM revealed that a care plan for Resident #5's respiratory care was not done. The Education Manager (who is in training for completing MDS assessments) stated she would be responsible for developing Resident #5's care plan. The Education Manager stated I would had developed a care planned for respiratory. This is done usually when we get a discharge report from the hospital or an order from the doctor. The Education Director stated she did not know why the resident did not have a care plan addressing respiratory care completed. Interview with Director of Nursing (DON) 04/22/21 at 5:53 PM revealed the facility should have developed a care plan for Resident #5 addressing respiratory care and the [CONDITION(S)] machine use. The DON stated We recently have been going thru all care plans to make sure they are correct. We do this once a month as a team (Interdisciplinary Team) which consist of DON, unit managers, MDS, Education Trainer. The DON stated that she hadn't noticed anyone not having a care plan for oxygen use.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an appropriate discharge was completed for one (1) of two (2) sampled residents (Resident #1). Review of the record revealed Resident #1 was discharged from the facility; however, the facility failed to ensure the resident's physician documented the reason for discharge in the medical record. The facility also failed to ensure appropriate information was communicated with the receiving health care institution prior to the resident's discharge. The findings include: Review of the facility policy titled Transfer or Discharge Documentation Standard of Practice, dated October 2017, revealed when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Further review of the policy revealed that should the resident be discharged for any reason, the basis for the discharge will be communicated to the receiving facility or provider. Review of Resident #1's medical record revealed the facility admitted the resident on 06/19/2015 with [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed a discharge order dated 01/24/2020 and signed by Medical Director (MD) #2. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility conducted a Brief Interview for Mental Status (BIMS). The BIMS score was fifteen (15) and determined that the resident was cognitively intact. Further review of the MDS revealed Resident #1 requires physical assistance of two persons with transfers and personal hygiene. Review of Resident #1's Care Plan dated 10/27/2019 revealed the facility developed interventions to address the resident's potential discharge, and interventions included ongoing consideration of the resident's needs related to appropriateness of the discharge plan. Interview with the Social Services Director (SSD) on 02/26/2020 at 2:30 PM revealed she had tried several times to assist Resident #1 with placement into a drug rehabilitation facility. The SSD stated Resident #1 refused assistance with placement. On 01/24/2020, Resident #1 admitted that he/she needed help with his/her drug problem and agreed to discharge to a drug rehabilitation facility. The SSD stated that she obtained assistance with placement at a local drug rehabilitation center from the director of a local non-profit organization that provides assistance to individuals that are seeking abstinence from addiction. The SSD stated she did not relay any medical information to the drug rehabilitation facility. Per the SSD, she thought Resident #1 would automatically be admitted on ce he/she arrived at the drug rehabilitation facility. The SSD stated she assisted with obtaining transportation for Resident #1 to the rehabilitation facility and the resident was discharged from the facility on 01/25/2020. Per the SSD, a facility supervisor accompanied Resident #1 to the drug rehabilitation facility. Review of the Discharge Plan/Summary dated 01/25/2020 revealed no evidence that the receiving facility was contacted prior to Resident #1's discharge. Further review revealed Resident #1 did sign the discharge plan/summary. Phone interview with Registered Nurse (RN) #1 on 02/26/2020 at 1:40 PM revealed she was the nurse assigned to Resident #1 on 01/25/2020, the date he/she was discharged to the drug rehabilitation facility. RN #1 stated she did not call the facility and give report on Resident #1. RN #1 stated she was present when Resident #1 signed the discharge paperwork and acknowledged that Resident #1 was agreeable to the discharge plan. RN #1 reported that a copy of the discharge paperwork was given to the supervisor who accompanied Resident #1 to the drug rehabilitation facility. Phone interview with RN #2 on 02/26/2020 at 1:45 PM revealed she accompanied Resident #1 to the drug rehabilitation facility on 01/25/2020. RN #2 stated she gave the staff at the receiving facility a copy of the discharge paperwork but did not give a verbal report. Phone interview on 02/26/2020 at 3:25 PM with the Director of the non-profit organization that provides assistance to individuals that are seeking abstinence from addiction revealed the facility SSD had contacted her for assistance with placement of Resident #1 in a drug rehabilitation facility. The Director reported that she contacted staff at the drug rehabilitation facility and was advised to send Resident #1 to the drug rehabilitation facility on 01/25/2020. The Director stated she did not relay any information regarding Resident #1's medical condition or level of care required. The Director stated she thought the nursing facility staff would communicate with the receiving facility. The Director reported that on 01/25/2020 staff at the drug rehabilitation facility contacted her and advised her that Resident #1 was not going to be admitted . Per the Director, she then contacted the nursing facility and relayed the message to the administrator. Interview with the Licensed Counselor (LC) at the drug rehabilitation facility on 02/27/2020 at 1:40 PM revealed she was the staff on duty the day Resident #1 arrived. The LC advised that she had not been given any report on the Resident's condition prior to his/her arrival. The LC reported that facility staff brought the resident in, provided a copy of the discharge instructions, and left the drug rehabilitation facility. After review of the medication and functional status noted on the discharge summary, the LC stated she determined the drug rehabilitation facility could not provide the level of care and assistance that Resident #1 required. Per the LC, she contacted the nursing facility and advised that Resident #1 could not be admitted because the facility was unable to meet his/her needs. The LC stated the nursing facility refused to readmit Resident #1. The LC stated Resident #1 then contacted his/her daughter to pick him/her up. Per the LC, Resident #1 stayed approximately five (5) to six (6) hours at the drug rehabilitation facility until his/her family arrived. Interview with Resident #1's Family Member (FM) 1 on 02/26/2020 at 11:30 AM revealed Resident #1 contacted her on 01/25/2020 after arriving at the drug rehabilitation facility. FM #1 reported that Resident #1 advised her that he/she was not going to be admitted and requested that she pick him/her up. FM #1 stated she was aware that Resident #1 was being transferred to the drug rehabilitation facility on 01/25/2020 and had been assured by the nursing facility that he/she would be admitted . Per FM #1, she was agreeable to the transfer to the rehabilitation facility. However, FM #1 stated she was unable to provide care to Resident #1 and she took him/her to a local motel. Interview with the Administrator on 02/25/2020 at 2:45 PM and again on 02/27/2020 at 11:10 AM revealed she contacted Medical Director (MD) #2 regarding Resident #1's discharge. The Administrator stated that MD #1, who is Resident #1's primary physician, would not respond to the facility's request to discharge Resident #1 to the drug rehabilitation facility. The Administrator stated the Medical Director did write the discharge order and was aware of the situation. The Administrator stated she was contacted on 01/25/2020 by staff from the drug rehabilitation facility but declined to accept Resident #1 back to the facility because Resident #1 posed a danger to other residents. The Administrator reported that the discharge was done correctly and that Resident #1 agreed to the discharge. The facility staff and Administrator were unable to provide evidence that the Medical Director documented any discharge instructions or communicated with the receiving facility. Interview with MD #2 on 02/27/2020 at 3:05 PM revealed he was the Medical Director for the nursing facility. MD #2 stated that he became involved with Resident #1's discharge when MD #1 failed to take appropriate measures to ensure discharge to a drug rehabilitation facility. MD #2 reported that Resident #1 was using illicit drugs and posed a danger to other residents. MD #2 acknowledged that he gave the order to discharge Resident #1 to a drug rehabilitation facility and that the discharge was resident initiated. MD #2 offered no explanation for his failure to document a discharge note or contact the receiving facility regarding the discharge.

Based on interview, closed record review, and review of the facility's policies, it was determined the facility failed to provide an appropriate discharge for one (1) of two (2) sampled residents (Resident #1). Resident #1 was discharged from the facility on 01/25/2020 to a drug rehabilitation facility. The facility failed to ensure the receiving facility was capable of providing care and services to meet the needs of Resident #1. The facility also failed to communicate with the receiving facility regarding the medical needs of Resident #1. The findings include: Review of the facility policy titled Transfer or Discharge Documentation Standard of Practice, dated October 2017, revealed that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Further review of the policy revealed that should the resident be discharged for any reason, the basis for the discharge will be communicated to the receiving facility or provider. Review of Resident #1's medical record revealed the facility admitted the resident on 06/19/2015 with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility conducted a Brief Interview for Mental Status (BIMS); the BIMS score was fifteen (15) and determined that the resident was cognitively intact. Further review of the MDS revealed Resident #1 requires the physical assistance of two persons with transfers and personal hygiene. Review of Resident #1's Care Plan dated 10/27/2019 revealed the facility developed interventions to address the resident's potential discharge, and interventions included ongoing consideration of the resident's needs related to appropriateness of the discharge plan. The comprehensive care plan did not identify any concerns related to a pending discharge on 01/25/2020. Further review of the care plan revealed identified problems dated 07/15/2019 which included that staff assistance was needed with bed mobility (supervision to limited assistance), with transfers, locomotion with wheelchair, and dressing. The care plan revealed the resident required limited to extensive assistance with toileting and limited assistance with bathing. Interview with the Social Services Director (SSD) on 02/26/2020 at 2:30 PM revealed the SSD had contacted a local referral agency for assistance with admission of Resident #1 to a drug rehabilitation facility. The SSD reported that she had tried several times previously to assist Resident #1 with placement into a drug rehabilitation facility and that Resident #1 has refused assistance on several occasions. The SSD stated that on 01/24/2020, Resident #1 admitted that he/she needed help with his/her drug problem and agreed to discharge to a drug rehabilitation facility. Per the SSD, she obtained assistance with placement at a local drug rehabilitation center from the director of a local non-profit organization that provides assistance to individuals that are seeking abstinence from addiction. The SSD stated she did not relay any medical information to the drug rehabilitation facility. The SSD stated she thought Resident #1 would automatically be admitted on ce he/she arrived at the drug rehabilitation facility. The SSD stated she assisted with obtaining transportation for Resident #1 to the drug rehabilitation facility and Resident #1 was discharged from the facility on 01/25/2020. A facility supervisor accompanied Resident #1 to the drug rehabilitation facility on 01/25/2020. Review of the Discharge Plan/Summary dated 01/25/2020 revealed no evidence that the receiving facility was contacted prior to Resident #1's discharge. Further review revealed the facility indicated in the discharge note that Resident #1 required total help with ambulation and required assistance with personal care and grooming. Review of the discharge medications revealed Resident #1 was scheduled to receive diabetic medications including insulin injections and was scheduled opioid mediation five (5) times per day. Further review of Resident #1's medical record revealed a discharge order dated 01/24/2020 and signed by Medical Director (MD) #2. The facility was unable to provide documented evidence that communication with the receiving facility occurred regarding the medical condition and care needs of Resident #1. Phone interview with Registered Nurse (RN) #1 on 02/26/2020 at 1:40 PM revealed she was the nurse assigned to Resident #1 on 01/25/2020, the date he/she was discharged to the drug rehabilitation facility. RN #1 stated she did not call the drug rehabilitation facility and give report on Resident #1. RN #1 stated she was present when Resident #1 signed the discharge paperwork and acknowledged that Resident #1 was agreeable to the discharge plan. RN #1 reported that a copy of the discharge paperwork was given to the supervisor who accompanied Resident #1 to the drug rehabilitation facility. Phone interview with RN #2 on 02/26/2020 at 1:45 PM revealed she accompanied Resident #1 to the drug rehabilitation facility on 01/25/2020. RN #2 stated she gave the staff at the receiving facility a copy of the discharge paperwork but did not give a verbal report. Interview with the Licensed Counselor (LC) at the drug rehabilitation facility on 02/27/2020 at 1:40 PM revealed she was the staff on duty the day Resident #1 arrived. The LC advised that she had not been given any report on the resident's condition prior to his/her arrival. The LC reported that facility staff brought the resident in, provided a copy of the discharge instructions, and left the facility. After review of the medication and functional status noted on the discharge summary, the LC stated she determined that the drug rehabilitation facility could not provide the level of care and assistance that Resident #1 required. Interview with the Administrator on 02/25/2020 at 2:45 PM and again on 02/27/2020 at 11:10 AM revealed she contacted Medical Director (MD) #2 regarding Resident #1's discharge. The Administrator stated that MD #1, who is Resident #1's primary physician, would not respond to the facility request to discharge Resident #1 to the drug rehabilitation facility. The Administrator stated the Medical Director did write the discharge order and was aware of the situation. The Administrator stated she was contacted on 01/25/2020 by staff from the drug rehabilitation facility but declined to accept Resident #1 back to the facility because Resident #1 posed a danger to other residents. The Administrator reported that the discharge was done correctly and that Resident #1 agreed to the discharge. The facility staff and Administrator were unable to provide evidence that the Medical Director documented any discharge instructions or communicated with the receiving facility. Interview with MD #2 on 02/27/2020 at 3:05 PM revealed he was the Medical Director for the nursing facility. MD #2 stated that he became involved with Resident #1's discharge when MD #1 failed to take appropriate measures to ensure discharge to a drug rehabilitation facility. MD #2 reported that Resident #1 had tested positive for illicit drugs and posed a danger to other residents. MD #2 acknowledged that he gave the order to discharge Resident #1 to a drug rehabilitation facility and that the discharge was resident initiated. MD #2 offered no explanation for his failure to document a discharge note or contact the receiving facility regarding the discharge.

Based on interview and record review, it was determined the facility failed to protect the discharge rights of one (1) of three (3) sampled residents (Resident #1). The facility issued Resident #1 a discharge notice that listed the reasons for discharge as being for Resident #1's welfare and because the resident's needs could not be met in the facility, and because the health of individuals in the facility would otherwise be endangered. However, review of Resident #1's record and the discharge notice revealed no evidence of the required physician documentation related to reasons for the resident's transfer/discharge. The findings include: An interview with the Administrator on 10/22/19 at 10:07 AM revealed the facility did not have a discharge policy. A review of the closed medical record for Resident #1 revealed the facility admitted the resident on 06/13/19 with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) Assessment completed for Resident #1 dated 0[DATE] revealed the resident was assessed to be cognitively intact with a Brief Interview for Mental Status (BI[CONDITION]) score of fifteen (15). The MDS assessment indicated that the resident did not ambulate, used a wheelchair for mobility, and required the extensive assistance of two staff members for transfers. The resident also required the use of an indwelling urinary catheter, had a Stage 4 pressure ulcer to the right heel, and an unhealed surgical incision at the site of the amputation. Further review of the medical record revealed documentation of resident behaviors of cursing staff on 07/30/19, being disrespectful to staff on [DATE], and hitting an employee with a power wheelchair on 09/30/19. There was no evidence of physician documentation or orders to address the resident's behavior on 09/30/19 or the discharge on 10/01/19. A review of Social Services Director (SSD) progress notes dated 09/30/19 at 5:29 PM revealed the resident had an incident with the power wheelchair on 09/30/19. Per the SSD note, the resident stated he/she was going to run over an employee and later did hit an employee with the motorized wheelchair. Continued review of the SSD note revealed the SSD talked with the resident regarding the incident and the resident apologized stating, Sorry. However, the resident refused to be reevaluated for the safe use of the power chair, became upset, and wanted to leave the facility against medical advice. Further review of the note revealed Law Enforcement was contacted and came to the facility and spoke with Resident #1, and talked the resident into agreeing to utilize a regular wheelchair until the resident was reevaluated for the use of the power wheelchair. Further review of the record revealed the facility Administrator petitioned the court on 10/01/19 to involuntarily admit Resident #1 for psychiatric care and obtained a court order for involuntary hospitalization on [DATE]. According to the record, the resident was issued a discharge notice and transported to a psychiatric hospital on [DATE]. A review of the discharge notice dated 10/01/19 revealed Resident #1 was being discharged from the facility because the transfer/discharge was necessary for the resident's welfare and because the resident's needs could not be met in the facility, and because the health of individuals in the facility would otherwise be endangered. A review of a letter from the facility Medical Director dated 10/04/19 revealed Resident #1 had made multiple verbal and physical threats that have been reported as aggressive and at times sexually explicit. Per the letter, Resident #1 used his/her documented criminal history and multiple incarcerations to intimidate others in the facility, threatening to run over anything or anyone in his/her way. Further review of the letter revealed Resident #1 is deemed a high risk for perpetrating abuse to staff, families, and other residents. Per the Medical Director's letter, in order to protect the safety of other residents, staff, and Resident #1, alternative placement should be sought as his/her current residence as the facility is no longer appropriate. Interview with the Administrator on 10/22/19 at 11:05 AM revealed after Resident #1's behaviors of threatening to run into staff with the wheelchair and then intentionally running into staff with the wheelchair, the facility decided to discharge the resident to a psychiatric hospital and not allow the resident to return to the facility for the safety of residents and staff at the facility. According to the Administrator, the resident's physician was out of the country and not available when the incident occurred and the notice was given. The Administrator contacted the Medical Director and discussed the resident's behavior; however, no physician orders were given nor did the Medical Director evaluate Resident #1 or document the reason for the resident's discharge for the notice. The Administrator stated she petitioned the court for an involuntary admission to a psychiatric hospital and issued Resident #1 a discharge notice on 10/01/19. An interview with the Medical Director on 10/22/19 at 10:30 AM revealed the Medical Director was made aware of the incident and the discharge by the Administrator, but did not evaluate the resident or document in the medical record because Resident #1 had removed the Medical Director as Resident #1's physician. The Medical Director stated he did send a letter to the facility outlining the concerns he had with the resident's behavior and recommending alternate placement be sought.

Based on interview and record review, it was determined the facility failed to allow one (1) of three (3) residents (Resident #1) to return to the facility after a psychiatric evaluation. Resident #1 was transferred to a psychiatric hospital on [DATE] and issued a discharge notice. The psychiatric hospital did not plan to admit the resident because the resident did not meet criteria for admission. The facility would not allow the resident to return to the facility after the psychiatric evaluation. The findings include: A review of the facility policy titled Transfer Agreement, (undated) revealed the facility had entered into transfer agreements with local health care facilities to assure that services are readily available when needed by residents. An interview with the Administrator on 10/22/19 at 10:07 AM revealed the facility did not have a discharge policy. A review of the closed medical record for Resident #1 revealed the facility admitted the resident on 06/13/19 with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) Assessment completed for Resident #1 dated 0[DATE] revealed the resident was assessed to be cognitively intact with a Brief Interview for Mental Status (BI[CONDITION]) score of fifteen (15). The MDS assessment indicated that the resident did not ambulate, used a wheelchair for mobility, and required the extensive assistance of two staff members for transfers. The resident also required the use of an indwelling urinary catheter, had a Stage 4 pressure ulcer to the right heel, and an unhealed surgical incision at the site of the amputation. Further review of the medical record revealed documentation of resident behaviors of cursing staff on 07/30/19, being disrespectful to staff on [DATE], and hitting an employee with a power wheelchair on 09/30/19. There was no evidence of physician documentation or orders to address the resident's behavior on 09/30/19 or the discharge on 10/01/19. In addition, there was no evidence of any physician's orders to transfer the resident for psychiatric services. According to the record, the facility obtained a court order for psychiatric evaluation and the resident was transferred to a psychiatric hospital on [DATE]. The facility issued a discharge notice at that time listing the psychiatric hospital as the location of discharge. A review of the psychiatric hospital record for Resident #1 revealed the resident was evaluated by the psychiatric hospital and did not meet criteria for admission. According to the hospital record, Resident #1 did not have a mental illness, was not suicidal, was not homicidal, and did not want to be admitted to the hospital. Per the psychiatric hospital record, the long-term care facility would not allow Resident #1 to return. Continued review revealed Resident #1 was admitted to the psychiatric hospital because the facility would not accept the resident for readmission and the resident had nowhere else to go. An interview with the psychiatric hospital Risk Manager on 10/21/19 at 8:40 AM revealed the hospital had contacted the facility and spoken with the Administrator, who would not allow Resident #1 to return to the facility because the facility had discharged the resident. The Administrator was aware the hospital had not accepted Resident #1 for admission. Interview with the Administrator on 10/22/19 at 11:05 AM revealed after Resident #1's behaviors of threatening to run into staff with the wheelchair and then intentionally running into staff with the wheelchair, the facility decided to discharge the resident to a psychiatric hospital and not allow the resident to return to the facility for the safety of residents and staff at the facility. According to the Administrator, she was contacted by the psychiatric hospital regarding the resident not meeting criteria for admission and informed the psychiatric hospital that Resident #1 had been discharged and the facility was not accepting the resident back to due to the resident being a risk to the safety of other residents at the facility.

Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure potentially hazardous foods were held and served at the appropriate temperatures to prevent foodborne illnesses. On 06/19/19, during the lunch meal, the milk temperature was observed to be 54 degrees Fahrenheit and the temperature of the salad was 55 degrees Fahrenheit. The facility had a census of 74 residents on the day of the visit and only four (4) residents were identified by the facility as receiving tube feeding nutrition. The findings include: Review of the facility policy, Food Storage Cold Foods, revised (MONTH) (YEAR), revealed all perishable foods would be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. Interview with the Dietary Manager on 06/19/19 at 1:40 PM revealed the facility procedure during the tray line was for staff to place cold foods and drinks on ice until placed on resident trays. Observation of the noon meal on 06/19/19 revealed the last meal cart left the kitchen at 1:05 PM and the last tray was served at 1:13 PM. Food temperatures and palatability were checked at 1:14 PM (nine minutes after leaving the kitchen) on a test tray pulled from the cart after the last resident tray was served. The milk was 54 degrees Fahrenheit and the salad was 55 degrees Fahrenheit. Review of the Service Line Checklist dated 06/19/19 revealed temperatures of foods on the tray line were obtained prior to the food being served. Further review of the checklist revealed temperatures were documented as being obtained on 06/19/19 by the cook, and the milk was recorded as being 35 degrees Fahrenheit, juice was 55 degrees Fahrenheit, salad was 53 degrees Fahrenheit, and three-bean salad was 55 degrees Fahrenheit. Interview with the Cook on 06/19/19 at 1:30 PM and at 2:50 PM revealed that cold foods/drinks are placed on ice when removed from the cooler/refrigerator. The Cook stated if the cold foods were greater than 41 degrees Fahrenheit when removed from the refrigerator, the foods/drinks were placed back into the refrigerator to cool further or new foods were fixed to replace. The cook stated she placed the juice and salads back into the refrigerator after checking the temperatures and had rechecked the temperatures but forgot to document the rechecked temperatures. The Cook stated cold food and drinks are placed on ice on the tray line until placed on resident trays. Interview with the Dietary Manager on 06/19/19 at 1:40 PM and 3:00 PM revealed the juice and salad temperatures were too high when checked on 06/19/19 prior to lunch service and should have been put back into the cooler. The Dietary Manager stated the food/drink temperatures should have been rechecked/documented after cooling and before service. The Dietary Manager agreed the temperature of the milk and salad was too high at point of service.

Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to provide drinks consistent with resident preferences related to coffee choices for five (5) of thirty-eight (38) sampled residents that attended the resident council meeting. The residents stated they preferred caffeinated coffee; however, the facility only served decaffeinated coffee. The findings include: Review of the facility's policy titled Dining and Food Preferences, revised (MONTH) (YEAR), revealed the individual tray assembly ticket would identify all food items appropriate for the resident based on the resident's diet order, allergies [REDACTED]. During a resident council meeting on 02/13/19 at 10:30 AM, five (5) residents stated they preferred to drink caffeinated coffee; however, the facility only served decaffeinated coffee, and they were never given a choice of caffeinated or decaffeinated coffee. One (1) resident stated he/she quit drinking the facility's coffee, and started drinking soft drinks in order to get the caffeine. Another resident stated everyone who drank coffee should have a choice between caffeinated or decaffeinated. Interview with the Dietary Manager (DM) at 2:20 PM on 02/14/19 revealed the facility only served decaffeinated coffee. However, the DM stated she had ordered one (1) case of caffeinated coffee on 01/18/19, but it was kept in the kitchen, and if a resident preferred regular coffee they had to come to the kitchen and ask for it. However, the facility had taken no action to ensure residents were aware that they could request caffeinated coffee. The DM stated decaffeinated coffee was the only kind of coffee routinely served to the residents.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain an infection prevention and control program to ensure a safe, sanitary, and comfortable environment was maintained and that prevented the development and transmission of communicable diseases and infections for one (1) of thirty-eight (38) sampled residents. Nursing staff were observed on 02/12/19 and 02/13/19, to enter the room of Resident #1, who was on contact precautions, without donning personal protective equipment (PPE). On 02/13/19, Licensed Practical Nurse (LPN) #1 was observed to leave Resident #1's room and go into the hallway with an isolation gown on and was observed to remove the gown in the hallway. The findings include: Review of the facility's policy, Infection Control Program and Standard of Practice, revised (MONTH) (YEAR), revealed the standard of practice was to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. The policy further stated all isolation precautions and handwashing techniques for staff and residents would comply with the Centers for Disease Control and Prevention's (CDC) long-term care facility guidelines. Review of the CDC long-term care guidelines revealed healthcare personnel caring for residents on contact precautions were to wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated surfaces/areas in the resident's room. Review of Resident #1's medical record revealed the facility admitted the resident on 07/20/18 with [DIAGNOSES REDACTED]. Continued review of the medical record revealed Resident #1 was discharged from the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 01/31/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed the resident required limited assistance of two (2) or more persons to complete the task of transferring and extensive assistance of one (1) person for toileting. Review of Resident #1's comprehensive care plan, dated 01/25/19, revealed Resident #1 had a [DIAGNOSES REDACTED]. Review of the SRNA assignment sheet, undated, revealed Resident #1 was on contact precautions related to [MEDICAL CONDITION]. Observation of Resident #1 on 02/12/19 at 11:35 AM, revealed PPE was located outside the resident's room and signage was posted for visitors to report to the nurses' station prior to entry. Interview with Resident #1 revealed he/she was aware that precautions were in place related to the [DIAGNOSES REDACTED]. Observation during the noon meal on 02/12/19 at 12:45 PM, revealed State Registered Nurse Aide (SRNA) #6 entered Resident #1's room to deliver a meal tray without donning PPE. She then exited the room and continued to pass lunch trays to other residents. Observation on 02/13/19 at 11:47 AM, during wound care for Resident #1 revealed upon the surveyor's arrival to the resident's room Registered Nurse (RN) #1 and LPN #1 were both already in the resident's room; however, neither nurse was wearing PPE. Further observation revealed after observing the surveyor putting on PPE, RN #1 and LPN #1 both put on PPE. Observation during wound care for Resident #1 revealed LPN #1 was observed to leave the resident's room with the isolation gown on and removed the gown in the hallway. Interview with SRNA #6 on 02/14/19 at 9:50 AM, revealed she worked primarily as a restorative aide. She stated she did deliver Resident #1's lunch tray on 02/12/19 without putting on PPE. She stated she was not sure what kind of precautions the resident was on and that she would usually ask one of the nurses but had failed to do so. She also stated that when she opened the resident's door and entered she observed Therapy in the room, so she just placed the tray on the bedside table. Interview with LPN #1 on 02/13/19 at 12:15 PM, revealed she and RN #1 had not put on PPE because Housekeeping had just sterilized the room. However, she stated it was expected that whenever a resident was on precautions/isolation, all staff would put on appropriate PPE prior to entering the room. Interview with the Director of Nursing/Infection Control Nurse on 02/14/19 at 10:21 AM, revealed PPE should be worn every time you enter the room of a resident on contact precautions. She stated all staff are educated during orientation and annually regarding infection control procedures. She added there had also been specific education provided to the staff on Resident#1's unit related to the resident's contact precautions.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to maintain kitchen equipment in a clean and sanitary condition. Observation on 02/12/19 and 02/14/19 revealed the drip pan underneath the range top had an excessive buildup of dried and burned food debris. In addition, the drip pan underneath the range grill contained an excessive amount of oil. The findings include: Review of the facility's policy titled Equipment, revised (MONTH) (YEAR), revealed non-food contact equipment would be clean and free of debris. Observation at 9:45 AM on 02/12/19 revealed the drip pan underneath the range top was heavily soiled with a buildup of burned and dried food debris. Further observation at 10:30 AM on 02/14/19 revealed the drip pan underneath the range grill contained approximately two (2) gallons of liquid oil. Interview with a Dietary employee at 10:35 AM on 02/14/19 revealed the drip pans were supposed to be wiped/cleaned daily, and thoroughly cleaned every week. Further interview revealed the drip pans should not have that much food debris and oil.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure one (1) of eighteen (18) sampled residents received the necessary care and services to maintain bowel and bladder function. The facility assessed Resident #18 to have bowel and bladder incontinence and developed a care plan for the resident to be on a toileting program. However, Resident #18 was continent of bowel and bladder and utilized an incontinence brief because staff did not assist the resident to the bedpan/bathroom timely. The findings include: Interview with the Director of Nursing (DON) on 12/14/17 at 2:45 PM revealed the facility did not have a policy regarding toileting residents. Review of the facility's care plan policy, revised in September 2017, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident. Person-centered focused on the resident as the locus of control and supported the resident in making their own choices and having control over their daily lives. Review of the medical record for Resident #18 revealed the facility readmitted the resident on 09/29/17, with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set (MDS) with an assessment reference date of 10/03/17 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #18 was cognitively intact and interviewable. The assessment revealed the resident was incontinent of bowel and bladder. Review of the comprehensive care plan for Resident #18 dated 06/06/17 revealed the resident required an individualized toileting plan due to frequent incontinence of bowel and bladder. Observation of Resident #18 on 12/12/17 at 11:00 AM revealed the resident was lying in bed. An interview with the resident revealed the resident wore an incontinence brief but was not incontinent of bowel or bladder and was aware when he/she needed to void or have a bowel movement. Resident #18 stated she utilized an incontinence brief because staff often did not respond timely when the resident needed to use the bathroom. The resident stated he/she preferred to use a bedpan. Interviews with State Registered Nurse Aide (SRNA) #4 on 12/13/17 at 5:20 PM and SRNA #5 on 12/12/17 at 5:35 PM revealed staff provided incontinence care for Resident #18 every two hours. SRNA #5 stated she thought Resident #18 preferred to wear incontinence briefs. SRNA #4 stated she was not aware the resident preferred to use a bedpan or go to the bathroom. Interview with the DON on 12/14/17 at 2:45 PM revealed she monitored resident care and obtained reports from nursing staff but was not aware that Resident #18 was not being toileted when needed. The DON stated staff should provide a bedpan or bedside commode, or take the resident to the bathroom timely.

Based on interview, record review, and review of a job description, it was determined the facility failed to follow the plan of care for one (1) of one (1) sampled resident (Resident #1) related to Resident #1 requiring the assistance of two (2) persons for toileting but only receiving the assistance of one (1) person for toileting on 10/04/17. The findings include: Review of the POS [REDACTED]. Review of Resident #1's medical record revealed the facility readmitted Resident #1 on 09/05/17 with [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of six (6), which indicated severe cognitive impairment. Review of Resident #1's Comprehensive Care Plan revised 09/04/17 revealed Resident #1 required the assistance of two individuals for toileting and bed mobility. Review of an Employee Counseling/Disciplinary Report dated 10/04/17 revealed SRNA #10 was counselled for not following the plan of care. Interview with State Registered Nurse Aide (SRNA) #10 on 10/11/17 at 2:45 PM, revealed the SRNA was aware that Resident #1 required the assistance of two (2) staff persons for toileting and bed mobility. SRNA #10 stated on 10/04/17 when Resident #1 requested to use the bedpan, no one was available to assist the SRNA so she assisted Resident #1 to the bedpan without assistance. Interview with SRNA #10 further revealed she had gotten a written counsel for assisting Resident #1 to the bedpan without assistance of another staff person. Interview with Registered Nurse (RN) #3 on 10/11/17 at 11:49 AM, revealed SRNA #10 told RN #3 that she put Resident #1 on a bedpan without the assistance of another staff person. Further interview with RN #3 revealed SRNA #10 had been counselled for not following the plan of care. Interview with the Director of Nursing (DON) on 10/11/17 at 3:15 PM, revealed SRNA #10 should have followed the care plan for Resident #1. Further interview with the DON revealed she had not identified any other concerns with staff not following resident care plans.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) sampled residents (Resident #1). On 04/26/17 at approximately 7:00 AM, Resident #1 reported to Licensed Practical Nurse (LPN) #2 that he/she had been assisted to the bedpan the previous night (exact time unknown) by staff. However, the resident reported that staff never returned to remove the bedpan. Resident #1 stated he/she fell asleep, and when the resident woke up on 04/26/17, at approximately 7:00 AM, the resident was lying on the bedpan. The findings include: Review of the facility's policy titled Perineal Care, not dated, revealed when a resident is assisted to use the bedpan, staff will afford the resident privacy. However, the policy did not address how long staff should wait before checking on the resident and removing the bedpan. Review of the medical record revealed the facility admitted Resident #1 on 01/05/17, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated Resident #1 was moderately cognitively impaired. Further review of the MDS revealed Resident #1 was incontinent and required extensive assistance with toileting. Interview with Resident #1 on 06/21/17 at 10:30 AM, revealed that he/she had recently been left on the bedpan all night. Resident #1 could not recall the exact date that the incident occurred, or the name of the staff who had placed him/her on the bedpan. However, the resident stated that when he/she woke up the next morning he/she was still on the bedpan. The resident stated he/she had rung the call light several times to have staff remove the bedpan, but according to the resident the light was not answered. Resident #1 then stated that he/she fell asleep and woke up the next morning with the bedpan underneath him/her. Interview with SRNA #1 on 06/21/17 at 12:25 PM, revealed on 04/25/17 at approximately 10:45 PM, she placed Resident #1 on the bedpan. SRNA #1 stated that her shift ended at 11:00 PM, so she gave report to SRNA #4, who would be providing care to Resident #1. SRNA #1 stated she informed SRNA #4 that Resident #1 was on the bedpan. Interview with SRNA #4 on 06/21/17 at 2:25 PM, revealed she was responsible for Resident #1's care from 04/25/17 at 11:00 PM until 04/26/17 at 7:00 AM. However, SRNA #4 stated she was not informed by SRNA #1 that Resident #1 was on the bedpan before she started her shift at 11:00 PM. SRNA #4 further revealed that she had not placed Resident #1 on the bedpan during her shift, and stated that she had not checked Resident #1 during the night for any incontinence episodes or toileting issues. SRNA #4 denied that Resident #1 rang his/her call light for assistance during the 11:00 PM to 7:00 AM shift on 04/25-26/17. Interview with the Director of Nursing (DON) on 06/21/17 at 2:45 PM revealed when a resident was placed on a bedpan, the SRNAs should check back with the resident every few minutes to see if the resident was ready for the bedpan to be removed. The DON stated that SRNAs were also required to check on residents every two (2) hours to see if the residents had any incontinence episodes or needed toileting assistance. The DON further revealed she had not identified any concerns with residents being left on the bedpan for extended periods of time. Interview with the Administrator on 06/21/17 at 3:30 PM revealed when a resident was placed on the bedpan, the SRNAs should not leave the resident on the bedpan longer than fifteen (15) minutes. The Administrator also stated that staff should be checking on residents every two (2) hours to ensure the resident's needs were being met, and to ensure residents were not in need of incontinence care/toileting assistance.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an allegation of potential neglect was reported to the appropriate state agencies, failed to ensure residents were protected from further potential neglect, and failed to conduct a thorough investigation of the neglect allegation for one (1) of three (3) sampled residents (Resident #1). Resident #1 reported to Licensed Practical Nurse (LPN) #2 on 04/26/17 at approximately 7:00 AM that he/she had been left on the bedpan overnight. However, the facility failed to immediately initiate an investigation of the allegation, failed to ensure staff involved were not afforded the opportunity to commit further acts of neglect during the investigation, and failed to report the potential neglect to the State survey and certification agency as required, until 05/26/17, thirty (30) days after the allegation was reported by Resident #1. The findings include: Review of the facility's policy titled Abuse Prohibitions Standards of Practice, dated September 2016, revealed when reports or suspicions of neglect were made an investigation would be immediately initiated. The policy also stated that the Administrator or designee would immediately initiate an investigation into any allegation of neglect. Further review of the policy revealed the alleged perpetrator would be removed from the facility immediately, and not be allowed in the facility pending the outcome of the investigation. In addition, all incidents of alleged neglect would be reported to the appropriate state and federal agencies. Review of the medical record revealed the facility admitted Resident #1 on 01/05/17, with [DIAGNOSES REDACTED]. An interview obtained with Resident #1 on 06/21/17 at 10:30 AM, revealed that staff had placed him/her on a bedpan recently, and although he/she had rung the call light several times to be removed from the bedpan, staff failed to answer the call light. The resident then stated he/she fell asleep, and woke up the next morning with the bedpan still underneath him/her. Interview with SRNA #1, who cared for Resident #1 on 04/25/17 during the 3:00 PM to 11:00 PM shift, revealed she had placed the resident on the bedpan at approximately 10:45 PM, but reported to SRNA #4 during shift change at 11:00 PM that the resident was on the bedpan, and would need to be removed. Interview with Licensed Practical Nurse (LPN) #2 on 06/21/17 at 6:50 PM revealed at the beginning of LPN #2's shift on 04/26/17 at 7:00 AM, Resident #1 rang the call light and reported that he/she had been left on the bedpan all night after falling asleep while on the bedpan. Further review of the investigation revealed Resident #1 was unsure of the time that staff had placed him/her on the bedpan the night before. LPN #2 stated the bedpan was underneath Resident #1, and the resident's buttocks were reddened. LPN #2 stated she immediately reported the incident to the Unit Manager. Interview with the Unit Manager on 06/21/17 at 12:23 PM revealed that once she was notified of the incident by LPN #2 on the morning of 04/26/17, she went to the resident's room and assessed the resident. The Unit Manager stated that Resident #1's buttocks were red and it appeared the resident had been on the bedpan an extended amount of time. The Unit Manager stated she notified the Director of Nursing (DON) of the incident, and was instructed to talk to the SRNAs who had cared for Resident #1 during the 11:00 PM to 7:00 AM shift on 04/25-26/17. Further interview with the Unit Manager on 06/21/17 at 12:23 PM and review of an interview note made by the Unit Manager dated 04/26/17, revealed she interviewed SRNAs #2 and #4 on 04/26/17, who had been responsible for Resident #1's care during the 11:00 PM to 7:00 AM shift on 04/25-26/17. The note further revealed that the SRNAs denied being aware that Resident #1 had been on the bedpan when they came on shift at 11:00 PM on 04/25/17. However, the facility was unable to provide evidence of further investigation by the facility other than the interview note made by the Unit Manager on 04/26/17. The facility failed to interview SRNA #1 regarding the allegation, failed to interview other residents for potential neglect issues, failed to interview other staff members who were working in the facility during the 11:00 PM to 7:00 AM shift on 04/25-26/17, failed to protect other residents from further potential neglect, and failed to immediately notify the State survey and certification agency of the potential neglect allegation as required until 05/26/17, after the state agency responsible for adult protection entered the facility to investigate the allegation of potential neglect involving Resident #1. During an interview with the Director of Nursing (DON) on 06/21/17 at 2:45 PM, the DON stated she had interviewed SRNA #2 and SRNA #4, but had not documented the interviews. Further interview revealed she was not aware that the allegation of potential neglect was required to be reported to the authorities including the State survey and certification agency. Interview with the Administrator on 06/21/17 at 3:30 PM revealed the neglect allegation had been discussed in the morning meeting on 04/26/17 but that an official investigation had not been initiated due to miscommunication between administrative staff. The Administrator stated the investigation conducted immediately after the incident should have been more thorough and reported to the appropriate state agencies.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the medical record was complete and accurate for two (2) of twenty-four (24) sampled residents (Resident #1 and Resident #8). Resident #1's medical record was not complete and accurate as it related to pressure sores when staff did not follow the facility's policies and procedures for documentation of wounds. Furthermore, according to the Assessment Date, all Body Map Assessments provided by the facility for the period of time between 02/25/15 and 04/15/15 appeared to have been completed on 07/28/15, the day they were requested by the State Survey Agency. (Refer to F280 and F314.) In addition, the facility failed to ensure Resident #8's medical record included documentation to reflect the resident's refusal of scheduled wound care. Furthermore, the facility failed to ensure the narcotic count sheets for one (1) of two (2) medication carts on the North Hall were complete with nurses' signatures. The facility's failure to ensure the medical record for each resident having pressure sores was complete and accurate was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/29/15, and was determined to exist on 02/23/15. The facility was notified of the Immediate Jeopardy on 07/29/15. An acceptable Allegation of Compliance (AOC) was received on 08/06/15, alleging removal of the Immediate Jeopardy on 08/05/15. The State Survey Agency determined the Immediate Jeopardy was removed on 08/05/15 as alleged, which lowered the scope and severity to D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Review of the facility's Quick Reference Guide titled Pressure Ulcer Assessment, undated, revealed the results of all wound assessments were to be documented in the medical record. Continued review revealed the nurse should document the physical characteristics of each pressure ulcer, including location, category/stage, size, tissue type, color, condition of the surrounding skin, wound edges, drainage, odor, and a description of any sinus tracts, undermining or tunneling (characteristics observed with highly staged or complex ulcers). Review of the facility's policy titled Skin System Policy and Procedure, revised 08/14, revealed the intent of the policy was to promote the prevention of pressure ulcer development and promote healing of pressure ulcers that were present. Continued review revealed an interdisciplinary approach would be used to assist in the appropriate documentation of wound classification and/or pressure ulcer staging. According to the policy, a skin assessment would be completed upon admission and weekly thereafter. Interview with the Assistant Director of Nursing (ADON) on 07/24/15 at 5:00 PM, revealed the facility did not have a policy related to maintaining complete and accurate medical records. She explained the facility practice for skin assessments and related documentation as follows: each resident was to have a head-to-toe skin assessment each week; the nurse performing the assessment was to initial the Treatment Administration Record (TAR) to indicate the assessment was done as scheduled; the nurse was to complete documentation in the computer; the nurse was to indicate whether the skin was intact or not, and if any areas that were identified were new or existing; if there was any non-intact skin, the nurse was to document on the Body Map, which provides a visual diagram of exactly where each area is located, and allows the nurse to label each area according to the type of each wound; the nurse was responsible for documenting all problem areas on the Wound Assessment Report, where a detailed description of any non-intact areas was entered. The ADON stated every area was to be measured by the nurse and entered on the report. Continued interview revealed if the nurse followed the protocol correctly, all wounds would be identified and when the nurse logged into the computer system, he/she could tell if a particular wound was new or previously identified. She further stated any new wound was to be reported to the Physician for treatment orders, which were to be entered on the TAR; the nurse completing the skin assessment should be able to tell at a glance if a specific wound had been identified previously by looking at the TAR. Review of the closed clinical record revealed the facility admitted Resident #1 on 10/02/13 with [DIAGNOSES REDACTED]. Review of the Wound Assessment Report, dated 10/19/14, revealed Resident #1 was assessed to have a new area of denuded skin on the left inner buttock. The wound was assessed to be 0.3 centimeters (cm) by 0.2 cm. Continued review of the Wound Assessment Reports provided by the facility revealed the next report was dated 12/02/14. The report indicated an area of irritation/excoriation on the coccyx was newly identified, measured 2.8 cm by 2.0 cm, and was described as denuded skin. Although the area was classified as newly identified, the status was documented as deteriorated. No other areas, including the left inner buttock identified on 10/19/14, were mentioned. No other Wound Assessment Reports for the period between 10/19/14 and 02/23/15 were provided. Review of the Body Map Assessments dated 12/23/14, 01/23/15, and 02/23/15 revealed Resident #1 was assessed to have excoriation to the left buttock area, which was non-pressure. No other Body Map Assessments for the period of time between 10/19/14 and 02/23/15 were provided. Review of the Nurse's Notes for October 2014 through February 2015 revealed Resident #1 was documented to have denuded skin to the buttocks beginning on 10/19/15. Continued review of the Nurse's Notes, and review of the comprehensive Care Plan, the TAR, the Skin Inspection Report, the Wound Assessment Reports, and the Body Map Assessments for the same period of time revealed no documented evidence of any other skin concerns or any pressure ulcers. However, review of hospital records revealed Resident #1 was transported to the Emergency Department (ED) on 02/23/15, and was admitted by the hospital. Review of the Physician's Note made in the ED, and review of photographs taken when the resident was admitted , revealed the presence of multiple abrasions, Stage I and Stage II pressure areas on the buttocks, and areas of necrotic tissue on both heels. Review of the facility's Nurse's Notes revealed Resident #1 went out to the hospital on [DATE], and was readmitted by the facility on 02/25/15 with multiple areas of skin breakdown. The facility documented the pressure areas present when the resident returned, and identified new areas on the coccyx and the left hip, on 03/05/15 and 03/16/15, respectively. However, there was no documented evidence the facility ever identified any additional pressure ulcers, particularly on the feet, ankles, or toes. Review of Wound Assessment Reports for the period between 02/25/15 and 04/15/15 revealed the following significant findings: on 03/05/15, the assessment did not address the pressure ulcers on the left and right buttocks, but did describe an 8.0 cm x 2.5 cm area of excoriation on the coccyx; on 03/10/15, the assessment only referred to the SDTI on the right great toe; on 03/11/15, the assessment addressed the ulcers on the heels but no other areas; on 03/16/15, two (2) new wounds to the left hip were identified as a 2.0 cm x 1.5 cm Stage II pressure ulcer, and a 13 cm x 9.2 cm Stage I pressure ulcer - no other wounds were documented on this date; on 03/17/15, twelve (12) days after the coccyx area was described on 03/05/15, the area was reassessed to have deteriorated to a 10.75 cm x 7.0 cm pressure ulcer which was unstageable due to the presence of slough and eschar; on 03/25/15, the facility assessed and documented the coccyx and heel ulcers but the left hip ulcer was not assessed again until 03/31/15, fifteen (15) days after it was identified on 03/16/15, when the two (2) original ulcers had merged into one Stage II ulcer at 5.5 cm x 1.5 cm. The last Wound Assessment Report completed by the facility on 04/13/15, addressed four (4) areas, the coccyx, the left hip, and the left and right heels. On 07/28/15, the State Survey Agency requested a copy of all Body Map Assessments completed between 02/23/15 and 04/15/15. The facility provided a reprint of all Wound Assessment Reports during the time period. The Wound Assessment Reports themselves were identical to those previously provided by the facility; however, they had been reprinted and now included a Body Map Assessment printed on the back of each Wound Report. Review of the Reports revealed each Wound Assessment Report included the specific date the assessment was completed and the date it was printed (07/28/15); however, review of the Body Map Assessments on the back of each Wound Report revealed all were identical, and each included an Assessment Date of 07/28/15, in addition to the print date of 07/28/15. The same four (4) pressure areas, including the left hip, left buttock, and the bilateral heels, were pinpointed on each Body Map Assessment and printed on the Wound Assessments Reports beginning 02/26/15 through 04/13/15; however, according to the Wound Reports, the left hip ulcer was not identified until 03/16/15. In addition, each Body Map reflected an area on the left buttock, the same area documented as excoriation/denuded skin prior to 02/23/15, although the color-coded symbol was changed from green to red, which indicated the wound progressed from a non-pressure area to a pressure ulcer. Furthermore, there was no documented evidence on the Body Map Assessments to reflect the merging of multiple pressure areas on the buttocks into one large pressure ulcer over the coccyx. Review of hospital records revealed Resident #1 was hospitalized again on 04/15/15. Review of photographs taken at the hospital, and review of wound assessment notes, revealed the resident had five pressure areas not previously identified by the facility, located on the bilateral ankles, left great toe, right foot, and right fifth toe. Review of the April 2015 TAR for Resident #1 revealed treatments were in place for the left hip, coccyx, and both heels prior to the resident being discharged to the hospital. Continued review revealed no documented evidence of treatments in place for any other areas. Subsequent interview with the ADON on 08/03/15 at 12:40 PM, revealed she became the formal DON on 07/31/15. Continued interview revealed there was discussion about Resident #1 in Skin Committee meetings, but she was unable to locate or provide any notes from the meetings. The DON recalled the resident's coccyx, left hip, and heel wounds, but did not remember anything about any other wounds on the resident's feet or ankles. Review of the TAR for April 2015 with the DON revealed no treatment orders were in place for any wounds other than the coccyx, left hip, and heels. The DON acknowledged the additional wounds present when Resident #1 arrived at the hospital on [DATE] were not documented in facility records. The DON could think of no reason for how the wounds were missed other than the nurses assumed they were existing, and they failed to follow the facility's policies related to assessing, measuring, and documenting newly identified sores. She further acknowledged the wounds on the resident's right foot, left toe, and bilateral ankles were new at some point; however, with the lack of documentation it was impossible to know when they developed. 2. Review of the facility's policy titled Refusal of Treatment, revised November 2010, revealed if a resident refused treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services would interview the resident to determine what and why the resident was refusing in order to try to address the resident's concerns and explain the consequences. Continued review revealed if the resident refused to accept treatment, detailed information relating to the refusal should be entered into the resident's medical record to include at least the following: the date and time staff attempted to give a medication or treatment, the medication or treatment refused, the resident's response and reason for the refusal, the name of person attempting to administer the treatment, that the resident was informed of the purpose of the treatment and the consequences of not receiving the medication/treatment, the resident's condition and any adverse effects due to such refusal, the date and time the physician was notified as well as the physician's response, all other pertinent observations, and the signature and title of the person recording the data. Review of the clinical record revealed the facility admitted Resident #8 on 07/14/15 with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 07/14/15, revealed Resident #8 was alert and oriented with no memory problems. Review of Resident #8's physician's orders [REDACTED].#8's Treatment Administration Record (TAR), dated July 2015, revealed the resident to have an order for [REDACTED]. Further review revealed wound care was refused on 07/15/15 during the 7:00 AM shift, and not performed on 07/14/15, 07/15/15, 07/16/15, 07/17/15, or 07/20/15 on the 7:00 PM shift; however, there was no documented evidence to indicate why the care was refused or not performed. Interview with Licensed Practical Nurse (LPN) #4 on 07/24/15 at 6:56 AM, revealed she was Resident #8's primary nurse on the 7:00 PM shift. Further interview revealed she would normally perform wound care between 10:30 PM and 7:30 AM. Continued interview revealed Resident #8 had refused his/her wound care, reporting to LPN #4 that he/she was already tired, sleepy, and it was too late; however, there is no documented evidence the resident had refused care. LPN #4 reported she should have documented each refusal of care or treatment with detailed documentation; however, she got busy and forgot. Interview with the Director of Nursing (DON), on 08/03/15 at 6:25 PM, revealed if a resident refused care, her expectation was for staff to document in the medical record to reflect the refusal. ***The facility provided an acceptable Allegation of Compliance (AOC) on 08/06/15. The facility implemented the following actions to remove Immediate Jeopardy: 1) Resident #1 had a Pressure Ulcer Care plan developed which was in place and reflected interventions for protection of Skin and Skin Integrity, to promote healing, to prevent infection and development of further pressure ulcers; however, there was undocumented evidence that the resident's care plan was not followed and/or revised for any identified pressure ulcer. It was reported the clinical record of Resident #1 was incomplete. The count of the pressure ulcers noted on Resident #1 did not match the photographic evidence, and documentation needed to validate care and treatment was provided for these pressure ulcers was not provided and had to be considered as lost or nonexistent. There was no documented evidence of a Comprehensive Skin Assessment for Resident #1 prior to discharge. 2) One hundred percent of the resident census (71) had head to toe skin assessments completed by 08/04/15 by the Director of Nursing, Unit Managers, Staff Development RN, and Wound Nurse. No additional unidentified pressure ulcers were identified. 3) The Weekly Skin Assessment Sheet (exhibit A) was reviewed and approved by the QA Committee on 07/30/15; the QA Committee consists of the Administrator, Director of Nursing, MDS, Social Services, Unit Managers, Rehabilitation Therapy Director, Staff Development RN, and the Medical Director. It is to be used weekly by the Charge Nurse, Wound Care Nurse, and/or Unit Manager for each in-house resident to identify any newly developed and/or existing pressure ulcers. Any new pressure ulcers identified will be communicated to the physician for potential treatment orders and to the Director of Nursing and to the Interdisciplinary Team (IDT) to implement interventions and update the comprehensive plan of care. The IDT consists of the Director of Nursing, Unit Managers, Dietary Manager, Rehabilitation Therapy Manager, and Social Services. The results of the Weekly Skin Assessment sheets will be reviewed a minimum of five (5) times per week by the Director of Nursing and/or the Assistant Director of Nursing and the Administrator. Any newly developed pressure ulcers will be reported immediately to the Director of Nursing and the Administrator. Staff responsible for the use of the Weekly Skin Assessment Sheet includes but is not limited to the Charge Nurse, Unit Manager, Weekend Manager, and the Director of Nursing. The Administrator will be responsible for oversight and to report to the QA Committee at least monthly or as outlined in this plan. 4) Licensed Nursing Staff have been in-serviced by the DON, Unit Managers, and Staff Development RN with a completion date of 08/04/15 on how to identify risk factors for developing pressure ulcers and how to develop a comprehensive care plan to address: prevention for breakdown or further breakdown, interventions to promote healing and prevent infection, and interventions to include assessment, monitoring, and updating the comprehensive care plan with changes in residents' condition that may indicate a comprehensive review to update interventions as indicated and healing or decline of pressure ulcers, which is included in the Facility Skin System. The Braden Scale tool and the resident's medical history will be reviewed with the licensed nurses to assist in developing a comprehensive plan of care for pressure ulcers upon admission, readmission, and/or changes in the resident's condition. In addition, the Director of Nursing, Unit Managers, and or RN Staff Development Coordinator provided re-education for the Certified Nursing Assistants on skin reporting utilizing the Stop and Watch Form during bathing and ADL care by 08/04/15. 5) All residents have been assessed for the potential of skin breakdown using the Skin Assessment Worksheet (exhibit A), the Braden Tool, and the Stop and Watch tool (exhibit B), and current medical history with review and update of their comprehensive care plans to ensure risks have been identified and interventions were implemented to promote healing and prevent further breakdown, infection, and any unidentified pressure ulcers. This was completed on 08/04/15 by the DON, Unit Managers, Staff Development RN, and/or RN Supervisor. Information from the evaluation will determine if additional assessment and interventions would be necessary for each resident in the facility. Appropriate interventions were implemented and Care Plans updated initially by the DON and Staff Development RN, and thereafter by the RN Unit Managers and Charge Nurse by 08/04/15. Skin assessments were completed on the total in-house census of 71 residents and no unidentified pressure ulcers were found. 6) The Regional Quality Manager for Preferred Care Partners Management Group provided education regarding the Weekly Skin Management Guidelines on or before 08/04/15 for the Interdisciplinary Team (IDT) which consisted of the DON, Unit Managers, Wound Nurse, Dietary Manager, Therapy Manager, and Social Services Director. 7) Initial education for the Director of Nursing, Staff Development, and Unit Managers was provided by the Preferred Care Partners Management Group, Regional Quality Manager by 08/04/15 regarding use of the Care Plan as a communication tool to direct resident care and to follow the comprehensive plan of care related to pressure ulcers, and consistently following the skin care protocol which included the following: accurate weekly skin assessments, reporting of new or existing identified pressure ulcers, accurate pressure wound assessments to identify detection of decline or healing process, to identify risk issues to prevent breakdown and to promote healing and to effectively implement a comprehensive care plan and interventions, to accurately document pressures regarding healing or decline to include measurement and description, and to obtain physician's orders [REDACTED]. 8) The remaining Licensed Facility Nursing Staff education was educated by the DON, Unit Managers, and Staff Development RN with a completion date of 08/04/15 with a post-test given. As of 08/04/15, a total of 15 of 20 licensed nurses have received this education and as of 08/04/15, a total of 22 of 34 nurse aides received the education by the Staff Development RN, DON, Unit Managers, or Wound Nurse. All nursing staff received the required wound education prior to working their next shift by the Staff Development RN, Unit Managers, Wound Nurse, or DON. All new nursing hires have been educated during general orientation, with a post-test given by the Staff Development RN prior to their working on a unit regarding following the comprehensive care plan interventions, reporting skin breakdown to licensed nurses and the Stop and Watch Tool, communication with the physician in developing a plan of care, including treatment if indicated, to promote healing, prevent infection, and prevent further breakdown. Education also included how to perform an accurate wound assessment and identification of causal factors of breakdown in order to implement effective interventions. 9) The Quality Assurance Committee members (Administrator, Director of Nursing, MDS, Unit Managers, and Staff Development RN) reviewed and approved the education material on 08/04/15. Records of the in-service on the educational materials included signatures of attendance, signature of in-services received, and copies of testing for efficacy of the training. Nursing in-service education on the subjects noted was completed by 08/04/15. 10) Members of the QA Committee developed a tool on 07/31/15 to validate assessments and Care Plans were being utilized per policy protocol. This was implemented on 07/31/15 and is ongoing. In addition, the DON, Unit Managers, Staff Development RN, or Wound Nurse are responsible to reassess 5 resident skin assessments per week to ensure accuracy of licensed nurses' skin assessment within 24 hours of the resident's scheduled 7-day assessment. This will be updated to the QA Committee approved pressure ulcer tracking tool as completed by the DON, Staff Development RN, Unit Managers, and Wound Nurse. Any concerns identified with accuracy of the skin assessment will have re-education provided by the Director of Nursing, Unit Managers, Staff Development RN, or Wound Nurse to the licensed nurse weekly for 3 months until 10/30/15. The Director of Nursing will discuss the results of accuracy and if any education should be provided regarding the reassessments during the next scheduled QA Meeting. 11) Monitoring will be done by the Administrator, DON, Staff Development RN, RN Unit Managers, and Wound Nurse. Any issues identified will be corrected immediately and taken to the next scheduled QA meeting for review and a revised plan of action if warranted. The Administrator will provide oversight on a weekly basis and this practice will become effective on 07/31/15. 12) QA Meetings will be held with two or more team members in attendance daily 5 days a week and on weekends if necessary for review of data to ensure compliance: completion and accuracy of skin assessments and comprehensive care plan for any new and/or existing pressure ulcers. Any findings of newly developed or existing pressure ulcers and the interventions implemented will be reviewed for effectiveness or need for additional interventions until the situation is controlled. QA Committee members will review minimally 5 days a week for 30 days or additionally as necessary until 09/01/15; then one time weekly until 09/30/15 or as needed; then monthly thereafter or as needed sooner. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Resident #1 was no longer in the facility. 2) Review of the facility's documentation dated 07/30-08/04/15, and interviews with Unit Manager (UM) #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Staff Development RN on 08/06/15 at 2:45 PM, and the DON on 08/06/15 at 4:40 PM, revealed a skin assessment was conducted for each resident in the facility and no additional unidentified pressure ulcers were identified. 3) Review of the facility's 100% skin assessment sheets revealed facility staff utilized the Weekly Skin Assessment Sheet approved by the QA committee on 07/30/15. Interviews with UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Staff Development RN on 08/06/15 at 2:45 PM, the DON on 08/06/15 at 4:40 PM, Licensed Practical Nurse (LPN) #1 on 08/06/15 at 1:25 PM, RN #1 on 08/06/15 at 2:55 PM, and LPN #3 on 08/06/15 at 3:25 PM, revealed the Weekly Skin Assessment Sheet was being utilized to conduct weekly skin assessments and to conduct skin assessments for new or readmitted residents to the facility. Per interview with LPN #1 on 08/06/15 at 1:25 PM, RN #1 on 08/06/15 at 2:55 PM, LPN #3 on 08/06/15 at 3:25 PM, UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Therapy Manager on 08/06/15 at 2:30 PM, the Staff Development RN on 08/06/15 at 2:45 PM, the Social Services Director on 08/06/15 at 3:15 PM, and the DON on 08/06/15 at 4:40 PM, revealed any concerns identified with a newly developed pressure ulcer and/or existing pressure ulcers would be reported to the physician, to the DON, and to the IDT to implement interventions and to update the resident's comprehensive plan of care. According to staff interviews, no new pressure ulcers have been identified since 07/29/15. Review of the documentation dated 08/03-05/15, and interview with the Administrator on 08/06/15 at 3:00 PM, revealed he provided oversight to ensure the skin assessments were done correctly in accordance with the facility's protocols and training. 4) Review of the In-service Training related to risk factors for the development of pressure ulcers and the development of a comprehensive care plan revealed education had been conducted for the Licensed Staff by the Staff Development RN on 08/03/15 and 08/04/15, which included the prevention of skin breakdown, interventions to promote healing and to prevent infection, skin/wound assessment, and monitoring and updating the residents' comprehensive care plan. Interview conducted on 08/06/15 at 1:25 PM with LPN #1, 08/06/15 at 2:55 PM with RN #1, 08/06/15 at 3:25 PM with LPN #3, 08/06/15 at 1:20 PM with UM #1, and 08/06/15 at 2:05 PM with UM #2 revealed all the staff interviewed had attended the training and was knowledgeable related to risk factors related to the development of pressure ulcers and the development of the comprehensive care plan for residents with pressure ulcers to include prevention, healing, wound assessment, and monitoring for infection. Staff was also able to verbally relate the purpose of the Stop and Watch Form and to state how to communicate issues/concerns with pressure ulcers with other staff. Staff also completed a post-test. Per interview with the Administrator on 08/06/15, at 3:00 PM, the facility had not hired any new employees since 07/29/15; however, all new employees would receive training on the facility's skin care protocols during orientation when hired by the facility. Further review of the In-service Training dated 08/03-05/15, revealed the Staff Development RN provided education for the Certified Nurse Aides (CNAs) regarding skin reporting utilizing the Stop and Watch form during bathing and ADL care. Interviews conducted on 08/06/15 with CNA #16 at 1:21 PM, CNA #20 at 1:28 PM, CNA #1 at 1:41 PM, CNA #5 at 1:47 PM, CNA #15 at 1:55 PM, CNA #7 at 2:00 PM, CNA #22, at 2:05 PM, CNA #23 at 2:07 PM, CNA #18 at 2:20 PM, and CNA #24 at 3:40 PM verified each staff member had attended the training and was knowledgeable about the use of the Stop and Watch form and reporting any changes in a resident's skin condition. 5) Review of the facility's documentation dated 07/30-08/04/15, and interviews with UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Staff Development RN on 08/06/15 at 2:45 PM, and the DON on 08/06/15 at 4:40 PM, revealed a skin assessment was conducted for each resident in the facility and no additional unidentified pressure ulcers were identified. 6) Review of In-service Training dated 08/03/15, revealed the Preferred Care Partners Management Group provided training regarding the Weekly Skin Management Guidelines for the Interdisciplinary Team (IDT) which consisted of the DON, Unit Managers, Wound Nurse, Dietary Manager, Therapy Manager, and Social Services Director. Interviews conducted with UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Therapy Manager on 08/06/15 at 2:30 PM, the Staff Development RN on 08/06/15 at 2:45 PM, the Social Services Director on 08/06/15 at 3:15 PM, and the DON on 08/06/15 at 4:40 PM revealed each of the IDT members attended the training and had knowledge of the Weekly Skin Management Guidelines. 7) Review of In-service Training dated 08/03/15, revealed the Regional Quality Manager provided training for the DON, Staff Development Nurse, and Unit Managers related to use of the care plan as a communication tool and following the comprehensive care plan and to consistently follow the facility skin care protocols. Interviews on 08/06/15 with UM #1 at 1:20 PM, UM #2 at 2:05 PM, the Staff Development RN at 2:45 PM, and the DON at 4:40 PM, confirmed each of the staff members attended the in-service training and had knowledge of the care plan process and the facility skin care protocols. In addition, a post-test was provided. 8) Review of the In-service Training related to risk factors for the development of pressure ulcers and the development of a comprehensive care plan revealed education had been conducted for the Licensed Staff by the Staff Development RN on 08/03/15 and 08/04/15, which included the prevention of skin breakdown, interventions to promote healing and to prevent infection, skin/wound assessment, and monitoring and updating the resident's comprehensive care plan. Interview conducted on 08/06/15 at 1:25 PM with LPN #1, 08/06/15 at 2:55 PM with RN #1, 08/06/15 at 3:25 PM with LPN #3, 08/06/15 at 1:20 PM with UM #1, and 08/06/15 at 2:05 PM with UM #2 revealed all the staff interviewed had attended the training and was knowledgeable related to risk factors related to the development of pressure ulcers and the development of the comprehensive care plan for residents with pressure ulcers to include prevention, healing, wound assessment, and monitoring for infection. Staff was also able to verbally relate the purpose of the Stop and Watch Form and to state how to communicate issues/concerns with pressure ulcers with other staff. Staff also completed a post-test. Per interview with the Administrator on 08/06/15 at 3:00 PM, the facility had not hired any new employees since 07/29/15; however, all new employees would receive training on the facility skin care protocols during orientation when hired by the facility. 9) Review of the Daily QA Meeting Sign-In Sheets revealed the QA Committee

Based on observation, interview, record review, review of facility policy, and review of professional literature including the website for the National Pressure Ulcer Advisory Panel and the online version of The Journal for Ostomy Wound Management, it was determined the facility failed to ensure newly developed pressure ulcers were identified promptly, and appropriate treatments implemented, for two (2) of twenty-four (24) sampled residents (Residents #1 and #11). The facility failed to identify tissue injury on Resident #1's heels prior to his/her transfer to the hospital on [DATE], where the Physician and the nurse documented the presence of necrotic tissue on both heels. After Resident #1 returned to the facility on [DATE], several pressure areas were tracked with regular assessments; however, on 04/15/15, the resident was again transferred to the hospital, where five (5) previously unidentified pressure ulcers were photographically documented. Facility records review revealed no documented evidence that these five (5) areas had been identified, assessed, monitored, or treated by the facility, while Resident #1 resided in the facility, as they should have been according to the facility's policy. (refer to F280 and F514). In addition, observation of a skin assessment for Resident #11 on 07/24/15 revealed the resident had a deep tissue injury to the left heel that had not previously been identified by the facility. The facility's failure to ensure each resident having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/29/15, and was determined to exist on 02/23/15. The facility was notified of the Immediate Jeopardy on 07/29/15. An acceptable Allegation of Compliance (AOC) was received on 08/06/15, alleging removal of the Immediate Jeopardy on 08/05/15. The State Survey Agency determined the Immediate Jeopardy was removed on 08/05/15 as alleged, which lowered the Scope and Severity to D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Skin System Policy & Procedure, revised August 2014, revealed the facility would ensure the provision of treatment and services to promote healing, prevent infection, and prevent new sores from developing. Continued review revealed steps in the procedure included the following: all residents were to be assessed for skin needs upon admission or readmission and weekly thereafter; the Skin Committee would meet at least weekly to review the care of residents with pressure ulcers; staging and measuring would be performed by the assigned nurse to maintain continuity in documentation of progression of wound healing; and the assigned nurse manager would provide oversight of the resident's skin care and report to the Skin Committee on a weekly basis. Further review revealed upon identification of skin impairment the nurse would: obtain treatment orders from the Physician; update the Treatment Administration Record (TAR); and notify the assigned nurse manager and the Skin Committee of the change in the resident's skin condition requiring additional oversight and monitoring. Review of the facility's Skin Committee Process Guidelines, reviewed August 2014, revealed all residents with pressure sores or other complex wounds would be reviewed by the Skin Committee. Continued review revealed the Skin Committee would provide documentation to support their findings and recommendations. Review of the facility's Quick Reference Guide, titled Pressure Ulcer Assessment, undated, revealed pressure ulcers were to be assessed at least weekly after identified, and results of the assessments were to be documented to include the following: location; category or stage of the wound; size, including length, width, and depth; type of tissue and color of the wound; condition of the surrounding skin; a description of wound edges, sinus tracts, undermining, or tunneling; the presence of any drainage; and odor. 1. Review of the closed clinical record revealed the facility admitted Resident #1 on 10/02/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/09/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of Section G for functional status revealed Resident #1 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Review of Section H for bowel and bladder function revealed Resident #1 was frequently incontinent. Review of Section M for skin condition revealed the facility did not assess Resident #1 to have any Stage I or higher pressure ulcers, or to be at risk for developing a pressure ulcer. Review of the Nurse's Notes for 10/19/14, revealed Resident #1 had denuded skin to the left buttock which was being treated with [MEDICATION NAME] ointment. Review of the Note dated 10/25/14, revealed the resident's skin was intact; however, on 10/29/14, the Nurse's Notes reflected denuded skin to the bilateral buttocks with a new physician's orders [REDACTED]. On 11/01/14, the resident was documented to have skin intact. Continued review of the Nurse's Notes revealed daily, between 11/08/14 and 12/07/14, Resident #1 had denuded skin to the buttocks. Further review revealed the presence of denuded skin on 12/13/14, 12/20/14, 12/27/14, 01/09/15, 01/11/15, 01/17/15, and 01/24/15. Interview with Registered Nurse (RN) #2 on 06/18/15 at 2:52 PM revealed she described denuded skin to be superficial, irregular in shape, and caused by friction, not pressure. She stated the treatment was a barrier cream. Interview with the Director of Nursing (DON) on 06/23/15 at 10:40 AM, revealed she described denuded skin to be related to moisture, like diaper rash. She stated it was not a pressure sore. According to Medicinenet.com, denuded skin refers to erosion of some or all of the epidermis (the thin outermost layer of the skin), leaving a denuded surface. Review of the Comprehensive Care Plan for Resident #1 revealed the problem of risk for skin impairment with an onset date of 12/10/13. There was no documented revision date after that date. Continued review revealed the stated goals included the following: the resident would remain intact and free of skin breakdown or irritation for 90 days, with the stated goal date of 05/31/15. Further review of the Care Plan revealed an intervention for weekly skin checks; however, the Care Plan did not contain documented evidence to reflect any specific skin problems prior to 02/25/15 when Resident #1 was readmitted from the hospital, although according to the Nurses Notes, the resident had denuded skin on the buttocks beginning 10/19/14. In addition, the Care Plan did not include interventions related to monitoring of any identified skin concerns through utilization of the Body Map Assessments or Wound Assessment Reports. (The Body Map Assessments were utilized by the facility to document the location of areas with non-intsact skin) Interview with RN #4, on 07/29/15 at 2:40 PM, revealed the assigned nurse was to perform a head-to-toe skin assessment for each resident weekly. She explained the weekly documentation was first completed on the Skin Inspection Report, where the nurse selected one of the following options: skin intact; skin not intact-existing; or skin not intact-new. Continued interview revealed if the resident's skin was intact, the nurse did not have to document further. If the skin was not intact, the nurse was responsible for completing or updating the Body Map Assessment for a visual indicator of where the problem areas were located on the body, and a Wound Assessment Report where the wound characteristics such as type of wound, pressure-ulcer staging, measurements, and the presence of any drainage or odor was documented. Further interview revealed complete documentation was important to allow for tracking of new and existing wounds to evaluate improvement or deterioration in the wounds, and to determine if treatment regimens were effective. Review of the Skin Inspection Report generated by the facility's computer charting system revealed Resident #1 was assessed on 01/03/15, 01/09/15, 01/11/15, 01/17/15, 01/24/15, 02/07/15, 02/14/15, and 02/21/15 for skin status of Skin Not Intact - Existing, which indicated there were no new pressure areas or skin problems. Review of the Body Map Assessments dated 12/23/14, 01/23/15, and 02/23/15 revealed Resident #1 was assessed to have excoriation to the left buttock area, which was non-pressure. Continued review revealed no documented evidence any other Body Map Assessments were completed in conjunction with the weekly Skin Inspection Reports between 12/23/14 and 02/23/15. Review of the Wound Assessment Report, dated 10/19/14, revealed Resident #1 was assessed to have a new area of denuded skin on the left inner buttock. The wound was assessed to be 0.3 centimeters (cm) by 0.2 cm. Continued review of the Wound Assessment Reports provided by the facility revealed the next report was dated 12/02/14. The report indicated an area of irritation/excoriation on the coccyx was newly identified and measured 2.8 cm by 2.0 cm. Further review revealed the irritation/excoriation was described to be denuded skin. Although the area was classified as newly identified, the status was documented as deteriorated. Neither Wound Assessment Report gave an indication of whether the areas identified were open or not opened. Further interview with the Director of Nursing (DON), on 06/23/15 at 10:40 AM, revealed the denuded areas were not open wounds but were very superficial, like diaper rash. No other areas, including the left inner buttock identified on 10/19/14 were mentioned. Furthermore, no documented evidence of any other Wound Assessment Reports completed between 10/19/14 and 02/23/15 were provided by the facility. Interview with RN #4 on 07/29/15 at 2:40 PM, revealed each weekly Skin Inspection Report for non-intact skin should have a corresponding Body Map Assessment and Wound Assessment Report. However, there was no documented evidence these assessment forms were completed according to the facility's policy and practices. Review of the Nurse's Notes for February 2015 revealed Resident #1 continued to have denuded skin to the buttocks, as documented on 02/08/15, 02/14/15, 02/21/15, and 02/22/15. Further review of the Nurse's Notes, for this time period, revealed no reference to any other skin concerns. Continued review of the Nurse's Notes for 02/23/15 revealed the resident exhibited increased pain and screaming out, Lord, kill me, and labored respirations with decreased oxygen saturation. Resident #1 was transported from the facility to the Emergency Department (ED) of the hospital, a distance of 27.8 miles, by Emergency Medical Services (EMS) for evaluation and treatment. The travel from the facility to the hospital was twenty-eight (28) minutes. Review of the EMS transport record, dated 02/23/15, revealed the transport crew arrived on the scene at the facility at 4:09 AM, and departed with Resident #1 en route to the hospital at 4:18 AM. Continued review revealed the EMS arrived at the hospital ED with the resident 28 minutes later, at 4:46 AM. Further review revealed no skin assessment was documented by the EMS staff during the transport from the facility to the hospital. Review of the ED record revealed Resident #1 was clocked in at 4:53 AM on 02/23/15, 44 minutes after EMS arrived on the scene at the facility. Review of the ED Physician's documented physical examination, dated 02/23/15 at 5:26 AM, revealed the presence of multiple grade II decubitus ulcers and patches of skin excoriation in the lumbosacral and buttocks area, and necrotic tissue over the heels. (Necrotic refers to tissue death due to irreversible injury of the cells in a specific area.) The total elapsed time between EMS arriving at the facility to transport the resident and evaluation of the resident by the ED Physician was one (1) hour and seventeen (17) minutes. Continued interview with the DON on 06/23/15 at 10:40 AM, revealed she believed Resident #1's ulcers, including the necrotic ulcers on the heels, occurred at the hospital, or en route to the hospital. She stated based on the facility's documented skin assessments and her conversations with staff, the resident had nothing on the heels prior to transfer and admittance to the hospital on [DATE]. She further stated Resident #1 only had denuded skin on the buttocks prior to 02/23/15. The DON described denuded to be excoriation related to moisture, similar to diaper rash. Continued interview revealed the resident's heels were brownish, leathery upon return to the facility on [DATE]. A review of professional literature from the website of the National Pressure Ulcer Advisory Panel (NPUAP), the online version of the Ostomy Wound Management (OWM) journal, and review of guidance for surveyors published by the Centers for Medicare and Medicaid Services, revealed it was difficult to determine the exact amount of time it takes for a pressure ulcer to develop depending on a variety of factors. It is clear from the literature that a stage I or stage II pressure ulcer can develop in a matter of 2-6 hours; however, it is very important that pre-existing signs which suggest that deep tissue damage (suspected deep tissue injury) has already occurred, such as intact purple or very dark areas surrounded by deep redness, are identified in order to prevent progression to a stage III or stage IV ulcer. Further review revealed eschar, one form of necrotic tissue, can develop in a matter of days. Interview with the ED Physician, on 07/15/15 at 3:15 PM, revealed he had documented the Note describing Resident #1's necrotic heels. He stated the wounds were not newly acquired. Continued interview revealed his assessment was conducted at the time of the documentation, i.e., on 02/23/15 at 5:26 AM. Review of the ED Nurse's Notes for 02/23/15 at 6:43 AM revealed Resident #1 was assessed by the nurse to have redness and excoriation on the perineal area and inner thighs, unstageable decubiti on the bilateral heels, Stage I areas on the left outer leg and the left upper arm near the shoulder, a Stage I decubitus (pressure sore or ulcer) covering most of the left and right buttocks area, and multiple Stage II areas over the coccyx. (Staging of pressure sores is a method of characterizing the severity of the wound, with Stage I being the most superficial and Stage IV indicating full thickness tissue involvement with exposed muscle, tendon, and/or bone). Further review of the ED record revealed Resident #1 was admitted to the hospital for further care. According to the NPUAP, an unstageable ulcer indicates full thickness skin or tissue loss; however, the depth of the ulcer cannot be measured because the wound bed is obscured by slough or eschar, two forms of necrotic, or dead tissue. Interview on 07/15/15 at 2:55 PM with the ED Nurse, who performed and documented the skin assessment on 02/23/15 at 6:43 AM revealed she did recall Resident #1. She stated she did not remember all of the specifics about the assessment, but knew the resident's heels were very dark in color, necrotic in appearance, as if the wounds had been there a while. Review of the hospital's Admission Assessment, dated 02/23/15 at 8:45 AM and electronically signed by the admitting RN, revealed Resident #1 was admitted to the nursing unit from the ED at 8:15 AM. Continued review revealed a yes response to the question, Is there an indication of a pressure ulcer present on admission?. Further review revealed the reader was directed to refer to photographs taken on admission. Review of photographs taken at the hospital upon admission revealed multiple areas of Stage I and Stage II skin breakdown on the buttocks. Continued photographic review revealed visual evidence of black, necrotic tissue on both heels. In addition, the right great toe exhibited signs of a suspected deep tissue injury (SDTI), an injury characterized by purplish-red skin caused by damage of underlying soft tissue due to prolonged pressure and/or friction. Review of the Hospital Discharge Summary, dated 02/25/15, revealed Resident #1 was discharged from the hospital and transferred back to the facility with [DIAGNOSES REDACTED]. Telephone interview with Registered Nurse (RN) #3 on 06/23/15 at 11:18 AM, revealed she no longer worked at the facility, but she did remember taking care of Resident #1. She stated the resident returned from the hospital in February with several wounds. She further stated she did not recall seeing any pressure sores on the resident's heels before he/she went to the hospital on [DATE]. Interview with Certified Nursing Assistant (CNA) #8 on 07/23/15 at 3:45 PM revealed she was familiar with and had cared for Resident #1 before being hospitalized in February 2015. She stated the resident was ambulatory prior to the hospitalization , and always wore socks and tennis shoes. She further stated the resident was afraid the shoes would be stolen if he/she took them off, and sometimes wore them to bed. Continued interview revealed CNA #8 did not recall Resident #1 having black heels, but acknowledged there were probably days when the resident's shoes were never removed. Interview with CNA #12 on 07/24/15 at 2:35 PM revealed she remembered Resident #1 from early in the year, before he/she went to the hospital in February. She stated the resident sometimes wore his/her shoes and socks to bed, but sometimes she could talk the resident into letting her remove them. She stated she did not remember what the resident's heels looked like before going to the hospital in February. Interview with CNA #13 on 07/29/15 at 10:02 AM revealed she was familiar with Resident #1, both before and after the hospitalization in February 2015, until his/her discharge from the facility on 04/15/15. She stated the resident always wore socks and tennis shoes before going out to the hospital in February 2015. She further stated she removed the resident's shoes when he/she got into bed, but he/she usually kept his/her socks on. She stated she did not recall seeing anything wrong with the resident's feet. Review of the facility's Nurse's Notes revealed Resident #1 was readmitted by the facility on 02/25/15 with multiple areas of skin breakdown. According to the Wound Assessment Report completed on that date, the resident's skin was assessed as follows: abrasion, 3.0 cm by 2.3 cm on the left rear shoulder; two Stage II pressure ulcers on the left buttock, measuring 0.7 cm by 1.7 cm and 1.5 cm by 2.0 cm; two Stage II pressure ulcers on the right buttock, 0.5 cm by 0.5 cm and 1.3 cm by 1.0 cm; unstageable pressure ulcer with slough (dead tissue that is shed by a wound) and eschar (hard, leathery brown/black tissue formed of dead cells) on the right heel, 4.5 cm by 9.5 cm; unstageable SDTI on the left heel, 5.7 cm by 5.5 cm; and SDTI to the right great toe, 1.5 cm by 1.0 cm. Review of the Wound Assessment Report, dated 02/26/15, revealed Resident #1 was assessed to have an abrasion to the left shin measuring 4.0 cm by 4.5 cm. On 07/28/15, the State Survey Agency requested a copy of all Body Map Assessments completed between 02/23/15 and 04/15/15. The facility provided a reprint of all Wound Assessment Reports during the time period. The Wound Assessment Reports themselves were identical to those previously provided by the facility; however, they had been reprinted and now included a Body Map Assessment printed on the back of each Wound Report. Review of the Reports revealed each Wound Assessment Report included the specific date the assessment was completed and the date it was printed (07/28/15); however, review of the Body Map Assessments on the back of each Wound Report revealed all were identical, and each included an Assessment Date of 07/28/15, in addition to the print date of 07/28/15. The same four (4) pressure areas, including the left hip, left buttock, and the bilateral heels, were pinpointed on each Body Map Assessment and printed on the Wound Assessments Reports beginning 02/26/15 through 04/13/15; however, according to the Wound Reports, the left hip ulcer was not identified until 03/16/15. In addition, each Body Map reflected an area on the left buttock, the same area documented as excoriation/denuded skin prior to 02/23/15, although the color-coded symbol was changed from green to red, which indicated the wound progressed from a non-pressure area to a pressure ulcer. Furthermore, there was no documented evidence on the Body Map Assessments to reflect the merging of multiple pressure areas on the buttocks into one large pressure ulcer over the coccyx. Review of the Progress Notes, dated 03/26/15 and signed by the Advanced Practice Registered Nurse, revealed Resident #1 had non-specified [MEDICAL CONDITION] and ulcers to the bilateral heels and left buttock, and a Stage IV area to the coccyx. Review of subsequent Wound Assessment Reports revealed the following significant findings: on 03/05/15, the assessment did not address the pressure ulcers on the left and right buttocks, but did describe an 8.0 cm by 2.5 cm area of excoriation on the coccyx; on 03/10/15, the assessment only referred to the SDTI on the right great toe; on 03/11/15, the assessment addressed the ulcers on the heels but no other areas; on 03/16/15, two (2) new wounds to the left hip were identified as a 2.0 cm by 1.5 cm Stage II pressure ulcer, and a 13 cm by 9.2 cm Stage I pressure ulcer - no other wounds were documented on this date; on 03/17/15, twelve (12) days after the coccyx area was described on 03/05/15, the area was reassessed to have deteriorated to a 10.75 cm by 7.0 cm pressure ulcer which was unstageable due to the presence of slough and eschar; on 03/25/15, the facility assessed and documented the coccyx and heel ulcers but the left hip ulcer was not assessed again until 03/31/15, fifteen (15) days after it was identified on 03/16/15, when the two (2) original ulcers had merged into one Stage II ulcer at 5.5 cm by 1.5 cm. The last Wound Assessment Report completed by the facility, on 04/13/15, addressed four (4) areas, the coccyx at 12.0 cm by 10.0 cm, the left hip at 7.0 cm by 3.5 cm, the left heel at 5.0 cm by 5.5 cm, and the right heel at 8.5 cm by 4.0 cm. The left hip wound was characterized as a Stage II ulcer, while the coccyx and heel wounds were described as unstageable. Review of the Nurse's Notes dated, between 03/05/15 and 04/15/15 revealed no reference to any wounds other than those documented on the Wound Assessment Reports. Further review of the Nurse's Notes for 04/15/15 revealed Resident #1 was transferred to the ED at the request of the state-appointed Guardian, for an evaluation of the resident's wounds. Interview with the facility's Medical Director, who was also the Attending Physician for Resident #1, on 06/19/15 at 3:50 PM revealed he was aware of Resident #1's wounds identified when the resident returned from the hospital on [DATE]. He acknowledged the wounds did worsen over time and stated in his opinion the wounds would never have healed. He further stated he attempted multiple interventions, including changes in wound treatments and the addition of nutritional supplements. He further stated he observed the sores soon after the resident returned from the hospital in order to determine the appropriate approach to treatment. He explained subsequent inspections of the wounds were made by his Advanced Registered Nurse Practitioner (ARNP). Further interview revealed the ARNP was on emergency leave from the practice with an unknown date of return. (Due to the tragic nature of the emergency, no attempt was made to interview the ARNP). Interview with the state-appointed Guardian, on 07/14/15 at 3:00 PM, revealed she could not recall the date, but reported she visited Resident #1 and observed the nurse performing the resident's dressing changes to the heels and to the coccyx. She stated she couldn't believe what she saw, and reported the stench was horrible. Continued interview revealed the Guardian notified her supervisor and the decision was made to transfer Resident #1 to the ED per EMS. Review of the ED Note signed by the Physician on 04/15/15 at 11:46 PM revealed Resident #1 was evaluated and admitted for management of multiple ulcers, including a large sacral wound which was the probable source of the resident'[MEDICAL CONDITION] (a complication of an infection, which spreads through the bloodstream, potentially affecting every body system). Review of the Hospital History and Physical, signed 04/16/15 at 12:00 AM, revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of photographs taken at the hospital, digitally dated, and timed for 04/16/15 between 9:49 AM and 10:02 AM, and review of Wound Assessment Notes electronically entered on 04/16/15 between 10:46 AM and 10:56 AM, revealed a total of nine (9) wounds were documented. Four (4) of the wounds had been identified at the facility prior to the resident's transfer to the hospital on [DATE] and were documented as follows: an unstageable right heel ulcer which was covered with 100% black eschar; an unstageable left heel ulcer which was covered with 100% black eschar; an unstageable sacral/coccygeal ulcer, with the wound bed consisting of 100% wet necrotic tissue, and characterized by a purulent (pus-like) and foul-smelling drainage; and a left hip ulcer of 100% black eschar. In addition to these wounds, five (5) previously unidentified wounds were photographically documented with accompanying notes: an unstageable 1.0 cm by 0.8 cm ulcer with a small area of black eschar on the right lateral foot; an unstageable 1.5 cm by 1.0 cm ulcer on the right lateral fifth toe; a 2.0 cm by 1.5 cm SDTI on the left lateral ankle; an unstageable 2.2 cm by 3.5 cm ulcer with 100% black eschar on the right lateral ankle; and a 1.5 cm by 1.0 cm SDTI on the left great toe. Subsequent interview with the facility's Medical Director on 07/29/15 at 11:45 AM revealed he received a copy of all Wound Assessment Reports as they were completed by the facility and had personal collaboration with his ARNP regarding Resident #1's status. Upon reviewing the photographs taken at the hospital on [DATE], the Medical Director stated the wounds to the coccyx, left hip and bilateral heels were about what he expected based on the information he had received from the facility. Continued interview revealed he had no evidence the additional ulcers evident in the photographs were identified by the facility or had been communicated to him. The Medical Director, based on the photographs taken at the hospital ED, described the ulcers on Resident #1's right foot and bilateral ankles as Stage II ulcers that had probably been present a couple of weeks. He further stated it was difficult to know exactly how long the SDTI to the left great toe had been present, but probably less than two (2) weeks. Review of the facility's April 2015 TAR for Resident #1 revealed treatments were in place for the Stage II ulcer on the left hip, and the unstageable ulcers to the coccyx and both heels, prior to the resident being transferred to the hospital on [DATE]. (Resident #1 did not return to the facility.) Continued review of the TAR revealed no documented evidence of ulcers on the right and left lateral ankles, right lateral foot, right fifth toe, or left great toe being identified or treated at the facility. Review of the Comprehensive Care Plan revealed no documented evidence the facility had identified the ankle, foot, and toe ulcers, or had developed interventions for monitoring or treating the wounds at any time prior to 04/15/15 when Resident #1 was discharged to the hospital. Continued interview with RN #2, on 06/18/15 at 2:52 PM, revealed she was responsible for measuring all known ulcers on the weekends. She stated she usually did the measurements on Sunday, and charted her findings on Monday. She further stated she was provided a list by the DON of the wounds/ulcers she was responsible for measuring, and her focus was on those wounds identified on the list. Continued interview revealed she remembered Resident #1, but could not recall the details of his ulcers. Further review of the Wound Assessment Reports for Resident #1, dated 04/06/15 and 04/13/15, revealed they were signed by RN #2. Interviews with RN #2 on 07/24/15 at 3:00 PM and 5:01 PM revealed she only measured areas noted on the list provided by the DON (who was no longer employed by the facility). She stated the areas she assessed each weekend were those the DON instructed her to measure. She explained the unit nurses were responsible for performing and documenting a weekly head-to-toe skin assessment; any new areas should be indicated on a Body Map Assessment and a Wound Assessment Report should be initiated. RN #2 thought the lists the DON provided her came from the Wound Assessment Reports, so if new areas did not make it to the Wound Report, they might not show up on the list she worked from when she did her measurements. She further stated she sometimes mentioned any concerns she had with the former DON, but could not be certain she had talked to the DON about Resident #1. RN #2 explained she felt weak in identifying and describing pressure ulcers, and had asked the former DON and the Education Nurse for specialized training related to wounds but she had not received it. She reported she did her own research on-line, and looked at pictures, to make sure she was describing wounds accurately. Continued interview revealed RN #2 did not save the lists she worked from each week. She reported since the DON no longer worked at the facility, she did not have access to the lists. Furthermore, RN #2 revealed she was no longer responsible for the weekly wound measurements and did not know who was responsible. Interview with the Education Nurse on 07/28/15 at 5:25 PM revealed she provided training on the facility's policies related to skin assessments, including documentation, for new hires during the orientation process. She stated the training should continue as the new nurse worked on the unit with oversight while transitioning to working independently. She further stated she did not recall, and did not provide documented evidence of a specific in-service related to the staging of wounds, or providing accurate wound descriptions. She stated she had done one-on-one training with staff when they had questions. Continued interview revealed she encouraged the nurses to refer to their nursing textbooks. The Education Nurse was unaware if RN #2 had asked for training related to assessing and staging pressure ulcers. Interview with RN #1 on 07/28/15 at 3:30 PM revealed she recalled Resident #1 and knew he had pressure ulcers, but she did not remember well enough to describe specific wounds. She explained the facility's process for performing and documenting skin assessments as follows: each resident was to have a head-to-toe skin assessment conducted weekly; skin concerns included bruises, red areas, or open areas; results of each skin assessment were to be documented in the computer; if any new areas were identified, the Physician was to be notified; if orders were received, the treatment was to be added to the

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised to reflect changes in the resident's skin condition, for one (1) of twenty-four (24) sampled residents (Resident #1). Resident #1's Care Plan identified the resident to be at risk for skin impairment, but was not revised to show the actual problem of denuded skin on the buttocks, which was documented in the Nurse's Notes to exist from 10/19/14 until 02/23/15, when Resident #1 was admitted to the hospital. After the resident was readmitted to the facility on [DATE], the care plan revisions did not include specific interventions for monitoring the multiple pressure ulcers, which the facility had not identified prior to the resident going to the hospital (they were identified upon admission to the hospital). Nor did the Care Plan reflect the status of the ulcers when they deteriorated and signs of infection were present. The facility's failure to revise the Comprehensive Care Plan for each resident having pressure sores to ensure the necessary treatment and services was provided to promote healing, prevent infection, and prevent new sores from developing caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/29/15, and was determined to exist on 02/23/15. The facility was notified of the Immediate Jeopardy on 07/29/15. An acceptable Allegation of Compliance (AOC) was received on 08/06/15, alleging removal of the Immediate Jeopardy on 08/05/15. The State Survey Agency determined the Immediate Jeopardy was removed on 08/05/15 as alleged, which lowered the scope and severity to D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Care Plan Policy Statement, undated, revealed a comprehensive care plan designed to meet the medical, nursing, mental, and psychological needs was developed for each resident. Continued review revealed any licensed nurse or interdisciplinary team member could update the care plan to reflect changes. Continued review revealed resident assessments were ongoing and care plans were to be revised as information about the resident and the resident's condition changed. Review of the facility's Skin System Policy & Procedure, revised 08/14/15, revealed for a resident with a pressure ulcer or other skin compromise, the Care Plan would be reviewed and updated each week until the wound healed. Review of the clinical record revealed Resident #1 was admitted by the facility on 10/02/13 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for October 2014 through February 2015 revealed Resident #1 had denuded skin to the buttocks, beginning 10/19/14 and continuing through 02/22/15. Review of the Wound Assessment Reports, beginning 02/25/15 when Resident #1 was readmitted following a hospitalization , revealed the presence of multiple pressure ulcers, abrasions, and a suspected deep tissue injury (SDTI). Continued review of the Wound Reports for the period between 02/25/15 and 04/13/15, revealed multiple smaller Stage II ulcers on the resident's bilateral buttocks merged to become one large pressure ulcer over the coccyx. Continued review revealed the coccyx ulcer deteriorated when it became larger and deeper, and developed purulent (pus-like) and foul-smelling drainage. On 04/13/15, Resident #1's coccyx ulcer measured 12 cm (centimeters) by 10 cm. Review of Resident #1's Comprehensive Care Plan revealed a problem onset date of 12/10/13, with the resident being assessed by the facility to be at risk for skin impairment. Continued review revealed treatment goals included the following: skin will remain intact; and resident will be free from skin breakdown/irritation, with a goal date of 05/31/15. Interventions included the following: weekly skin checks; turn and reposition every two (2) hours; keep skin clean and dry; and treatments as ordered by the Physician. Further review revealed the Care Plan was not revised as ulcers worsened to include interventions related to monitoring or tracking of the ulcers, observing for signs of infection, or any specific directives related to the individual wounds. Continued review of the Care Plan revealed Resident #1's denuded skin, present between October 2014 and February 2015 was not documented on the Care Plan. Further review revealed the Care Plan did not show healing of the SDTI and the abrasions. In addition, the Care Plan did not reflect any wound measurements or changes in character of the identified wounds, including the development of purulent, foul-odor drainage as the coccyx wound deteriorated. The facility's failure to follow its policies related to skin assessments and care planning resulted in the development of five (5) new pressure ulcers, which were not identified by the facility, but were documented by written description and photographs upon the admission of Resident #1 to the hospital on [DATE]. Interview with the Assistant Director of Nursing (ADON) on 07/24/15 at 5:00 PM, revealed attendees at morning clinical meetings discussed the care plan, and the former Director of Nursing (DON) made recommendations for new interventions. However, the ADON could not say whether the interventions actually made it to the Care Plan; and review of the written interventions revealed the only dated revisions after the first pressure ulcers were documented on 02/25/15 were related to treatments as ordered, a positioning device, and replacement of the standard mattress with an air mattress. Subsequent interview with the ADON and the Assistant Minimum Data Set (MDS) Coordinator on 08/03/15 at 12:40 PM revealed any nurse, the Unit Manager, or the DON could update the Care Plan between MDS assessments when the MDS Coordinator or her Assistant entered changes. The ADON further stated the care plan book was brought to daily clinical meetings for review and updates, but she stated Resident #1's Care Plan was not as specific as it could have been, and did not meet the intent of the facility's policies related to skin assessments and care planning. Interview with the Administrator on 07/22/15 at 11:00 AM revealed the MDS staff updated the care plans as scheduled MDS assessments were completed. He stated off-cycle updates were made daily during the clinical meetings. During interview, on 08/03/15 at 3:40 PM, the Administrator revealed that during the survey, he was finding out the former DON had failed to share information with the management team, and the facility was just becoming aware of the problems related to wound assessment and tracking. Continued interview revealed it was the Administrator's expectation for any new pressure ulcers to be identified and reported up to the Unit Manager and the DON. In addition, he stated his expectation was for all wounds to be communicated to the Quality Assurance team for investigation and tracking, and for care plan updates. He further stated the facility had recognized staff education was needed related to the entire process for skin assessments and wound management, including the care planning process related to pressure ulcers, and training of staff was in progress. **The facility provided an acceptable Allegation of Compliance (AOC) on 08/06/15. The facility implemented the following actions to remove Immediate Jeopardy: 1) Resident #1 had a Pressure Ulcer Care plan developed which was in place and reflected interventions for protection of Skin and Skin Integrity, to promote healing, to prevent infection and development of further pressure ulcers; however, there was undocumented evidence that the resident's care plan was not followed and/or revised for any identified pressure ulcer. It was reported the clinical record of Resident #1 was incomplete. The count of the pressure ulcers noted on Resident #1 did not match the photographic evidence, and documentation needed to validate care and treatment was provided for these pressure ulcers was not provided and had to be considered as lost or nonexistent. There was no documented evidence of a Comprehensive Skin Assessment for Resident #1 prior to discharge. 2) One hundred percent of the resident census (71) had head to toe skin assessments completed by 08/04/15 by the Director of Nursing, Unit Managers, Staff Development RN, and Wound Nurse. No additional unidentified pressure ulcers were identified. 3) The Weekly Skin Assessment Sheet (exhibit A) was reviewed and approved by the QA Committee on 07/30/15; the QA Committee consists of the Administrator, Director of Nursing, MDS, Social Services, Unit Managers, Rehabilitation Therapy Director, Staff Development RN, and the Medical Director. It is to be used weekly by the Charge Nurse, Wound Care Nurse, and/or Unit Manager for each in-house resident to identify any newly developed and/or existing pressure ulcers. Any new pressure ulcers identified will be communicated to the physician for potential treatment orders and to the Director of Nursing and to the Interdisciplinary Team (IDT) to implement interventions and update the comprehensive plan of care. The IDT consists of the Director of Nursing, Unit Managers, Dietary Manager, Rehabilitation Therapy Manager, and Social Services. The results of the Weekly Skin Assessment sheets will be reviewed a minimum of five (5) times per week by the Director of Nursing and/or the Assistant Director of Nursing and the Administrator. Any newly developed pressure ulcers will be reported immediately to the Director of Nursing and the Administrator. Staff responsible for the use of the Weekly Skin Assessment Sheet includes but is not limited to the Charge Nurse, Unit Manager, Weekend Manager, and the Director of Nursing. The Administrator will be responsible for oversight and to report to the QA Committee at least monthly or as outlined in this plan. 4) Licensed Nursing Staff have been in-serviced by the DON, Unit Managers, and Staff Development RN with a completion date of 08/04/15 on how to identify risk factors for developing pressure ulcers and how to develop a comprehensive care plan to address: prevention for breakdown or further breakdown, interventions to promote healing and prevent infection, and interventions to include assessment, monitoring, and updating the comprehensive care plan with changes in residents' condition that may indicate a comprehensive review to update interventions as indicated and healing or decline of pressure ulcers, which is included in the Facility Skin System. The Braden Scale tool and the resident's medical history will be reviewed with the licensed nurses to assist in developing a comprehensive plan of care for pressure ulcers upon admission, readmission, and/or changes in the resident's condition. In addition, the Director of Nursing, Unit Managers, and or RN Staff Development Coordinator provided re-education for the Certified Nursing Assistants on skin reporting utilizing the Stop and Watch Form during bathing and ADL care by 08/04/15. 5) All residents have been assessed for the potential of skin breakdown using the Skin Assessment Worksheet (exhibit A), the Braden Tool, and the Stop and Watch tool (exhibit B), and current medical history with review and update of their comprehensive care plans to ensure risks have been identified and interventions were implemented to promote healing and prevent further breakdown, infection, and any unidentified pressure ulcers. This was completed on 08/04/15 by the DON, Unit Managers, Staff Development RN, and/or RN Supervisor. Information from the evaluation will determine if additional assessment and interventions would be necessary for each resident in the facility. Appropriate interventions were implemented and Care Plans updated initially by the DON and Staff Development RN, and thereafter by the RN Unit Managers and Charge Nurse by 08/04/15. Skin assessments were completed on the total in-house census of 71 residents and no unidentified pressure ulcers were found. 6) The Regional Quality Manager for Preferred Care Partners Management Group provided education regarding the Weekly Skin Management Guidelines on or before 08/04/15 for the Interdisciplinary Team (IDT) which consisted of the DON, Unit Managers, Wound Nurse, Dietary Manager, Therapy Manager, and Social Services Director. 7) Initial education for the Director of Nursing, Staff Development, and Unit Managers was provided by the Preferred Care Partners Management Group, Regional Quality Manager by 08/04/15 regarding use of the Care Plan as a communication tool to direct resident care and to follow the comprehensive plan of care related to pressure ulcers, and consistently following the skin care protocol which included the following: accurate weekly skin assessments, reporting of new or existing identified pressure ulcers, accurate pressure wound assessments to identify detection of decline or healing process, to identify risk issues to prevent breakdown and to promote healing and to effectively implement a comprehensive care plan and interventions, to accurately document pressures regarding healing or decline to include measurement and description, and to obtain physician's orders [REDACTED]. 8) The remaining Licensed Facility Nursing Staff education was educated by the DON, Unit Managers, and Staff Development RN with a completion date of 08/04/15 with a post-test given. As of 08/04/15, a total of 15 of 20 licensed nurses have received this education and as of 08/04/15, a total of 22 of 34 nurse aides received the education by the Staff Development RN, DON, Unit Managers, or Wound Nurse. All nursing staff received the required wound education prior to working their next shift by the Staff Development RN, Unit Managers, Wound Nurse, or DON. All new nursing hires have been educated during general orientation, with a post-test given by the Staff Development RN prior to their working on a unit regarding following the comprehensive care plan interventions, reporting skin breakdown to licensed nurses and the Stop and Watch Tool, communication with the physician in developing a plan of care, including treatment if indicated, to promote healing, prevent infection, and prevent further breakdown. Education also included how to perform an accurate wound assessment and identification of causal factors of breakdown in order to implement effective interventions. 9) The Quality Assurance Committee members (Administrator, Director of Nursing, MDS, Unit Managers, and Staff Development RN) reviewed and approved the education material on 08/04/15. Records of the in-service on the educational materials included signatures of attendance, signature of in-services received, and copies of testing for efficacy of the training. Nursing in-service education on the subjects noted was completed by 08/04/15. 10) Members of the QA Committee developed a tool on 07/31/15 to validate assessments and Care Plans were being utilized per policy protocol. This was implemented on 07/31/15 and is ongoing. In addition, the DON, Unit Managers, Staff Development RN, or Wound Nurse are responsible to reassess 5 resident skin assessments per week to ensure accuracy of licensed nurses' skin assessment within 24 hours of the resident's scheduled 7-day assessment. This will be updated to the QA Committee approved pressure ulcer tracking tool as completed by the DON, Staff Development RN, Unit Managers, and Wound Nurse. Any concerns identified with accuracy of the skin assessment will have re-education provided by the Director of Nursing, Unit Managers, Staff Development RN, or Wound Nurse to the licensed nurse weekly for 3 months until 10/30/15. The Director of Nursing will discuss the results of accuracy and if any education should be provided regarding the reassessments during the next scheduled QA Meeting. 11) Monitoring will be done by the Administrator, DON, Staff Development RN, RN Unit Managers, and Wound Nurse. Any issues identified will be corrected immediately and taken to the next scheduled QA meeting for review and a revised plan of action if warranted. The Administrator will provide oversight on a weekly basis and this practice will become effective on 07/31/15. 12) QA Meetings will be held with two or more team members in attendance daily 5 days a week and on weekends if necessary for review of data to ensure compliance: completion and accuracy of skin assessments and comprehensive care plan for any new and/or existing pressure ulcers. Any findings of newly developed or existing pressure ulcers and the interventions implemented will be reviewed for effectiveness or need for additional interventions until the situation is controlled. QA Committee members will review minimally 5 days a week for 30 days or additionally as necessary until 09/01/15; then one time weekly until 09/30/15 or as needed; then monthly thereafter or as needed sooner. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Resident #1 was no longer in the facility. 2) Review of the facility's documentation dated 07/30-08/04/15, and interviews with Unit Manager (UM) #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Staff Development RN on 08/06/15 at 2:45 PM, and the DON on 08/06/15 at 4:40 PM, revealed a skin assessment was conducted for each resident in the facility and no additional unidentified pressure ulcers were identified. 3) Review of the facility's 100% skin assessment sheets revealed facility staff utilized the Weekly Skin Assessment Sheet approved by the QA committee on 07/30/15. Interviews with UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Staff Development RN on 08/06/15 at 2:45 PM, the DON on 08/06/15 at 4:40 PM, Licensed Practical Nurse (LPN) #1 on 08/06/15 at 1:25 PM, RN #1 on 08/06/15 at 2:55 PM, and LPN #3 on 08/06/15 at 3:25 PM, revealed the Weekly Skin Assessment Sheet was being utilized to conduct weekly skin assessments and to conduct skin assessments for new or readmitted residents to the facility. Per interview with LPN #1 on 08/06/15 at 1:25 PM, RN #1 on 08/06/15 at 2:55 PM, LPN #3 on 08/06/15 at 3:25 PM, UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Therapy Manager on 08/06/15 at 2:30 PM, the Staff Development RN on 08/06/15 at 2:45 PM, the Social Services Director on 08/06/15 at 3:15 PM, and the DON on 08/06/15 at 4:40 PM, revealed any concerns identified with a newly developed pressure ulcer and/or existing pressure ulcers would be reported to the physician, to the DON, and to the IDT to implement interventions and to update the resident's comprehensive plan of care. According to staff interviews, no new pressure ulcers have been identified since 07/29/15. Review of the documentation dated 08/03-05/15, and interview with the Administrator on 08/06/15 at 3:00 PM, revealed he provided oversight to ensure the skin assessments were done correctly in accordance with the facility's protocols and training. 4) Review of the In-service Training related to risk factors for the development of pressure ulcers and the development of a comprehensive care plan revealed education had been conducted for the Licensed Staff by the Staff Development RN on 08/03/15 and 08/04/15, which included the prevention of skin breakdown, interventions to promote healing and to prevent infection, skin/wound assessment, and monitoring and updating the residents' comprehensive care plan. Interview conducted on 08/06/15 at 1:25 PM with LPN #1, 08/06/15 at 2:55 PM with RN #1, 08/06/15 at 3:25 PM with LPN #3, 08/06/15 at 1:20 PM with UM #1, and 08/06/15 at 2:05 PM with UM #2 revealed all the staff interviewed had attended the training and was knowledgeable related to risk factors related to the development of pressure ulcers and the development of the comprehensive care plan for residents with pressure ulcers to include prevention, healing, wound assessment, and monitoring for infection. Staff was also able to verbally relate the purpose of the Stop and Watch Form and to state how to communicate issues/concerns with pressure ulcers with other staff. Staff also completed a post-test. Per interview with the Administrator on 08/06/15, at 3:00 PM, the facility had not hired any new employees since 07/29/15; however, all new employees would receive training on the facility's skin care protocols during orientation when hired by the facility. Further review of the In-service Training dated 08/03-05/15, revealed the Staff Development RN provided education for the Certified Nurse Aides (CNAs) regarding skin reporting utilizing the Stop and Watch form during bathing and ADL care. Interviews conducted on 08/06/15 with CNA #16 at 1:21 PM, CNA #20 at 1:28 PM, CNA #1 at 1:41 PM, CNA #5 at 1:47 PM, CNA #15 at 1:55 PM, CNA #7 at 2:00 PM, CNA #22, at 2:05 PM, CNA #23 at 2:07 PM, CNA #18 at 2:20 PM, and CNA #24 at 3:40 PM verified each staff member had attended the training and was knowledgeable about the use of the Stop and Watch form and reporting any changes in a resident's skin condition. 5) Review of the facility's documentation dated 07/30-08/04/15, and interviews with UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Staff Development RN on 08/06/15 at 2:45 PM, and the DON on 08/06/15 at 4:40 PM, revealed a skin assessment was conducted for each resident in the facility and no additional unidentified pressure ulcers were identified. 6) Review of In-service Training dated 08/03/15, revealed the Preferred Care Partners Management Group provided training regarding the Weekly Skin Management Guidelines for the Interdisciplinary Team (IDT) which consisted of the DON, Unit Managers, Wound Nurse, Dietary Manager, Therapy Manager, and Social Services Director. Interviews conducted with UM #1 on 08/06/15 at 1:20 PM, UM #2 on 08/06/15 at 2:05 PM, the Therapy Manager on 08/06/15 at 2:30 PM, the Staff Development RN on 08/06/15 at 2:45 PM, the Social Services Director on 08/06/15 at 3:15 PM, and the DON on 08/06/15 at 4:40 PM revealed each of the IDT members attended the training and had knowledge of the Weekly Skin Management Guidelines. 7) Review of In-service Training dated 08/03/15, revealed the Regional Quality Manager provided training for the DON, Staff Development Nurse, and Unit Managers related to use of the care plan as a communication tool and following the comprehensive care plan and to consistently follow the facility skin care protocols. Interviews on 08/06/15 with UM #1 at 1:20 PM, UM #2 at 2:05 PM, the Staff Development RN at 2:45 PM, and the DON at 4:40 PM, confirmed each of the staff members attended the in-service training and had knowledge of the care plan process and the facility skin care protocols. In addition, a post-test was provided. 8) Review of the In-service Training related to risk factors for the development of pressure ulcers and the development of a comprehensive care plan revealed education had been conducted for the Licensed Staff by the Staff Development RN on 08/03/15 and 08/04/15, which included the prevention of skin breakdown, interventions to promote healing and to prevent infection, skin/wound assessment, and monitoring and updating the resident's comprehensive care plan. Interview conducted on 08/06/15 at 1:25 PM with LPN #1, 08/06/15 at 2:55 PM with RN #1, 08/06/15 at 3:25 PM with LPN #3, 08/06/15 at 1:20 PM with UM #1, and 08/06/15 at 2:05 PM with UM #2 revealed all the staff interviewed had attended the training and was knowledgeable related to risk factors related to the development of pressure ulcers and the development of the comprehensive care plan for residents with pressure ulcers to include prevention, healing, wound assessment, and monitoring for infection. Staff was also able to verbally relate the purpose of the Stop and Watch Form and to state how to communicate issues/concerns with pressure ulcers with other staff. Staff also completed a post-test. Per interview with the Administrator on 08/06/15 at 3:00 PM, the facility had not hired any new employees since 07/29/15; however, all new employees would receive training on the facility skin care protocols during orientation when hired by the facility. 9) Review of the Daily QA Meeting Sign-In Sheets revealed the QA Committee met on 08/04/15 and review of the in-service records revealed the educational materials included signatures of attendance, signature of in-services received, and copies of efficacy of the training. 10) The Pressure Ulcer tool was reviewed on 08/06/15 and verified the tool was being utilized to validate skin assessments and care planning for residents with pressure ulcers. The QA Committee members were reviewing the tool daily. Interviews conducted on 08/06/15 with the Administrator at 3:00 PM, UM #1 at 1:20 PM, UM #2 at 2:05 PM, the Staff Development RN at 2:45 PM, the MDS Nurse at 3:35 PM, and the DON at 4:40 PM confirmed the tool was being used to validate skin assessments were conducted and documented correctly and care plans were being updated and followed for residents with pressure ulcers. Interviews conducted on 08/06/15 with LPN #1 at 1:25 PM, with RN #1 at 2:55 PM, and with LPN #3 at 3:25 PM, revealed licensed nurses were responsible to complete a head to toe skin assessment for residents weekly as assigned on the skin assessment schedule. LPN #1, RN #1, and LPN #3 stated the skin assessment was documented on the Skin Assessment Sheet with the man figure on it. Interviews conducted on 08/06/15 with UM #1 at 1:20 PM, UM #2 at 2:05 PM, the Staff Development RN at 2:45 PM, and the DON at 4:40 PM revealed they were responsible to reassess 5 resident skin assessments weekly to ensure the skin assessments had been completed accurately by the licensed nurse who was assigned to complete the scheduled skin assessment. The reassessment had been done within 24 hours of the resident's scheduled 7-day assessment. The UMs, Staff Development RN, and DON stated no problems had been identified with the reassessments they had completed. 11) Review of the documentation dated 08/03-05/15, and interview with the Administrator on 08/06/15, at 3:00 PM, revealed he provided oversight to ensure the skin assessments were done correctly in accordance with the facility's protocols and training. 12) Review of the facility's documentation dated 08/04-06/15 revealed daily QA meetings were conducted to review the completion and accuracy of skin assessments and comprehensive care plan for any new and/or existing pressure ulcers. No newly developed pressure ulcers have been identified since 07/29/15. Interviews conducted on 08/06/15 with UM #1 at 1:20 PM, UM #2 at 2:05 PM, the Therapy Manager at 2:30 PM, the Staff Development RN at 2:45 PM, the Administrator at 3:00 PM, the Social Services Director at 3:15 PM, and the DON at 4:40 PM, confirmed daily QA meetings were held to review the completion and accuracy of skin assessments and comprehensive care plans for any new and/or existing pressure ulcers.

Based on observation, interview, record review, review of the facility's investigation, and review of facility policies, it was determined the facility failed to have an effective system to ensure comprehensive care plans were reviewed and revised to include the need for a Wanderguard bracelet (a bracelet that causes the exit doors of the facility to alarm and/or lock when a resident is within four feet of the exit door) for residents who were identified by the facility as an elopement risk for one (1) of three (3) sampled residents (Resident #1). The facility failed to revise the care plan for Resident #1 to ensure the resident received a Wanderguard bracelet for safety. (Refer to F323.) On 02/22/14, Resident #1 eloped from the facility without staff knowledge and was not identified as missing for approximately three and one-half hours. A facility neighbor observed Resident #1 to be in the resident's yard (which is approximately 60 yards from the facility) at 12:30 PM picking up garbage. Facility staff did not identify Resident #1 was missing until approximately 4:00 PM. Facility staff located Resident #1 at his/her home and escorted the resident back to the facility at approximately 4:30 PM. Facility staff assessed the resident to have no injuries. The facility's failure to have an effective system in place to ensure the care plan was reviewed and revised with interventions to prevent elopement placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident. The facility was notified of the Immediate Jeopardy on 03/05/14. The Immediate Jeopardy was determined to exist on 02/22/14, and is ongoing. On 03/13/14, the facility submitted an Allegation of Compliance alleging removal of the Immediate Jeopardy on 03/12/14. The Allegation of Compliance could not be verified based on staff interviews and review of documentation. Interviews with four (4) State Registered Nurse Aides (SRNAs) and one (1) Licensed Practical Nurse (LPN) revealed they were unfamiliar with the corrective action taken by the facility to remove the Immediate Jeopardy. Additionally, it was determined the facility failed to complete training and in-services with staff as detailed in the Allegation of Compliance. The findings include: Review of the facility's policy, "Protocol for Care Plan" (undated), revealed an individual comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was required to be developed for each resident. Any licensed nurse and/or interdisciplinary team member could update the care plan to reflect changes. The policy stated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. Review of the facility's policy, "Elopement Prevention: Resident" (undated), revealed the facility would provide supervision and assistive devices to each resident to prevent avoidable accidents. Mechanisms (door alarms, Wanderguards, and Wanderguard system) and procedures (nursing assessment, care plan, regular staff rounds, protected list of residents at increased risk in the wander risk book and supervision) were used to help to mitigate the risk of a resident leaving a safe area without staff supervision. Review of the facility's investigation initiated on 02/22/14 revealed at approximately 4:00 PM staff was unable to locate Resident #1. Staff was aware Resident #1's home was close to the facility, and went to the resident's home. Upon arriving at the resident's home, Resident #1 was found inside the home. When interviewed on 02/23/14 at 1:30 PM regarding exiting the facility, Resident #1 stated a "man" had assisted him/her out of the facility. Review of the medical record for Resident #1 revealed the facility admitted the resident on 03/25/13. Review of an elopement assessment conducted by facility staff for Resident #1 on 09/23/13, revealed facility staff assessed the resident to be an elopement risk and the facility's intervention was to have the resident utilize a Wanderguard. Again, on 12/20/13, the facility assessed Resident #1 to be an elopement risk and the intervention was a Wanderguard. Review of Resident #1's Elopement Care Plan, dated 03/25/13, revealed the resident was at risk for elopement and facility staff was to encourage the resident to share, reassure the resident, offer redirection, and reassess the resident for elopement quarterly, and as needed. Further review revealed no update or revision to the care plan to include the Wanderguard intervention, which the facility assessed the resident to require. Observation and interview with Resident #1 on 02/28/14 at 10:20 AM, and again at 5:40 PM, revealed Resident #1 had a Wanderguard bracelet on her/his right wrist during the interview. Resident #1 stated he/she had never worn a bracelet like that prior to exiting the facility on 02/22/14. Resident #1 stated the bracelet was placed on him/her by facility staff after returning to the facility on [DATE]. Observations in Resident#1's room on 02/28/14 revealed the resident's clothes were packed and the resident stated he/she was "going home today." Interview on 02/28/14 at 11:11 AM with Licensed Practical Nurse (LPN) #1, on 02/28/14 at 5:02 PM with State Registered Nurse Aide (SRNA) #4, on 03/04/14 at 12:30 PM with LPN #3, and on 03/04/14 at 2:42 PM with LPN #5 revealed Resident #1 did not utilize a Wanderguard bracelet prior to leaving the facility without staff knowledge on 02/22/14. Interview on 03/07/14 at 3:50 PM with the Unit Manager revealed the Social Worker or Unit Managers could update and revise residents' care plans. Further interview revealed when Resident #1 eloped on 02/22/14, she updated the resident's elopement plan of care to include an intervention for a Wanderguard bracelet to prevent elopement. The Unit Manager stated prior to 02/22/14, Resident #1's elopement plan of care did not have an intervention for the use of the Wanderguard system. Interview with the Administrator on 03/05/14 at 3:05 PM revealed he was not aware Resident #1 did not have a Wanderguard bracelet on the day he/she eloped. He stated he thought Resident #1 had a Wanderguard bracelet on when he/she left the faciity on [DATE], and had utilized one since admission.

Based on interview, record review, and a review of the facility's policy/procedures and investigations, it was determined the facility failed to ensure policies and procedures related to abuse were implemented for one of three sampled residents (Resident #1). On 07/22/13, the facility initiated an abuse investigation after Adult Protective Services informed the facility they were investigating an allegation of abuse of Resident #1 by Licensed Practical Nurse (LPN) #1. However, review of a Concern/Grievance Report form completed by the Director of Nursing (DON) on 07/18/13, revealed the family of Resident #1 had reported to the DON on 07/18/13 that staff was "repeatedly telling" Resident #1 "that (he/she) did not know anything" and the resident's "family didn't care anything about (him/her) and that is why (he/she) was here." However, the DON stated she did not view the concern voiced by the family of Resident #1 as an allegation of abuse, and took no action to report the allegation immediately to the Administrator, initiate an investigation, or protect residents in the facility from further abuse. The facility's failure to ensure policies and procedures were implemented to protect residents from abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. The Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/18/13. The facility was notified of the Immediate Jeopardy on 08/14/13. An acceptable Allegation of Compliance was received on 08/15/13, and alleged removal of the Immediate Jeopardy on 08/14/13. The state survey agency determined the Immediate Jeopardy was removed on 08/14/13, prior to exit, which lowered the scope/severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's abuse policy and procedure, undated, revealed the facility had developed processes in an effort to prevent abuse and to ensure allegations of abuse were reported in an effort to provide residents a safe environment. The facility policies and procedures contained all required components of abuse prohibition, including identification, investigation, protection, and reporting of all abuse allegations. The policy also stated the Administrator was responsible for the assurance of the policy. Review of the facility's investigation initiated on 07/22/13, revealed Adult Protective Services entered the facility on 07/22/13, and reported to the Administrator they were investigating an allegation of abuse of Resident #1 by Licensed Practical Nurse #1. Interview with the Administrator on 08/07/13, at 11:39 AM, revealed at that time the facility immediately initiated an investigation and reported the alleged abuse to state agencies as required. A review of a Concern/Grievance Report form completed by the DON on 07/18/13, revealed the family of Resident #1 had reported to her on 07/18/13 they were "concerned" because they had been informed that staff was "repeatedly telling (Resident #1) that (he/she) did not know anything because of (his/her) brain surgery and that (his/her) family didn't care anything about (him/her) and that's why (he/she) was here." Documentation on the Complaint/Grievance Form revealed the Administrator had signed and dated the form on 07/19/13 and noted the facility planned to resolve the complaint/grievance by instructing all staff to "not enter room unless accompanied by another staff member." Interviews conducted on 08/06/13 at 2:09 PM with Resident #1's Family Member #1 and on 08/07/13 at 2:52 PM with Family Member #2, revealed they had been informed by Resident #1's roommate on 07/18/13, that LPN #1 had "yelled and pointed her finger" at Resident #1 on 07/17/13. Family Member #2 stated Resident #1's roommate provided them with the name of the alleged perpetrator, LPN #1, and they verified LPN #1 had provided care to Resident #1 on 07/18/13. Family Member #2 stated his/her intentions were to notify the Long Term Care Ombudsman of the complaint, but within 30 minutes of asking LPN #1 for her name, the DON came to Resident #1's room and asked them if they had concerns regarding Resident #1. The resident's family members stated they "made it clear" to the DON that they were concerned that Resident #1 was being abused in the facility and that the resident's roommate had told them that LPN #1 had yelled and pointed her finger at Resident #1 on 07/17/13. Family Member #2 stated the DON assured them she would initiate an investigation, take appropriate action, and make all required notifications to state agencies. Interviews conducted with Resident #1's roommate on 08/06/13 at 12:45 PM and 08/07/13 at 3:40 PM, confirmed the roommate had told Resident #1's family on 08/17/13, that he/she had observed LPN #1 yell at and point her finger at Resident #1. In an interview on 08/06/13 at 1:15 PM, the DON confirmed staff called her at approximately 6:30 PM on 07/18/13, because Resident #1's family appeared to have some concerns. The DON stated she came to the facility and talked to Resident #1's family and filled out the Concern/Grievance Report form. However, the DON stated that Resident #1 appeared to be confused at that time, and therefore she did not identify the concern to be an allegation of abuse. The DON reportedly took no immediate action to address the family's concerns or to ensure Resident #1 was protected from abuse at the facility. The DON denied Resident #1's family reported LPN #1 as the alleged perpetrator and acknowledged she exited the facility and LPN #1 remained in the facility to provide direct care to residents, including Resident #1. Based on interview, the DON failed to implement an investigation, failed to report the allegation to the Administrator and state authorities immediately, and failed to protect residents from further potential abuse. The DON stated she provided the Complaint/Grievance report form to the Administrator on 07/19/13. The Administrator stated in interview on 08/07/13 at 11:39 AM that although he had signed and dated the Concern/Grievance Report form on 07/19/13, he had not actually read the report form, and was basing his actions to have two staff members present when care was being provided to Resident #1 on the DON's verbal account to him that staff was attempting to redirect Resident #1 when she became confused and had misconstrued their actions. However, the Administrator took no further action to investigate to determine why the family or Resident #1 had misconstrued the staff's actions, or if the family or Resident #1 had alleged the actions to be abusive or neglectful. According to the Administrator, Adult Protective Services (APS) entered the facility on 07/22/13 and informed him of the allegation of abuse and, at that time, an investigation was initiated and the facility's abuse policies/procedures were implemented. --A review of the Allegation of Compliance (AOC) revealed the following: Beginning on 08/08/13, Resident #1 was interviewed daily by the Regional Nurse Consultant, the Administrator, or a Licensed Nurse to identify any concerns. On 07/22/13, the facility suspended LPN #1 who was allegedly abusive to Resident #1, and an investigation was initiated. On 08/09/13, the Social Worker and/or Regional Nurse Consultant had completed interviews with all residents who were interviewable to identify any allegations of abuse or neglect. Beginning on 08/10/13, five interviewable residents will be interviewed daily by the Administrator, Interim DON, Unit Manager, Social Worker, Licensed Nurse, or the Regional Nurse Consultant for four weeks to ensure any abuse, neglect, or misappropriation is reported, investigated, and recognized. On 08/12/13, the Social Worker or Business Office Associate had contacted 22 families of residents who were unable to be interviewed to identify any allegations of abuse or neglect. The Social Worker or Business Office Associate continued to contact five families daily until 08/13/13, to identify any allegation of abuse or neglect. Beginning on 08/13/13, two family members of residents who are not interviewable will be interviewed by the Administrator, Interim DON, Unit Manager, Social Worker, or a Licensed Nurse. This will continue for four weeks and then decrease to four interviews per month until modified by the Quality Assurance (QA) Committee to sustain removal. To ensure the same family members are not being interviewed each time, a list of resident family members who have been interviewed is being maintained to ensure the facility interviews as many families as possible. The Interim DON, Unit Manager, or Treatment Nurse conducted a head-to-toe skin assessment on all facility residents to identify any signs or symptoms of abuse. This was completed on 08/09/13. Beginning on 08/12/13, five head-to-toe skin assessments will be completed weekly by the Treatment Nurse, Interim DON, Unit Manager, or Education Training Director. This will continue for four weeks and then the assessments will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. Reeducation of all facility staff by the Interim DON, Unit Manager, Administrator, Education Training Director, or Regional Nurse Consultant began on 08/07/13, and was completed on 08/09/13. A copy of the abuse policies/procedures was given to all staff. Staff was required to demonstrate understanding regarding the policy/procedures. No staff will be permitted to work in the facility until they have received reeducation and received a copy of the abuse policy/procedures. At the end of each shift all nursing staff having worked will be interviewed by the Administrator, Interim Director of Nursing, Unit Manager, Charge Nurse, or the Regional Nurse Consultant to identify any reports of abuse or neglect. This began on 08/09/13, and will continue until 08/17/13. Beginning on 08/17/13, the Education Training Director, Administrator, Interim DON, or Regional Nurse Consultant will interview a minimum of five employees each shift for four weeks to ensure that no abuse or neglect was reported to them, that they did not witness any abuse or neglect, and that they know what constitutes abuse or neglect and how to report it. After four weeks, the interviews will decrease to four interviews per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/07/13, the Regional Nurse Consultant reeducated the Administrator and DON regarding the abuse and neglect policy/procedures which included recognizing and reporting abuse allegations. On 08/09/13, the Regional Nurse Consultant completed reviewing all Concern/Grievance Report forms completed in the past 30 days to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Beginning on 08/10/13, the Regional Nurse Consultant will monitor and review all grievances five times per week for four weeks to ensure any grievances received are reviewed to ensure if there was an allegation of abuse it was investigated and reported. After four weeks, the reviews will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/09/13, the Regional Nurse Consultant completed a review of all allegations of abuse and neglect submitted over the past three months to identify any allegation that had not been investigated or reported timely as required. Beginning on 08/10/13, the Regional Nurse Consultant will monitor and review all allegations of abuse or neglect five times per week for four weeks to ensure abuse or neglect allegations are received and investigated per policy. After the four weeks, the reviews will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/09/13, the phone numbers of the Administrator, Interim DON, and Regional Nurse Consultant were posted at the entrance to the facility for residents, families, or staff to utilize for abuse reporting at any time. Beginning on 08/08/13 all newly hired employees will be educated by the Education Training Director on the facility's abuse policy/procedures, given a copy of the policy, and instructed who to contact if abuse or neglect was identified or reported. On 08/12/13, a resident council meeting was held with the Administrator to identify any abuse or neglect concerns. Beginning on 08/12/13, for three weeks a weekly resident council meeting will be held with the Administrator or Regional Nurse Consultant to ask residents about abuse or neglect and to ensure they are knowledgeable on how to report it. After three weeks, the meetings will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. The facility held a Quality Assurance meeting on 08/12/13 with the Administrator, Interim DON, Regional Nurse Consultant, Housekeeping/Maintenance Director, Dietary Director, Unit Manager, Education Training Director, and Medical Records Director. The meeting was conducted to identify any issues related to abuse or neglect. On 08/09/13, Concern/Grievance Report forms were placed at each nurses' station and in the front lobby of the facility to allow for resident, family, or staff utilization. The Business Office Assistant will ensure the forms are in place five times per week for four weeks, and then once per month and remain ongoing until modified by the QA Committee to sustain the removal. Beginning on 08/12/13, a meeting consisting of QA Committee members including the Administrator, Interim DON, Education Training Director, Regional Nurse Consultant, Dietary, Housekeeping/Maintenance, and Medical Director to be in attendance or on the phone with the team, is to be held once a week for four weeks, and then every two weeks for four weeks, to review all audit findings and make recommendations for changes to the plan. This will be ongoing until all issues are resolved. --The State Survey Agency validated the corrective actions taken by the facility as follows: Review of facility documentation and an interview with Resident #1 on 08/19/13 at 12:48 PM revealed the Regional Nurse Consultant, the Administrator, or a Licensed Nurse was interviewing Resident #1 daily to identify any concerns. Review of an Employee Counseling/Disciplinary Report form dated 07/22/13, and interview with LPN #1 on 08/06/13 at 2:30 PM, revealed the facility suspended LPN #1 from employment at the facility on 07/22/13. Review of facility documentation and random interviews conducted on 08/19/13 at 11:40 AM with Resident #2, at 11:42 AM with Resident #3, at 11:48 AM with Resident A, at 11:53 AM with Resident B, and at 11:57 AM with Resident C revealed the Social Worker and/or Regional Nurse Consultant had completed interviews with residents who were interviewable to identify any allegations of abuse or neglect on 08/09/13. Review of Resident Interview Sheets and interviews on 08/19/13 at 2:03 PM with the Administrator, at 3:30 PM with the Interim DON, at 2:35 PM with the Unit Manager, at 1:55 PM with the Social Worker, at 2:33 PM with Licensed Nurse #1, and at 2:09 PM with the Regional Nurse Consultant, revealed five interviewable residents had been interviewed daily since 08/10/13 to ensure any abuse, neglect, or misappropriation was reported, investigated, and recognized. Any issues identified were reported to the required authorities. Review of facility documentation on 08/19/13, and interviews with the Social Worker at 1:55 PM, and with the Business Office Associate at 2:23 PM, revealed they had contacted 22 families as of 08/12/13, of residents who were unable to be interviewed to identify any allegations of abuse or neglect, and no concerns were identified. Review of facility documentation on 08/19/13 and interviews with the Administrator at 2:03 PM, the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, the Social Worker at 1:55 PM, and Licensed Nurse #1 at 2:33 PM, revealed since 08/13/13, two family members of residents who were not interviewable had been interviewed daily. Additionally, observations on 08/19/13, revealed a Family List was maintained of families who had been contacted. Review of Resident Skin Assessments on 08/19/13, and interviews with the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, and the Treatment Nurse at 3:38 PM, revealed they had conducted head-to-toe skin assessments on all facility residents as of 08/09/13. No concerns related to abuse/neglect were identified. Review of Resident Skin Assessments on 08/19/13 and interviews with the Treatment Nurse at 3:38 PM, the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, and the Education Training Director at 3:49 PM, revealed five Resident Skin Assessments had been conducted from 08/12/13 through 08/16/13. No concerns related to abuse/neglect were identified. Review of in-service training records, employee sign-in sheets, and interviews with Certified Nursing Assistant (CNA) #10 at 3:05 PM, CNA #11 at 3:18 PM, CNA #12 at 3:25 PM, LPN #10 at 3:09 PM, and LPN #11 at 3:18 PM, revealed all facility staff had been reeducated by the Interim DON, Unit Manager, Administrator, Education Training Director, or Regional Nurse Consultant from 08/07/13 through 08/09/13. Interviews revealed all staff had received a copy of the abuse policies/procedures, and had been required to demonstrate understanding by completing a questionnaire regarding the policy/procedures. Review of facility documentation and interviews on 08/19/13 at 2:03 PM with the Administrator, at 3:30 PM with the Interim Director of Nursing, at 2:35 PM with the Unit Manager, at 2:09 PM with the Regional Nurse Consultant, with Certified Nursing Assistant (CNA) #10 at 3:05 PM, with CNA #11 at 3:18 PM, with CNA #12 at 3:25 PM, with LPN #10 at 3:09 PM, and with LPN #11 at 3:18 PM, revealed all staff was being interviewed at the end of each shift to identify any reports of abuse or neglect. Review of facility documentation on 08/19/13 and interviews with the Education Training Director at 3:49 PM, the Administrator at 2:03 PM, the Interim DON at 3:30 PM, and the Regional Nurse Consultant at 2:09 PM, revealed five staff members had been interviewed on 08/17/13 and 08/18/13. Interviews on 08/19/13, with the Regional Nurse Consultant at 2:09 PM, and the Administrator at 2:03 PM, revealed the Regional Nurse Consultant had retrained the DON and Administrator on 08/07/13. The training focused on the facility's abuse and neglect policy/procedures which included recognizing and reporting abuse allegations. Review of a Grievance Face Sheet and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had reviewed all Concern/Grievance Report forms completed in the past 30 days on 08/09/13, to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Review of a Grievance Face Sheet and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had reviewed all Concern/Grievance Report forms completed from 08/09/13 through 08/18/13 to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Review of an Allegation of Abuse Binder on 08/19/13, and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had completed a review of all allegations of abuse and neglect submitted over the past three months to identify if any allegation had not been investigated or reported timely as required on 08/09/13. Review of an Allegation of Abuse Binder on 08/19/13, and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had completed a review of all allegations of abuse and neglect submitted from 08/10/13 through 08/18/13. Observation on 08/19/13 at 12:18 PM, revealed the phone numbers of the Administrator, Interim DON, and Regional Nurse Consultant were posted at the entrance to the facility. Review of Newly Hired employee files on 08/19/13, and an interview with LPN #11 at 3:15 PM, revealed she was educated upon hire on 06/19/12 by the Education Training Director on the facility's abuse policy/procedures, was given a copy of the policy, and instructed who to contact if abuse or neglect is identified or reported. Review of Resident Council Meeting minutes dated 08/12/13, revealed a resident council meeting was held with the Administrator to identify any abuse or neglect concerns. No concerns were identified. Interviews on 08/19/13, at 2:03 PM with the Administrator, at 3:30 PM with the Interim DON, at 2:09 PM with the Regional Nurse Consultant, at 3:00 PM with the Housekeeping/Maintenance Director, at 3:05 PM with the Dietary Director, at 2:35 PM with the Unit Manager, at 3:49 PM with the Education Training Director, and at 2:26 PM with the Medical Records Director, revealed minutes from a Quality Assurance meeting dated 08/12/13 revealed a meeting was conducted to discuss the identified deficient practice and identify any issues related to abuse or neglect. Observations on 08/19/13 at 12:30 PM revealed Concern/Grievance Report forms were in place at each nurses' station and in the front lobby of the facility. Interview with the Medical Records Director on 08/19/13 at 2:26 PM revealed she was responsible to ensure the forms were in place at the designated areas five times per week.

Based on interview, record review, and review of the facility's investigation and policy and procedures, it was determined the facility failed to ensure an allegation of abuse was reported immediately to the Administrator and to other officials in accordance with state law, including the state survey and certification agency, as required for one of three sampled residents (Resident #1). On 07/18/13 the Director of Nursing (DON) documented a complaint received from Resident #1's family member that staff was "repeatedly" telling the resident that he/she "didn't know anything" because of his/her "brain surgery" and that the resident's family "didn't care anything about (him/her) and that's why (he/she) was here." However, interview with the DON on 08/06/13 at 1:15 PM revealed she "did not consider this an allegation of abuse" and failed to take any action to immediately report the allegation to the Administrator of the facility and state agencies as required. In addition, the facility failed to conduct a thorough investigation of the allegation and took no action to protect residents from further abuse/potential abuse until 07/22/13, four days after the allegation had been received. The facility's failure to immediately report an allegation of abuse, failure to protect residents from further abuse, and failure to investigate an allegation of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/18/13. The facility was notified of the Immediate Jeopardy on 08/14/13. An acceptable Allegation of Compliance was received on 08/15/13, and alleged removal of the Immediate Jeopardy on 08/14/13. The state survey agency determined the Immediate Jeopardy was removed on 08/14/13, prior to exit, which lowered the scope/severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Concern/Grievance Policy, undated, revealed the Administrator would receive and log all Concern/Grievance forms after initiation, and take the Concern/Grievance form to the "next" daily "stand-up" meeting for review. According to the policy if the concern/grievance was determined to be an allegation of abuse or neglect it would be immediately reported to the proper authorities. Review of the facility's abuse policy, undated, revealed the facility "had designed and implemented processes which strive to ensure the prevention and reporting of resident abuse." The policy revealed all allegations of abuse would be reported to the Administrator and Director of Nursing (DON) immediately; and would be reported to state agencies and all other agencies as required. The policy defined verbal abuse as "oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families." The policy also revealed the facility would provide for the immediate safety of the resident upon identification of potential abuse, and would investigate and review each allegation thoroughly. Review of the facility's documentation revealed the facility initiated an abuse investigation on 07/22/13, after Adult Protective Services had entered the facility and informed the Administrator that an allegation of abuse to Resident #1 by Licensed Practical Nurse (LPN) #1 was being investigated. However, review of a Complaint/Grievance Report contained in the facility's investigation revealed the family had voiced concerns that Resident #1 was being abused at the facility to the DON on 07/18/13, The DON had documented on the form that Resident #1's family was concerned that staff was "repeatedly telling (Resident #1) that (he/she) didn't know anything because of (his/her) brain surgery and that (his/her) family didn't care anything about (him/her) and that's why (he/she) was here." Interview with Resident #1's Family Member #1 on 08/06/13 at 2:09 PM, and Family Member #2 on 08/07/13 at 2:52 PM, revealed Resident #1 was upset when they arrived to visit on 07/18/13. The resident's roommate reported to them that Licensed Practical Nurse (LPN) #1 had "yelled and pointed her finger" at Resident #1 on 07/17/13. Both family members stated they reported the information, including the name of the alleged perpetrator to the DON on 07/18/13. The family members stated they had made it clear to the DON that they were concerned that Resident #1 was being abused at the facility and expected action to be taken. Family Member #2 stated the DON assured them she would take appropriate action including notification of all authorities as required. However, Family Member #2 stated he/she learned on 07/19/13 that the facility had not reported their concerns to state agencies and reported the incident to Adult Protective Services as an allegation of abuse. Interviews with Resident #1's roommate on 08/06/13 at 12:45 PM, and 08/07/13 at 3:40 PM, confirmed the roommate had reported to Resident #1's family that he/she had observed LPN #1 "yell at" and" point her finger" at Resident #1. Observation of Resident #1 on 08/06/13, at 10:05 AM revealed the resident to be in bed and in no acute distress. Although Resident #1 answered questions readily, the resident displayed confusion and cognitive impairment. Review of LPN #1's employee record revealed the LPN was suspended from employment at the facility on 07/22/13, after Adult Protective Services entered the facility to investigate the allegation of abuse. The facility's investigation unsubstantiated abuse by LPN #1, and she returned to work on 07/24/13. However, the facility later terminated the employee for being verbally inappropriate to Resident #1. The DON confirmed in an interview on 08/06/13 at 1:15 PM, that staff had called her on 07/18/13, because Resident #1's family had indicated they had some concerns. The DON stated she came to the facility and completed the Complaint/Grievance Report form as a result of the conversation with Resident #1's family. However, the DON stated Resident #1 had appeared confused on 07/18/13 when she was talking to the resident's family and, therefore, she had not viewed the complaint as an allegation of abuse. The DON acknowledged she had not immediately notified the Administrator or the state survey agency of the allegation and had not initiated an investigation or implemented measures to ensure residents were protected from further abuse. The DON stated she had not been informed at the time of the report on 07/18/13 of the name of the staff person that had reportedly made the comment to Resident #1 on 07/17/13. The DON stated "to the best" of her "recollection" she gave the Concern/Grievance report to the Administrator on 07/19/13, but stated it was not discussed in the "stand-up" meeting held on 07/19/13. Interviews conducted with the Administrator on 08/07/13 at 11:39 AM, and 08/19/13 at 1:05 PM, revealed the DON had "verbally" told him of the complaint/grievance reported on 07/19/13 by Resident #1's family. However, the Administrator stated the DON had reported that Resident #1 had been disoriented and therefore, the Administrator never considered the family's concerns an allegation of abuse. The Administrator stated he did not ask the DON any additional questions related to the complaint, did not attempt to contact Resident #1's family members, and had not reviewed the Concern/Grievance Form at that time. The Administrator stated the Concern/Grievance Report form was not discussed in the "stand-up" meeting on 07/19/13, because he had thought the issue was resolved. The Administrator stated he took no action to investigate or report the alleged abuse to the state survey agency until 07/22/13, when Adult Protective Services entered the facility to investigate an allegation of abuse related to Resident #1. The Administrator stated at that time LPN #1 was suspended from employment at the facility pending the outcome of the investigation. According to the Administrator, the facility was unable to substantiate abuse by LPN #1 to Resident #1 and the LPN returned to work at the facility on 07/24/13. However, the Administrator stated LPN #1 was later terminated from employment at the facility for being verbally inappropriate with Resident #1. --A review of the Allegation of Compliance (AOC) revealed the following: Beginning on 08/08/13, Resident #1 was interviewed daily by the Regional Nurse Consultant, the Administrator, or a Licensed Nurse to identify any concerns. On 07/22/13, the facility suspended LPN #1, who was allegedly abusive to Resident #1, and an investigation was initiated. On 08/09/13, the Social Worker and/or Regional Nurse Consultant had completed interviews with all residents who were interviewable to identify any allegations of abuse or neglect. Beginning on 08/10/13, five interviewable residents will be interviewed daily by the Administrator, Interim DON, Unit Manager, Social Worker, Licensed Nurse, or the Regional Nurse Consultant for four weeks to ensure any abuse, neglect, or misappropriation is reported, investigated, and recognized. On 08/12/13, the Social Worker or Business Office Associate had contacted 22 families of residents who were unable to be interviewed to identify any allegations of abuse or neglect. The Social Worker or Business Office Associate continued to contact five families daily until 08/13/13, to identify any allegation of abuse or neglect. Beginning on 08/13/13, two family members of residents who are not interviewable will be interviewed by the Administrator, Interim DON, Unit Manager, Social Worker, or a Licensed Nurse. This will continue for four weeks and then decrease to four interviews per month until modified by the Quality Assurance (QA) Committee to sustain removal. To ensure the same family members are not being interviewed each time, a list of resident family members who have been interviewed is being maintained to ensure the facility interviews as many families as possible. The Interim DON, Unit Manager, or Treatment Nurse conducted a head-to-toe skin assessment on all facility residents to identify any signs or symptom of abuse. This was completed on 08/09/13. Beginning on 08/12/13, five head-to-toe skin assessments will be completed weekly by the Treatment Nurse, Interim DON, Unit Manager, or Education Training Director. This will continue for four weeks and then the assessments will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. Reeducation of all facility staff by the Interim DON, Unit Manager, Administrator, Education Training Director, or Regional Nurse Consultant began on 08/07/13, and was completed on 08/09/13. A copy of the abuse policies/procedures was given to all staff. Staff was required to demonstrate understanding regarding the policy/procedures. No staff will be permitted to work in the facility until they have received reeducation and received a copy of the abuse policy/procedures. At the end of each shift all nursing staff having worked will be interviewed by the Administrator, Interim Director of Nursing, Unit Manager, Charge Nurse, or the Regional Nurse Consultant to identify any reports of abuse or neglect. This began on 08/09/13, and will continue until 08/17/13. Beginning on 08/17/13, the Education Training Director, Administrator, Interim DON, or Regional Nurse Consultant will interview a minimum of five employees each shift for four weeks to ensure that no abuse or neglect was reported to them, that they did not witness any abuse or neglect, and that they know what constitutes abuse or neglect and how to report it. After four weeks, the interviews will decrease to four interviews per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/07/13, the Regional Nurse Consultant reeducated the Administrator and DON regarding the abuse and neglect policy/procedures which included recognizing and reporting abuse allegations. On 08/09/13, the Regional Nurse Consultant completed reviewing all Concern/Grievance Report forms completed in the past 30 days to identify if any grievance had been reported that constituted an allegation of abuse that was not recognized. Beginning on 08/10/13, the Regional Nurse Consultant will monitor and review all grievances five times per week for four weeks to ensure any grievances received are reviewed to ensure if there was an allegation of abuse it was investigated and reported. After four weeks, the reviews will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/09/13, the Regional Nurse Consultant completed a review of all allegations of abuse and neglect submitted over the past three months to identify any allegation that had not been investigated or reported timely as required. Beginning on 08/10/13, the Regional Nurse Consultant will monitor and review all allegations of abuse or neglect five times per week for four weeks to ensure abuse or neglect allegations are received and investigated per policy. After the four weeks, the reviews will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/09/13, the phone numbers of the Administrator, Interim DON, and Regional Nurse Consultant were posted at the entrance to the facility for residents, families, or staff to utilize for abuse reporting at any time. Beginning on 08/08/13, all newly hired employees will be educated by the Education Training Director on the facility's abuse policy/procedures, given a copy of the policy, and instructed who to contact if abuse or neglect was identified or reported. On 08/12/13, a resident council meeting was held with the Administrator to identify any abuse or neglect concerns. Beginning on 08/12/13 for three weeks, a weekly resident council meeting will be held with the Administrator or Regional Nurse Consultant to ask residents about abuse or neglect and to ensure they are knowledgeable on how to report it. After three weeks, the meetings will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. The facility held a Quality Assurance meeting on 08/12/13 with the Administrator, Interim DON, Regional Nurse Consultant, Housekeeping/Maintenance Director, Dietary Director, Unit Manager, Education Training Director, and Medical Records Director. The meeting was conducted to identify any issues related to abuse or neglect. On 08/09/13, Concern/Grievance Report forms were placed at each nurses' station and in the front lobby of the facility to allow for resident, family, or staff utilization. The Business Office Assistant will ensure the forms are in place five times per week for four weeks and then once per month and remain ongoing until modified by the QA Committee to sustain the removal. Beginning on 08/12/13 a meeting, consisting of QA Committee members including the Administrator, Interim DON, Education Training Director, Regional Nurse Consultant, Dietary, Housekeeping/Maintenance, and Medical Director to be in attendance or on the phone with the team, is to be held once a week for four weeks, and then every two weeks for four weeks, to review all audit findings and make recommendations for changes to the plan. This will be ongoing until all issues are resolved. --The State Survey Agency validated the corrective actions taken by the facility as follows: Review of facility documentation and an interview with Resident #1 on 08/19/13 at 12:48 PM revealed the Regional Nurse Consultant, the Administrator, or a Licensed Nurse was interviewing Resident #1 daily to identify any concerns. Review of an Employee Counseling/Disciplinary Report form dated 07/22/13, and interview with LPN #1 on 08/06/13 at 2:30 PM, revealed the facility suspended LPN #1 from employment at the facility on 07/22/13. Review of facility documentation and random interviews conducted on 08/19/13 at 11:40 AM with Resident #2, at 11:42 AM with Resident #3, at 11:48 AM with Resident A, at 11:53 AM with Resident B, and at 11:57 AM with Resident C revealed the Social Worker and/or Regional Nurse Consultant had completed interviews with residents who were interviewable to identify any allegations of abuse or neglect on 08/09/13. Review of Resident Interview Sheets and interviews on 08/19/13 at 2:03 PM with the Administrator, at 3:30 PM with the Interim DON, at 2:35 PM with the Unit Manager, at 1:55 PM with the Social Worker, at 2:33 PM with Licensed Nurse #1, and at 2:09 PM with the Regional Nurse Consultant, revealed five interviewable residents had been interviewed daily since 08/10/13 to ensure any abuse, neglect, or misappropriation was reported, investigated, and recognized. Any issues identified were reported to the required authorities. Review of facility documentation on 08/19/13, and interviews with the Social Worker at 1:55 PM and with the Business Office Associate at 2:23 PM, revealed they had contacted 22 families as of 08/12/13, of residents who were unable to be interviewed to identify any allegations of abuse or neglect, and no concerns were identified. Review of facility documentation on 08/19/13 and interviews with the Administrator at 2:03 PM, the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, the Social Worker at 1:55 PM, and Licensed Nurse #1 at 2:33 PM revealed since 08/13/13, two family members of residents who were not interviewable had been interviewed daily. Additionally, observations on 08/19/13, revealed a Family List was maintained of families who had been contacted. Review of Resident Skin Assessments on 08/19/13, and interviews with the Interim DON at 3:30 PM, with the Unit Manager at 2:35 PM, and with the Treatment Nurse at 3:38 PM revealed they had conducted head-to-toe skin assessments on all facility residents as of 08/09/13. No concerns related to abuse/neglect were identified. Review of Resident Skin Assessments on 08/19/13 and interviews with the Treatment Nurse at 3:38 PM, the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, and the Education Training Director at 3:49 PM, revealed five Resident Skin Assessments had been conducted from 08/12/13 through 08/16/13. No concerns related to abuse/neglect were identified. Review of in-service training records, employee sign-in sheets, and interviews with Certified Nursing Assistant (CNA) #10 at 3:05 PM, CNA #11 at 3:18 PM, CNA #12 at 3:25 PM, LPN #10 at 3:09 PM, and LPN #11 at 3:18 PM, revealed all facility staff had been reeducated by the Interim DON, Unit Manager, Administrator, Education Training Director, or Regional Nurse Consultant from 08/07/13 through 08/09/13. Interviews revealed all staff had received a copy of the abuse policies/procedures, and had been required to demonstrate understanding by completing a questionnaire regarding the policy/procedures. Review of facility documentation and interviews on 08/19/13 at 2:03 PM with the Administrator, at 3:30 PM with the Interim Director of Nursing, at 2:35 PM with the Unit Manager, at 2:09 PM with the Regional Nurse Consultant, with Certified Nursing Assistant (CNA) #10 at 3:05 PM, with CNA #11 at 3:18 PM, with CNA #12 at 3:25 PM, with LPN #10 at 3:09 PM, and with LPN #11 at 3:18 PM, revealed all staff was being interviewed at the end of each shift to identify any reports of abuse or neglect. Review of facility documentation on 08/19/13 and interviews with the Education Training Director at 3:49 PM, the Administrator at 2:03 PM, the Interim DON at 3:30 PM, and the Regional Nurse Consultant at 2:09 PM, revealed five staff members had been interviewed on 08/17/13 and 08/18/13. Interviews on 08/19/13, with the Regional Nurse Consultant at 2:09 PM, and with the Administrator at 2:03 PM, revealed the Regional Nurse Consultant had retrained the DON and Administrator on 08/07/13. The training focused on the facility's abuse and neglect policy/procedures which included recognizing and reporting abuse allegations. Review of a Grievance Face Sheet and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had reviewed all Concern/Grievance Report forms completed in the past 30 days on 08/09/13, to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Review of a Grievance Face Sheet and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had reviewed all Concern/Grievance Report forms completed from 08/09/13 through 08/18/13 to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Review of an Allegation of Abuse Binder on 08/19/13, and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had completed a review of all allegations of abuse and neglect submitted over the past three months to identify if any allegation had not been investigated or reported timely as required on 08/09/13. Review of an Allegation of Abuse Binder on 08/19/13, and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had completed a review of all allegations of abuse and neglect submitted from 08/10/13 through 08/18/13. Observation on 08/19/13 at 12:18 PM, revealed the phone numbers of the Administrator, Interim DON, and Regional Nurse Consultant were posted at the entrance to the facility. Review of Newly Hired employee files on 08/19/13, and an interview with LPN #11 at 3:15 PM, revealed she was educated upon hire on 06/19/12 by the Education Training Director on the facility's abuse policy/procedures, was given a copy of the policy, and was instructed who to contact if abuse or neglect is identified or reported. Review of Resident Council Meeting minutes dated 08/12/13, revealed a resident council meeting was held with the Administrator to identify any abuse or neglect concerns. No concerns were identified. Interviews on 08/19/13, at 2:03 PM with the Administrator, at 3:30 PM with the Interim DON, at 2:09 PM with the Regional Nurse Consultant, at 3:00 PM with the Housekeeping/Maintenance Director, at 3:05 PM with the Dietary Director, at 2:35 PM with the Unit Manager, at 3:49 PM with the Education Training Director, and at 2:26 PM with the Medical Records Director, revealed minutes from a Quality Assurance meeting dated 08/12/13 revealed a meeting was conducted to discuss the identified deficient practice and identify any issues related to abuse or neglect. Observations on 08/19/13 at 12:30 PM revealed Concern/Grievance Report forms were in place at each nurses' station and in the front lobby of the facility. Interview with the Medical Records Director on 08/19/13 at 2:26 PM revealed she was responsible to ensure the forms were in place at the designated areas five times per week.

Based on interview, record review, review of the facility's investigation, and a review of policy/procedures it was determined facility Administration failed to ensure its resources, including policies related to abuse and neglect, were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for one of three sampled residents (Resident #1). On 07/18/13, Resident #1's family members reported to the Director of Nursing (DON) that they were concerned Resident #1 was being abused by staff. However, Administration failed to ensure abuse policies and procedures were implemented. The facility failed to initiate an investigation of the allegation, failed to protect residents from further abuse, and failed to report the allegation of abuse immediately to state agencies when the allegation was reported to the DON on 07/19/13. (Refer to F225 and F226.) The Administration's failure to ensure facility policies/procedures related to abuse prevention were implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/18/13. The facility was notified of the Immediate Jeopardy on 08/14/13. An acceptable Allegation of Compliance was received on 08/15/13, and alleged removal of the Immediate Jeopardy on 08/14/13. The state survey agency determined the Immediate Jeopardy was removed on 08/14/13, prior to exit, which lowered the scope/severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy and procedure related to abuse, undated, revealed the facility had developed policies in an effort to prevent abuse and to ensure allegations of abuse were reported appropriately. The facility's policies and procedures defined verbal abuse as oral, written, or gestured language including disparaging and derogatory terms to the resident or family members. According to the policy, abuse was prohibited and allegations of abuse would be investigated, residents protected from further potential abuse during the course of the investigation, and allegations would be immediately reported to the state agency. The policy also revealed the Administrator was responsible for ensuring compliance with the policy and allegations of abuse would be reported to state agencies. A review of the facility's investigation revealed Adult Protective Services (APS) entered the facility on 07/22/13 to initiate an allegation that facility staff, Licensed Practical Nurse (LPN) #1, had abused Resident #1. Based on documentation, the facility initiated an investigation of the alleged abuse of Resident #1 on 07/22/13. A review of a Concern/Grievance Report form completed and dated by the DON on 07/18/13, revealed Resident #1's family had reported concerns that Resident #1 was being abused by staff. However, interview with the DON on 08/06/13 at 1:15 PM revealed the DON failed to investigate the allegation because Resident #1 had appeared confused when she was speaking to the resident's family on 07/18/13. In addition, the DON failed to immediately report the family members' concerns as suspected abuse to the state agencies, failed to initiate an investigation, and failed to ensure residents, including Resident #1, were protected for further potential abuse during the facility's investigation. The DON stated she submitted the Concern/Grievance form to the Administrator on 07/19/13. The Administrator acknowledged in interview conducted on 08/07/13 at 11:39 AM that the DON had given him the Concern/Grievance form on 07/19/13, and verbally described to him that Resident #1's family had voiced concerns. According to the Administrator, the DON informed him there had been a misunderstanding, and staff had only been attempting to reorient Resident #1 after the resident had been confused. The Administrator stated at that point he felt the concern had been addressed, and he failed to read the documentation on the form. The Administrator stated he implemented a plan to have two staff members present in the room when care was provided to Resident #1. The Administrator stated he did not implement the facility's abuse policy/procedures, and took no action to ensure an investigation was initiated, residents were protected, and that the allegation was reported to the state survey agency as required. According to the Administrator, at the time of the allegation investigation by the state agency on 08/06/13, the facility had not identified the concerns that family members of Resident #1 had reported to the DON on 07/18/13 as an allegation of abuse, and had not taken any action to investigate or report the family members' concerns immediately to the state agency as required, a timeframe of 19 days after the DON had received and documented the allegation. --A review of the Allegation of Compliance (AOC) revealed the following: Beginning on 08/08/13, Resident #1 was interviewed daily by the Regional Nurse Consultant, the Administrator, or a Licensed Nurse to identify any concerns. On 07/22/13, the facility suspended LPN #1 who was allegedly abusive to Resident #1, and an investigation was initiated. On 08/09/13, the Social Worker and/or Regional Nurse Consultant had completed interviews with all residents who were interviewable to identify any allegations of abuse or neglect. Beginning on 08/10/13, five interviewable residents will be interviewed daily by the Administrator, Interim DON, Unit Manager, Social Worker, Licensed Nurse, or the Regional Nurse Consultant for four weeks to ensure any abuse, neglect, or misappropriation is reported, investigated, and recognized. On 08/12/13, the Social Worker or Business Office Associate had contacted 22 families of residents who were unable to be interviewed to identify any allegations of abuse or neglect. The Social Worker or Business Office Associate continued to contact five families daily until 08/13/13, to identify any allegation of abuse or neglect. Beginning on 08/13/13, two family members of residents who are not interviewable will be interviewed by the Administrator, Interim DON, Unit Manager, Social Worker, or a Licensed Nurse. This will continue for four weeks and then decrease to four interviews per month until modified by the Quality Assurance (QA) Committee to sustain removal. To ensure the same family members are not being interviewed each time, a list of resident family members who have been interviewed is being maintained to ensure the facility interviews as many families as possible. The Interim DON, Unit Manager, or Treatment Nurse conducted a head-to-toe skin assessment on all facility residents to identify any signs or symptom of abuse. This was completed on 08/09/13. Beginning on 08/12/13, five head-to-toe skin assessments will be completed weekly by the Treatment Nurse, Interim DON, Unit Manager, or Education Training Director. This will continue for four weeks and then the assessments will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. Reeducation of all facility staff by the Interim DON, Unit Manager, Administrator, Education Training Director, or Regional Nurse Consultant began on 08/07/13 and was completed on 08/09/13. A copy of the abuse policies/procedures was given to all staff. Staff was required to demonstrate understanding regarding the policy/procedures. No staff will be permitted to work in the facility until they have received reeducation and received a copy of the abuse policy/procedures. At the end of each shift all nursing staff having worked will be interviewed by the Administrator, Interim Director of Nursing, Unit Manager, Charge Nurse, or the Regional Nurse Consultant to identify any reports of abuse or neglect. This began on 08/09/13, and will continue until 08/17/13. Beginning on 08/17/13, the Education Training Director, Administrator, Interim DON, or Regional Nurse Consultant will interview a minimum of five employees each shift for four weeks to ensure that no abuse or neglect was reported to them, that they did not witness any abuse or neglect, and that they know what constitutes abuse or neglect and how to report it. After four weeks, the interviews will decrease to four interviews per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/07/13, the Regional Nurse Consultant reeducated the Administrator and DON regarding the abuse and neglect policy/procedures which included recognizing and reporting abuse allegations. On 08/09/13, the Regional Nurse Consultant completed reviewing all Concern/Grievance Report forms completed in the past 30 days to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Beginning on 08/10/13, the Regional Nurse Consultant will monitor and review all grievances five times per week for four weeks to ensure any grievances received are reviewed to ensure if there was an allegation of abuse it was investigated and reported. After four weeks, the reviews will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/09/13, the Regional Nurse Consultant completed a review of all allegations of abuse and neglect submitted over the past three months to identify any allegation that had not been investigated or reported timely as required. Beginning on 08/10/13, the Regional Nurse Consultant will monitor and review all allegations of abuse or neglect five times per week for four weeks to ensure abuse or neglect allegations are received and investigated per policy. After the four weeks, the reviews will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. On 08/09/13, the phone numbers of the Administrator, Interim DON, and Regional Nurse Consultant were posted at the entrance to the facility for residents, families, or staff to utilize for abuse reporting at any time. Beginning on 08/08/13 all newly hired employees will be educated by the Education Training Director on the facility's abuse policy/procedures, given a copy of the policy, and instructed who to contact if abuse or neglect was identified or reported. On 08/12/13, a resident council meeting was held with the Administrator to identify any abuse or neglect concerns. Beginning on 08/12/13 for three weeks, a weekly resident council meeting will be held with the Administrator or Regional Nurse Consultant to ask residents about abuse or neglect and to ensure they are knowledgeable on how to report it. After three weeks, the meetings will decrease to one per month and remain ongoing until modified by the QA Committee to sustain the removal. The facility held a Quality Assurance meeting on 08/12/13 with the Administrator, Interim DON, Regional Nurse Consultant, Housekeeping/Maintenance Director, Dietary Director, Unit Manager, Education Training Director, and Medical Records Director. The meeting was conducted to identify any issues related to abuse or neglect. On 08/09/13, Concern/Grievance Report forms were placed at each nurses' station and in the front lobby of the facility to allow for resident, family, or staff utilization. The Business Office Assistant will ensure the forms are in place five times per week for four weeks, and then once per month and remain ongoing until modified by the QA Committee to sustain the removal. Beginning on 08/12/13, a meeting consisting of QA Committee members including the Administrator, Interim DON, Education Training Director, Regional Nurse Consultant, Dietary, Housekeeping/Maintenance, and Medical Director to be in attendance or on the phone with the team, is to be held once a week for four weeks, and then every two weeks for four weeks, to review all audit findings and make recommendations for changes to the plan. This will be ongoing until all issues are resolved. --The state survey agency validated the corrective actions taken by the facility as follows: Review of facility documentation and an interview with Resident #1 on 08/19/13 at 12:48 PM revealed the Regional Nurse Consultant, the Administrator, or a Licensed Nurse was interviewing Resident #1 daily to identify any concerns. Review of an Employee Counseling/Disciplinary Report form dated 07/22/13, and interview with LPN #1 on 08/06/13 at 2:30 PM, revealed the facility suspended LPN #1 from employment at the facility on 07/22/13. Review of facility documentation and random interviews conducted on 08/19/13 at 11:40 AM with Resident #2, at 11:42 AM with Resident #3, at 11:48 AM with Resident A, at 11:53 AM with Resident B, and at 11:57 AM with Resident C revealed the Social Worker and/or Regional Nurse Consultant had completed interviews with residents who were interviewable to identify any allegations of abuse or neglect on 08/09/13. Review of Resident Interview Sheets and interviews on 08/19/13 at 2:03 PM with the Administrator, at 3:30 PM with the Interim DON, at 2:35 PM with the Unit Manager, at 1:55 PM with the Social Worker, at 2:33 PM with Licensed Nurse #1, and at 2:09 PM with the Regional Nurse Consultant, revealed five interviewable residents had been interviewed daily since 08/10/13 to ensure any abuse, neglect, or misappropriation was reported, investigated, and recognized. Any issues identified were reported to the required authorities. Review of facility documentation on 08/19/13, and interviews with the Social Worker at 1:55 PM, and the Business Office Associate at 2:23 PM, revealed they had contacted 22 families as of 08/12/13, of residents who were unable to be interviewed to identify any allegations of abuse or neglect, and no concerns were identified. Review of facility documentation on 08/19/13 and interviews with the Administrator at 2:03 PM, the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, the Social Worker at 1:55 PM, and Licensed Nurse #1 at 2:33 PM, revealed since 08/13/13, two family members of residents who were not interviewable had been interviewed daily. Additionally, observations on 08/19/13, revealed a Family List was maintained of families who had been contacted. Review of Resident Skin Assessments on 08/19/13, and interviews with the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, and the Treatment Nurse at 3:38 PM, revealed they had conducted head-to-toe skin assessments on all facility residents as of 08/09/13. No concerns related to abuse/neglect were identified. Review of Resident Skin Assessments on 08/19/13 and interviews with the Treatment Nurse at 3:38 PM, the Interim DON at 3:30 PM, the Unit Manager at 2:35 PM, and the Education Training Director at 3:49 PM, revealed five Resident Skin Assessments had been conducted from 08/12/13 through 08/16/13. No concerns related to abuse/neglect were identified. Review of in-service training records, employee sign-in sheets, and interviews with Certified Nursing Assistant (CNA) #10 at 3:05 PM, CNA #11 at 3:18 PM, CNA #12 at 3:25 PM, LPN #10 at 3:09 PM, and LPN #11 at 3:18 PM, revealed all facility staff had been reeducated by the Interim DON, Unit Manager, Administrator, Education Training Director, or Regional Nurse Consultant from 08/07/13 through 08/09/13. Interviews revealed all staff had received a copy of the abuse policies/procedures, and had been required to demonstrate understanding by completing a questionnaire regarding the policy/procedures. Review of facility documentation and interviews on 08/19/13 at 2:03 PM with the Administrator, at 3:30 PM with the Interim Director of Nursing, at 2:35 PM with the Unit Manager, at 2:09 PM with the Regional Nurse Consultant, with Certified Nursing Assistant (CNA) #10 at 3:05 PM, CNA #11 at 3:18 PM, CNA #12 at 3:25 PM, LPN #10 at 3:09 PM, and LPN #11 at 3:18 PM, revealed all staff was being interviewed at the end of each shift to identify any reports of abuse or neglect. Review of facility documentation on 08/19/13 and interviews with the Education Training Director at 3:49 PM, the Administrator at 2:03 PM, the Interim DON at 3:30 PM, and the Regional Nurse Consultant at 2:09 PM, revealed five staff members had been interviewed on 08/17/13 and 08/18/13. Interviews on 08/19/13, with the Regional Nurse Consultant at 2:09 PM, and the Administrator at 2:03 PM, revealed the Regional Nurse Consultant had retrained the DON and Administrator on 08/07/13. The training focused on the facility's abuse and neglect policy/procedures which included recognizing and reporting abuse allegations. Review of a Grievance Face Sheet and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had reviewed all Concern/Grievance Report forms completed in the past 30 days on 08/09/13, to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Review of a Grievance Face Sheet and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had reviewed all Concern/Grievance Report forms completed from 08/09/13 through 08/18/13 to identify if any grievance had been reported which constituted an allegation of abuse that was not recognized. Review of an Allegation of Abuse Binder on 08/19/13, and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had completed a review of all allegations of abuse and neglect submitted over the past three months to identify if any allegation had not been investigated or reported timely as required on 08/09/13. Review of an Allegation of Abuse Binder on 08/19/13, and interview with the Regional Nurse Consultant on 08/19/13 at 2:09 PM, revealed she had completed a review of all allegations of abuse and neglect submitted from 08/10/13 through 08/18/13. Observation on 08/19/13 at 12:18 PM, revealed the phone numbers of the Administrator, Interim DON, and Regional Nurse Consultant were posted at the entrance to the facility. Review of Newly Hired employee files on 08/19/13, and an interview with LPN #11 at 3:15 PM, revealed she was educated upon hire on 06/19/12 by the Education Training Director on the facility's abuse policy/procedures, was given a copy of the policy, and was instructed who to contact if abuse or neglect is identified or reported. Review of Resident Council Meeting minutes dated 08/12/13, revealed a resident council meeting was held with the Administrator to identify any abuse or neglect concerns. No concerns were identified. Interviews on 08/19/13, at 2:03 PM with the Administrator, at 3:30 PM with the Interim DON, at 2:09 PM with the Regional Nurse Consultant, at 3:00 PM with the Housekeeping/Maintenance Director, at 3:05 PM with the Dietary Director, at 2:35 PM with the Unit Manager, at 3:49 PM with the Education Training Director, and at 2:26 PM with the Medical Records Director, revealed minutes from a Quality Assurance meeting dated 08/12/13 revealed a meeting was conducted to discuss the identified deficient practice and identify any issues related to abuse or neglect. Observations on 08/19/13 at 12:30 PM revealed Concern/Grievance Report forms were in place at each nurses' station and in the front lobby of the facility. Interview with the Medical Records Director on 08/19/13 at 2:26 PM revealed she was responsible to ensure the forms were in place at the designated areas five times per week.

Based on observation, interview, and record review, it was determined the facility failed to ensure that one (1) of four (4) sampled residents (resident #1) received adequate supervision and assistive devices to prevent accidents. Resident #1 was admitted to the facility on [DATE], with a known history of falls with injury. On September 12, 2010, at 2:00 a.m., resident #1 was placed at the nurses' station and a sounding alarm applied to the resident's chair due to repeated attempts to get out of the bed/chair unassisted and increased agitation. However, staff left the resident unattended, out of visual sight and auditory range, and the resident was found lying on the floor with a laceration to the back of the head and a fractured right hip. The findings include: Resident #1 was admitted to the facility on Saturday, September 11, 2010, at approximately 3:00 p.m. Resident #1 had a previous admission to the facility from July 5, 2010 until July 24, 2010, for rehabilitation of a fractured left hip as the result of a fall at home. An interview with the Administrator on October 28, 2010, at 4:45 p.m., revealed resident #1's spouse had contacted the facility requesting the resident be readmitted to the facility due to the spouse's declining health and resident #1's increased falls at home. A review of resident #1's admitting physician orders [REDACTED]. According to the Administrator in the interview on October 28, 2010, at 4:45 p.m., resident #1's admission was discussed in the "morning meeting" on Friday, September 10, 2010. The Administrator stated resident #1's risk of falls was discussed, but was based on the facility's familiarity of the resident from the resident's previous admission. The Administrator revealed that during the meeting on September 10, 2010, no comprehensive information gathering had been conducted with the family, or interdisciplinary meetings conducted, to determine if resident #1's care needs had changed, or if the facility was capable of maintaining the resident's safety. The Administrator explained all new admissions to the facility were placed on 30-minute checks for 24 hours, which was determined, in the meeting, to be adequate to ensure resident #1's safety. The Administrator stated during resident #1's admission in July 2010 the resident's family had stayed continually with the resident, and no behavioral problems or falls had occurred. A review of a facility staffing form dated September 11-12, 2010, revealed on the 11:00 p.m. to 7:00 a.m. shift resident #1's unit was staffed with one RN and two Certified Nursing Assistants (CNAs). An interview was conducted on October 28, 2010, at 3:00 p.m., with CNA #1, who was caring for resident #1 on the 11:00 p.m. to 7:00 a.m. shift on September 11-12, 2010. The CNA stated resident #1 was at the nurses' station in a geri-chair when he/she arrived for work on September 11, 2010, for reportedly being agitated and continually attempting to get out of the bed/chair. CNA #1 recalled RN #1 directing the CNAs to "watch" resident #1, however, no special assignment or arrangements were made to facilitate "watching" the resident, and the CNAs continued to be responsible for the care of the other residents on the unit (approximately 40 residents). CNA #1 stated the nurse provided no other instructions or interventions to be utilized to prevent resident #1 from attempting to get up unassisted or ensuring the resident remained safe. CNA #1 stated at approximately 2:20 a.m. on September 12, 2010, CNA #2 went on lunch break, and CNA #1 was providing care to another resident in their room when RN #1 alerted him/her that resident #1 had sustained a fall. According to the CNA, he/she was unable to visualize resident #1 or hear the resident's alarm sounding prior to the incident. A review of a written statement signed by CNA #2 dated September 13, 2010, revealed CNA #2 was on lunch break when the incident occurred. Interviews were conducted on October 28, 2010, at 2:45 p.m. and 4:15 p.m., with Registered Nurse (RN) #1, who cared for resident #1 on the 7:00 p.m. to 7:00 a.m. shift on September 11-12, 2010. RN #1 stated when resident #1's family left the facility at approximately 9:30 p.m. on September 11, 2010, "that is when all the trouble started," explaining resident #1 became upset, agitated, and confused. RN #1 recounted how resident #1 was "restless and couldn't keep (him/her) in the bed or a chair." Further interview with RN #1 and a review of nurse's notes for resident #1 dated October 10, 2010, at 10:30 p.m., revealed resident #1 had gotten out of bed unassisted, and became physically aggressive when staff attempted to assist the resident back to bed. Resident #1's physician was contacted and an order obtained to administer resident #1 Haldol by mouth. RN #1 stated the medication was administered, and resident #1 was placed at the nurses' station in a reclined geri-chair with a sensor pad alarm. However, RN #1 stated no provisions were made to ensure staff could visualize resident #1 or hear the resident's alarm sounding at all times, despite the resident's continued agitation, verbalizations of going home, and attempts to get out of the chair unassisted. Further interview with RN #1 on October 28, 2010, at 2:45 p.m. and 4:15 p.m., and review of a facility investigation (undated) revealed at 2:00 a.m. on September 11, 2010, resident #1 remained at the nurses' station in the geri-chair "talking some," when RN #1 went into the medication room, leaving resident #1 unattended. RN #1 voiced being aware CNA #2 was off the floor for break at that time, leaving CNA #1 to care for all residents on the unit, including resident #1, but stated resident #1 had "calmed down and I didn't think (resident #1) would try to get up." RN #1 went on to explain that upon exiting the medication room at approximately 2:20 a.m., the sensor pad alarm in the geri-chair at the nurses' station was sounding, and resident #1 was found approximately 25 feet from the nurses' station on the floor with a laceration to the back of the head and complaining of right leg pain. Further review of resident #1's nurse's notes dated September 12, 2010, at 5:45 a.m., and an Accident/Incident report dated September 12, 2010, revealed the resident was admitted to the hospital with [REDACTED].